Risk factors associated with cast complications in horses: 398 cases (19972006)

John C. Janicek, DVM, MS, DACVS; Scott R. McClure, DVM, PhD, DACVS; Timothy B. Lescun, BVSc, MS, DACVS; Stefan Witte, Dr med vet, DACVS; Loren Schultz, DVM, MS, DACVPM; Carly R. Whittal, DVM; Canaan Whiteld-Cargile, DVM

ObjectiveTo determine the frequency of and risk factors for complications associated with casts in horses. DesignMulticenter retrospective case series. Animals398 horses with a half-limb or full-limb cast treated at 1 of 4 hospitals. ProceduresData collected from medical records included age, breed, sex, injury, limb affected, time from injury to hospital admission, surgical procedure performed, type of cast (bandage cast [BC; berglass tape applied over a bandage] or traditional cast [TC; berglass tape applied over polyurethane resin-impregnated foam]), limb position in cast (exed, neutral, or extended), and complications. Risk factors for cast complications were identied via multiple logistic regression. ResultsCast complications were detected in 197 of 398 (49%) horses (18/53 [34%] horses with a BC and 179/345 [52%] horses with a TC). Of the 197 horses with complications, 152 (77%) had clinical signs of complications prior to cast removal; the most common clinical signs were increased lameness severity and visibly detectable soft tissue damage. Cast sores were the most common complication (179/398 [45%] horses). Casts broke for 20 (5%) horses. Three (0.8%) horses developed a bone fracture attributable to casting. Median time to detection of complications was 12 days and 8 days for horses with TCs and BCs, respectively. Complications developed in 71%, 48%, and 47% of horses with the casted limb in a exed, neutral, and extended position, respectively. For horses with TCs, hospital, limb position in the cast, and sex were signicant risk factors for development of cast complications. Conclusions and Clinical RelevanceResults indicated that 49% of horses with a cast developed cast complications. (J Am Vet Med Assoc 2013;242:9398)

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asts are a common form of external coaptation used to immobilize limbs of horses that have sustained injuries resulting in skeletal instability; casts are also used to provide stability after internal xation or for improved healing of soft tissue wounds of horses.1,2 Types of casts for horses are typically described by the proximal extent of the cast on a limb. Distal limb casts encompass the foot and interphalangeal joints, and the proximal extent of such casts is just distal to the metacarpophalangeal or metatarsophalangeal (ie, fetlock) joint.3,4 Such casts are commonly used to immobilize injuries of the distal aspects of limbs, such as lacerations of the soft tissues at the palmar or plantar aspects of limbs just proximal to the coronary band (ie, heel
From the Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, MO 65211 (Janicek, Schultz, Whittal); the Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, IA 50011 (McClure); the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Purdue University, West Lafayette, IN 47907 (Lescun); and the Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA 30602 (Witte, Whiteld-Cargile). Dr. Janiceks present address is Weems and Stephens Equine Hospital, 5960 Hospital Rd, Aubrey, TX 76227. The authors thank Dr. Stephanie Caston for preparation of the gure. Address correspondence to Dr. McClure (mcclures@iastate.edu). JAVMA, Vol 242, No. 1, January 1, 2013

ABBREVIATIONS
BC TC Bandage cast Traditional cast

bulb lacerations). The most commonly applied type of cast is a half-limb cast, which extends from the foot to the proximal aspect of the metacarpal or metatarsal region.5 Full-limb casts extend from the foot to the level of the proximal aspect of the radius or tibia. Half-limb and full-limb casts are typically applied for the treatment of fractures, tendon and ligament disruptions, joint luxations, and wounds. Tube casts are most commonly applied for the treatment of young horses with angular limb deformities of the forelimbs.5 Such casts extend from the distal metacarpal region (just proximal to the fetlock joint) to the level of the proximal aspect of the radius or tibia. The foot is not enclosed in such a cast so that soft tissues are loaded during weight bearing; this is intended to avoid development of soft tissue laxity. Tube casts do not bear any of the load on a limb during weight bearing. Full-limb and half-limb casts typically consist of polyurethane resinimpregnated berglass tape strips placed over a thin layer of padding. Excessive padding placed under a cast may deform and slip, resulting in
