So hi there, I'm, I'm Andrew Wood, and I'm gonna be discussing a practical approach to acute severe lameness. So the learning objectives, of this, webinar are to look at the clinical assessment of an acute severe lameness, look a bit into triaging these acute lamenesses when they occur. We'll touch on some of the common conditions encountered when sort of faced with an acute severe lameness, and then we'll also discuss the first aid treatment of these cases and also method, methods of coaptation just at the end.

So it's important to note that, you know, although, although these cases can be very lame and therefore, you know, you wanna feel like you want to get to a diagnosis straight away and you feel like that'll be, you know, a really easy thing to do, it's often not the case and these are really quite challenging cases, especially in the acute phase. And it's really important to perform a thorough clinical examination on these cases, as rushing to obtain a diagnosis can lead to misinterpretation of the findings, or you know, you could potentially overlook a lesion that's actually more relevant to this lameness. And so these cases require really good decision making, as your decision and judgement might affect the overall prognosis of this horse, you know, for example, if it needs, you know, early referral or treatment, and it might also actually determine, you know, more severely if the horse, you know, lives or not, and so, you know, that's a really big decision to make.

But the main thing to do in these cases is not panic and, you know, don't expect to get to the diagnosis straight away in every case, as I said, and remember that not every lame horse has a fracture. So common scenarios that we're gonna see is, you know, sudden lameness from the field, . Post exercise, you know, after work, you know, we're gonna be thinking about sort of fractures and potentially some soft tissue injuries, post shoeing, that'd be quite a common finding, you know, nail binds or potentially abscesses as well, but also, you know, it's worth noting that a lot of these cases will have an unknown, you know, reason for the lameness and, and initially sometimes an unknown sort of source of the lameness.

So triage, so what is triage, so it's the initial assessment of a patient in order to determine the urgency of their need for treatment and the nature of the treatment that they then require. And so why does that matter in our in our horses with acute lameness? Well, it's because acute acute pain and lameness is distressing for the animals, and some conditions might worsen if they're untreated.

Early treatment and recognition of the the the issue might actually lead to a better prognosis in some cases, and so this is why the sort of the detailed clinical examination is very, very important. And triage will importantly as well for the owner, provide a clear timeline and will help manage their emotional and also sometimes their financial expectations of this, of this case. And finally, you know, why does triage matter in terms of everyone that's going to be present in this case, it's, it's mainly safety, you know, these cases can be very unsafe in some situations.

The horses can be unpredictable when there's distress and, and discomfort. And so one of the main things we need to do is make sure that everyone involved is safe. And so what does it achieve, so it allows us to differentiate between these sort of true emergencies, and differentiate these from, you know, serious but, but horses that are stable and potentially don't need, you know, as urgent treatment.

And it also means that we have some structure in this really stressful situation, and it's important that like, you know, as as many years of experience as you might have, you might be nervous about this case in terms of rushing, you know, trying to get a good diagnosis, trying to please the client, but the client will also definitely be stressed and so it's good to have a plan when you get there of what to do. And so when you're heading out to these acute lamenesses or potentially if they're coming into your clinic, these are the sorts of things you should be thinking about. And obviously you might want to take a history on route, but the owner's often going to be distressed and so sometimes it's actually better to do this once you've assessed the situation at the yard.

And you know, remember again, you might not get to the diagnosis straight away and so be prepared for this. So, the first thing to do when you get to these cases is assess the suitability of the horse to examine. So, for example, if we'll use this case as an example, this horse is recumbent and caught on a fence.

Obviously, the initial diagnosis of what's going on with this horse is potentially less important than actually keeping everyone and the horse safe and potentially getting the horse off of this fence. And so that's where stuff like sedation and stuff there, you know, come, comes in handy. So we want to assess, you know, where the horse is, you know, is the horse recumbent, which obviously in this case is, where it's recumbent.

So for example, it might be on a very uneven surface, if people are moving around, they might actually injure themselves. And also, you know, it might be in a situation where the horse, you know, could be distressed and thrashing about in this fence, and so therefore it's maybe gonna be prone to sort of hurting other people, around them. So sedation's very useful in these cases, especially in a case, for example, like this, it's recumbent, but any horse that's acutely non-weight bearing and distressed.

But be very careful, you know, you don't want to over sedate these horses, especially, you know, for example, they've got a fracture, you don't want to over sedate them as they might become more aotactic and, and worsen that injury. But you've got to remember that distressed horses will often take more sedation than you would otherwise think. And so some horses that you sedate won't look very sedated unless you give them a, unless you give them a lot.

And making this situation safe will often precede any history taking or clinical exam of the horse, because, you know, that is the main priority is keeping everyone there safe and the horse safe. So I would often make a visual assessment of these horses, when I was approaching them, and sometimes this can be involved, you know, taking the history when you're walking from the car to the horse, for example. You know, look for any, any areas of blood, you know, the horse might not be actively bleeding, but there might be blood on the ground, which indicates that potentially something more traumatic has happened.

And, you know, for example, you might see if the horse is standing and it's waving its leg in the air, then it's quite obvious potentially what's, what's going on. Assess the degree of lameness in more sort of, you know, cases that are actually ambulatory, you know, sometimes the the horses actually might not be as lame as was described on the phone, and it's important to sort of remember that this horse was initially non-weight bearing lame and the owner might be very distressed, even if the horse has had, you know, say just a bang in the field and is now very, very comfortable. And so, you know, the degree of distress of this horse, you know, we've got to take that into account as well.

Some horses will be very stoic, but they'll be very, very lame. And so these horses won't take as much, you know, sedation, for example. And this is what we've got to bear in mind, you know.

You know, we've got to make these horses safe if they're really distressed and sedation is going to be key to this, and some people worry about getting sedation before they examine the horse because they think it might disrupt the pain or anything like that, you know, it might make the assessment of pain harder, but actually in my experience, I think that horses, if they are going to be sore somewhere, they're gonna be sore regardless of sedation, especially in the acute phase. So definitely, you know, give these horses sedation, if necessary to examine them cos it's gonna make everyone a bit safer. So the first stage of triage is obviously often taking the history, and this is really important and it's often, you know, overlooked, in some cases, especially when you're rushing in trying to treat these horses and get to a diagnosis, when actually the history could really, really help you in sort of determining what's going on.

And so when did this lameness develop, did it happen overnight, did it happen when they're exercising the horse, you know, these are gonna be things that are really gonna, gonna help you sort of get to your diagnosis. You know, did, did they see this injury happening or did they not see it happening, again, you know, if they saw it happening, it might be more likely to be a kick or something like that in the field. And you know, what does this horse do for a job, that's a really important thing, again, that's quite often overlooked.

