Healing of equine heel bulb lacerations: Evidence behind casting compared to bandaging alone

PICO question 
In horses with heel bulb lacerations, does casting the distal limb compared to bandaging result in increased speed of healing and functional outcome? 
  
Clinical bottom line 
Category of research question 
Treatment 
The number and type of study designs reviewed 
A single retrospective study was found to be relevant to the topic along with one case report and two case series, including one tutorial article 
Strength of evidence 
The majority of the current recommendations come from expert opinions, making the level of evidence low 
Outcomes reported 
There are currently insufficient data to compare the effect of foot/slipper casts versus bandaging alone on the rate of healing of equine heel bulb lacerations 
Conclusion 
Based on the information from these three publications, it is not possible to recommend the use of a foot cast over a bandage alone at this time 
  
How to apply this evidence in practice 
The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. 
Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care. 
  



The evidence
The literature comprises several non-peer reviewed publications, such as CPD material and tutorial articles. Only one retrospective case study, including a large number of horses treated with bandaging and/or casting, was found. Based on the publications currently available, there is sparse evidence that casting is superior to bandaging for healing of heel bulb lacerations in the horse and the quality of the evidence is considered low.
Summary of the evidence 1

Limitations:
 Specific location of wounds non-identified (unknown how many involved the coronary band, heel bulb, pastern, etc.)  No group treated with bandaging only for comparison/control  Type of synovial lavage non-specified (arthroscopic versus through-and-through needle lavage)  Incoherent information on systemic antibiotics  No details on regional antimicrobials for contaminated wounds  Doses for intra-articular medication and intravenous regional limb perfusions are not specified  Little detail regarding complications, namely none on cast sores

Appraisal, application and reflection
There are very few studies evaluating the efficacy of using distal limb casts when treating heel bulb lacerations compared with bandages alone in horses. Based on the publication from Janicek et al. (2005), casting as opposed to bandaging may reduce the treatment duration of heel bulb lacerations. However, the length of treatment and the success of wound healing are both directly related to the way these wounds are approached, namely if they are treated by primary or secondary closure (Janicek et al., 2005). Since the number of horses in each group (bandaging versus casting) treated with primary closure versus delayed primary or second intention healing was not specified, the conclusion that distal limb casting results in faster healing of heel bulb laceration remains questionable. Janicek et al. (2005) recommended all heel bulb wounds which are minimally contaminated with debris and of short duration following injury (< 8 hours) be managed by primary closure and physical support of the site with either a bandage or a cast. In cases of wounds severely contaminated or traumatised, the authors recommended a foot bandage for 7-10 days prior to cast immobilisation. While these recommendations are very logical and allow more frequent monitoring of the wound healing and care, the study results are inconclusive when it comes to favour bandaging or casting to speed up wound healing. On the other hand, Burba et al. (2013), an expert opinion article aimed at veterinary surgeons, stated that heel bulb lacerations were best treated by primary closure when possible and with the use of a foot cast. As this is an opinion piece rather than an original study, no compelling evidence in favour of using foot casts over bandaging was found for these cases.
The potential involvement and treatment of synovial sepsis appears to be an important factor influencing outcome in cases of heel bulb laceration. Janicek et al. (2005) reported that lacerations involving a synovial structure had a significantly poorer outcome than those without. Synovial involvement also influences the approach to the wound. In the study by Janicek et al. (2005), all wounds communicating with synovial structures were left to heal by second intention following surgical management of sepsis. The authors recommended that all lacerations involving synovial structures are considered contaminated and