Orthopaedic injuries on the racecourse

Racecourse veterinary surgeons are employed by individual racecourses to provide veterinary care on race-day. To join these teams, you must have been qualified for at least 5 years, work predominantly in equine practice and have attended the Association of Racecourse Veterinary Surgeon (ARVS) casualty management seminar. A shadowing scheme has been introduced for new vets, organised through the British Horseracing Authority (BHA). The ARVS Manual (2015) covers the full requirements of a racecourse veterinary surgeon and should be studied before joining a racecourse team.

Essential skills for the role are good communication, attentiveness and knowledge of how to manage common equine injuries, including support techniques for the transport of injured horses. Decision making on the course needs to be succinct as scenarios often play out in the public eye (Wright, 2017a). Euthanasia is often required on humane grounds, or is carried out electively. If working at point-to-point events, the basic principles will be the same, but the available facilities and support personnel will vary and individual connections will need to reimburse you for treatments. The majority of incidents seen by racecourse veterinary surgeons involve musculoskeletal injuries (Williams et al, 2001). This article summarises the management of these injuries, although this article is limited in its scope in terms of covering this topic comprehensively, so the reader is encouraged to use the references for more details, or attend the annual ARVS casualty management seminar.

Equipment

All racecourse veterinary surgeons should be equipped to provide first aid and emergency treatment on the course and in the stables, as well as to transport these horses to their home yard or a referral centre. This requires and reasonable volume of bandages, casting materials, splints, medicines and surgical kit.

Suggested equipment is listed in the ARVS manual and Box 1.

Box 1.Equipment to carry on the racecourseEquipment that is recommended to have on raceday. This should be added to as required:

• Sedation (alpha-2 agonists and butorphanol), syringes and needles. It is useful to have sedation pre-loaded.
• Somulose, 50ml syringes, 16G and 14G catheters, superglue.
• Anaesthetic drugs (ketamine and diazepam)
• Sound moderated firearm (if used). Keep the bullets separately in your pocket and use a trigger lock.
• A non-steroidal anti-inflammatory drug and dexamethasone
• Small supply of bandages, dressings, scissors
• Stethoscope
• Cotton wool (small amount to use as ear plugs for horses).

In larger casualty bags/in the car/in the vet box:

• Head collar and lead rope, bridle, two lunge lines, 10m strong rope.
• Bandaging, splinting and casting materials suitable for wound dressings, Robert Jones bandaging, splinting and standing casts, flexion splint, gutter splints, wooden foot wedges, wooden splints of various lengths, a hand saw.
• Racing Foundation aluminium splints (Figure 1), compression boots and flexion splints
• Oxygen.

Communication

Discussion of injuries with the trainer, owner and other connections will be required. The racecourse veterinary surgeon must not discuss veterinary treatment with members of the public. All horses requiring treatment need a triplicate BHA Veterinary Consultation Form completing, with a copy for the trainer, the racecourse veterinary surgeon and the BHA veterinary officer. For significant injuries, it is always worth communicating with the home vet directly, as these horses will need follow-up treatment. Decisions about veterinary care at the racecourse can also be made collaboratively if necessary.

Support techniques

Various techniques to support fractures and soft tissue injuries, to provide anxiety relief and to enable transport without exacerbating the injury are mentioned and illustrated here, and it is worth becoming familiar with these.

Recently, a collaborative project between the Racecourse Association, ARVS and the National Trainers Federation has gained Racing Foundation funding to provide all UK racecourses with kits containing compression boots, flexion splints and adjustable modular aluminium splints (Figure 1). These are designed to be fitted to the injured horse at the racecourse and provide support during travel to an appropriate referral centre before being returned to the racecourse. These kits significantly improve vets’ ability to provide ideal limb support to a variety of musculoskeletal injuries effectively and easily. Radiographs can be taken through the compression boot.

Managing the injured horse

Most injuries occur during racing and will be attended to during or immediately after the race. The racecourse will have a plan of deployment for the racecourse veterinary surgeon, which will need to be discussed with the senior veterinary surgeon and may be described in the standing orders. Racecourse veterinary surgeons will need to be familiar with the plan, the course and its access routes. It also helps to become familiar and friendly with your fellow racecourse veterinary surgeons, the veterinary officer, the BHA equine welfare officers, the horse ambulance and the recovery (dead horse) vehicle drivers, grounds staff, the clerk of the course, and any other staff allocated to assist with the care of horses. Rehearsals of scenarios involving injured horses should be carried out at the start of each season. This can be achieved by gathering the entire team early at the first meeting of the year.