Initially you want to rush to get to a diagnosis, but sometimes we've got to think about what is this horse's function and therefore, what is the prognosis long-term of this injury going to be, obviously once we've got to the diagnosis, because that could really adjust your decision making in terms of what the owner wants to do and how they want to progress with these cases. Does the horse have any underlying lameish issues? Again, this is really important because some apparently acute lameness is actually could just be an exacerbation of an already underlying chronic lameness, for example, chronic arthritis can sometimes present as very, very, you know, lame, a very, very lame horse, for example, hawk, a horse with hawk arthritis can sometimes present very, very lame after, you know, running around the field, for example, and so you've got to take these into account as well.

And how is a horse managed to exercise, for example, you know, one of the main things I would commonly ask if a horse has been kicked is, you know, are there other horses in the field with shoes on, as this could really affect the, extent of injury this horse has and make certain things more likely than others. And then finally, you know, have these horses recently been treated with anything, and that is where we've got to think about stuff like steroid induced laminitis. So the first thing to say in the initial examination is you can get pain relief straight away, it's rarely indicated and it can make the examination so much easier.

And again, this is where sedation, and I've gone on about sedation quite a lot, but this is where sedation again is, is, is, is vital and this might be needed to examine these horses. But remember to look at these horses as a whole, as they might have sustained multiple injuries, and thorough clinical palpation is essential, and it's gonna help guide your diagnosis. Often subtle, you know, often the findings initially will be very subtle, for example, they might only have a slight joint effusion if they had, say, a problem with the joint.

And so don't get distracted by the, by, by, you know, the owner or a large wound that's on there. Do a thorough c kind of exam as something might be missed that's actually more relevant than the than the large wound, that's on the leg. You know, obviously, as I said, check for swellings and effusions, often there's none initially, and you may actually have to clean off some of these horses if for example they're coming in from the field, as some certain wounds can be covered in dirt, and stuff like that.

Unless the cause of the lameness is very obvious, who's test the horse in all scenarios is sometimes. These can be missed, and this is probably the most common source of non-weight bearing lameness, and as I say, these can present with, with no clinical signs at all, sometimes they won't even have heat in the hoof, but sometimes actually they can present with limb swelling, and, and, you know, and so it might be that you think there's a more proximal issue, but actually just the edoema from the inflammation in the foot has caused some limb swelling, and so always hoof test these horses. Then we want to assess the suitability of the horse to walk and trot, you know, ideally we'd like to see this horse walk to see how, how lame it is unless it's, you know, obviously lame when standing still.

Trotting, you know, often that is very contraindicated in some horses, but actually some horses when you arrive at them will have improved to such a degree. That they're no longer lame at war, and actually you do want to assess these horses at trot because sometimes there will be a significant lameness at trot, and so whereas you might not be very worried if you see these horses, you know, no sound at walk, if there's still a severe lameness at trot, then you actually might be a bit more worried. Obviously we're not doing a full lameness examination on these horses, we're not trotting them in a, on a, on the lunge, for example, but just a few strides of trot, especially if the horse is severely lame, will help you, in guiding that.

And try and try and examine these horses and walking. Before you've sedated them, and again, as I say, be careful about the amount of sedation you use, and to be safe at all times. So after your initial examination, you might have an idea of which category your patient falls into and actually, although this diagram here, you know, it's just as a rough guide would make it seem very clear, there's a lot of areas of grey in between these.

For example, not every fracture needs to be rushed into the hospital, but it's good to have an idea of what, what horses you want to immediately treat or potentially euthanize or that want urgent referral. Others that might just need urgent stabilisation, and others that actually might just need some pain relief and some time to for the diagnosis to become a bit more clear. It's really important to think about the, the type of horse that you're going to be faced with or the type of horse you have been faced with, you know, is it a racehorse, for example, you know, one of the top differentials in a racehorse that's come off the gallops would be a fracture, for example, versus a cob that's been found laying in the field, most likely realistically to be an abscess.

Has this horse exercised recently? Has it not, you know, this is, you know, it's not every horse is gonna fit this mould, but don't get, you know, don't get sidetracked in thinking every lame horse, as I said, it's a fracture, but also in the, in the same vein, you know, if it's a thoroughbred and you are highly suspicious of a fracture, it doesn't necessarily mean it is a 100% a fracture. And think about the different ages of the horse, you know, younger horses might have a more less of a tolerance for pain than older horses, for example, and other horses such as cobs tend to be a bit more stoic than, than your sort of thoroughbreds, for example.

So further diagnostics in the field, so you, you need to remember by this stage you've already actually done a lot of the diagnostics, so hoof testers and clinical exam, and so that's gonna really, you know, guide your next step. And I'll touch on all these diagnostic imaging modalities when we go through each specific type of non-weight bearing lames. The, the first thing to consider when you want to do any more diagnostic imaging is deciding is, is this form of diagnostic imaging going to change my decision in the case or what, how, how the case progresses.

And so if the answer to this is no, then I wouldn't rush into doing it, for example, if you think these horses just need pain relief, or if it's obviously needs referral to an institute or potentially euthanasia, then don't mess around doing diagnostics that are actually just going to waste time and potentially could affect the prognosis and the welfare of these horses. In the same vein, if it's not safe to do diagnostics where the horse is, on the yard, and, you know, then don't do them, you know, bring that horse, into, into the stable, for example, or bring it to a premises that's more suitable. And so actually it might be more suitable to stabilise some of these horses, the initial phase, for example, if it's in the middle of a muddy field until you get some diagnostics rather than dragging all your equipment out, to the field.

And radiographs are often the first go to imaging modality, and if you think you're going to do them, then I would do them probably first, to be honest with you, and it as it avoids getting gas into the tissues when you're sort of potentially gonna be tapping these joints, I think gas in the tissues might just sort of do, you know, change your findings slightly on the radiographs as I'll show later, and also, you know, radiographs are gonna help guide your decision, you know, if you've got an obvious fracture straight away, then there's no further diagnosis is needed, and potentially referral or, or, or another treatment option might be indicated. And these cases can be really hard to X-ray, it's even with sedation and analgesia, sometimes these horses will stay non-weight bearing, but you need to just try and get the best diagnostic images as you can, as these, you know, aren't gonna potentially affect the prognosis. And if you're not sure what views to get or how to, you know, get this horse to to stand a bit better, then call, always, you know, call for assistance in the in these cases.