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excessive movement of the limb within the cast and an uneven distribution of pressure on the skin of a horse. Placement of too little padding under a cast results in rubbing or increased pressure of rigid cast material on the skin.1 Use of polyurethane resinimpregnated foam as cast padding decreases cast complications.6 In some horses for which less rigid stability is needed (typically those for which the cast is applied to provide soft tissue protection), BCs are used.7 Such casts consist of berglass cast tape placed over a compressed bandage. Casts placed over a thin layer of polyurethane padding and those placed over bandages are applied for different purposes; however, potential complications of both types of cast may be similar. Casts can be applied in various congurations for the treatment of different conditions or to minimize complications in horses. The amount of cast material placed at the toe or heel of a foot (for functional toe extension or heel support, respectively) and choice of limb position (ie, amount of limb exion or extension) in a cast may depend on the condition being treated (eg, placement of a fetlock joint in exion for the treatment of exor tendon lacerations) or surgeon preference. Bandaging of the contralateral limb and elevation of the contralateral foot may balance weight bearing between limbs and prevent development of contralateral limb laminitis or angular limb deformities.8 Casts may be used alone or with other devices to provide limb stability. Complications attributable to casts can develop, such as soft tissue wounds caused by motion or pressure of a cast (ie, cast sores).1,2,7,9 Such cast sores often heal via second-intention healing with few long-term consequences; however, lameness may develop.7 Less common cast complications include breakage of the cast, osteopenia, development of fractures attributable to osteopenia, fracture of bones at the proximal aspect of the cast, and damage to tendons or avulsion of ligaments from bone.1015 Full-limb casts on hind limbs can cause peroneus tertius rupture and coxofemoral joint luxation.5 Joints immobilized in a cast may have reduced range of motion after removal of the cast because of joint capsule brosis; thinning of articular cartilage attributable to extracellular matrix degradation may also develop.11,13,14 The objective of the study reported here was to determine the frequency of complications associated with half-limb and fulllimb casts in horses and to identify risk factors for such complications. Materials and Methods Selection of casesMedical records (including radiographic images) of horses that underwent cast application at the University of Missouri, Iowa State University, Purdue University, and the University of Georgia veterinary medical teaching hospitals from January 1997 through December 2006 were reviewed. Horses treated with transxation pin casts, distal limb casts (such as those for treatment of heel bulb lacerations), tube casts, or plaster of Paris casts and those
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for which casts were removed immediately after recovery from anesthesia were excluded from the study. All horses included in the study had casts that included the hoof and were either a TC consisting of a stockinette, resin-impregnated foam, and berglass casting tape or a BC consisting of berglass casting tape placed over a compressed cotton bandage. During the years included in the present study, personnel at all 4 hospitals used a similar standard TC application technique that included placement of a stockinette, orthopedic felt at the proximal aspect of the cast, resin-impregnated foam padding,a and then berglass casting tape. Various amounts and types of bandage materials were used for BCs; however, such casts were considered similar enough to be included in 1 group of the present study. ProceduresInformation collected from medical records and radiographic images included the hospital where horses were treated, signalment (ie, age, breed, and sex), injury or medical problem at the time of hospital admission, type of tissue involved in the injury (bone vs soft tissue), limb affected, emergency care prior to referral, time from injury to hospital admission, surgical procedure performed, length of cast (full-limb vs halflimb), type of cast (TC vs BC), limb position in the cast (exed [ie, exion of fetlock and proximal and distal interphalangeal joints], extended [ie, extension of fetlock and proximal and distal interphalangeal joints], or neutral [ie, dorsal cortices of phalangeal and third metacarpal or metatarsal bones aligned]; Figure 1), and outcome (cast complication vs no cast complication). Data were recorded in a spreadsheetb for further analysis. For horses with a cast complication, information collected from medical records included the type of complication, time in the cast before clinical signs attributable to the complication were detected, type of clinical signs attributable to the complication, and treatments for the cast complication. The site of cast breakage was recorded for casts that broke. The number and locations of cast sores were recorded. For horses with cast sores that were identied prior to cast removal, the rst cast sore identied prior

