How to Apply and Reapply a Standing Bandage Cast for the Treatment of Severe Distal Limb Injury

This paper presents a practical technique for cast application in standing horses for the management of severe lacerations involving or over joints. The described technique provides rigid support to the limb while allowing continued wound and joint access through reapplication of a bivalved cast shell over a new bandage. This system allows lacerations over and communicating with joints to be managed in the field with continued joint lavage, wound debridement, and delayed primary closure, while maintaining rigid support, which is critical in high-motion areas and traumatic joint luxations. Author’s address: Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853; e-mail: [email protected].

1. Introduction

In addition to use in arthrodesis and fracture repair, casts are often required when treating wounds, joint luxations,^1–3  and tendon lacerations.⁴  Standard casts, with only thin layers of cast padding under casting tape, are difficult to apply well in the standing patient, and even with careful and accurate application, they can lead to rapid development of severe cast rub sores. Consequently, standard casts are applied to anesthetized horses, and many clinicians prefer horses with casted limbs to remain hospitalized. This hospitalization is not financially possible for many cases.

Because of the bandage thickness, a bandage cast generally has a slower onset of cast rub sores and can be safely maintained outside of the hospital by an astute owner or caretaker. Additionally, because of bandage thickness, it is easier to detect when the bandage material has compressed or shifted within the cast, necessitating cast removal. When the cast is bivalved, it can be removed, the underlying bandage can be changed, and the same cast shell can be reapplied. This technique allows for continued semi-rigid support with continued access to the limb under the cast, which is not possible in a standard cast, where the need for continued support would require that another cast be made. 

Equine clinicians commonly apply foot casts to the standing patient to treat heel bulb lacerations. Nearly as easily, half (up to the level of the carpometacarpal/tarsometatarsal joint) or full limb (up to the proximal radius/tibial plateau) bandage casts can be applied without general anesthesia. The biggest advantages of the bandage cast are as follows:

• increased room for error during application compared with a standard cast, allowing the clinician to easily and effectively apply it to the standing patient
• increased patient comfort because of normal weight-bearing conformation and increased cast padding with reasonable stability
• improved long-term maintenance of a clean bandage and wound environment, reducing the frequency of required bandage changes
• continued access to the limb through bivalved cast removal for examination or treatment (joint lavage, wound debridement, delayed closure, etc.) while maintaining semi-rigid support between examinations with reapplication of the bivalved cast shell
• reduced risk and slower onset of cast rub sores caused by cast padding thickness and the ability to frequently change the underlying bandage
• increased padding thickness, which accommodates changes in limb swelling that are often inevitable with traumatic injury while maintaining some (reduced) rigidity

2. Materials

Bandage materials are as follows:

• non-adherent dressing
• stretchable gauze dressing
• sheet cotton (two sheets per layer for two layers)
• 6-in non-stretch gauze (three rolls)
• cohesive stretchable dressinga

Other materials include the following:

• Gigli wire in flexible plastic tubing
• water-curable fiberglass cast tape rolls (3- to 5-in width)
• acrylic (polymethyl methacrylate)
• elastic tape
• porous non-elastic tape

3. Methods

Wound Assessment and Care

Before bandage cast application, the wounds must be addressed. This assessment includes wound duration, wound contamination, structures involved, and possibility of successful primary closure. Wound care may include systemic, regional limb perfusion and/or intrasynovial antibiotic administration, wound debridement, primary or delayed closure, and/or second-intention healing. When synovial structures, flexor tendons, collateral ligaments, or bone are involved, referral to a surgical facility is often indicated; however, these wounds can be managed in the field when referral is not elected.

Support provided by a bandage cast may be used for soft-tissue laceration in high-motion areas, collateral ligament, or tendon injury. After the need for semi-rigid support is established, the care required and expected duration of casting should be discussed with the owner. For example, in a heavily contaminated wound with significant soft-tissue swelling, the owner should expect that the bandage cast will need to be bivalved and changed regularly with careful monitoring and wound care, which will be time consuming. Similarly, when using a bandage cast for support to an open joint, the owner should be prepared for additional joint lavages and wound care that may require several veterinary visits, especially when the wound is left open to heal by second intention. With severe swelling, a second cast shell may also be required as the swelling resolves. In contrast, after successful primary closure of a minimally swollen laceration over the dorsum of the fetlock, the owner can expect that bandage cast removal may occur in 3 wk, with minimal daily care. In any case, the owner should be prepared for careful cast monitoring and instructed to schedule immediate follow-up exams if and when abnormalities develop.

Bandage Cast Indications

Bandage cast indications include the following:

• open joint laceration
• joint luxation (open or closed) (Fig. 1)
• laceration in a high-motion area (i.e., dorsum of the metacarpophalangeal joint) 
• tendon injury

Bivalved Bandage Cast Indications

Bivalved bandage cast indications are the scenarios listed above where the wounds are expected to be especially exudative or continued care is required (i.e., repeat joint lavage, wound debridement, or delayed primary closure).

Standing Cast Application

Casting

The horseshoe is often removed, and the foot should be trimmed and cleaned. Because the cast is for short-term support and will be changed more frequently than a traditional cast, a fully extended, weight-bearing posture can be used. Maintenance of the hoof–pastern axis in the casted limb obviates the need for additional pads to increase limb length on the contralateral foot. Therefore, the contralateral limb can be left barefoot, be left in the pre- existing shoe, or have added support materials to recruit the palmar sole and frog for weight-bearing support if severe unilateral lameness is expected.

The horse should be adequately sedated so that it will remain quiet throughout cast application and cast curing, because movement can result in stretched, wrinkled, and misfitted casts and increased risk of cast complications. It is important to keep in mind that some horses can be startled by the sudden inability to flex the hindlimb when casting hindlimbs and may react adversely with rapid and extreme abduction and attempted hyperflexion of the casted limb.

In standard cast application, a double layer of stockinette is rolled onto the limb to create a uniform, non-shifting, comfortable padding that will allow cast material adherence, while protecting the hair and skin from adhering to the casting tape. In a bandage cast, it is not required. [...]