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Buttons

I’ll never forget my first solo attempt at surgery on a horse. A work horse in the next town was cut and needed suturing. I got directions to the place and was there shortly. No one was around when I drove in, but tied to a ring on the side of the barn was a big Belgian. He was facing me with his head down. I walked up to him and patted him on the left shoulder. This side seemed OK. I ducked under his neck and around to his right side, looking for a wound. Nothing there. I walked all around him, checking each leg, because that’s where horses usually get cut. Nope. I guessed that I had the wrong horse.

I stood back a few feet, and then it caught my eye. You have to understand that this was close to a one ton horse which means that there is a lot to take in at a glance. I just hadn’t been looking high enough. There it was, right in front of my face, the most awful looking sight I had ever seen. I took a step back. No good. I still couldn’t take it all in. I took two more steps back. Now I could see the whole ugly thing. He was cut from the top of his croup down across his hip and down behind the stifle. It was a huge gash. Without exaggeration, this laceration was over three feet long, and at one point was eight inches deep. The muscles near the wound edge had already started to pull back the skin, and at its widest point there was a foot of separation.

I had been out of vet school just a month, and all of my surgery to this point had been under very controlled situations with instructors looking on. I felt like I had been hit with a pail of ice cold water. As I was staring at the wound with my mouth open, Leonard came out of the barn. “Sorry, Doc, didn’t hear you drive up. That’s Bob, and he’s a mess, ain’t he? He come ‘round the corner goin’ full tilt and hooked hisself on a piece of steel roof that I ain’t tacked down since that last storm ripped it. Do you think you can fix him, or should we just lay him away?”

All the possibilities and their implications flashed through my brain. Finally I spoke. It was just one word. “Buttons.”

“Buttons?”

“Yes, buttons. I’ll need lots of buttons. See if your wife can dig out a couple of handfuls from her sewing basket. The bigger the buttons the better.” I needed both the buttons and the chance to be alone for a few minutes to fight the panic rising up from my gut. By the time Leonard had returned with the buttons I had everything that I needed from my vehicle. I threw the two dozen buttons into a disinfecting solution. As I cleaned up the wound I explained the purpose of the buttons.

In very large gaping wounds sutures alone can’t hold the skin edges together. The stitches will hold, but the tissue doesn’t, and the nylon, steel, or whatever is used will pull right through the skin. However, if the suture material is run through buttons on each side of the cut the pressure is taken by them and not the skin. The idea was not original with me. Buttons, gauze, surgical tubing, and all kinds of things have always been used in large wounds to keep sutures under tension from cutting through the skin.

Once I got busy with the job ahead of me, I calmed down somewhat and began injecting a local anesthetic along the wound edges. I kept my hand on the horse as I injected the local so that my shaking hands wouldn’t be as obvious. A typical horse wound will take somewhere between 10 and 20cc. I used over 300cc on Bob, and would have used more, but that’s all I had.

I had to stand on a plastic 5 gallon pail to reach the top of the incision. First I pulled the sliced muscles together as best as I could with absorbable suture. Almost three hours later I was tying the last of the skin sutures using heavy nylon. I had put in several drains, used up all of my suture material, dulled many needles, and used every one of those buttons. I stepped back to look at my handiwork. The three foot long incision was pulled together and lined on both sides with buttons of every description. There were coat buttons, pants buttons, and even a few dress buttons. I gave the horse some penicillin and a tetanus booster, and told Leonard not to let Bob lie down. He walked Bob into a straight stall, and told me that it should be OK as he had never seen Bob lay down, “not once.”

I drove back to the office feeling exhausted, but good. I walked in to tell my boss about how I had spent the afternoon. Before I got started the phone rang. It was Leonard. “Remember I told you I had never seen that horse lay down. Well, he did, and all them buttons and everything just popped right out.”

I asked my boss to drive back out with me. I couldn’t face it alone. Sure
enough, all “them buttons” and probably 10 pounds of muscle were hanging out of the wound. Things were a bigger mess than when I arrived at the farm hours before. When Bob lay down the strain on the skin line was too much and everything, including the buttons, had pulled through the skin. We cut through the tattered mess of skin, sutures and muscle to try to neaten things up. All this time I was thinking about how we could ever possibly bring the skin back together again. Before I could offer an opinion I heard my boss telling Leonard how to clean the wound out every day. “Wait a minute,” I exclaimed, “We can’t leave Bob gaping open like this!”

“Well, we can,” said my boss, “and what’s more, that’s just what we’re going to do.” I started to protest but he stared me down, and after things were cleaned up we got back in the vehicle. As we drove back to the office, he said he probably wouldn’t have sutured the wound in the first place.

I stopped and saw the horse regularly after that. It was a never to be forgotten lesson for me in how nature takes care of massive injuries. Within a few weeks healing tissue had filled the gap of the wound. Three months later new skin was well on its way across the defect. In six months there was just a long raised scar. One year after the accident you could feel the scar with your finger, but it was covered by skin and hair and not visible to the eye. Bob, totally healed, was back to pulling logs out of the woods.

I’ve attended many cut horses since, and now, decades later, have to agree with my old boss. There are some wounds in horses that are best left alone. In my experience huge tears over heavily muscled areas often heal best when left open. I still sometimes suture big wounds, and sometimes it works. However, there have also been times that I have had to go back and remove the sutures that couldn’t hold a huge wound closed.

Some pastern and heel cuts also don’t do well when sutured. This is especially true when they are in an area that is constantly flexing. Some wounds are too contaminated to suture. In others, the time lag is too long, and the edges just can’t be pulled together.

I am not suggesting that you ignore these wounds. By all means, have your veterinarian out to look at your cut horse. Call as soon as you discover a wound so that if it needs suturing it can get done within a few hours. On the other hand, don’t be surprised if your vet says that this one might heal better without interference.

 

David A. Jefferson, DVM

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