Emergency conditions of

the equine thorax

Rolfe
M.M.
Radcliffe,
DVM,
Rolfe
Radcliffe
Diplomate
ACVSACVS
DVM,
Diplomate
Cornell University

Thoracic Surgery
Summary
1.
2.
3.
4.
5.
6.
7.

Sequellae
Patient Stabilization
Diagnosis
Treatment
Surgical Considerations
Complications and Prognosis
Thoracoscopy

Thoracic Trauma
Sequellae
1.
2.
3.
4.
5.
6.
7.

SQ emphysema
Pneumothorax
Pneumomediastinum
Hemothorax
Pleuritis
Diaphragmatic hernia
Lung, heart, vessels, abdomen
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999

Thoracic Trauma
Clinical Signs
Pain 10/15 horses
(5 sustained rib fractures)
Abnormal respiration - 10
(tachypnea, shallow, labored or distressed)
Decreased lung sounds - 8
Fluid lines (radiographs) - 6
SQ emphysema - 12

Laverty, S, et al, EVJ 28(3), 1996

Thoracic Trauma
Diagnosis

Deformed chest wall

Palpation (rib fractures)
Flail chest
Radiographs and ultrasound
Thoracic or abdominal paracentesis
Thoracoscopy
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999

Thoracic Trauma
Radiology/ Ultrasound

Diaphragmatic hernia
Pneumothorax
Pleural fluid (hemorrhage)
Atelectatic lung
Rib fractures
Foreign bodies

T. Divers

Hendrix, SM and Baxter, GM, VCNA-EP, 2005

Thoracic Trauma
Diaphragmatic Hernia
Colic and dyspena
Acquired from blunt trauma
Radiology, ultrasound, thoracentesis
Treatment: Primary closure via midline
ceiliotomy, rib resection, thoracoscopy or
laparoscopy

T. Divers

Auer, JA & Stick, JA, Equine Surgery,

2nd Ed, 1999

Thoracic Trauma
Pneumothorax
T. Divers

1. Open: open chest wound - air enters

pleural space during inspiration
2. Closed: lung laceration - air enters pleural
space from lung
3. Tension: chest wound - one way valve creates
severe tension in pleural space
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999

Thoracic Trauma
Pneumothorax
T. Divers

Causes: Pleuropneumonia (17/40), open

thoracic wounds (9), closed thoracic trauma (7),
surgery of the respiratory tract (4)
Pneumothorax: bilateral 47.5%
unilateral 42.5%
Prognosis: worse if pleuropneumonia
Boy, MG, et al, JAVMA 216(12), 2000

Thoracic Trauma
Treatment
1. Patient stabilization
2. Conservative management
3. Surgical exploration
Wound debridement/ lavage
Thoracotomy
Thoracoscopy
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999

Thoracic Trauma
1. Patient Stabilization
Emergency Treatment
Remove pleural air
Close or bandage thoracic wounds quickly
Prevent tension pneumothorax
Control hemorrhage if possible
Fluid therapy, blood transfusions, antibiotics,
oxygen supplementation
Hendrix, SM and Baxter, GM, VCNA-EP, 2005

Thoracic Trauma
1. Patient Stabilization
Emergency Thoracentesis
Teat cannula or catheter
High in 12-15th intercostal space
Extension set + 3-way stopcock
60 ml syringe or suction pump

T. Divers

Auer, JA & Stick, JA, Equine Surgery,

2nd Ed, 1999

Thoracic Trauma
1. Patient Stabilization
Tension Pneumothorax
Pleurocutaneous fistula
Rapid cardiopulmonary collapse
Severe Hypoxemia (PaO2 22-28 mm Hg)
Thoracentesis (Patm = Ppleural)
Pneumothorax less detrimental

S. Fubini

Auer, JA & Stick, JA, Equine Surgery,

2nd Ed, 1999

Thoracic Trauma
2. Conservative

N. Ducharme
Patient stabilization
Prevent tension pneumothorax
Simple rib fractures
Wounds without severe lung lacerations,
continued hemorrhage, deep penetration,
abdominal cavity

Laverty, S, et al, EVJ 28(3), 1996

Thoracic Trauma
3. Surgery

Patient stabilization
Deep penetrating wounds
Lung lacerations
Complicated rib fractures (flail chest)
General Anesthesia with positive pressure
ventilation
Colahan, PT, et al, Equine Medicine
and Surgery, 5th Ed, 1999

Thoracic Trauma
3. Surgery

Explore pleural space

Control hemorrhage
Lavage pleural cavity
Repair lung lacerations
Repair rib fractures
Stabilize flail chest

N. Ducharme

Laverty, S, et al, EVJ 28(3), 1996

Thoracic Trauma
Surgery
Lung Lacerations

Rib fractures lacerate lung parenchyma

Warm saline to detect bronchial damage
Close bronchioles
Appose lung margins
Mattress pattern with atraumatic needles
Fowler, ME, 1973, JAVMA, 162(11)

Thoracic Trauma
Surgery
Close Bronchioles
Stapled or sutured

Fowler, ME, 1973, JAVMA, 162(11)

