Veterinary Surgery, 17, 1, 2-5, 1988

Osseous Sequestration in the Horse

A Review of 68 Cases

M. F. CLEM, DvM, MS, R. M. DEBOWES, DVM, MS, DiplornateACVS,

J. v. YOVICH, BVMS, MS, DiplornateACVS, J. P.
DOUGLASS, DVM, MS, DiplornateACVR,
and S. M. BENNETT, DVM

Sixtyeight cases of cortical bone sequestration in 67 equine patients were reviewed with
regard to the clinical presentation, method of treatment, and outcome. All lesions were
located in skeletal areas with minimal soft tissue coverage, with 53% of them in the metatar-
sal and metacarpal bones. At the time of admission, 60% of the patients with limb lesions
were lame; the majority improved with therapy. After sequestrectomy, there was a trend for
surgical wounds which could be managed by primary closure to heal more rapidly (3.8
weeks) than wounds which required second intention healing (6.4 weeks). The appearance
of healed wounds, as evaluated by owners, was acceptable in 45 cases. Dissatisfaction
with the appearance of the healed wounds in 22 cases suggested a need to address the
issue of cosmetic results.

SEQUESTRUM is a piece of dead bone separated from
A sound bone by necrosis.' Bone sequestra result from a
combination of local cortical ischemia and bacterial con-
taminati~n.*-~ In the horse, local vascular stasis may be
produced by periosteal disruption after trauma in an area of
minimal soft tissue ~ o v e r a g e Previous
.~ investigators have
reported a preponderance of equine sequestra in the lower
limbs and have described surgical The cur-
rent study characterizes 68 osseous sequestra in 67 horses,
with specific regard to clinical findings and outcome of
treatment.
Materials and Methods
Sixty-seven case records of equine bone sequestra from
two veterinary hospitals provided enough data for inclusion
in a retrospective study. Each case history was reviewed for
information about the type and duration of injury, previous
therapy, and response. Presenting signs, lesion location,
bacteriologic findings, type of treatment, and postoperative
results were summarized. Owners were contacted at varying
times after treatment (9 months to 10 years; mean, 3 years)
to assess each patient's soundness and the appearance of the
affected site.
Results
The 67 horses included 43 Quarter horses, 10 Thorough-
breds, 4 Arabians, 4 Appaloosas, 3 Paint horses, 2 Mor-
gans, and 1 Paso Fino. There were 31 females, 26 intact
males, and 10 geldings. Their ages at admission were 4
months to 8 years (average, 2.5 years) (Fig. 1).
An inciting cause for the lesions was known or presumed in
5 1 cases. Causes included lacerations (26), puncture wounds
(9), and contusions (without obvious skin deficits) associated
with kicking injuries or entanglement in fencing (16).
After the injury or the owner's initial awareness of the
problem, 1 day to more than 1 year (average, 7.5 weeks)
elapsed before admission to the university hospital. During
this time, 70% of the horses received some form of therapy,
often under the supervision of a veterinarian. Treatments
included bandaging, topical medications, and parenteral
antibiotics, but not surgery. All were unsuccessful. A few

From the Department of Surgery and Medicine, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas (Clem,
DeBowes, Douglass, Bennett) and the Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado
State University, Fort Collins, Colorado (Yovich).
Presented at the 21st Annual Meeting of the American College of Veterinary Surgeons, Orlando, February 1986.
Reprint requests: Michael F. Clem, DVM, MS, Department of Surgery and Medicine, College of Veterinary Medicine, Kansas State
University, Manhattan KS 66506.

