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Discussion on Deep wound complicated by punctured tendon sheath
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Posted on Monday, Oct 15, 2001 - 1:13 pm:
Hi Dr O
As usual the Advisor has been a great source of information and comfort to me at a nervewracking time - I was wondering if you should have a sort of 999 accident page telling people in a panic which sections to look in as it took me a while to find the deep wound stuff under skin (obvious I know but not when you're in a panic).
My horse is currently at the specialist horse vet hospital after a bad wound sustained on a cross country ride. The question I want to ask you (probably unanswerable) is how much worse the problem is likely to be now that they know she also punctured a tendon sheath? Here's the background.
She got caught either on wire or on a thorn bush in a deep drain on the ride (another horse was trapped in the same drain for over an hour - we thought he was a goner but in fact had not broken anything, his leg was trapped and he is OK). The drain was full of stagnant boggy water and leaf mould. She ripped open an upside down U shaped wound approx 4 inches wide by 2 inches high, about 3 inches below the hock on the anterior surface of the right hind. The tendons were exposed. Bleeding was venous only, probably 2-3 pints in all.
She got first aid immediately but I'm afraid it wasn't clean. She got (in true hunting fashion) a stock made into a pad bunged in the wound and someone's not very clean tail bandage to hold it on.
We got her up to the vet hospital within a couple of hours but had to wait another hour for the vet to return from a call (because the chief vet was also on the cross country ride!). We hosed out the wound when we got there, dressed it cleanly while waiting for the vet. She wasn't lame at all after the accident (in fact I got back up on her before someone told me she was badly cut and to get down), but she started to stiffen up and get in pain when we got to the hospital.
The vet spent considerable time cleaning and flushing the wound, said there was no tendon damage, stitched it up very neatly (about 15 stitches). He said if it got infected they will put her under general anaesthetic, clean it again and put her in a cast. She is on industrial-strength quantities of antibiotics and anti-inflammatories.
Unfortunately today (48 hours later) they say she has punctured the tendon sheath which is causing gooey oily stuff to weep from the wound so the stitches will likely not hold but they want to leave them in as long as poss to help the healing. The chief vet says he thinks the wound will weep about 3 weeks and the mare will be out of action for 8 weeks but that they have a lot of successful experience with similar nasty wounds. They are flushing the wound with antibiotic and saline from one side to the other each day - personally if she does not get an infection I would consider it a miracle considering the crap that went into the wound.
So, are there any other consequences of the tendon sheath puncture other than the soggy stitches? And why might they put it in a cast? Surely that just makes it soggier and more likely to become pus-y although it keeps the wound still?
Otherwise, the mare is a bit downhearted and off her feed obviously but she's putting weight on the leg and happy to accept carrots etc - she walked across the box to get a carrot today - not completely dejected by any means. I think the swelling and heat are down a bit in the last 18 hours. I presume from reading your articles it will likely be the best part of a week before they know if they have to open it up again?
Also, and this is a question to all, not just Dr O, there are a couple of management things where I am not sure if I am just being fussy because I'm worried about her - I don't want to handle it wrong because I am very glad I was able to get her treated so quickly. I told them she eats course mix (you call it sweet feed) but they keep giving her a sort of general mix with lots of nuts in and she's not eating it properly - could be because she doesn't like nuts, could be because she feels bad. I also said they needed to give her loads of hay as she is hard to keep weight on when in a stable and she is tucked up from the charity ride and its consequences. The girl told me they normally feed hay on demand but I keep going up and finding she has none - I personally think it's really important that she eats well at this stage. How should I approach this do you think?
All the best, thank God for the Advisor!
Imogen
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Posted on Monday, Oct 15, 2001 - 6:40 pm:
You are right, the horse needs hay. I would ask the caretaker to give more hay or if she cared if I brought some of my own. Do not give alfalfa but a good mix hay--timothy and orchard is good.
If she ate the carrot, she would probably eat hay.
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Posted on Tuesday, Oct 16, 2001 - 6:38 am:
Imogen,
When you can't find it in the menus, always remember to do a search. It can quickly locate pages for you.
Imogen I really cannot say much not being able to examine the wound and there are some inconsistancies between your description and their treatment choices. I do agree with you, putting a infected tendon sheath under a cast is nonsense and it is what makes me think perhpas you are not completely understanding what is happening. I think they believe the sheath is not infected at this time, just leaking synovial fluid and they are hoping to keep it that way.