Thoracic Trauma
Surgery
Rib Fractures

Control pain!
Remove rib fragments
Round sharp rib edges
Rib stabilization: Quill sutures, wires, plates
Adults heal without fixation
(Caution: closed pneumothorax)
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999

Thoracic Trauma
3. Surgery
External splint - flail chest

N. Ducharme

Thoracic Trauma
3. Surgery

Remove air from pleural cavity

Place thoracic drains (remove fluid and air)
Wound closure (muscle transposition)
Skin closure techniques
Wound management
Hendrix, SM and Baxter, GM, VCNA-EP, 2005

Thoracic Trauma
Surgery
Standing vs. GA

GA required in most complicated cases

Risk tension pneumothorax (standing)
Thin, fenestrated caudal mediastinum
Bilateral pneumothorax fatal
Ultrasound and radiography
Colahan, PT, et al, Equine Medicine
and Surgery, 5th Ed, 1999

Thoracic Trauma
Surgery
Penetrating Wounds
S. Fubini
Trauma (fence posts, gates, pipes,
trees, wheelbarrows)
Access both thoracic and abdominal cavities
Diaphragm extends to 6th rib on expiration
Explore: foreign bodies
Standing surgery
Laverty, S, et al, EVJ 28(3), 1996

Thoracic Trauma
Surgery
Thoracic Trauma - Foals
20% incidence of thoracic asymmetry
9 foals with rib fractures
No clinical signs
History of dystocia
Primiparous mares
Fillies > colts
Jean D, et al, 1999, EVJ, 31(2)

T. Divers

Thoracic Trauma
Surgery
Rib Fractures - Foals
760 necropsy specimens
19 of 76 (28%) foals died from rib fractures
Internal fixation (2.7mm reconstruction plates,
cortical screws, cerclage wire, Steinmann pins)
12/14 (86%) survived
Steinmann pins: cyclic failure, implant
Schambourg, MA, et al, 2003, EVJ, 35
migration
Bellezzo, F, et al, 2004, EVJ, 36(7)

Thoracic Trauma
Surgery
Reconstruction
Plate
+ Screws
+ Cerclage Wire

Bellezzo, F, et al, 2004, EVJ, 36(7)

Thoracic Trauma
Surgery
Rib Fractures - Foals

Multiple rib fx repair (ribs 2-9)

Life threatening when >3-5 ribs involved
Securos - cranial cruciate ligament repair
Holes drilled through outer cortex only
Decreased damage to parietal pleura
Kraus, BM, et al, 2005, Vet Sx, 34

Thoracic Trauma
Surgery
Wound Closure
1.
2.
3.
4.

Primary closure or second intention

Primary muscle flap
Diaphragmatic advancement flap
Prosthetic mesh

Hendrix, SM and Baxter, GM, VCNA-EP, 2005

Thoracic Trauma
Surgery
Muscle Pedicle Flap
1. Longissimus - rotate ventral
2. External abdominal oblique - rotate dorsal
3. Z-plasty
4. Dogs: Polypropylene mesh, muscle flaps,
mesh & omental pedicle, mesh & PMMA,
diaphragmatic advancement flaps
Stone WC, et al, 1994, JAVMA, 205(6)

Thoracic Trauma
Surgery

Muscle
Pedicle
Flap

Stone WC, et al, 1994, JAVMA, 205(6)

Thoracic Trauma
Surgery
Skin Closure - tension relief
1.
2.
3.
4.
5.

V-Y flaps
Z-Plasty
Skin flaps (H-plasty, Rotating flaps)
Mesh expansion
Tension sutures
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999

Thoracic Trauma
Complications

Pleuritis (50% mortality)

Severe abdominal or musculoskeletal injury
Pleural abscesses
Subcutaneous emphysema
Pnemothorax
Laverty, S, et al, EVJ 28(3), 1996

Thoracic Trauma
Prognosis
73% survival
15 horses: SQ emphysema (12),
pneumothorax (12), pneumomediastinum (6),
hemothorax (5)
Foreign body removal (2), suture wounds (6),
packed wounds (7)
Laverty, S, et al, EVJ 28(3), 1996

Thoracic Trauma
Conclusions
Favorable prognosis
Thoracic empyema uncommon
Euthanasia from extrathoracic trauma
(colon perforation, renal trauma, luxated spine)
Foreign bodies rare
SQ emphysema with axillary wounds
Laverty, S, et al, EVJ 28(3), 1996

Thoracic Surgery
Thoracoscopy
Summary
1.
2.
3.
4.