Observing the horses at all times during racing is important, as information about potential injuries can be gleaned from how a horse pulls up or how it has fallen.

When a horse is injured, the jockey will dismount if the horse has not fallen already. When attending, communicate this via radio to your senior veterinary surgeon. Observe the horse as it pulls up and as you approach, noting any lameness in the limbs if evident. This may avoid having to ask the jockey to trot up a lame horse if the injured limb is not obvious. Note the saddle cloth number for identification. If a serious injury is obvious when approaching the horse, the horse ambulance and/or recovery vehicle should asked to attend via radio. Ground staff should erect screens and bypass fences (if required) without being instructed. However, the racecourse veterinary surgeon is in charge of the situation, and should direct other members of the team, as appropriate, to ensure this happens.

Ensure the horse is suitably restrained. Fit a head collar over the bridle if necessary and attach a lead rope or lunge line. It is advisable to sedate all horses with serious injuries to relieve distress and provide analgesia. Large doses, usually double the normal dose of α-2 agonist and butorphanol, will be required in these scenarios. Fit a catheter for all horses with serious injuries, especially if there is any suspected cardiovascular compromise (such as bleeding out from an upper limb fracture). If the field is likely to pass again, cotton wool or ear plugs can be inserted to assist in calming the injured horse.

The injury should be assessed and, if it does not compromise the horse's welfare, the horse should be transported to the stables by the horse ambulance, where further treatment and discussion with the horse's connections can take place. If indicated, apply support bandages, compression boots or splints. Instruct the horse ambulance driver whether the horse needs to be unloaded from the front or back of the ambulance. Generally, forelimb injuries are better backed off and hind limb injuries are better walked off forwards (Furst, 2019).

If a horse is uninjured and sound, it may be walked back to the stables or unsaddling area, although if there is any doubt then the horse is best transported in the horse ambulance.

If an injury is so severe that the horse's welfare would be compromised by transport (such as open fractures of long bones) and the horse thus requires euthanasia on humane grounds, then euthanasia can be carried out on course. Racecourse veterinary surgeons need to be familiar with and comfortable performing euthanasia on horses in an excited or sympathetic state. This must carried out via injection on public racecourses (unless severe extenuating circumstances mean the use of firearms is necessary), but firearms are still used in point-to-points. If firearms are used, the racecourse veterinary surgeon must be licensed and competent in their use.

Recumbent horse management will be discussed with regard to spinal fractures. Horses with some fractures and soft tissue injuries may have poor prospects for future racing or have limited economic value, but may not meet British Equine Veterinary Association (BEVA) guidelines for euthanasia under mortality insurance policies, as the guidelines pertain to humane destruction on welfare grounds. Sometimes horses do not meet these criteria, but are euthanised because of economic or temperament reasons, for example, a horse with a severe tendon injury that is treatable but has no chance of being a racehorse again, may not be suitable to rehabilitate for another role. In this situation, elective euthanasia at the racecourse may be requested in order to avoid transporting an injured horse for euthanasia at home. The racecourse veterinary surgeon must be familiar with the BEVA guidelines for humane destruction and explain the insurance implications if the horse is insured for mortality. Some racecourses will pay for carcass disposal costs for elective euthanasia, but this needs to be clarified and the costs explained if they do not. An elective euthanasia consent form should be signed (ARVS, 2015).

Soft tissue wounds

Lacerations to the limbs are common (Williams et al, 2001) and are usually contaminated. Hosing with tap water is useful to lavage the wounds (Caston, 2012; Freeman et al, 2020). Management is as for wounds seen in normal practice, but with diligent examination, palpation and digital exploration to help ascertain whether synovial structures or tendons are involved. If there is any doubt about this, the horse should be referred to a hospital for further investigation.

It is not expected that investigations such as joint sampling are carried out on course, but this is at the discretion of the racecourse veterinary surgeon. If a synovial sample is taken it should be put in EDTA and plain tubes for cytology and culture, with intrasynovial and systemic antibiotics administered if communication with the wound looks likely. Wounds to the palmar or plantar distal limb (knee or hock down) often result from being struck into by another horse and thus commonly involve tendons or tendon sheaths (Figure 2a) (Williams et al, 2001). This may be distant to the wound site owing to the relative movement of the skin and tendons during galloping. Lameness is not a good guide to the seriousness of a soft tissue wound at the racecourse. Wounds should only be sutured or stapled on course if they are clean or well debrided, and do not involve synovial structures or fractures (Caston, 2012; Bladon, 2013). Wounds that are deemed suitable for repair on course may be stapled (Figure 2b) or sutured, depending on the wound type, location, skin tension and the preference of the racecourse veterinary surgeon. Dressings, bandaging, antibiotics and anti-inflammatory treatments should be used as normal for wound management. Plans for the next treatment and dressing change should be clearly communicated to the horse's connections, including on the veterinary consultation form.

