CASE RE­PORT

Two in­ci­dents on the same farm il­lus­trate how well horses can recover from jaw in­juries, even when the causes and treat­ments are very dif­fer­ent.

EQUUS - - Equus - By Tom Moates

A tale of two mandibles: Two in­ci­dents on the same farm il­lus­trate how well horses can recover from jaw in­juries, even when the causes and treat­ments are very dif­fer­ent.

The words “bro­ken jaw” sum­mon im­ages of grue­some in­juries, un­com­fort­able treat­ments and long, un­cer­tain re­cov­ery pe­ri­ods. And, when it comes to peo­ple, that often isn’t too far off. But for horses, jaw frac­tures are not nec­es­sar­ily de­bil­i­tat­ing in­juries. In fact, most bro­ken equine jaws are rel­a­tively easy to treat, with min­i­mal pain and a good prog­no­sis.

This for­tu­nate fact is il­lus­trated by the tale of two jaw frac­tures that hap­pened to oc­cur, just weeks apart, at A and O Sta­bles in McCoy, Vir­ginia, last year. The farm is owned by Ash­ley Roberts, DVM, an as­so­ciate vet­eri­nar­ian at Ap­palachian Vet­eri­nary Ser­vices in nearby Riner, Vir­ginia. The horses, their in­juries and the treat­ments they re­quired were about as dif­fer­ent as could be, but the end re­sult in both cases was a full re­cov­ery.

Buddy: One bad move

Buddy, a big, bay Quar­ter Horse geld­ing boarded at Roberts’ farm, is an easy­go­ing horse with a his­tory of good health. He was 18 years old when Roberts found him early one Novem­ber morn­ing stand­ing over his bucket just look­ing at his grain.

“When I see a horse not eat­ing the first thing I think about is a colic,” says Roberts. But Buddy was def­i­nitely not col­ick­ing; he was bright and alert. “It was like he wanted to eat but he just couldn’t,” she says. “He was show­ing in­ter­est in his grain but he just couldn’t take a bite and chew.”

Tak­ing a closer look at the geld­ing, Roberts no­ticed that the left side of his face was swollen. Feel­ing care­fully, she de­ter­mined that the left un­der­side of his jaw---just a few inches be­hind his lower lip---was dra­mat­i­cally dif­fer­ent in size than the same area on the right.

“At that time I was pretty sure [his mandible] was bro­ken,” Roberts says. The mandible is the lower bone of the jaw; the bone above is called the max­illa. The lower in­cisors are an­chored to the front por­tion of the mandible, with the cheek teeth and mo­lars em­bed­ded along its length. Be­hind the teeth, the bone curves up­ward to form what might col­lo­qui­ally be re­ferred to as the horse’s “cheek.”

Buddy re­sisted Roberts’ ef­forts to ex­am­ine him. “He was re­luc­tant to let me look in his mouth,” she says. “I gave him some bute and called his owner to tell her what was go­ing on.” She de­cided to head into her of­fice to re­trieve a ra­dio­graph ma­chine and a sec­ond set of hands to help.

Roberts re­turned with Kent Adams, DVM, the founder of Ap­palachian Vet­eri­nary Ser­vices, and to­gether the pair took a se­ries of ra­dio­graphs of Buddy’s swollen, ten­der jaw.

The im­ages showed a frac­ture in the por­tion of the mandible called the “in­ter­den­tal space,” where there are no teeth, but only on the left side.

“Usu­ally if [the mandible] breaks in that sec­tion, it breaks on both sides,” says Roberts. “So the fact that we could only see one break on his ra­dio­graphs made it kind of pe­cu­liar.”

See­ing no ev­i­dence of a flesh wound on Buddy’s jaw, Roberts ruled out a kick from a pas­ture­mate or a sim­i­lar “bat­tle in­jury.” In­stead, she thought the geld­ing might have bro­ken his jaw by grab­bing onto some­thing---the stall door or even the edge of his water bucket---with his teeth and then pulling back sud­denly, per­haps be­cause he was star­tled.

“That’s a pretty com­mon in­jury in young horses. Foals and year­lings, they’ll kind of latch onto some­thing and then spook and jerk back and it just snaps their bot­tom jaw,” she says. Even though Buddy was older, this seemed the most likely ex­pla­na­tion,

Roberts and Adams talked to Buddy’s owner and rec­om­mended a re­fer­ral to the Vir­ginia–Mary­land Col­lege of Vet­eri­nary Medicine hospi­tal in nearby Blacks­burg, Vir­ginia, for po­ten­tial surgery to sta­bi­lize the frac­ture. Buddy’s owner agreed and made ar­range­ments to have him shipped the next day.

In the mean­time, Roberts kept Buddy on bute through the night and soaked his evening grain in water to cre­ate a slurry. “By that time, he was eat­ing a lit­tle bit,” she says.