Figure 1Illustration depicting exed (ie, exion of metacarpophalangeal or metatarsophalangeal [ie, fetlock] and proximal and distal interphalangeal joints; A), neutral (ie, alignment of the dorsal cortices of the phalangeal and third metacarpal or metatarsal bones; B), and extended (ie, extension of fetlock and proximal and distal interphalangeal joints; C) positioning of the distal aspect of a limb of a horse in a cast. (Copyright by Dr. Stephanie Caston. Printed with permission.) JAVMA, Vol 242, No. 1, January 1, 2013

to cast removal was identied as the primary cast sore. For horses with cast sores that were not identied until the rst cast change or after cast removal, the largest cast sore was identied as the primary cast sore. Placement of a horse in a cast for a problem was considered 1 casting episode, even if the cast was changed during treatment. The time to development of cast complications was calculated as the time from cast placement to the time that cast complications were detected. All horses were maintained in the same type of cast during each casting episode. Some cast complications (including osteopenia, decreased range of joint motion, and cartilage thinning) were not evaluated in the present study. Horses that were euthanized during the study period because of a poor prognosis, implant failure, laminitis, gastrointestinal tract disease, or nancial constraints prior to cast removal were not included in the study. Statistical analysisDescriptive statistical data were reported as median (range). A statistical analysis programc was used to determine a generalized linear mixed modeld via a logit link function with a binomial response to data by use of only those variables (hospital, sex, and limb position in the cast) that were signicant in the logistic regression model. In this model, the estimated values and P values for those 3 variables (hospital, sex, and limb position in the cast) were comparable with those determined via logistic regression. Cast type was a confounding variable in the model; when horses where classied by cast type (TC vs BC), hospital, sex, and limb position in the cast remained signicant for horses with a TC but not for those with a BC. Few horses were included in the BC group; therefore, statistical analyses for this group had low power. Therefore, data for horses with a BC were removed and analyses were repeated for horses with a TC via those same statistical procedures. Interactions between variables could not be determined because of the low number of horses included in some categories. Values of P 0.05 were considered signicant. Results Three hundred ninety-eight horses met the criteria for inclusion in the study. One hundred eighty-three horses were treated at Purdue University, 114 horses

were treated at the University of Missouri, 81 horses were treated at Iowa State University, and 20 horses were treated at the University of Georgia. The median age of horses was 8 years (range, 1 day to 26 years); the median weight of horses was 431 kg (948 lb; range, 23 to 818 kg [51 to 1,800 lb]). Horses included 70 sexually intact males, 134 castrated males (ie, geldings), and 193 sexually intact females; sex was not recorded for 1 horse. Breeds included Quarter Horse (n = 164), Paint (59), Thoroughbred (38), Arabian (27), Standardbred (16), Tennessee Walking Horse (10), warmblood (8), Appaloosa (7), Miniature (7), pony (7), Saddlebred (7), draft (6), mule (6), Morgan (4), Missouri Fox Trotting Horse (3), and Peruvian Paso (2); breed was not recorded for 27 horses. A cast was applied to a forelimb of 152 horses (71 left and 81 right forelimbs) and a hind limb of 246 horses (120 left and 126 right hind limbs). The median time from injury to hospital admission was 1 day (range, 30 minutes to 365 days). Prior to referral, treatments included application of a bandage (n = 88 horses), splint (36), temporary cast for transportation (19), or therapeutic shoe (3). Information regarding application of stabilization devices prior to hospital admission was unknown for 127 horses, and no such devices were applied for 125 horses. A cast was applied for the treatment of injuries involving hard tissues (bones, joints, or physes) for 185 horses. Procedures performed prior to application of casts for these horses included internal xation (n = 122 horses) and closed fracture reduction (25). A cast was applied for the treatment of soft tissue injuries (involving tendons, ligaments, tendon sheaths, bursas, or other lacerations or wounds) for 213 horses. One hundred fty-four horses underwent wound debridement, and 47 horses underwent tendon sheath lavage and debridement prior to cast application. Bandage casts were applied for 53 horses, and TCs were applied for 345 horses. The distal aspect of the limb was in a exed, neutral, and extended position in the cast for 28, 98, and 248 horses, respectively (Table 1). Limb position in the cast was not recorded for 24 horses. A cast complication was detected for 197 of 398 (49%) horses, and no cast complications were detected for 201 (51%) horses (Table 1). One hundred seventynine of the 345 (52%) horses with a TC had a compli-