If the horse is suppose to have hay and you find she never has any I think you need to bring to someones attention who can do something about it.
DrO
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Posted on Tuesday, Oct 16, 2001 - 10:20 am:
Hi Dr O
I think I wasn't very clear in my explanation. You are correct, the tendon sheath is leaking synovial fluid. When I said the tendons were exposed I meant I could see the muscles, tendon and bone, not that the tendon sheath was ripped. The vet nurse says the leakage of synovial fluid is not quite so bad today.
I think the swelling is down but the heat is nearly worse than yesterday so I guess it probably is infected but I suppose some of the heat is just the trauma and bruising etc.
The horse is eating OK (not brilliantly) now, and she munched away at the carrots and apples I brought. There were also more DrOppings in the stable which I thought a good sign. I spoke to the vet nurse about the hay again, just asking was she eating the hay OK, within the hearing of the chief vet, pointing out the horse was on grass up to Saturday when the accident happened so I hope the message got through without anyone's back being put up.
I was quite cheered up until I was chatting to the lady who mucks out and she told me we should have hosed down for a lot longer on Saturday when we were waiting for the vet, and not stopped (we only did it for about 10 minutes). I asked her why did she not say anything at the time, she said it wasn't her place... so I guess there must have been muttering in the yard about it being infected now which made me very miserable as I feel it maybe could have been avoided.
I'm actually more depressed about this now than I was when it happened - I was up at 4 am this morning worrying about the mare but I suppose no news is good news until they tell me any different.
They did say that if they cast it they would first open it up under general anaesthetic and clean it all out again.
All the best, any more information or advice from anyone much appreciated.
Imogen
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Posted on Tuesday, Oct 16, 2001 - 12:11 pm:
Imogen, I'm so sorry...your post reminded me of my "post traumatic shock" to my horse's injury too. Miserable feeling, tons of 2nd guessing - all useless. The best thing now that I'm the other side of it was the actual research and application of common sense and good sound knowledge. You certainly sound like you have quite a store of that. It also sounds from your post that the wound was cleaned rather aggressively within a relatively short amount of time (6 hours or less?). Just for perspective on that: my horse's injury was caused by rusted old barb wire, he walked the mile plus down the mountain to his stable with no initial wound care, and no aggressive wound cleaning could be started (because of all the bleeding) until the vet arrived over 4 hours later - about 6 hours total time from time of injury! Aggressive maintenance kept infection and healing at bay and steady. I think you've gotten your horse to where this can be done for her. I had to keep mine at the stables and do the maintenance myself - but I heartily agree with you about what I term "busy feed"...my horse's world got very small, very fast...so keeping him occupied and happy was a priority and gave him an extra edge. I hope your horse has other contact from another equine - preferably one she enjoys as that also can help. I guess I'd summarize by saying: Take stock of the things she does have on her side (health, age, attitude, location, care, etc), try to maximize the things you can (improved care, bandaging, feed routine, distractions/activities), and let go of the rest as there are never easy answers. Keep us posted on her progress - we're all here for you! Dawn 
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Posted on Wednesday, Oct 17, 2001 - 3:36 am:
Thanks Dawn, I appreciate your message. There is a traditional square yard of boxes at this vet hospital and the mare has an injured foal in the box beside her so she is happy enough from the company point of view - she has a neighbour and can see other horses across the yard.
I will know she is feeling a lot better when she puts her head out of the box though - mostly she is lurking against the back wall at the moment. That might be partly because they have anti-weave grates on the doors which she isn't used to, and because the weather has turned very autumnal.
How is your horse now?
All the best
Imogen
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Posted on Wednesday, Oct 17, 2001 - 5:16 am:
Hello Imogen,
Concerning how to determine when it becomes infected. Horses are generally much lamer when there is infection present. I usually use the first 24 hours to determine how much lameness is due to trauma in a soft tissue injury and the becomes the zero point and then as increase of lameness after that I attribute to infection until proved otherwise.