Tendon and ligament injuries

Superficial digital flexor tendon and suspensory ligament overstrain injuries are common during the high speeds associated with racing (Williams, 2001; Kummerle et al, 2019), and superficial digital flexor tendon injuries account for the majority (Ely et al, 2009). The horse may be pulled up or the injury may be noted after the race.

With superficial digital flexor tendon injuries lameness is variable, but horses are usually mildly to moderately lame at this acute stage, with pain on palpation of the injury site when the leg is lifted. Swelling and tendon or ligament structure varies from minimal initial swelling to an enlarged soft or spongey tendon (Figure 3a). Hyperextension or sinking of the fetlock when weight-bearing may be present with more severe injuries. Cold hosing, analgesics and anti-inflammatories should be given (Kummerle, 2019) and appropriate limb support applied.

Horses who do not have fetlock sinking associated with superficial digital flexor tendon injuries may be supported in a multi layered bandage. Horses with significant fetlock sinking should be supported in fetlock flexion (Figure 4a) (flexion splint or heel wedge and dorsal +/- palmar splint; Figure 4b and 4c) or a bandage cast (Figure 5a), a compression boot (Figure 5b) or a splinted Robert Jones bandage (Figure 5c) (ARVS, 2015; Kummerle, 2019).

Horses with suspensory breakdown are best supported in fetlock flexion (flexion splint or heel wedge and dorsal +/- palmar splint).

Horses with proximal tendon or musculotendinous junction injuries resulting in haemorrhage into the carpal sheath can be severely lame. Needle aspiration to release the haemorrhagic fluid from the carpal sheath can give relief of the lameness (Bladon, 2013).

Horses can luxate the superficial digital flexor tendon calcaneal insertion from the point of the hock during racing (Figure 3b), usually resulting in unusual gait abnormality or lameness. These horses can also become severely distressed when asked to move, so should be given adequate sedation to alleviate this. The luxations are usually lateral and may fully luxated or unstable, where the superficial digital flexor tendon can be seen to flick laterally when walked. Occasionally, the superficial digital flexor tendon can split with a portion lying medial and lateral to the point of the hock (Lischer and Auer, 2019). These horses have a good long-term prognosis (Wright and Minshall, 2011) and can be sedated and transported with no additional support applied to the limb.

Appendicular fractures

Limb fractures are a sad but inevitable injury in racehorses galloping at high speeds, often combined with jumping obstacles. Fractures necessitating euthanasia are the predominant cause of fatality on a racecourse (Williams, 2001; Parkin et al, 2004; Boden, 2007).

Any open contaminated long bone fractures, and fractures of the humerus and femur carry a hopeless prognosis and should be euthanised on humane grounds without moving the horse (Milner, 2011; Eliashar, 2011; Wright, 2017c). Femoral and humeral fractures may not be immediately obvious but are associated with severe lameness, limb shortening and progressive swelling caused by associated haemorrhage (Figure 6a and 6b). Femoral fractures can exsanguinate the horse if it is not euthanised first (Wright, 2017c). For other confirmed or suspected fractures the horse should be sedated, and appropriate support placed to stabilise the injured limb. This will alleviate the horse's distress. It can then be transported in the horse ambulance to the stables for further assessment and decision making. If a fracture is not obvious in a lame horse, it is best transported without any additional limb support.

With the advent of digital and wireless radiography many racecourse veterinary surgeons will now take radiography equipment to the racecourse routinely (Figure 7). This provides a significant advantage in determining fracture configurations, planning support techniques and gaining further opinions on best management and prognosis. It requires planning to organise time and personnel to operate the equipment and attend to radiation safety. How the costs of this service are covered will need to be negotiated with each racecourse.

The most common racehorse fractures are sagittal plane distal metacarpal/tarsal (condylar) fractures, pelvic and tibial stress fractures, sagittal plane proximal phalangeal (P1) fractures, carpal bone (third, radial, accessory) and sesamoid fractures. (Williams et al, 2001; Parkin et al, 2004).