Ultrasound can be very useful in a lot of these cases, including fractures and where it gives details of the, you know, good details of the cortical bone surface and it's also useful in hard to reach areas such as the pelvis. Synovial centesis is always useful if you if you suspect synovial involvement, but remember to consider again it goes back to the state of the leg and the conditions you're in as to whether that's gonna be useful, in this situation or whether actually it's gonna be indicated because for example, if a horse has a big cellulitic leg or it's got mud all over it's like in the middle of a field, potentially deferring this to a later stage where you're in a more suitable, suitable environment or the leg in a more suitable state would be better. Some things are contraindicated in certain cases, for example, diagnostic analgesia.

And I would definitely wouldn't rush to do this, unless you were pretty sure that the lameness was coming from the foot, for example, if you had raised digital pulses and you had, you know, pain on hoof testers in a hot hoof, but certainly, you know, if you are isolating your foot, that can be useful just to one, confirm it's in the foot, and 2, make the horse a bit more comfortable to move in from the field. Blood work, I, I don't think that's really useful in the initial phase. Sometimes it's good to check for the systemic status of these horses, for example, if they've lost a lot of blood.

And serum amyloid A, for example, lots of people do that, and that can be useful, but usually it's good to stabilise these horses first. And actually sometimes this SEE, if it's, for example, a septic joint might not have increased if you're testing the synovial fluid, and actually sometimes as well it's hard to differentiate between severe inflammation and infection. So before we do any diagnostics, we need to, as I've said before, consider if this horse needs any immediate first aid.

And it's easy to forget this when you're in a rush to get the diagnosis and you know, you might be struggling with a horse, you know, that's not wanting to bear its weight and actually wear some, you know, analgesia might actually make this, the rest of the diagnostics very, you know, much easier. As I said, I don't think analgesia is ever contraindicated, and it's gonna make the horse less distressed and it's gonna help your further diagnosis. There's always a question between phenobbutasone or Fanexin, I think either is fine, anecdotally, phenobbutasone is potentially better for musculoskeletal pain.

Sedation, again, yeah, as I've touched on before, very, very useful, and some of these horses, for example, the one in the fence, you might actually have to give these horses a short general anaesthetic, a short general anaesthetic, to, get them out of the fence, for example, and also in this case, you know, for example, the horse stuck in the fence, you need to make sure that everyone in the environment is safe, and so, for example, a short general anaesthetic might, might be better. Extension 300. Oh I was just I'm back on the phone there, .

So in this case as well, I wouldn't co-op these cases straight away, unless you're very sure of what's going on, you know, sometimes co-optation can be contraindicated in some cases, but certainly if you've got an open wound that you're worried about, you can definitely cover these whilst you're doing additional diagnostic tests. You might need to apply pressure to these legs, and if, if the wound's, you know, heavily bleeding, a tourniquet can be useful in these cases, or also, you know, a pressure bandage, and sometimes, you know, worth, worth remembering some of these horses won't have had any tetanus prophylaxis, and so it's worth considering if these horses have had this, especially when they have extensive wounds. So I'll now go through some of the more common scenarios of non-weight bearing lameness cases you might see, and this, this will definitely won't be a comprehensive list of diagnosis, but allow you to make a good start and, you know, making, and start making plans for these horses.

We won't go through the treatment options for every horse, but you know, hopefully you'll get an idea of how to manage these horses. So the number one thing, thing to consider is subtalar abscessation. It's by far the most common reason for non-weight bearing lameness in a horse.

These horses are commonly at pasture or found and and found lame, but they can also occur with the horses are found in the box or even after exercise sometimes. Obviously, as we all know, most will have heat in the foot and a bounding digital parts, but sometimes they don't have any localising signs. And this is why it's important to hoof test every single horse that you see with a non-weight bear lameness unless it's got an obvious reason for that.

But also I would be aware that some horses, especially horses with a really quite thick soles, won't respond to this in the early phases. But certainly, as I said before, if you're presented with a case that has minimal localising signs to the, to further up the leg and it's non-weight bearing, then certainly foot related issues are one of the situations where, you know, I don't think it'd be contraindicated to put a foot block in, and if the horse got better, then you can be, you know, more confident that that lameness, is coming, coming from the foot. We do need to be aware of diffusion, for example, if you're doing an axial cyst or a nerve block, just be careful because the horses that, for example, have a pastern fracture could, you know, block out to this, and you could worsen the fracture if, if you allow this horse to move.

As I said before, these cases can be really quite confusing, as you can sometimes get quite a lot of distal edoema, and it actually might make you think this horse is a septinous synovitis or a cellulitis. And so it's worth bearing these in mind and as I say, always just testing these horses. Further diagnostics and subsequentation is really, really required, and but sometimes you can radiograph these later down the line if you're not, not winning with them, and sometimes you can see gas, other times you might not.

But also, you know, these horses might have actually have a fracture, when you've been treated them for a subsolar abscess. Nail penetrations would be the next thing, you know, a lot of people say try and leave the nail in, and I think this is true when you're taking the radiographs, but if there is any possibility that this nail might go in further by not pulling it out, then I would just, I would always pull these out as actually the nail going in further could damage some, some more vital structures, further into the foot. If the nail's in, always take orthogonal views of the foot as the location of the nail is actually gonna determine which structure we're gonna worry about.

And obviously, you know, this is gonna determine what, what we're gonna do to the horse, for example, a, a, a nail that's gone in the sort of palmar plantar aspect of the heel bulb might not be of concern on a lateral X-ray, but actually a DP X-ray might show you that it's gone into the into the digital flexor tendon sheath, for example. And the most important sites are gonna be the, the, the sort of mid to palmar aspect of the frog as the underlying soft tissue structures and and joints are in this, in this sort of area. And so we'd worry about the DDFT, the distal interphalangeal joint, and the navicular bursa, most commonly.

And usually sort of, you know, for example, if you've seen these and the nail's been removed, the superficial wound can heal quite early and there actually might not be, you know, any, any obvious penetrating track deep into this, into the frog's sulcus, but I would certainly be worried, and, you know, for example, in, in this diagram here, I'd be very, very worried if I saw a nail that had gone in in areas C or D. Or, or be, you know, going through the digital flex attendant. And heel bubble lacerations would be the sort of other, other common thing we would often see and quite often these aren't associated with any marked lameness and they just need, need some wound care, to be honest with you, but often they are associated with marked lameness and it's easy to forget sometimes that actually deeper structures such as the tendon sheath and coffin joint can be effective with these, so if these horses are non-weight bearing, then it is definitely worth considering, considering further diagnostics in these cases.