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Table 1 Frequency of cast complications in 398 horses undergoing application of TCs (n = 345) or BCs* (53) for treatment of various injuries. TC Half-limb (n = 278) Limb position Flexed Neutral Extended Unknown Total Forelimb 9/12 (75%) 14/32 (44%) 39/68 (57%) 3/9 (33%) 65/121 (54%) Hind limb 10/15 (67%) 22/44 (50%) 40/93 (43%) 2/5 (40%) 74/157 (47%) Full-limb (n = 67) Forelimb Hind limb 0 1/1 (100%) 2/6 (33%) 5/10 (50%) 4/7 (57%) 21/34 (62%) 1/2 (50%) 6/7 (86%) 7/15 (47%) 33/52 (63%) Half-limb (n = 24) Forelimb 0 2/3 (67%) 1/6 (17%) 0 3/9 (33%) Hind limb 0 0/1 (0%) 4/14 (29%) 0 4/15 (27%) BC Full-limb (n = 29) Forelimb 0 0 0/7 (0%) 0 0/7 (0%) Hind limb 0 2/2 (100%) 8/19 (42%) 1/1 (100%) 11/22 (50%) Total 20/28 (71%) 47/98 (48%) 117/248 (47%) 13/24 (54%) 197/398 (49%)

Data are number of horses with cast complications/total number of horses with a cast for each combination of variables (%). *Traditional casts consisted of a stockinette, resin-impregnated foam, and berglass casting tape and BCs consisted of berglass casting tape placed over a compressed cotton bandage. Limb position in the cast (exed [ie, exion of metacarpophalangeal or metatarsophalangeal {ie, fetlock} and proximal and distal interphalangeal joints], neutral [ie, alignment of the dorsal cortices of the phalangeal and third metacarpal or metatarsal bones], extended [ie, extension of fetlock and proximal and distal interphalangeal joints], or unknown [limb position in the cast was not reported]). n = No. of horses. JAVMA, Vol 242, No. 1, January 1, 2013 Scientic Reports 95

cation, and 18 of the 53 (34%) horses with a BC had a complication. Of the 345 horses with a TC, 278 had a half-limb cast (139 [50%] of which had a complication) and 67 had a full-limb cast (40 [60%] of which had a complication). Of the 53 horses with a BC, 24 had a half-limb cast (7 [29%] of which had a complication) and 29 had a full-limb cast (11 [38%] of which had a complication). Of the 197 horses with a cast complication, 152 (77%) had clinical signs of complications prior to cast removal. The most common clinical sign of cast complications was increased severity of lameness (n = 55 horses); other complications included visible cast sores (44), discharge or staining of the cast with exudate (ie, strikethrough; 16), soft tissue swelling proximal to the cast (12), palpably increased temperature of a portion of the limb under the cast (11), fracture (3), pyrexia (2), and intolerance to casting (1). Of the 3 (0.8%) horses with secondary fractures associated with casting, 1 horse (that had undergone arthrodesis of a proximal interphalangeal joint) with a half-limb TC on a forelimb fractured the proximal aspect of the third metacarpal bone 27 days after cast application, 1 horse (that had undergone surgical repair of a fractured third metatarsal bone) with a half-limb TC on a hind limb fractured the proximal aspect of the third metatarsal bone 7 days after cast application, and 1 horse (that had undergone surgical repair of a fractured calcaneus) with a full-limb BC on a hind limb fractured the proximal aspect of the tibia 14 days after cast application. The most common cast complication was cast sores, which developed in 179 of 398 (45%) horses; 165 of 345 (48%) horses with a TC and 14 of 53 (26%) horses with a BC developed cast sores. Thirty of 52 (58%) horses with a full-limb TC on a hind limb had cast sores, which was the conguration with the highest percentage of cast sores; the cast sore for 17 (57%) of those horses was at the level of the proximal aspect of the tibia. For horses with half-limb TCs, the location with the highest frequency of cast sores was at the most proximal aspect of the cast (62/278 [22%] horses). Overall, the location with the highest frequency of cast sores in horses with any type of TC was the palmar or plantar aspect of the fetlock region (44/345 [13%] horses). Cast sores of a heel bulb were detected in 14 (4%) horses of the present study. Cast sores were detected less frequently at other locations, including the palmar or plantar aspect of the metacarpal or metatarsal region (n = 5 horses), lateral or medial malleolus of the tibia (4), calcaneus (4), middle of the plantar aspect of the metatarsal region (2), coronary band (2), and proximal aspect of the radius, accessory carpal bone, palmar aspect of the region from the coronary band to the proximal aspect of the rst phalangeal bone (ie, pastern), and dorsal aspect of the carpal joint region (1 each). The median time to detection of complications for horses with any type of cast was 12 days (range, 1 to 97 days). The median time to detection of complications for horses with a TC was 12 days (range, 1 to 97 days). For horses with half-limb TCs, median time to detection of complications was 12.5 days (range, 2 to 97 days; 12 days [range, 2 to 44 days] for forelimbs and 13 days [range, 2 to 97 days] for hind limbs]). For horses with full-limb TCs, median time to detection of