The next morn­ing, Roberts ac­com­pa­nied Buddy and his owner to the uni­ver­sity clinic, where surgery res­i­dent Ricky Tra­han, DVM, was part of the team man­ag­ing the case. He re­as­sured them about Buddy’s prospects: “Horses can do sur­pris­ingly well with bro­ken jaws,”

says Tra­han. “If you can sta­bi­lize the area, they have the ca­pac­ity to eat just fine and gen­er­ally heal very well.”

Good blood cir­cu­la­tion in the area con­trib­utes to the speedy heal­ing of jaw frac­tures, he adds: “The face and mouth and gen­er­ally most tis­sues in that area have a good blood sup­ply, which pro­motes heal­ing and keeps in­fec­tions at bay. Sure, you can get in­fected teeth and si­nuses, but in­juries to the face, like a torn eyelid or a bro­ken jaw, typ­i­cally heal very well if the blood sup­ply is not com­pro­mised.”

A sec­ond set of ra­dio­graphs con­firmed that Buddy’s mandible was bro­ken only on the left side, which made a fairly straight­for­ward re­pair pos­si­ble. “Be­cause the right side of his jaw was sta­ble, we were able to use that to our ad­van­tage,” Tra­han says.

With Buddy stand­ing and se­dated, the sur­geons an­chored a wire to the ca­nine tooth on the right side of the jaw. Then they ran that wire across the front of the mouth---weav­ing through the front teeth---and at­tached it to the sec­ond pre­mo­lar on the left side just past the frac­ture site. “The pur­pose of the wire is to sta­bi­lize the mouth,” ex­plains Tra­han. “Peo­ple with bro­ken jaws often have them wired shut, but that’s not nec­es­sary with horses. You can just run wire from one side to the other and they con­tinue to hap­pily eat and drink.”

Sure enough, by evening on the day of the surgery, Buddy had fully re­cov­ered from se­da­tion and hap­pily ate some soaked feed. He re­mained at the

vet­eri­nary school for three days, mainly so that his food and water in­take, as well as his level of dis­com­fort, could be closely mon­i­tored.

When Buddy came home, there was one sig­nif­i­cant change to his daily rou­tine: “You can’t let a horse graze with a bro­ken jaw,” says Roberts. “If they pull on grass it will stress the area and break the wire. He went on stall rest, es­sen­tially, but he could go out in our in­door arena be­cause it doesn’t have any grass.”

To off­set the lack of graz­ing, Roberts made some ad­just­ments to Buddy’s diet. “To get enough fiber into him we started adding al­falfa pel­lets and beet pulp and rice bran---all soaked as well ---in with his feed. He was get­ting be­tween a gal­lon and a half and two gal­lons of mush per feed­ing. He could have hay, but it had to be chopped.”

Tra­han pre­scribed the non­s­teroidal anti-in­flam­ma­tory firo­coxib for Buddy in­stead of bute to re­duce the risk of ul­cers or other side ef­fects. The geld­ing stayed on that med­i­ca­tion for a week, along with a course of an­tibi­otics. Each day, Roberts in­spected the wire in Buddy’s mouth and rinsed the area with a mild an­ti­sep­tic so­lu­tion.

Three months af­ter he was in­jured, Buddy re­turned to the uni­ver­sity clinic for a recheck. By now the wire was gone---hav­ing bro­ken and fallen away on its own---but it didn’t mat­ter: Ra­dio­graphs re­vealed the site was heal­ing well.

Back at home, Buddy slowly made the tran­si­tion from chopped for­age and soaked grain to his reg­u­lar diet, and his owner be­gan rid­ing him, first in a bit­less bri­dle and then with his reg­u­lar snaf­fle.

“He has done great and has never looked back,” Roberts says. “He ac­tu­ally went to his first dres­sage show re­cently.”

Star: Just for kicks

Only 15 days af­ter Roberts dis­cov­ered Buddy’s in­jury, she found Star, an­other Quar­ter Horse geld­ing boarded on her prop­erty, hov­er­ing over his full feed bucket one morn­ing with­out tak­ing a bite. The age of this horse made the sight par­tic­u­larly trou­bling: He was 33 at the time.

Men­tally run­ning through the list of ail­ments that could stop an older horse

from eat­ing, Roberts ex­am­ined Star. She quickly found the likely source of the prob­lem.

“He had a large wound, about two inches across, at the corner of his left mandible---where it be­gan to curve up­ward. At the time, there was no swelling. So I just thought it was a wound and his mouth was sore.”

Roberts gave Star a dose of bute to ward off in­flam­ma­tion and help al­le­vi­ate pain and left him with his break­fast to see if he would eat any­thing once the med­i­ca­tion kicked in. Be­cause of his age and miss­ing teeth, the geld­ing al­ready was get­ting a slurry of com­plete feed twice a day.