But for me, you know, if you're in doubt over a foot related issue, just poultice the horse, you know, if you're gonna say I need this horse needs more time to rest, for example, put a poultice on, you've got nothing to lose by putting a poultice on on these horses. So as I said, I would always take orthogonal views, as it might seem fine on one view and not on the other ad, and so, so we always take orthogonal views of these. If the nail has been removed, the foreign body has been removed, then it's important to probe these wounds, you know, I would always block the foot first to do it, otherwise the horse is gonna resent you doing this.

And again, take orthogonal rods, obviously you've not got orthogonal rods here, but certainly the case on the left hand side, you would be less worried about that seems. Tracking just into the digital cushion, whereas the one on the right-hand side, you'd be much, much more worried about sort of the DDFT insertion and potentially even tracking to the coffin joint. And interestingly, this horse on the right did actually end up having a septic navicular bursa and, and coffin joint.

With foot penetrations, it can be useful to form contrast bursography, . Important to note, you know, I, I probably wouldn't be rushing to do this, you know, straight away in the field. I think that especially on, on many yards, it's very hard to do this, you know, it needs, it needs a reasonable amount of people, somebody to hold the legs, somebody to hold the plate, somebody to hold the horse, and also, you know, you are pushing a needle into a synovial compartment quite deep in with a spinal needle.

And so you've got to think about the sterility of the surrounding situation, but certainly this can be. Really, really useful if we've got a solar penetration. One of the most important structures we worry about is the navicular bursa.

And so if you are capable of putting a needle into the navicular bursa under X-ray guidance, that can be very useful. And as you can see here in this left-hand image, this horse, had a slower penetration actually of 4 weeks' duration. And so the, the sole attracted, it, it, it healed up.

But interestingly, when we, distended this navicular bursa with some contrast, you can see clearly that it is, it's tracking out of the bursa and down through the sole. Compared to the horse on the right hand side of the screen, where actually this horse again had a penetrating tract into the soul, and actually as you can see here, the navicular burst is intact, and so we'd be less worried about penetration of the more vital structures in this case. And if that's not possible, this is always another technique that you could use.

You can sort of inject contrast through the track of the solar, the solar defect, especially in a, in a very, very acute case where the sore defect is probably still a reasonable size, and actually, as you can see here in this image, the navicular bursa is sort of has been sort of filled with some fluid as well, so this obviously again would indicate that this bursa was, was, was also septic and had been penetrated. So moving on to fractures, you know, if, if, if you're in, if you're in doubt, you can always, you know, if the horse has some swelling in the sort of foetal region, something like that, you can treat these horses as a fracture. And also remember in the early phases of, of, of fractures, the clinical science can often underestimate, .

The actual extent of the injury, you know, you might only, for example, in this, condylar fracture on the left hand side, initially when you see this horse, it might only have a mild fetlock effusion and, and not much else, and actually, you know, it's actually got quite a severe fracture there, and so always, always consider that, and so, you know, I'd be getting my X-ray machine out quite quickly if I thought these horses had a fracture. Again, it goes back to remember the horse you're dealing with, you know, a thoroughbred on the track is much more likely to have a stress-related injury, whereas a cob in the field is most likely to have had probably a kick. And so fractures are going to be more common if you work with athletes, for especially thoroughbreds, and, and, you know, we also, so we want to be thinking about these, these sites here, proximal P1, metacarpal metatarsal condyles, and also the pelvis in these situations.

You know, for example, you've got a thoroughbred pulling up, laying on the gallops or, or on the track. Site goes to the skin and, and, and those horses that are representing lame in the field, and they're really prone to fracture of their kit, and it's important to know, know these sites. The horse has a lot of bony protuberances, and it's especially important on the sort of medial tibia and medial radius where quite often horses will present from the field with a quite an innocuous wound and some might even be actually quite comfortable by the time you see them.

But be very, very suspicious that there is literally in some of these areas only skin and then the bone under them and still be very suspicious of a fracture. If for example, you've got a wound on the medial radius or medial tibia, and sometimes I'll be getting my X-ray machine out quite early in these cases and actually also sometimes repeating x-rays further down the line as we'll discuss. So when we're clinically examine these fractures, you know, what we look, look for, you know, joint effusions, for example, might be an indication of haemorrhage, in a joint from that has an articular component to the fracture.

This would be common in the fetlock, for example, with condylar and proximal phalanx fractures. Quite often you'll get localised swelling or edoema over the fractures. And this is a good indicator of, you know, where potentially the injury is, but sometimes you can get diffuse edoema of the region due to the degree of inflammation.

But usually these horses will be focally painful, most focally painful over the site of, of injury. When we go back to the medial radius and tibia, percussion can be really useful in these cases, so I would just percuss with my knuckles and up and down the medial radius and medial tibia, and these can sometimes just detect small fractures in these areas if the horse, resents you doing this. Joint flexion can be, you know, if the, again, there's an articular component to these fractures, joint flexion can be very, very sore, and so that can be useful, especially in the initial phases when sometimes other clinical findings might be limited.

Again, hoof testers, this just comes back to sort of peel bone fractures, for example. Pel bone fractures usually will respond to the hoof testers. Wound location, so wound location can act as a guide of a guide to where to start looking, but actually they sometimes might have a fractured distance to where this wound is, and so don't be distracted just by the wound.

And for example, we need to think about limb positioning when these horses might have been kicked or might have sustained the injury because actually when the limb was flexed, the skin overlying the bone might be in a different location than it is when this horse is now potentially weight bearing or actually indeed now non-weight bearing because it's, it's, it's slime. We've got to be aware that there's many types of fractures that can present in the same way. For example, all three of these horses, have a dropped elbow, and.

There's not one diagnosis for these cases, you know, for example, differentials in these cases would be electronal fractures, humeral fractures, radial fractures, or some sort of radial nerve paralysis. So don't explain, don't, don't assume rather that these horses that have dropped elbows, for example. All have a fracture, they might not.

And so for example, actually all these horses here have different injuries. So for example, the horse on the left had an electronal fracture, the horse in the middle had a radial nerve paralysis. This is a slightly uncommon scenario.

This, this was actually post-general anaesthetic, but this is something you could find in a horse that had been recumbent for a time. And actually the horse on the right, interestingly, had just had a smack to the biceps tendon and so therefore was like this for a few hours, but then actually came, came right again. And so again, you know, just because you're seeing these clinical signs of a dropped elbow, you might assume this horse probably has an electronon fracture, it might not actually, so just don't rush to a diagnosis again just because you want to, you know, you're determined to find a fracture and so don't rush to this diagnosis, for example.