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complications was 10.5 days (range, 1 to 27 days; 13.5 days [range, 8 to 20 days] for forelimbs and 9.5 days [range, 1 to 27 days] for hind limbs). The median time to detection of complications for horses with a BC was 8 days (range, 1 to 28 days). For horses with half-limb BCs, median time to detection of complications was 14 days (range, 4 to 25 days; 14 days [range, 8 to 20 days] for forelimbs and 10.5 days [range, 4 to 25 days] for hind limbs). For horses with full-limb BCs, median time to detection of complications was 8 days (range, 1 to 28 days); all such horses had casts on hind limbs. Casts of 20 of 398 (5%) horses broke (17/345 [5%] horses with a TC and 3/53 [6%] horses with a BC). Full-limb TCs on hind limbs broke more frequently (8/52 [15%] horses) than did any other cast conguration. Casts broke in the fetlock joint region for 4 of 278 (1%) horses with a half-limb TC. The bottom of the cast (ie, portion of the cast distal to the foot) broke for 3 half-limb TCs on a forelimb, 1 full-limb TC on a hind limb, and 1 half-limb BC on a hind limb. The location of the cast breakage was not recorded for 4 horses of the present study. The median time to breakage for any cast conguration was 4.5 days (range, 0 to 36 days). The median time to breakage for TCs was 4 days (range, 0 to 36 days). For half-limb TCs, median time to breakage was 7 days (range, 3 to 36 days; 12 days [range, 4 to 36 days] for forelimbs and 5.5 days [range, 3 to 11 days] for hind limbs). For full-limb TCs, median time to breakage was 3 days (range, 0 to 28 days; 1 day for the 1 horse with a forelimb cast of this type and 3 days [range, 0 to 28 days] for casts of this type on hind limbs). The median time to breakage of BCs was 5 days (range, 3 to 20 days). A cast broke for only 1 horse with a half-limb BC on a hind limb; time to cast breakage for this horse was 3 days. For full-limb BCs, median time to breakage was 12.5 days (range, 5 to 20 days); all casts of this type were on the hind limbs of horses. The median number of casts applied to limbs of each horse was 1 (range, 1 to 8 casts); the median number of casts for any cast conguration was 1, except for horses with full-limb TCs (median, 2 casts). Number of casts ranged from 1 to 8 for horses with half-limb TCs on forelimbs, 1 to 7 for horses with half-limb TCs on hind limbs, 1 to 5 for horses with full-limb TCs on forelimbs, 1 to 4 for horses with full-limb TCs on hind limbs, 1 to 2 for horses with half-limb BCs on hind limbs, 1 to 2 for horses with full-limb BCs on forelimbs, and 1 to 3 for horses with full-limb BCs on hind limbs; all horses with a half-limb BC on a forelimb had 1 cast. Overall, median time to removal or change of the rst cast was 15 days (range, 0 to 75 days). Median time to removal or change of the rst cast was 15 days (range, 0 to 75 days) for horses with TCs and 11 days (range, 1 to 32 days) for horses with BCs. For horses with half-limb TCs, median time to removal or change of the rst cast was 15 days (range, 1 to 75 days; 16 days [range, 1 to 56 days] for forelimbs and 15 days [range, 2 to 75 days] for hind limbs). For horses with full-limb TCs, median time to removal or change of the rst cast was 15 days (range, 0 to 50 days; 9 days [range, 1 to 24 days] for forelimbs and 16 days [range, 0 to 50 days] for hind limbs). For horses with half-limb BCs, median time to removal or change of the rst cast
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was 10 days (range, 1 to 26 days; 14 days [range, 3 to 20 days] for forelimbs and 9 days [range, 1 to 26 days] for hind limbs). For horses with full-limb BCs, median time to removal or change of the rst cast was 11 days (range, 1 to 32 days; 10 days [range, 1 to 21 days] for forelimbs and 11 days [range, 5 to 32 days] for hind limbs). Multiple casts were applied for 149 horses; 114 horses had 2 casts, 27 horses had 3 casts, 4 horses had 4 casts, 2 horses had 5 casts, 1 horse had 7 casts, and 1 horse had 8 casts. For TCs, hospital (P = 0.029), limb position in the cast (P = 0.008), and sex (P = 0.002) were identied as signicant risk factors for the development of cast complications. Horses treated at Purdue University had signicantly (P = 0.026; OR, 1.9) higher odds of developing cast complications versus horses treated at all other hospitals. Horses treated at Iowa