3

CLEM, DEBOWES, YOVICH, DOUGLASS, AND BENNETT
-
Age
Range - 4 months t o 8 years
-x = 2.5 years
. -
I
CI 1-2 2 3 3-5 5-7 >7
Age in Years
Fig. 1. Age distribution of 67 horses with bone sequestra.
horses responded initially to parenteral antibiotic therapy by
a decrease in swelling and wound drainage, but they consist-
ently returned to their initial clinical status when therapy
was discontinued.
Most of the sequestra occurred on the appendicular skele-
ton in areas of minimal soft tissue coverage, with 53% of
them involving the metacarpal or metatarsal bones (Fig. 2).
Ten (14.7%) of the lesions were on the medial (7) or lateral
(3) aspect of a distal radial metaphysis. Four (5.9%)
sequestra involving the skull were sequelae to open fractures
from kicking injuries. Sixty per cent of the horses with leg
wounds were slightly lame at admission, although the spe-
cific cause of lameness was not always recorded.
Complete blood counts (CBCs) and serum chemistry pro-
files were obtained in 34 cases during hospitalization. All
serum chemistry profiles and 30 (88%) of the CBCs were
within normal limits. Abnormal CBC values were character-
ized by neutrophilia and mild lymphopenia consistent with a
stress response.
Sixty-two horses were treated by sequestrectomy with
debridement and curettage. The other five horses received
only medical therapy. After sequestrectomy , the surgical
site was sutured completely in 44 cases (71%), partially
sutured in 5 (8%) and not sutured in 13 (21%). Of the 44
wounds in which complete primary closure was attempted,
5 (1 1.4%) dehisced. All five wounds that were partially
sutured also dehisced and were left to heal by second inten-
tion. Eleven of the 39 sutured closures that did not dehisce
continued to drain through either the suture line or a surgical
drain; all had stopped draining by the time of suture removal
on days 10 to 14.
Nineteen samples for bacterial culture were collected
intraoperatively from deep within the sequestrectomy site.
One or more organisms were isolated from I1 (58%) of
them. In a total of 20 isolates, beta hemolytic Streptococcus
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3
LESION INCIDENCE BY ANATOMIC LOCATION (n = 68)
# YO #
- -
- _ _ O h
Metatarsal 22 32.3 Tibia 2 2.9
Metacarpal 14 20.6 Tuber coxae 2 2.9
Radius 10 14.7 Patella 1 1.5
Phalanges 4 5.9 Olecranon 1 1.5
Skull 4 5.9 Scapula 1 1.5
Mandible 3 4.4 Poll 1 1.5
Calcaneus 3 4.4
Fig. 2. Incidence of bone sequestra by anatomic location. One ani-
mal had two sequestra, resulting in 68 lesions in 67 horses.
sp. was identified six times, and beta hemolytic Escherichia
coli and Bacteroides sp. three times each. The remaining
isolates included Corynebacterium equi, Actinobaccillus
sp., Staphylococcus aureus, Pseudomonas sp., and Proteus
mirabilis. All isolates were sensitive in vitro to one or more
broad-spectrum antibiotics. No correlation was noted be-
tween the isolation of bacteria from intraoperative samples
and the subsequent outcome of a case.
Treatments after surgery included bandaging, casting,
nonsteroidal anti-inflammatory agents, parenteral antibiot-
ics, topical medications, and hydrotherapy. Bandages were
used to protect the operative site and reduce swelling. Casts
were applied infrequently to limit the formation of exuber-
ant granulation tissue during healing of open wounds, rather
than to provide external support for osseous defects.
The success of therapy was evaluated by the owners'
assessments of resolution of signs, cosmetic appearance,
and acceptable function. Accordingly, 59 (95%) of the cases
managed surgically had successful resolution of clinical
signs and return to function. In the three not treated success-
fully by sequestrectomy, failure was attributed to other
problems incurred at the time of the original injury. Of the
five cases managed medically, four healed successfully.
Calculation of the time required for healing was based on
the owners' responses. In general, a wound was considered
by the owner to be healed when all treatment had been
discontinued or granulating wounds were covered by epithe-
lial tissue. The average healing time for wounds that were
sutured and healed by first intention was 3.8 2 2 . 2 weeks.
Wounds that were not sutured or dehisced after suturing
required an average healing time of 6.4 ? 4.5 weeks.
Equine sarcoids developed at the incision sites of two
wounds left to heal by second intention and required over 12
months to be resolved. They were not included in the calcu-
lation of average time to healing.
Forty of 67 wounds (59.7%) healed with appearances
acceptable to the owners; they included all 39 managed by
primary closure that did not dehisce. Five wounds (7.5%)
were considered acceptable, although they had persistent
fibrous swelling or scar tissue overlying the sequestmm site.
Twenty-two healed wounds (32.8%) had unacceptable ap-
pearances because of scar tissue. All five cases managed