So, as I said, I don't think radiography is ever the wrong thing to do in these cases, radiograph these legs if you're at all suspicious. It might seem like a waste of time if you find nothing and you might regret that and kick yourself for radiographing it when say it actually turns out to have a foot abscess, but it had lots of patterns for it, but you know what, it puts your mind at rest and it also puts the owner's mind at rest, and so I don't think it's ever contraindicated and it's certainly going to guide the rest of your treatment because just because you think it might have one thing, it might not. Sometimes there's actually nothing visible in these initial radiographs, but if you're still very suspicious or at all suspicious, I would box rest these horses for 10 to 14 days and re-X-ray them.

Be really careful with overinterpretation and underinterpretation of these, of these radiographs. Overinterpretation is more common, and quite often what we'll see is horses that have. Acute non-mbra lameness with some swelling, people will radiograph these and.

Get fixated on say a nutrient foramen, for example, because they want this horse to have a fracture, they perceive this horse that's gonna have a fracture because it's so lame, so just think about where these, you know, potential fracture lines are. Ultrasonography, as I said, it can be very useful in the pelvis, for example, and. Centigraphy can sometimes be called upon as well, and this can sometimes be useful in cases that there's nothing on X-ray, nothing on ultrasound, but you're still very suspicious of a fracture, but you might want to wait sort of 5 to 10 days before you do these, so these horses are gonna be stabilised in this time.

So just some top tips in terms of X-raying these horses, be really careful about superimposition of structures. And so for example, this horse here, on the left-hand side, this is the, it was the initial radiographs and, and so, and this horse, there's suspicion of a, of a P2 fracture, sagittal fracture of P2, which is actually a very, very uncommon, fracture configuration. And this was, this was a polo pony, and so especially in a polo pony, very uncommon fracture configuration.

And actually it turned out when we took a slightly different angle X-ray that this is actually just the frog and sulcus and some cracks in the heels, and so be really, really careful about where you're packing and try and pack out the frog and, you know, also think about the location. If it's an unusual fracture type or type location, then actually it probably isn't a fracture, and so think about what else could be going on in these cases, and if you are still concerned about that region, try and maybe get some different views, for example. And so actually this horse, in this case, for example, actually had a central tarsal bone fracture, and so this is where it's important to sort of not rush into the diagnosis of thinking every non-weight bearing horse has a, has an obvious fracture in the first X-ray you take.

So be careful with superimposition of gas artefacts. I kind of mentioned this earlier, but again it goes back to the, if the fracture, if it looks like there's a radiolucent line in an abnormal location, then it's probably not a fracture. And so seek different views or send these to somebody and get a second opinion on them.

For example, here in the distal tibia, there's this radiolucent line, which actually is a would be a very uncommon location to get a fracture, and actually I'm sure if we took some different views of this hawk, then we would find that that was actually gas in the subcutaneous tissues. But this can be confusing sometimes, for example, you can be presented the case with an open wound, and exposed bone, and it's very hard to tell if these horses have a fractured leg, for example, they might do, but sometimes it's very hard because there's so much gas and surrounding these tissues. Be careful of neutral framing want to know, know where these are, but definitely been caught out before and sometimes it can't even look sclerotic, but these aren't fractures.

And as I said, take multiple views of these limbs, for example, here this, this actually horse had a humeral head fracture. On the left hand radiograph, we didn't really suspect anything to start with, we could in hindsight, obviously, and actually on the oblique radiograph you can see it has a fracture of its humeral head, so always take multiple views if you're concerned, always take at least 4 orthogonal views if you can. This again comes down to take multiple views, so this, this this horse actually had a pedo bone sequestrum, that was removed 14 days previous and it came back in non-weight bearing lane.

And on the initial X-rays, there was, you know, a suspicion of, of something going on with that in the highlighted circle, but nothing obvious. But then when we actually took a DP X-ray, we can see this horse actually had a type 3 pedal bone fracture through the, previous surgery site, and so this horse was actually euthanized. So again, you know, taking multiple views of these is, is always important.

This is a good case of why to reradiograph the limb. As you can see, the radiograph of the right metatarsus, on the left hand side of the screen was initially taken and this horse was acutely lame, and in hindsight you can probably pick out the fracture lines that we can see on the right hand side, but initially we didn't, but we did rest this horse for 2, for sort of, well, 18 days and then re-X-ray actually you could see. Fracture here of this cannon bone, and so there's no harm in resting these horses for 2 weeks.

And sometimes you might get pressure from the owner, that these horses are actually much more comfortable, they want to turn them out, it's ridiculous, you've not found a fracture, but you need to stick to your guns in these cases and, and, and if you're suspicious of a fracture, re-X-ray them in 2 weeks after some box rest or even some cross tying in some, some, some, some cases. Again, this is an interesting case. This is 14 on the left, the initial presentation, then the right 14 days after.

Fracture line's more obvious, and this actually horse was much more comfortable, it was sound at walk. The owner wanted to turn out, didn't understand why it had to stay in the, in the box. But you know, this is a really important time for this horse to be rested in a box, otherwise we could get propagation of this fracture.

Oxygen can be useful to determine concurrent soft tissue injury, for example, in this fetlock region here with an apical femoid fracture, you can see that the suspensr ligament is also concurrently damaged, and so this can help guide prognosis in some cases. Pelvic ultrasound's really good, you know, for especially, you know, if, if we're dealing with a racehorse population, it's quite a common injury to find, and this is really good, you know, using a, a, a convex ultrasound scanner to scan down the pelvis as can be seen on the sort of right-hand side. Usually scanning down the ileal wing in 3 planes in transverse and longitudinal, and then scanning along the ileal shaft down towards the hip can be really useful, and as you can see in this horse here, it's quite obvious when these horses have fractures, the with a, with an ileal wing fracture here.

Important not to forget the tubersi in horses. Obviously, you know, not really a stress related injury, but it's certainly a horse that's potentially been kicked here or or has sat down or fallen or something like that on, onto its its rear end. And sometimes these horses can have tuberici fractures, and so actually it's really, really useful in this, this is an easy area to ultrasound as well, and it's really good to compare left and right, and that goes for the whole pelvis, you know, there's two sides, it's uncommon for them to fracture both sides, and so actually, comparing and contrasting both sides is, is always useful.

So moving on to tendons and ligaments, and we see two main types of issues with these tendons and ligaments, you know, strains and lacerations, and also, but we can't forget, you know, that sometimes these horses do get tears into intrathecal structures such as the digital flexor tendon sheath. Most of these cases are easy to palpate with swelling, swelling and pain and palpation, but sometimes you will get sort of diffuse swelling of the limb which can make palpation hard. Obviously it's much more easy if you've got a lacerated tendon and as it is in the picture.