State University had signicantly (P = 0.034; OR, 2.2) higher odds of developing cast complications versus horses treated at the University of Missouri. Horses treated at Purdue University had signicantly (P = 0.008; OR, 2.4) higher odds of developing cast complications versus horses treated at the University of Missouri. No other differences between hospitals were detected regarding odds of cast complications in horses. Horses that had the casted limb in a exed position had signicantly (P = 0.004; OR, 4.1) higher odds of developing cast complications versus horses with a casted limb in any other position. Horses with the casted limb in a exed position had signicantly higher odds of developing a cast complication than did horses with the casted limb in an extended (P = 0.003; OR, 4.5) or a neutral (P = 0.005; OR, 4.6) position. Geldings were signicantly (P < 0.001; OR, 2.7) more likely to develop cast complications versus sexually intact males and females combined. Geldings were signicantly more likely to develop cast complications than were sexually intact females (P = 0.006; OR, 2.1) or males (P = 0.002; OR, 3.1). Discussion Forty-nine percent of horses with a cast in the present study developed a complication. Clinical signs attributable to cast complications were detected prior to cast removal for 77% of horses with such complications. Cast sores were the most common complication, developing in 26% of horses with a BC and 57% of horses with a TC. In another study,9 57 of 70 (81%) horses with a half-limb cast developed cast sores, which was higher than the percentage of horses with a TC in the study reported here that developed a cast sore. In that other study,9 investigators prospectively examined horses for cast sores, including supercial sores. Those investigators may have been more likely to detect cast sores than were clinicians who evaluated horses with routine clinical problems in the study reported here. Another difference between this study and the other study9 was that investigators in that other study applied cotton padding on limbs, followed by a layer of plaster of Paris before applying berglass cast tape. Casts for horses of the study reported here included resin-impregnated foam padding, which decreases the development of cast sores.6
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Use of thermography may aid in the identication of cast sores prior to cast removal, which may decrease complications attributable to casts.9 The most common location of cast sores was the proximal aspects of casts and fetlock joint regions. Motion of tissues at the top of a cast is unavoidable, and sores commonly develop at such sites. Changes in fetlock joint angle during weight bearing can increase pressure on the palmar or plantar aspect of the fetlock joint region and cause sores in horses with a cast. Such fetlock joint motion can be exacerbated in horses with disrupted exor tendons or ligaments on the palmar or plantar aspect of a limb. Even after surgical repair, tendon or ligament tension can gradually decrease because of tearing of sutures through the tissue, which results in progressive extension of the fetlock joint.16,17 Such fetlock joint extension may be prevented via application of casts to limbs in a exed position. Results of the present study indicated that limb position was a signicant variable for the development of complications in horses with TCs. Complication rates were substantially higher (71%) for horses with limbs in a exed position in casts than they were horses with limbs in other positions in casts. Eighteen of the 28 (64%) horses for which limbs were casted in a exed position had injuries to the palmar or plantar supporting structures (ie, exor tendons and ligaments on the palmar or plantar aspect of a limb). Such horses may be predisposed to development of complications regardless of limb position in a cast because of limb instability caused by the initial injury. Cast sores also developed at other locations in horses of the present study. Some cast sores may have been attributable to inadvertent focal application of pressure by the clinician during cast application, focal swelling associated with the injury, or insufcient amount or uneven distribution of cast padding material. Only 3 of 398 (0.8%) horses in the present study developed a secondary fracture attributable to the cast. To our knowledge, no other studies have been conducted in which the incidence of such fractures was determined. In the present study, all casts were applied in accordance with current clinical recommendations; half-limb casts extended from the foot to the proximal aspect of the metacarpal or metatarsal region, and fulllimb casts extended from the foot to the level of the proximal aspect of the radius or tibia. Casts that end at the mid-diaphyseal region of a long bone increase the risks for development of secondary fractures and tendon and ligament injuries in horses.5 Casts of 5% of horses in the present study broke. The fetlock joint region and bottom of the cast were the most common sites of cast breakage. Damage to the bottom of a cast can be prevented via application of acrylic to that area. Casts are subjected to bending forces in the fetlock joint region; therefore, breakage of casts at that location may be expected. Cast breakage was most common for full-limb TCs on the hind limbs of horses (8/52 [15%] horses). Bending forces in the region of the tarsal joints may increase the risk of cast breakage at that location. Cast complications developed in horses during a short period. Median times to detection of complications