“A cou­ple of hours later I went back to check on him and he had eaten ev­ery­thing,” Roberts says, not­ing that, even so, a thor­ough ex­am­i­na­tion was nec­es­sary. “I called Star’s owner and told him that he had a wound that I needed to look at so I needed to se­date him.”

With Star se­dated and the area numbed, Roberts be­gan ex­plor­ing the wound and dis­cov­ered it to be much more ex­ten­sive than it ap­peared. “I re­al­ized the wound was three or four inches deep and it ba­si­cally trav­eled straight up to the in­side. If you feel a horse’s jaw there, it’s ba­si­cally skin and bone. There’s not re­ally any mus­cle there.” Us­ing her fin­gers and ster­ile gloves to care­fully ex­plore the depths of the wound, Roberts be­gan find­ing and re­mov­ing frag­ments of bone.

“Some of them were as big as two or three inches across and some of them were tiny---just a few mil­lime­ters across,” she says. As best she could sur­mise, Star had been kicked on the side of the face by a herd­mate and the blow had bro­ken his jaw.

“Surgery wasn’t re­ally an op­tion--even if we did want to wire his jaw, he didn’t have enough teeth left to an­chor it to,” says Roberts. “But he didn’t nec­es­sar­ily need that. The best I could tell from pal­pa­tion was the main part of the mandible was sta­ble. The bone frag­ments were from a frac­ture, but not one that was af­fect­ing the func­tion or sta­bil­ity of the jaw it­self.”

Roberts con­tin­ued to pull bone pieces out of Star’s wound un­til she had about 15 to 20, a pile large enough to nearly fill a shot glass. “I got as many as I pos­si­bly could,” she says, “and it was just a wound treat­ment from there.”

Star’s ad­vanced age made him more prone to in­fec­tion, even on his face, so in ad­di­tion to a stan­dard course of oral an­tibi­otics, Roberts em­ployed a wound-care tech­nique de­vel­oped for dairy cat­tle.

“I used an in­tra-mam­mary treat­ment that is for dairy cows,” Roberts ex­plains. “It’s an an­tibi­otic [cephapirin sodium] we use when they have mas­ti­tis, but it comes in a ster­ile sy­ringe with a long ster­ile tip ap­pli­ca­tor that goes in the teat. What I would do is squirt that in­tra-mam­mary treat­ment up into the wound.”

Although un­con­ven­tional for horses, Roberts was con­fi­dent in this ap­proach: “If it can go into the mam­mary gland it’s ob­vi­ously gen­tle enough to come into di­rect con­tact with the bone.” Roberts treated Star with the cephapirin sodium ev­ery other day, and the wound grad­u­ally healed. Roberts be­lieves this ad­di­tional an­tibi­otic treat­ment helped pre­vent in­fec­tion and fa­cil­i­tated Star’s steady re­cov­ery.

Just as with Buddy, Star’s heal­ing jaw could not with­stand the torque forces of graz­ing, so the geld­ing was kept off pas­ture. But, be­cause of his age, he was al­ready re­ceiv­ing com­plete pel­leted feed that in­cluded roughage so his nu­tri­tional needs were not a con­cern.

Through­out his or­deal, Star was a model pa­tient. “Other than right when I found it, he never stopped eat­ing,” says Roberts. “That is re­ally the key to why he did so well. He is known here at the barn as the En­er­gizer Bunny---noth­ing gets in his way. He’s go­ing to do his daily rou­tine or bust.”

Star’s wound was com­pletely closed about a month later, and the geld­ing healed with­out any prob­lems. “I was an­tic­i­pat­ing him de­vel­op­ing a se­questrum, which is a piece of dead bone that mi­grates to the sur­face, but he never did. I pal­pate his mandibles now, be­cause it’s amaz­ing to me, and I can still feel a con­cave area,” says Roberts. “But he’ll let you mess with it and he’s fine.”

Two horses, two bro­ken jaws, two full re­cov­er­ies. These suc­cesses were a re­sult of prompt care, ded­i­cated nurs­ing and, says Roberts, the good ap­petites of the pa­tients. “Horses gen­er­ally recover from jaw frac­tures re­ally well, but some have a re­ally hard time,” she says. “I think the key is eat­ing. If a frac­tured jaw stops a horse from eat­ing, things get very com­pli­cated very quickly and the out­look isn’t so good. In both cases, the horses kept eat­ing and I think that made a huge dif­fer­ence. It’s al­ways nice when things turn out this well.”

MANDIBLE PRIOR TO SURGERY IM­ME­DI­ATELY AF­TER SURGERY SUC­CESS­FUL RE­PAIR: Buddy’s mandible was frac­tured only on the left side, so the sur­geon was able to sta­bi­lize the area by an­chor­ing a wire to his right ca­nine tooth and run­ning it across the front of...

TWO MONTHS AF­TER SURGERY

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