And the best diagnosis in these cases of strains, for example, is ultrasound. If there's diffuse swelling, sometimes again this might be similar to the fractures, this might be another one to potentially leave for 7 to 14 days with a bandage on to get rid of the diffuse swelling. Which will make the palpation easier at the time of scanning, and also the scan might be more representative of the actual injury, as sometimes in these cases, what we can find is that the injury propagates further from the initial scan which might happen at the time of injury than it does at 14 days.

So even if you scan these initially, we want to scan them 14 days later after they've had a bandage and some rest and some, some cold hosing, some cryotherapy. It's important to divide the legs into zones when you're scanning and not just rush to diagnosis, save some images and move on, because actually you're gonna be wanting to recheck these animals further down the line and so we can either use the zones, there's, you know, from zone 1 down 2 to 3, or we can use distance from the accessory carpal, which is what I would use, quite commonly, and you obviously measure these, from the accessory carp bone or from the sort of the tarsus, for example, in the hind limb, and these can be useful as a landmark, but whatever you use as a landmark, have it noted on the ultrasound machine so that if you're not scanning it next, somebody else can. Interpret the images.

Really, you know, preparation of the limbs is really important, sometimes you find thoroughbreds, all you need to do is put some spirit on them, but quite often, you know, thorough clipping and some, you know, cleaning of the leg and actually sort of standoff can be really important as well. And the sort of things we're gonna be looking for in these strains is obviously enlargement of the tendon or ligament, fibre alignment, you know, you know, is a disruption to that, and also, you know, everyone talks about core lesions. And so this is kind of the sort of thing we're looking for, you know, this horse obviously has a core lesion, and an enlarged, superficial digital flexor tendon, .

We need to look at, you know, there's also gonna be disruptions of the, of the margination, so sometimes, you know, important to look at these on oblique images, sometimes there can be sort of marginal tears, especially within the digital flexor tendon sheath, for example. And non-weight bearing colour Doppler can also be useful as well to assess the, inflammation within the tendon or ligament. There's obviously an increased Doppler signal is going to indicate that there's some more inflammation there.

So lacerations of the flex tendons, they can cause horses to stand with the leg in abnormal positions, as can be seen in this diagram here. So with STFT lacerations, the fetlock joint is will be hyperextended relative to the normal limb when that limb's loaded. But actually when, when, when that horse is just standing normally, there might be no difference to the contralateral limb, but it's actually only when the other limb's lifted up that you notice that that is, there's some sinking of that fetlock.

If the SDFT and DDFT are lacerated, in addition to those signs just described, the toe might be raised off the ground, and if the suspensory ligament is completely transected transected in addition to those tendons, there's gonna be complete loss of support to that fetlock joint, and so it's gonna be hyperextended and actually the fetlock's gonna contact the ground, and that's actually the case in that, that first image we saw there during the stance phase. And so, you know, this horse is gonna be very, very distressed and this comes back to sort of your initial examination again, you know, getting these horses sedated and analgesic quickly. These are just some examples of how you can get lacerations without a wound that this horse had, so it's important to scan all structures, you know, for example, if you think you see a laceration or a wound somewhere and you scan next to it, and, and, and you say, great, I've got my answer, always scan a bit more distally, especially these flexor tendons, for example, as again this comes back to sort of wound location and where the limb was at the time of injury, especially with a, with a laceration.

Cos sometimes other things, you know, will be missed. And again, you know, for example, in this horse here has, it's not, it's not very easy to see, but it had a DDFT laceration, as you can see on the right hand, the left hand side of the image, and actually if we looked further up the sheath has actually got a, a laceration of its SDFT as well, and so don't get drawn in just because you've seen something for the first time. Don't get drawn in to think that's the actual diagnosis cos there actually might be multiple things going on that are going to, you know, determine the prognosis.

This here is is another one, another case in SDFT laceration, and there is some gas in the surrounding tissues, and this isn't too bad, but sometimes if you've got a wound associated with these lesions, it can be really, really hard to scan because there's so much gas disrupting your image. And so quite often in these cases, we'll get an initial assessment of what's going on, wipe the leg, and then actually re-scan these horses at a later date, when the gas is all, dissipated. So wounds and may be a very common cause again of acute lameness, and so.

Just it's worth noting that these horses might be very, very lame, and they might not involve the vital structure. Some horses with just severe lacerations can be painful just due to acute wound pain. And it's very important in these cases to know your anatomy.

Some wounds will be of no concern, some will be of moderate concern, and some will be of major concern over synovial involvement, or if it's close to a bone, for example, as we showed that picture earlier, you know, you might be worried about a fracture. But again, we've got to think about it in the same as sort of fractures and artefacts and the fractures, you know, does the wound fit the level of lameness? If not, there might be another injury, for example, you know, for example, a horse might have a large wound somewhere, for example, in the cannon bone, but it's got a small puncture into its tarsiccrural joint, for example, and so have a real good look at these horses.

It's important to clip, clean, and explore the wound with sterile gloves, but be reme remember these horses can be really unpredictable, especially when they're painful. And so in some cases, I, you know, I, I've, I've even, you know, put local anaesthetic into these wounds before even cleaning them, just so the you can examine these horses, and actually get some, get some stuff done without, you know. Being detrimental to your safety and also sometimes the owners.

Anatomy is obviously gonna be especially important when you've got synovial involvement, . And so when you've got synovial involvement or when you think there's a fracture involved, you need to know where these synovial structures are. And also, you know, don't be, don't be fooled.

And for example, if you think you've got a deep wound over a synoid wheel structure that's sound, it doesn't rule out sepsis, you know, for example, if these horses are leaking synovial fluid out, they might not be acutely lame to start with, as actually it's only when that joint then or the wound closes up, that the distention of the joint makes these horses lame. And again, a wound might be distant from a fracture site or where the joint is actually septic. And we want to determine what's going on in these cases and so we can plan and prognosticate for the owner, and we want to know, you know, obviously are these vital structures are affected, so how are we gonna do this, so we're gonna do this by, you know, further, further investigations.

So, as I said, the location of the wound's very important, so these, each of these three cases is slightly different, you know, and one would raise slightly different levels of concern. So, you know, the one on the left, for example, over the cannon bone, I would be really not worried at all. I don't think about any synovial structures in this case, we, we do seem to just have a wound that's got some exposed bone.

But this horse could be very painful because obviously the bone's exposed and they might have, had some trauma to this. The horse in the middle, obviously this is right over the front of the hawk, it's important to remember the difference between different areas of the leg, and the hawk has a lot of soft tissues over it, so whilst I'd be worried about this hawk having a, you know, infected joint, I'd be less worried than I would over the fetlock, which obviously is covered by minimal soft tissues as, as is the case in the right, where a wound here is very highly likely, to involve the synovial structures. Interestingly, don't be fooled again by, by location, you know, by the location of the wound palpably, you might think this is, you know, gonna be near the tarscrual joint, but actually when we x-rayed this horse, it showed that actually the wound location was nearer the distal tarsal joints and so again, thinking about sepsis of these joints as compared to the tarscrual joint.