Equipment
Technique
Anatomy
Applications
Vachon, AM and Fischer, AT, EVJ,
30(6), 1998
Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Equipment
57cm L, 10mm D, 30 Telescope
Sharp Tocar/cannula 15cm L, 11mm D
Camera, monitor, 300 W xenon light source,
CO2 insufflator
Biospy forceps, scissors, electrosurgery
Teat cannula, suction unit
Vachon, AM and Fischer, AT, EVJ,
30(6), 1998

Thoracic Surgery
Thoracoscopy
Technique

Standing technique (stocks)

8th, 10th and 12th intercostal spaces
Sedation - CRI detomidine
Good view of dorsal, lateral structures
GA - ventral, cranial thorax
Vachon, AM and Fischer, AT, EVJ,
30(6), 1998
Peroni, JF, et al, EVJ, 32(4), 2000

Thoracic Surgery
Thoracoscopy
Anatomy - R cranial hemithorax

Collapsed R lung
Esophagus
Aorta
Azygos vein

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - L cranial hemithorax
Collapsed L lung
Aorta

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - R cranial hemithorax

Collapsed R lung
Esophagus
Pulmonary veins
Vagus nerve

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - L cranial hemithorax

Collapsed L lung
Esophagus
Aorta
Mediastinal LN
Vagus nerve
Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - L dorsal hemithorax

Collapsed L lung
Aorta
Esophagus
Dorsal mediastinum

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - R caudal hemithorax
Diaphram
Ribs 14 and 15
Psoas major muscle

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - L caudal hemithorax

Collapsed L lung
Diaphram
Dorsal mediastinum
Esophagus

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - L caudal hemithorax
Collapsed L lung
Diaphram

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - R caudal hemithorax
Diaphragmatic hiatus
Ribs 14 and 15
Psoas major muscle

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Anatomy - L caudal hemithorax

Diaphragmatic hiatus
Aorta
Esophagus
Psoas major muscle

Peroni, JF, et al, EVJ, 33(3), 2001

Thoracic Surgery
Thoracoscopy
Retrospective study

32 thoracoscopies in 28 horses
Age 4 months - 25 years
16 pleuropneumonia, 12 other
26 standing, 6 under GA
Conclusion: safe and useful tool
Vachon, AM and Fischer, AT, EVJ,
30(6), 1998

Thoracic Surgery

Thoracoscopy
Applications
Diagnostic and therapeutic procedures:
1. Exploration
2. Biospy of lung, lymph node

Vachon, AM and Fischer, AT, EVJ,

30(6), 1998

Thoracic Surgery

Thoracoscopy
Applications
Diagnostic and therapeutic procedures:
3. Insertion of drain for pleural effusion, abscess
4. Transection of pleural adhesions

Vachon, AM and Fischer, AT, EVJ,

30(6), 1998

Thoracic Surgery

Thoracoscopy
Applications
Diagnostic and therapeutic procedures:
5. Pericardectomy
6. Diaphragmatic hernia repair

Vachon, AM and Fischer, AT, EVJ,

30(6), 1998

Thoracic Surgery

Thoracoscopy
Applications
Diagnostic and therapeutic procedures:
5. Partial pneumectomy
6. Plan thoracotomy approach

Vachon, AM and Fischer, AT, EVJ,

30(6), 1998
Malone, ED, et al, Vet Surg, 30(2), 2001

Thoracic Surgery

References
1.
2.

3.

Auer, JA and Stick, JA, Thoracic trauma. Equine

Surgery, 2nd Ed., WB Saunders, 1999
Bellezzo, F, et al, Surgical repair of rib fractures in 14
neonatal foals: case selection, surgical technique and
results. EVJ, 36(7), 2004
Boy, MG and Sweeney, CR, Pneumothorax in horses:
40 cases (1980-1997). JAVMA, 216(12), 2000

Thoracic Surgery

References
4. Colahan, PT, Mayhew, IG, Merritt, AM and Moore,
JN (eds), Diseases with physical causes. Equine
Medicine and Surgery, 5th Ed., Mosby, 1999
5. Fischer, AT and Vachon, AM, Thoracoscopy. Equine
diagnostic & surgical laparoscopy, WB Saunders, 2002
6. Fowler, ME, Intrathoracic surgery in large animals.
JAVMA, 162(11), 1973
7.

Hendrix, SM and Baxter, GM, Management of

complicated wounds. VCNA-EP, 21, 2005

Thoracic Surgery

References
8.
9.
10.
11.

Kraus, BM, et al, Multiple rib fracture in a neonatal

foal using a nylon strand suture repair technique. Vet
Surg, 34, 2005
Laverty, S, et al, Penetrating wounds of the thorax in
15 horses. EVJ 28(3), 1996
Malone, EM, et al, Thoracoscopic-assisted
diaphragmatic hernia repair using a thoracic-rib
resection. Vet Surg, 30(2), 2001
Peroni, JF, et al, Pleuropulmonary and cardiovascular
consequences of thoracoscopy performed in healthy
standing horses. EVJ, 32(4), 2000

Thoracic Surgery
References
12. Peroni, JF, et al, Equine thoracoscopy: normal
anatomy and surgical technique. EVJ, 33(3), 2001
13. Schambourg, MA, et al, Thoracic trauma in foals:
post-mortem findings. EVJ, 35, 2003
14. Stone, WC, et al, Use of a primary muscle pedicle flap
to repair a caudal thoracic wound in a horse. JAVMA,
205(6), 1994
15. Vachon, AM and Fischer, AT, Thoracoscopy in the
horse: diagnostic and therapeutic indications in 28
cases. EVJ, 30(6), 1998

Thoracic Surgery
Acknowledgements
Drs. Ducharme and Fubini
Dr. Divers

QUESTIONS?