Wound Worries
Understanding
wound management and proud flesh.
Story by
Dr. T.A. Banner
Photos by Christa Moody
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O ne
morning, as you go out to feed you notice that your horse is
not in his stall, but standing in the pasture against the fence.
You call, but he gives no response but to look back at you.
You curiously walk out and find him entangled in the fence and
multiple lacerations on his legs. Carefully you free him and
begin to evaluate the extent of the injuries and then call your
veterinarian.
After a thorough exam, you are told that there are no serious
injuries, but there are several cuts and abrasions that will
need management. The question is do you understand the healing
process and the potential complications associated with wound
care?
The Wound
A cut or laceration of the skin exposes the underlying subcutaneous
tissue which contains fat, connective tissue, blood vessels
and nerves. If the wound is deep, muscle, tendon, ligament,
and bone may also be exposed. The wound is now open to the environment
containing dirt, debris, bacteria and just about everything
else you can think of. Therefore, cleansing of the wound is
important to remove as many of the contaminates as possible.
In a healthy horse, the immune system can fight off much of
the contaminate infection but not always. Contamination with
one or all of these components may begin an infection, which
may require antibiotic therapy
The horse’s initial response to the injury is for inflammation
(heat, pain, redness and swelling) to occur. There is short
lag time in this inflammatory response; this is why wounds that
require sutures for closure should be done in the first few
hours after injury.
If possible, suturing or primary closure of the wound is the
best treatment and the best prevention of proud flesh or “exuberant
granulation tissue.”
In the first few days after the injury, the wound is preparing
for healing by sloughing out the damaged or dead cells, sending
in white cells to fight infection and fibroblast to begin collagen
synthesis. The epithelium or granulation tissue begins to grow
or proliferate which fills in the wound defects. The reason
it is called granulation tissue is due to its granular or cobblestone
appearance. This tissue is red, very fragile and bleeds easily
due to the high density of capillaries carrying in components
necessary for proper wound healing. The problem that we often
face is that the mechanism to slow down this proliferation of
tissue doesn’t work once it reaches the edge of the skin.
Once the tissue rises above the wound edge, it is called “proud
flesh”.
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Proud
Flesh
Proud flesh normally occurs on the limbs below the knee (carpus)
and hock. Since proud flesh is fragile it would seem to be
easy to manage but unfortunately it can turn into a costly,
unsightly problem if left untreated. The skin edges normally
heal over the bed of granulation tissue until the edges come
together where they will connect forming a scar. If proud
flesh occurs, the skin edges will stop the contraction process
as they will not go up and over the proud flesh. The wound
then stays open and the proud flesh continues to grow uncontrollably
like a head of cauliflower.
Proud
flesh can be managed in 2 ways; one is to surgically cut it
off and the second is to apply caustic or drying agents to
destroy the tissue to or just below the wound edge. In the
surgical removal, the horse may not need to be sedated due
to the proud flesh having no nerves running through it. However,
some horses may need sedation for safety reasons and to minimize
movement if cutting in a difficult area. |
Open
wounds, if let untreated, can lead to major proud flesh build
up. Early treatment is critical to prevent this from occurring.
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The flesh is cut back to or below the skin edge and a pressure
bandage is applied to control bleeding. A word of warning,
there may be a lot of blood associated with surgical removal
but it may be the only option if there is a lot of proud flesh.
(So you don’t worry, the average horse has 10 gallons
of blood). Since surgical excision does not cause the proud
flesh to stop growing, it may be necessary to surgically remove
it more than once. I will typically follow-up surgical excision
with applications of caustic powder on a 1-2x daily basis.
The other way to manage proud flesh is to use caustic powders
which cause the destruction of the epithelial cells resulting
in a killing back of the tissue. They are usually effective
on smaller areas of proud flesh and can be easily applied.
Caution must be used when applying, as the powder is caustic
to all cells and over or sloppy application can lead to areas
around the wound being irritated or damaged. Therefore, apply
carefully to only the exact areas you want to affect. While
the wound is healing, a portion of the flesh may be level
but another portion is still excessive, apply the powder only
to the excessive area. For example: if the wound measured
2 inches by 2 inches and only the upper ½ of the wound
had proud flesh, apply to that ½ only. Do not let it
get on the level granulation bed (lower ½) or edges
of the skin and hair. You end up adding a little bit of artwork
to the science of healing the wound. In cases dealing with
large wounds, skin flaps and skin grafting may be necessary
to decrease scar formation and achieve a better cosmetic result.
Another bit of caution is that granulation tissue is exactly
what parasite and flies are looking for. Summer sores often
get started in even the smallest of wounds so management is
critical. An ounce of prevention is truly worth a pound of
cure.
(For
more information on summer sores, please see the Summer
2006 edition of EC Magazine or visit us online at
www.ecmagazine.net).
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| Day
1: Wound First Occurs Day |
Day
3: Wound Starts the Healing Process |
Day
5: Wound starts to produce granulose tissue to help heal
the wound. |
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| Day
10: Proud flesh begins to form |
Day17: Proud Flesh has formed is very apparent |
Day 28: After removing proud flesh, the wound is healing
properly. |
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Dr.
Toots Banner is a practicing veterinarian and equine
dentist, located in Micanopy, FL. at his practice Riverside
Equine Dental Services. |
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