This case actually turned out to not have any communication with the sino wheel structures, and as I mentioned, you've got to remember, you know, there's a lot of soft tissue coverage over the haw, but don't be fooled again thinking cos this horse is sound, it's and it's over the hock, it's not a sino wheel sepsis, because also, you know, as I said, sinal wheel fluid can leak out and make these horses comfortable. Don't underestimate the size of the wounds, for example, this horse here, who had fractured splint bones, I'd be less worried about sepsis obviously in these locations, but, these limbs can be really diffusely swollen and you can't work out if there is a joint swollen or what's affected, X-rays can be really, really useful, and you know, these wounds might seem. Quite insignificant, but you know, blunt trauma can cause, some fractures of, of, of bones sunder and, you know, whilst these bones are only the splint bones and they're, you know, it's not an urgent case that needs treatment.

This horse was still very, very lame, and so you wanna, you know, for sure rule out fractures of, of any other underlying structures or any soft tissues as well. Radio graphs are good, it's saying they're septic, it it it's as if you see gas in the synovial structure, for example, on the left hand side here where you can see gas in the digital flexor tendon sheath, you can be pretty sure that's an infected structure, but just because we've not got gas in there doesn't mean it's not septic, so it's not a, it's not a fail-safe method of diagnosing septic joints and structures. Metallic probe can sometimes be useful in these wounds, to see how close they are actually to the synovial cavity, and I would quite commonly actually use .

Probes under ultrasound guidance as well to see sort of where the where the wound is and where it tracks to in relation to the synovial structures. Ultrasound's really useful again, you know, sometimes we can see gas in the joints, for example, this carpuss here had some gas and also you can see in the right hand image there's some soft tissue accumulation within the joint, and so again these would raise suspicion of the potentially a syal sepsis. The image on the right here can show how gas can really track quite distant from the wounds, so that actually this is interestingly the, the case earlier with the small wounds over the cannon bone with the fractured splint bones, gas actually tracked all the way down to the fetlock joint and so we actually did take a sample from this fetlock joint just because we were concerned about the proximity of the gas to the, to the joint.

And so very useful ultrasound in these cases, but sometimes it can preclude your assessment of the soft tissues. Synovicentesis can be performed and it's probably the most useful thing to do when you're determining if a horse has sepsis. We want to sort of put some, you know, get a sample from these joints initially, look at that fluid macroscopically, and then importantly what we want to do after this is distend the joints to see if there are if there's communication as we can see here on the left hand side, this horse with bilateral carpal wounds, the Antebrachichoocarpal joint is not affected or not not been penetrated and the joint sample looks macroscopically normal, whereas on the right hand side we saw there the fluid exiting the wound when it was distended, but here you can see that antebrachocarpal joint's under a lot of a lot of pressure and so probably unlikely to be a problem.

Really, you know, important with synovial structures again about knowing your anatomy is knowing where to tap these wounds, you know, a distant site from the wound is always important. Be wary of synovial tight fluid leaking from these wounds, as some may just be normally exudate. Be careful what you're tapping through, obviously you know you wouldn't want to tap through these structures here where there's really, you know, significant cellulitis and and infection of the skin, and so other diagnostics might be needed to try and rule in or out of sepsis.

Wounds is hard one to see, but this is on the medial side of the carcass, again we can put contrast in here just to make sure that there's no communication with the wound and sado wheel structures. And when to suspect sepsis, you know, total nuclear cell count over 20, neutrophils over 90 would be important. But there's no hard and fast rule, you know, it's a very, subjective, some, not subjective sometimes sometimes, but sometimes it's very varied, and actually you need to interpret these findings with the clinical findings of the horse as well.

Ser mammo IA can sometimes be useful, but I find it less useful. We can interpret the synovial fluid, but unfortunately synoid wheel fluid won't, increase unless it's been 6 hours post injury, so initially that might not be increased, the SAE in synovial fluid. But blood can be a good indicator of cynoidal sepsis, but also it will be increased with traumatic wounds as well, blood SEA, so again, not, not a fail-safe method of diagnosing sepsis.

Cellulitis, that's a great pretender, usually these horses are very lame, but they do ease with walking and look out for engorgement of the femoral blood vessel, especially in the hind limb. You're gonna get general, generalised pitting edoema, peratarsal cellulitis, but that can be very painful, and so these horses, you know, they can be really difficult cases even though they might seem like a cell, simple cellulitis. And if these horses aren't improving to standard treatment initially, then look for underlying issues, for example, the horse on the right here was treated for cellulitis for some time and actually had a septic digital flexor tendon teeth, and so these can present in varied ways, marked inflammation can cause a cellulitis of the, of, of the leg.

But quite often you have no idea of what's going on with these cases, and so. In these cases, what would I do? I'd probably block the foot because obviously that's the most common reason for non-weight bearing names in a lot of horses.

Confine them, and I'll use them, obviously put poultice on. Often we take survey radiographs of these common locations. Say for example, you had a racehorse, I would take some survey radiographs of common locations.

But often, you know, we might need nucleigraphy in these cases, in which case I'd be waiting 5 to 10 days before I did this. So now we need to decide what to do with these cases, and euthanasia is, is, is something that's always potentially indicated in these, cases, and, and the BV guidelines is something that's quite commonly followed in, in these cases, and it's important to note that these service as good guidance from insurance and mortality claims, but actually it doesn't necessarily mean that these horses, that there's no treatment options for them. So the scenarios you could be faced with are definite grounds for, you know, immediate euthanasia.

Ideally it's still good to get a second opinion with these cases. Suspected grounds for immediate euthanasia, again, I would definitely get a second opinion for these, or they might need to be transported for further investigations. If there's no grounds for immediate euthanasia, the owner then needs to contact the insurance company, potentially to discuss treatments, etc.

Definitely again get a second opinion from a colleague. If the animal requires urgent treatment to save its life, we need to be letting the insurance company know or the owner does. But the owner may request euthanasia, and it's important to note if they do do this, we need to get them to sign a consent form to say that they have requested euthanasia as you don't want this to come back and bite you in the long term.

To satisfy mortality claim, and then. It must, the horse must, have, sustained an injury or manifest an illness or disease that is so severe that it wants immediate destruction to relieve an incurable and excessive pain, and there's no other treatments, of option available to the horse at that time. Now that's quite a bold statement, and sometimes it's hard to make that decision yourself.