DrO
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Posted on Wednesday, Oct 17, 2001 - 11:03 am:
Imogen, my horse has had 10 months of complete rest due to the injury. Last weekend was the first time I got up on his back - it was wonderful! I kept wanting to panic real bad for the first 6 - 8 weeks of his injury due to the different phases; but I tempered myself by realizing that he never progressed to a worse state than the initial couple of days. Each and every day he was the same, or ever so slightly improved so I just followed his progress with my own inclinations and stayed positive in my outlook. You can find his "posts" under a search for "DDF". Glad to hear your mare has company near by, hopefully you can see her daily and make the visits fun and soft - I developed quite a relationship with my horse due to the ongoing visits and hands-on care. Keep good watch on her in the next week - she'll let you know how she's doing in little things only you'll be able to recognize. My thoughts are with you both - Dawn.
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Posted on Wednesday, Oct 17, 2001 - 11:50 am:
Hi,Imogen ~ I agree with Dawn. You did the best you knew how to do with your horse. Second guessing and beating up on yourself - while we ALL do it - just make you more miserable than you need to be. And, the opinion of someone who wasn't even there is not real relevant anyway You hang in there, make sure your horse has lots of hay and keep us posted. We're here for you
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Posted on Wednesday, Oct 17, 2001 - 1:41 pm:
Thanks all, the mare is much more cheerful and herself today - I caught her looking out of the box which made me feel hopeful - and the chief vet says that the wound is better too. He says it's "on the cards" that the stitches will pull after 10-12 days because of the fluid/sogginess but that the wound surfaces will be much closer together than they would have been otherwise at least which I presume (though he didn't spell it out) means a shorter recovery time and less proud flesh.
They say she is a great patient and stands for the wound to be flushed and dressed without any sedative which must make life less of a hassle for everyone.
I think the heat is down a bit too and I don't see any increase in lameness (thanks for that tip Dr O!) so fingers crossed. But she is still not eating the hard feed too well. I reckon if I was there I could get her to eat it, but as she is not looking run down, my pal at the local livery yard says, given that she's just standing in a box, as long as she's getting through the hay then it doesn't matter too much.
By the way, going back to the first message in this thread, of course you will all have worked out that I meant a 911 page (which is 999 in Britain and Ireland).
Dawn, you must be so pleased to have that horse back at last! Well done to you.
All the best
Imogen
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Posted on Friday, Oct 26, 2001 - 10:56 am:
Update - half the stitches pulled today (day 14 since the accident). The wound's now open about somewhere around 1 cm to half an inch but the stitches at the top of the upside down U shape are holding OK so far and the wound looks healthy although unfortunately my pathetic bandaging attempt slipped whenever she did what she did to bust the stitches, and now there is cotton wool adhering to some of the wound surfaces. The vet says he's going to come and look at it tomorrow.
She was let out of the vet hospital on day 11 as she was doing so well. Something I found a bit frustrating was I asked to be shown how to bandage her and came up at the time they suggested but all the vet did was talk me through it instead of actually showing me which would have been much more helpful.
They have been using a nappy over the wound, then cotton wool, then elastoplast bandage. It's the nappy bit I think we must be doing wrong because we can't seem to get it to stay in place - it's always DrOpped down when we come to change the bandage which must be making the wound soggier than it would be if it were in place.
Typical - the insurance company has now informed me that the mare was only covered for "life threatening" surgery. The bill is getting on for astronomical, not that I grudge the money to the mare, just that I love the way insurance companies always omit to tell you some little detail about what they are trying to sell you!
All the best
Imogen
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Posted on Saturday, Oct 27, 2001 - 9:08 am:
How is the lameness Imogen? I would not be too concerned about the wound opening, it will heal fine open and more safely than if it is closed particularly if close to a synovial sheath.
DrO
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Posted on Tuesday, Oct 30, 2001 - 2:26 am:
Hi Dr O
She does not seem to be lame at all but she's on box rest so it's a little hard to be really sure.
Because of the shape of the wound they seem to want to keep her quiet and not busting the rest of the stitches so I haven't taken her out and walked her around the yard at all. They said they will actually take out the rest of the stitches this week anyway - they left them in longer than usual due to the wound shape and the wetness from the synovial fluid leak. They also said that is likely to start drying up this week and it does seem to be reducing over the past couple of days.
There is a little swelling in the fetlock that comes and goes and a little heat that comes and goes but it's minor and I reckon that is just all the bandaging - we are trying very hard to keep it loose on the tendons (it also has to have a loop up over the hock to prevent it DrOpping down) but effectively covered to prevent crap getting in. She is finished on antibiotics now but still on bute so I suppose the next few days will tell now.
