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Wound Worries: Understanding Proud Flesh

 

Story by Dr. T.A. Banner Photos by Christa Moody

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”.

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.

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Open wounds, if let untreated, can lead to major proud flesh build up. Early treatment is critical to prevent this from occurring.


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.

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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