And so sometimes if you can't immediately decide that, then I would definitely, you know, provide effective first aid treatment. They contact the insurance company and failing that, arrange a second opinion from another vet, you know, these horses, you don't want to be euthanizing these horses unnecessarily, and also you don't want there to be blowback on you from the owner, but also we do need to decide, you know, determine these horses' welfare in these situations. So there are a few common, a few, few situations that require immediate euthanasia, and remember the horses in front of you, for example, common things are common, you know, a humeral fracture, for example, is a very uncommon source of lameness, and so, you know, it's unlikely that a horse you're presented with is gonna see this.

But it's useful to know these beaver guidelines just in case, you know, there is any discussion around whether these horses should be euthanized or not. There's, as to say, there's very few that require immediate, destruction. And to be honest with you, I would often always, seek a second opinion in these cases as it can be tricky.

So when to refer immediately, if we've got a suspected fracture. If it's opening or stable, some fractures might not need referring immediately, if we've got a septic salar structure or severe and penetrating wounds. Always important to speak to the hospital if you're gonna refer these, because it might be that the horse doesn't need referred, for example, if it's got a non-displaced fractured proximal limb, it might just need cross tied and actually transport might not be indicated.

We also probably want to stabilise these horses before they get to the hospital, and again, it's good to just phone the hospital and ask what stabilisation they'd recommend. Give the horse a detailed, give sorry, the hospital a detailed history from the horse and your clinical findings, you can really expedite the situation when this horse arrives in the hospital. Send any photos or imaging or any sort of joint taps are done, send them with the horse because sometimes you don't want these to be repeated and unnecessarily, you know, possibly earning more money or impact the horse's welfare.

Always good to give these horses the NSAIDs, but as I said, I would always check with the referral centre first if you're in doubt. So now finally we'll just touch on some coapitation, so the aims of coaptation are to stabilise the limb in an anatomically normal position. You want these horses to bear weight without excessive damage to the fracture ends or or soft tissue, and the aims are to reduce pain and anxiety, neutralise the distracting forces of the limb, restore the the limb control to the horse, provide counterpressure on these fracture sites, immobilise the adjacent joints, and importantly protect the soft tissues.

Gotta be really careful about distal limb support and proximal fractures is sometimes we can create a pendulum. For example, with radial fractures, as we've seen in this, diagram here, you know, if we, for example, had a horse with a dropped elbow that we thought, oh well that's got an electron fracture, and for example, electronron fractures might not need coaptation, you might put a dorsal splint on and you might just put a bandage on, which again wouldn't be indicated, then you could be, you know, at risk of, Causing a pendulum effect on a radial fracture that you've missed, for example, and so don't be putting on bandages, without knowing the accurate diagnosis, for example, a radial fracture, you'd need a lateral splint and potentially a cranial splint to prevent a pendulum effect. And so, as I said, you know, don't be co-opting these legs unless you know exactly what's going on with them, and sometimes you can make them worse.

And definitely seek advice in these cases, if you're ever concerned about what sort of method of coaptation, you know, Robert Jones bandages by himself, for example, are sometimes quite a poor form of stabilisation. So types of co amputation, so Robert Jones bandage, so you know, that's usually 10 to 15 layers of cotton wool, and the diameter of the limb you want to end up with is 3 times that of the limb. But these are really, really, you know, poor resisting bending forces, and so sometimes actually what's better is a modified Robert Jones, less layers, and actually combine these with splints and lateral and medial splints, especially in the distal limb are more common.

Slints can be made of PVC pipe, wood, or more more recently actually aluminium, which are very, very useful. And these can resist the movement and distracting forces of the fracture. We want them to be perpendicular to the ground, and they need to be applied tightly with either inelastic tape, so like duct tape, or the elastic tape needs to be pulled to the limit, so that there's no stretching so that these splints can't move.

And as I said, apply these in orthogonal planes over the bandage, and these can be a really, really good way of, of co-opting these, these especially distal limb fractures and sometimes the proximal limb fractures, as I said before, with the radius, for example, a sort of lateral and and cranial splint can be really, really useful. Bandage casts, they're really well tolerated and they're really easy to apply, it'd be one of my go to's, especially in distal limb fractures. And you can enclose the, the hoof if you need to, but sometimes you can do them right to the ground, and they provide good support.

Casts, they can be tricky to put on in the initial phase, so you want to prevent the movement during their application because that can sometimes affect the way the horse is bearing weight on the limb and could cause issues with you know, with making the fracture worse. And we sometimes want to make a window over the fracture sites as well, but these definitely do provide the best counterpressure and best immobilisation of the limbs. Kimdy splint, this is the sort of flexion splint.

It's good for some injuries related to the suspensory apparatus, some people rush to put this, this on every case they think is a distal limb fracture, but certainly, you know, it's not indicated in some cases, it provides no medial lateral support. And the compression boot again is really good as it provides good medialateral support and so this is good for distal limb fractures and also, you know, it's good because it's really lucent. But what we don't want to see is is situations like this with a commuted P1 fracture that has been sent in with a small bandage like this.

Again, just phone the centre that you're gonna send it to potentially if you're concerned. Limbs can be divided into four distinct regions and, and this book here is really, really good, if you're ever worried about what's crap legs with, you know, this has a really detailed breakdown summary of what to put on different types of fractures is that it can be important to to the horse in terms of prognosis going forward. The important things to know about coapputation is, you know, one, the Kinley splint is not appropriate for all.

It provides no medial lateral stability and so it is only useful in certain situations, and again, if you're in doubt, either consult that book or the referral centre you're sending to. We need to be aware of creating a pendulum, especially in proximal limb fractures, for example, a Robert Jones bandage with a lateral, radial fracture just with a Robert Jones bandage is gonna create a massive pendulum and you're gonna potentially propagate that fracture and also make it open. In these cases we need a lateral splint from the elbow to the distal, you know, a lateral splint from the from the shoulder to the ground and a cranial splint from the, distal metacarpus, to the, to the elbow.

Electron fractures, for example, they might not need coaptation if the triceps is intact, but if they do need coaptation, all they need is a, is a small cast and just to keep the, the knee extended, . And if you're in doubt, again, just ask, ask, ask for help on these cases, as some cases won't need co-optation. So in summary, you know, these cases can be challenging and stressful, but a good clinical examination is always essential.

And remember, only euthanasia cases you're absolutely sure and always seek a second opinion if you're in doubt. As I say, if you're in doubt, stabilise these patients and seek a second opinion. There's never as big a rush as you think with some of these cases, and sometimes actually a bit of time can, can provide further clarity on, on what's going on.

Thank you.