She also has appalling dandruff on her neck which she never ever had before (people normally comment on her beautiful glossy coat) - the vet said it's probably a bit of stress on her liver or reaction to all the antibiotics and bute or to the surgical spirit for all the injections, so I hope it improves as the drugs reduce! I'm glad there's no mirror in the stable as I am sure the patient would be mightily depressed if she could see herself!
Fingers crossed... the support of this board has been much appreciated. In the end I suppose we all just do whatever seems like the best common sense in trying to care for our animals but it's very reassuring to get other people's advice and knowledge.
All the best
Imogen
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Posted on Monday, Nov 19, 2001 - 1:40 pm:
Dear Dr O
Just a little update and query. The vet in charge of my mare is Italian, and obviously very competent but quite hard to communicate with - not that he doesn't speak English well, but that when you ask him something you get a dissertation on something else and only realise afterwards he didn't answer what you asked... nice chap, though and has done a great job on the wound.
I have asked him twice now if I can put the mare out when the wound heals over and I am not sure if he is understanding what I'm asking. First time I thought he told me she would have to stay in all winter but apparently not. Second time he said she could go out but I think he thought I meant, leave the stable at all as in go out for part of the day but come into the stable at night.
I meant, put her out in a nice cold wet Irish field with her pals 24 hours a day. It will be muddy when it rains but the field has a good grass cover which should last until after Christmas when they'll go onto hay.
The wound, which is now 5 weeks old, has dried up very well over the last week or so after a wobble last week when there was a little bit of heat and swelling in the leg so she went back on Vetrasul antibiotic for 5 days. There is about 1.5 inches diameter circle which the skin still has to grow over. He says he doesn't think there will be too much proud flesh. I think it will take another 2-3 weeks to heal over.
Obviously, I don't want to put her out too soon, or for her to get kicked, or get some sort of mud rash on the new scar, but it's taking me 2 hours a day to drive up to the yard where she is and muck her out and do the bandage, so obviously once she can come home and go out in the field, I want her to do that. I can start riding her in about 3 weeks they think but as she can't do anything (jumping etc.) there doesn't seem much point other than checking there's no residual lameness when ridden.
What am I looking for apart from the skin growing over that will tell me when I can return her to her pals? Do you have a view on whether it's a good idea to sedate them when first turned out to stop them galloping around and causing themselves further damage? I do not fancy bandaging her when in the field for fear the bandage might come loose if it rains and gets soggy.
Thanks for any tips you can give!
All the best
Imogen
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Posted on Tuesday, Nov 20, 2001 - 5:36 am:
Sound and the wound well granulated in I would say are the minimum. Yes, I sometimes sedate horses lightly when I first turn them back out: usually 1 to 2 mls ace in the muscle 15 minutes before turn out.
DrO
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Posted on Wednesday, Dec 5, 2001 - 3:13 pm:
Hi Dr O
I'm a bit down because there doesn't seem to be any progress with this wound healing over. There is still a good half inch to go and it will be eight weeks this Saturday since it happened.
Do you have any kind of rule of thumb about how long it takes for the skin to grow back? The wound's below and in front of the hock.
We're still dressing the wound every day (which is costing me a *fortune* in elastoplast bandage and melolin dressings and nappies and cotton wool) and she's still on box rest. There's not a lot coming out of the wound now - just a splodge on the melolin dressing most days.
The mare seems happy enough (thought there's a bit of a sign infection may be back, mild heat around the wound but no swelling) - it's me that's getting depressed!
All the best
Imogen
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Posted on Wednesday, Dec 5, 2001 - 3:37 pm:
Hello Imogen
I don't have a lot of practical advice, but I wanted to say 'chin up'; my Friend's appy (the 17.3hh one I posted about re: anaemia) had a similar wound over the summer and she had the same ordeal you are going through just now.
Reuben also learnt to stand quietly whilst his dressing was changed - they seem to know when you're trying to help! His wound healed up completely (small scar) and he is 'as sound as a pound' now.
Maybe healing is like other growth - slows over the winter period - faster in warmer weather? I don't know of any studies done, but it seems like a fair assumption to me.
As long as there IS progress, no matter how small, at least you're moving in the right direction. I too have been prey to the insurance 'loophole' - but it's like you say, you pay up and shut up, because you love your horse!
My thoughts are with you - keep going!