Distal metacarpal/tarsal (condylar) fractures are common and mostly lateral. In addition to mild-to-moderate lameness, there is usually fetlock joint distension, and if complete, these can displace and result in focal swelling and pain on palpation on the fractured side. Medial condylar fractures are more likely to propagate proximally and these cases are at greater risk of catastrophic displacement if not supported adequately in a cast, compression boot or splinted Robert Jones bandage. Complete fractures result in medio-lateral instability and require immobilisation with a bandage cast or compression boot, with the fetlock joint in extension. Fetlock flexion (such as with a flexion splint or heel wedge) results in displacement of the fracture and is thus contraindicated (Wright, 2017c).

Proximal phalanx fractures (P1) are common racecourse fractures and mostly affect forelimbs. Sagittal and parasagittal fractures are most common, but comminuted fractures occur also. Sagittal fractures present with lameness and varying degrees of fetlock effusion (and pastern effusion if complete). There may be pain on palpation of the dorsal pastern. P1 fractures are best supported in a compression boot, bandage cast or Robert Jones bandage with medial and lateral splints. Incomplete fractures may be managed in a Robert Jones bandage alone. Comminuted fractures need supporting in a compression boot or cast/bandage cast. If any dorsopalmar instability is present then casting or bandaging in flexion with a heel wedge is advised (Wright, 2017c).

Pelvic fractures present lame during or post race, and the signs will depend on whether displacement has occurred, which is more common (Figure 8) (Wright, 2017c). They are mostly ilial wing or less commonly ilial shaft fractures. Undisplaced fractures may only show lameness and spasm in the gluteal muscles, and possibly pain on deep palpation over this region. Displaced ilial wing fractures can present with ventral displacement of the tuber sacrale, with cranioventral displacement of the tuber coxae if the fracture is more lateral, and apparent narrowing of the pelvic width on the fractured side when viewed from behind (Pilsworth, 2003; Wright, 2017c). Ilial shaft fractures usually cause more lameness and present a greater risk of lacerating blood vessels, resulting in exsanguination. Ultrasonography can be used on the racecourse to help identify displaced fractures, which may also help to quantify the risks associated with transporting the horse. Undisplaced fractures are difficult to identify with ultrasound, unless local haemorrhage in the muscles can be seen (Shepherd and Pilsworth, 1994; Wright, 2017c). Whether to transport horses with confirmed or suspected pelvic fractures is a difficult decision, given the risk of further displacement of the fracture and exsanguination if the bone lacerates nearby major blood vessels. However, given the lack of facilities and staff to care for horses at most UK racecourses, they are generally returned either to their home yard or to a veterinary hospital. This should only be done after consultation with the trainer and the home veterinary surgeon. The horse should travel in an ambulance and should be carefully and quietly loaded and unloaded off the front of the ambulance at its destination. It will need cross tying and associated management if an ilial shaft fracture is possible.

Carpal fractures with no associated collapse can be managed with no additional support, or a pressage bandage to minimise associated swelling. Unstable accessory carpal bone fractures can benefit from a Robert Jones bandage and a dorsal splint, as the fracture displaces with carpal flexion (Wright, 2017c). Carpal fractures which collapse or are comminuted benefit from a Robert Jones bandage with dorsal and lateral splints, or a sleeve cast.

Most tarsal fractures and distal tibial stress fractures do not affect stability of the tarsus and these horses can be transported unsupported, or with a pressage bandage to reduce swelling. Fractures affecting stability should be placed in a sleeve cast (Wright, 2017c).

Sesamoid fractures can result in suspensory apparatus disruption if biaxial (Ely et al, 2009; Allen et al, 2017). These and palmar/plantar eminence P1/P2 fractures should be supported in fetlock flexion (flexion splint or heel wedge and dorsal splint in forelimb, plantar board in hindlimb).

It is beyond the scope of this article to discuss all fractures that may be encountered on the racecourse. The series of articles by Ian Wright (Wright, 2017a, b, c) provides an excellent treatise on fracture management and is essential reading. A brief reference is provided below for a simplified guide to support options, but each injury must be assessed individually in order to provide the best support, and discussion with the home vet or referral centre is critical when deciding how best to support a horse for transport (Table 1).