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were 12 days for TCs and 8 days for BCs. The reason for rapid development of BC complications was not known. Bandage casts may have been applied for horses that had wounds with severe soft tissue swelling. An increase in soft tissue swelling could have increased pressure on the skin; a decrease in swelling could have caused loosening of the BC. Bandage material in BCs might have moved or compressed after application, which may have caused a focal increase in pressure on soft tissues, lack of protection of soft tissues, or instability of the portion of the limb in the BC. Overall, horses with BCs had fewer complications than did horses with TCs; however, complications for horses with BCs were detected earlier after cast application than they were for horses with TCs. Overall, median time to removal or change of the rst cast was 15 days (range, 0 to 75 days); median time to removal or change of the rst cast was also 15 days for TCs. This period was shorter than expected. The reason for the short times to removal or change of the rst cast was not identied. This nding may be attributable to the early detection of complications (median time to detection of complications, 12 days). In the present study, the time to development of cast complications was dened as the time from application of the rst cast to detection of complications. Only 9 horses with cast complications developed those complications after the rst cast change; complications were detected for these horses during the period they wore the second cast. Results of the present study indicated that 34% of horses with BCs developed complications, compared with 52% of horses with TCs. This result was expected because BCs are heavily padded; however, our results did not suggest that BCs rather than TCs should be applied to horses. Bandage casts are typically applied for horses in which the amount of limb immobilization required is less than that attained with a TC and greater than that attained with a bandage.5 In the study reported here, BCs were less commonly applied to horses than were TCs and only 13% of horses had BCs. The majority (76%) of horses with BCs had casts for external coaptation of soft tissue injuries; such injuries were predominantly (87%) lacerations. Results of the present study indicated that the hospital where horses were treated was a signicant variable for risk of complications for horses with TCs. Variables regarding selection of cases could not be evaluated retrospectively. Horses with less severe injuries requiring less complicated care may have been treated at some of the hospitals in the present study. Some complications of horses that may have affected outcome were not evaluated in the present study. Horses were not evaluated for the detection of osteopenia, decreased range of motion of joints, or cartilage thinning; all of these complications can develop after immobilization of limbs with casts.1114 Contralateral limb support is typically provided for horses to decrease difference in foot height between limbs with casts and those without casts; this is intended to decrease complications.8 Elevation of the contralateral foot was not evaluated as a variable for risk of development of cast complications in the study reported here. Results of another study9 (conducted prospectively) that included 70 horses with casts indicated that
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increasing age, weight, limb swelling, time in a cast, and number of casts applied to a horse were signicant risk factors for development of cast complications. All of those variables were evaluated in the study reported here, but results indicated that none of them were signicant risk factors for the development of cast complications. The present study included horses treated at 4 hospitals by an unknown number of veterinarians; approximately 5.5 times as many horses were included in the study reported here as in the other study.9 Variations among data in the retrospective study reported here may have decreased the ability to detect risk factors for development of cast complications associated with 1 hospital or group of veterinarians.