Heidi
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Posted on Wednesday, Dec 5, 2001 - 11:06 pm:
Hi Imogen, great news on the wound treatment - sounds like you've actually followed through beautifully on it. The skin is very slow to heal - at least you don't have the super-slow healing tendon that I have as well (still not knitted after 1 year). The bandaging you're still doing sounds extensive, and as I remember - I was starting to simplify the process at this point and the only remaining concern was the proud flesh as the wound had completely covered over with granulation tissue protecting it from any infection. I went to non-stick telfa pads over the wound (gooped up with NFZ to help them stay in place) and soft cotton wrap that stuck back onto itself (rather than hard-to-remove vet wrap) and then covered it with the quilt wraps for padding and standing wraps to hold it all in place. It actually only took about 10 minutes - maybe a little more to undress, quick scrub and redress the area. I don't blame you for your care, just trying to assure you that it seems all is moving along well. You'd have had some pretty noticeable "flags" if something was going the wrong direction with her. My vet showed me the new skin growth when I had the wound undressed and had me compare the amount I'd seen - with how long the wound had been present. He said to expect that rate of growth throughout the healing process. Not knowing how large the wound was initially on your horse would make it difficult to tell how much you have left to go. But so long as you are not using caustic substances to prevent infection that wind up inhibiting skin growth and the edge of the skin is looking pink and healthy, you are well on your way. I'm sure Dr. O will point you in the right direction! Keep up the good work! Dawn (best healing is done by best care and patience)
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Posted on Thursday, Dec 6, 2001 - 6:34 am:
Hello Imogen,
1/2 inch to go sounds like progress to me! It should take about......2 perhaps 3 more weeks to heal up. 0.5 to 1mm a day is about right. If you think infection is starting up you need to have the vet take a look but without swelling and pain, the finding of increase heat may be just incidental.
DrO
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Posted on Friday, Dec 7, 2001 - 12:58 pm:
Thanks all, I just needed to be told it would get there eventually!
Actually it does look marginally better today so if I'm lucky, she might be back in action by Christmas.
I'll continue a watching brief on if the vet needs to come back. The heat is mild and not increasing so I've left it so far as I know they will DrOp by to check her anyway if they have a call near the yard (I feel I'm entitled to one freebie visit just on a volume discount basis at this stage!).
But any sign of swelling or resting the leg/lameness/pain and I'll get them straight away! At this stage I've invested so much time and money it would be madness not to call them.
All the best
Imogen
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Posted on Thursday, Jan 3, 2002 - 1:27 pm:
I hope this will be nearly the final message in this thread! I'm pleased to report I rode that mare today, she's back in action after 12 weeks off. She will have a "feelable" but not particularly visible scar. I'm amazed it healed so well given the severity of the wound. Just goes to show Dr O is right as usual!
One thing I would have done differently. My vet told me to turn her out in a small paddock with a quiet horse to start with (she'd been on box rest for 11 weeks). I knew this was a bad idea but you pay your money so you might as well follow the advice.
She went ballistic, demolished the wire around the paddock and had the quiet pony wired to the moon within 5 minutes. Fortunately no-one got injured though she did rip the wound open a couple of centimetres, and they eventually calmed down after about 45 minutes, but I don't know that a large field isn't better because then at least they gallop straight lines, not in small circles when they've been in for ages... I think a small paddock actually increases the chance of injury. Interested to know if any of the rest of you have a view on this.
The second day we left her out most of the day and when she was good and cold and hungry and tired, boxed her back to her own big field and herd. No fuss, had a nice roll, back to normal!
All the best
Imogen
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Posted on Thursday, Jan 3, 2002 - 2:59 pm:
Imogen, how exiciting for you! I'm very glad at the progressively positive response you're getting on this and hope it continues. My tendon-injured horse has moved progressively from a box stall (3 months), to a 20 x 20' round pen (4 months), to a 20' x 60' paddock run (5 months & counting) - and is only just now being allowed direct association time with a "quiet horse". He goes ballastic during that time for short intervals! He has not been allowed the direct company of the other horse until this time. Previously, however, he still acted up on each of the increased areas, but nothing like his behavior when: "oh my goodness, one of my own kind, eww...I get to touch him too!" seems to bring out in him. Just some perspective. Dawn
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Posted on Friday, Jan 4, 2002 - 7:06 am:
Congrats Imogen and thanks for the frequent updates, I think they are great learning experiences for the members.
DrO
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Posted on Friday, Jan 4, 2002 - 9:43 pm:
Great news Imogen! And ditto to what Dr.O said
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