Spinal trauma and fractures

Spinal injuries are most commonly associated with falls in National Hunt racing, but can occasionally occur on the flat. Stress fractures of the caudal thoracic or lumbar vertebral lamina can occur in racehorses and while an association with catastrophic fracture was not shown in a study by Hausler and Stover (1998), pathology in the caudal lumbar vertebrae has been shown to occur pre-fracture in Quarter horses (Collar et al, 2010).

After falling in a National Hunt race, most horses will get up and continue galloping, and an assessment of soundness is made from a distance. When a horse remains recumbent following a fall it is most commonly ‘winded’; this is an exhausted horse, which, less commonly, may have a spinal or upper limb fracture. Horses with cardiovascular compromise (such as internal haemorrhage or a fatal arrhythmia) usually slow down and show gait abnormality before becoming recumbent, but these horses may fall at a fence also. Occasionally a horse sustains a limb fracture in the strides just before a fence and falls. Many fallers with limb fractures regain their feet. Observing the fall is very helpful to ascertain the likelihood of serious injury, a tired horse that has a ‘soft’ fall is most likely exhausted, a fast/heavy fall is more likely to result in injury (in the author's experience).

When arriving at a recumbent horse, ensure the bridle is well attached (add a head collar and lunge line if necessary) and allocate a suitable person to control the head from a dorsal position. Ensure nobody (including yourself) goes into the ‘kick zone’ of the limbs. The horse will need to be undergo a recumbent horse examination in a systematic fashion, including careful palpation of the spine and upper limbs. It is difficult to discern neurological dysfunction in a recumbent racehorse, in an excited and often exhausted state. Swelling and pain on firm palpation at an injury site may be evident after several minutes. Voluntary movement will indicate possible injury sites. If the horse has not stood and no obvious abnormalities are detected after 10–15 minutes, it should be rolled. This is best achieved using the British Animal Rescue and Trauma Care Association (BARTA) rollover technique, which can be done with a 10 m rope or a lunge line. The rope is passed under the dependent fore and hind limb and brought back over the dorsum in the caudal thoracic region (Figure 9a). Three people holding the two ends of rope tightly together then walk backwards and the horse will be rolled with minimal distracting forces on the lower limbs. The person in charge of the head needs to be ready as an exhausted horse will often stand when stimulated by rolling (Figure 9b). Observe the horse as it is rolled as voluntary movement of head, neck and limbs often occurs at this time, which can help ascertain if spinal injury is likely (ARVS, 2015).

Cervical spinal fractures are more common than thoracolumbar and usually involve a fall with the neck in marked flexion (Piercy, 2013). If they fracture in the occipital to mid cervical region the horse may die suddenly. More caudal cervical fractures will likely be severely ataxic if they regain their feet. These horses may then become recumbent again. Thoracolumbar fractures are often associated with a fall where the horses’ back hits the ground. They usually result in horses having voluntary movement of the head, neck and forelimbs but none in the hindlimbs, although they may attain a dog sitting position after some time. If a horse remains recumbent for more than an hour it is unlikely to survive and euthanasia is advisable, even in the absence of a definitive diagnosis. The exception to this can be horses with cranial injury or loss of consciousness associated with head trauma, who may require longer to recover (Piercy, 2013). The horse is likely to need moving to allow racing to continue if it remains recumbent for a prolonged period and is not euthanised. This is challenging, but most horse ambulances carry drag mats or glides for loading recumbent (anaesthetised) horses or dragging recumbent horses to a more suitable location to allow treatment while racing continues. This is a rare scenario.

Conclusions

Most of the time spent as a racecourse veterinary surgeon is sociable and rewarding, and the majority of injuries attended can be treated successfully by providing first aid treatment at the racecourse and organising further treatment at a referral centre, or at the trainer's yard with the trainer's own vet. EQ

KEY POINTS

• To be a racecourse veterinary surgeon you should have good communication skills, attentiveness and knowledge of how to manage common equine injuries, including support techniques for the transport of injured horses.
• The initial treatment involves working partially in the public eye and while clinical treatment is not usually challenging, it involves succinct decision making and liaising with jockeys, trainers, owners, other vets and racecourse staff.
• Soft tissue injuries and wounds are treated as usual in equine practice, but the temptation to close contaminated wounds should be avoided, and if synovial involvement is suspected the horse should be referred for further assessment and treatment.
• Open long bone fractures, displaced humerus and femur fractures, and recumbent horses with spinal fractures are candidates for humane euthanasia on course. With most other injuries the horse can be sedated, supported as required, and transported back to the stables for further assessment and treatment.