a. b. c. d. Custom support foam, 3M Healthcare, Saint Paul, Minn. Excel, Microsoft Corp, Redmond, Wash. SAS, version 9.3, SAS Institute Inc, Cary, NC. PROC GLIMMIX without a RANDOM statement, SAS, version 9.3, SAS Institute Inc, Cary, NC.

References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Murray RC, DeBowes RM. Casting techniques. In: Nixon AJ, ed. Equine fracture repair. Philadelphia: WB Saunders Co, 1996;104113. Auer JA. Drains, bandages, and external coaptation. In: Auer JA, Stick JA, eds. Equine surgery. Philadelphia: WB Saunders Co, 2006;202218. Booth TM, Knottenbelt DC. Distal limb cases in equine wound management. Equine Vet Educ 1999;11:273280. Ketzner KM, Byron CR, Stewart M, et al. Wounds of the pastern and foot region managed with phalangeal casts: 50 cases in 49 horses (19952006). Aust Vet J 2009;87:363368. Booth TM, Dart AJ, Watkins JP Equine limb casts: classication . and indications. Compend Contin Educ Pract Vet 2003;25:701706. Bramlage LR, Embertson RM, Libbey CJ. Resin impregnated foam as a cast liner on the distal equine limb, in Proceedings. 37th Annu Meet Am Assoc Equine Pract 1991;481485. Booth TM, Dart AJ, Watkins JP Equine limb casts: materials . and methods. Compend Contin Educ Pract Vet 2003;25:708714. Stokes M, Hendrickson DA, Wittern C. Use of an elevated boot to reduce contralateral support limb complications secondary to cast application in the horse. Equine Pract 1998;20:1416. Levet T, Martens A, Devisscher L, et al. Distal limb cast sores in horses: risk factors and early detection using thermography. Equine Vet J 2009;41:1823. Richardson DW, Clark CC. Effects of short-term cast immobilization on equine articular cartilage. Am J Vet Res 1993;54:104113. Buckingham SH, Jeffcott LB. Osteopenic effects of forelimb immobilization in horses. Vet Rec 1991;128:370373. van Harreveld PD, Lillich JD, Kawcak CE, et al. Effects of immobilization followed by remobilization on mineral density, histomorphometric features, and formation of the bones of the metacarpophalageal joint in horses. Am J Vet Res 2002;63:276281. van Harreveld PD, Lillich JD, Kawcak CE, et al. Clinical evaluation of the effects of immobilization followed by remobilization and exercise on the metacarpophalangeal joint in horses. Am J Vet Res 2002;63:282288. Malone ED, Anderson BH, Turner TA. Proximal sesamoid bone fracture following cast removal in 2 horses. Equine Vet Educ 1997;9:185188. Trotter GW, Auer JA, Arden W, et al. Coxofemoral luxation in two foals wearing hindlimb casts. J Am Vet Med Assoc 1986;18:560561. Jann H, Blaik M, Emerson R, et al. Healing characteristics of deep digital exor tenorrhaphy within the digital sheath of horses. Vet Surg 2003;32:421430. Jann H, Good JK, Morgan SJ, et al. Healing of transected equine supercial digital exor tendons with and without tenorrhaphy. Vet Surg 1992;21:4045. JAVMA, Vol 242, No. 1, January 1, 2013

13.

14. 15. 16. 17.