4 OSSEOUS SEQUESTRATION IN THE HORSE
Age o f Sequestrum Patients
in Contrast t o All Equine Admissions
45 - osseous involvement is increased and extraosseous or peri-
0 Bone Sequesirum Case Admissions i n = 6 7 )
Overall Equine Hospiiol Admissions ( n = B 5 6 I1
- Although all horses were sound for their intended use at
0 25
g
c
20
Lc 15
O 10
a p 5
0
<I 1-2 2-4 4-7 7-10 10-15 '15
Age in Years
Fig. 3. Age distribution of horses with bone sequestra compared to
the total equine admissions at the participating hospitals.
medically were in this category. None of the horses under-
went skin grafting or other cosmetic procedures.
Of the 40 horses with lesions associated with lameness,
32 (80%)returned to soundness. The lameness that persisted
in eight horses was characterized as mild and, when a cause
was identified in the medical record, was attributed to dam-
age to adjacent structures (suspensory ligament or flexor
tendons) at the time of the original injury.
Discussion
Breed and sex distributions of the affected horses were
similar to those of age matched hospital populations. The
relatively high number of intact males was consistent with
the usual age at castration.
Comparison of the ages at admission with those of the
hospital populations indicated a trend toward a higher inci-
dence of bone sequestra in younger animals (Fig. 3). This
finding was consistent with a previous report on cortical
sequestration in the horse.3 Sequestrum formation usually
follows and it has been speculated that younger
horses are more likely to be involved in traumatic incidents.'
The periosteum plays a greater role in cortical circulation
in pediatric bone than in adult bone," so the consequences
of periosteal injury may be greater in young patients. Trau-
matic disruption of the periosteum and bacterial infection
have been implicated in the pathophysiology of cortical se-
q ~ e s t r a t i o n . ~Sequestration
-~ followed some form of trauma
in 76% of the horses in this study. Medical records did not
always define the extent of the initial injury, but not all
injuries resulted in obvious skin deficits or periosteal in-
volvement. It is conceivable that blunt trauma, without an
obvious skin defect, could produce sufficient damage in
deeper tissues to disrupt the efferent periosteal circulation.'
Bacterial invasion of the ischemic area could occur by sev-
eral routes, including a small, unnoticed, penetrating
wound. Contaminated wounds which obviously involved
the periosteum have been associated with subsequent se-
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questrum f ~ r m a t i o n . ~Almost
-~ all sequestra in this and
other studies occurred in skeletal areas with minimal soft
tissue ~ o v e r a g e . ~In- ~these areas, the likelihood of direct
osteal revascularization of the ischemic cortex after trauma
is reduced. l o
the time of the review, the persistence of lameness in eight
of them indicates that athletic soundness should be ad-
dressed in the prognosis of bone sequestrum cases which
may have involvement of adjacent structures. Recovery was
often delayed by medical therapy instituted without knowl-
edge of the presence of a sequestrum, reaffirming the indica-
tion for radiographic evaluation of nonhealing wounds in the
horse. 3 3
Administration of parenteral antibiotics occasionally pro-
duced transient reduction of drainage or swelling. Resolu-
tion of bone sequestra by parenteral antibiotic therapy has
been reported; however, all cases required protracted ther-
apy.6 A prolonged local inflammatory reaction may be
expected to increase the amount of unsightly scar tissue.
The radiographic appearance of the lesions treated medi-
cally indicated that the successful medical cases had mini-
mal lesions which may have been diagnosed more accu-
rately as superficial osteitis rather than bone sequestra. The
small number of cases managed medically precluded mean-
ingful statistical comparison with those treated surgically.
The cosmetic outcome was less than optimal in some
cases because of the persistence of fibrous swelling, bony
enlargement, or scar tissue. Such features are particularly
undesirable in show horses. In 39 of 44 wounds (88.6%),
complete primary closure of the sequestrectomy site led to
first intention healing. When compared with partial closure
or management as an open wound, there was a trend for
primary closure to produce more rapid healing; however, no
significant difference could be shown. Partial closure ap-
peared to have little benefit over management as an open
wound, since all wounds managed in this fashion subse-
quently dehisced and healed by second intention. The
choice is dictated usually by a lack of soft tissue available
for complete closure, a circumstance which may indicate a
need for dermoplastic procedures or delayed wound closure.
Skin grafts and delayed wound closure were not used in
these horses. These techniques have been described in cases
of bone sequestra or other lower limb wounds and may
reduce healing time or improve appearance in selected
cases.4. I '
Although the effectiveness of antibiotics for localized in-
fections can be questioned, administering them during
sequestrectomy is probably justified to inhibit the spread of
infection during dissection of adjacent tissues.' Eight spe-
cies of bacteria were identified in samples taken at the time
of sequestrectomy, but their sensitivity to antibiotics was
probably less important than thorough debridement and la-
vage. The administration of nonsteroidal anti-inflammatory

CLEM, DEBOWES, YOVICH, DOUGLASS, AND BENNETT
agents was probably beneficial in reducing postoperative
discomfort and swelling. Bandages were also used to help
diminish swelling and protect the surgical site. In cases
where bone has been left exposed after surgery, sterile
dressings have been advocated.'
In summary, cortical sequestration tended to occur in
young horses after some form of trauma to an area of mini-
mal soft tissue coverage. Injury resulting in sequestmm for-
mation frequently caused mild lameness when limb wounds
were involved. The resolution of lameness in most patients
indicated that a reasonably good prognosis for soundness
could be offered as long as appropriate consideration was
given to damage to adjacent structures. Failure to define the
true nature of the condition by radiographic evaluation led to
excessive time lapses between injury and definitive therapy.
Sequestrectomy would appear to be the treatment of choice,
although a small number of cases resolved with medical
therapy. When it was possible, complete closure of the
sequestrectomy site tended to hasten healing and improve
the postoperative appearance.
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5
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