Subedited by Dr Phil Tucak
This case provides an overview of the management of a non-healing wound in a dog. Jimmy is a seven-year-old male desexed greyhound who presented to the Animal Happiness Vet in Perth in July 2020 after a collision with another dog at the local park. Jimmy had exhibited lameness in the left hind leg for two days prior to presenting for examination.
After initial assessment of Jimmy, we suspected a toe fracture in the second digit of the left hind limb. A modified Robert-Jones support bandage was applied and a non-steroidal anti-inflammatory (meloxicam) was dispensed. Radiographs taken the next day (Figure 1) confirmed the diagnosis of a fractured phalange of digit 2. The initial Robert-Jones bandage was upgraded with the addition of a shoe splint to provide additional support, and it was advised that Jimmy should rest and be protected from play and prey triggers.
Seven days later Jimmy was rechecked and the bandage removed. A new bandage was reapplied. This dressing was changed again a further seven days later, revealing excessive pressure over the hock and resultant dermal necrosis at the proximal calcaneus (Figure 2). The toe fracture, by contrast, was healing rapidly and without complication.
At this point, 15 days post initial presentation, the splinted bandage was modified with the addition of a donut dressing and the application of flamazine and melolin dressings over the necrotic area of skin. The frequency of bandage changes was increased to every three days and the owner took care of bandaged changes in between rechecks at the veterinary clinic.
Nine days later, a purulent discharge was noted from the ulcerated wound and systemic antibiotics (amoxyclav) were started. In addition, one of the toe pads adjacent to the fractured toe (digit 3) had developed a corn lesion.
The following day, Jimmy was admitted for a general anaesthetic for a wound assessment and clean-up (Figure 3). In this procedure the surgeon chose to try and temporarily close the calcaneal wound after flushing and debriding the area. The corn lesion was also thoroughly debrided. At a second subsequent recheck four days later, discharge was discovered from deep within the ulcer that was not apparent at a recheck two days earlier.
Samples were taken of this discharge for culture and sensitivity testing, which revealed penicillinase producing Staphylococcus pseudintermedius that should be sensitive to the amoxyclav antibiotics. Despite this result, it was decided to add sulphatrimethoprim to the antibiotic regime. Manuka honey was also substituted for the flamazine and evidence of infection began to reduce.
However, at six weeks from the time of the suspected initial problem bandage application, it was apparent that the lesion was getting bigger from bandage change to subsequent bandage change and we began to feel that further surgery was going to be necessary.
At this point the bandage design was revisited and two significant changes were implemented. The donut dressing was suspected to be ineffective as it was almost always slipping distally between bandage changes. So instead, a revised dressing process over the Manuka honey and melolin layer simply involved building up multiple layers of softban padding—proximal and distal to the wound, and then just one or two layers of softban over the ulcer itself. In addition, a splint was moulded to the anterior aspect of the semi-extended hock and layered into the final cohesive bandage covering.
At this point, evidence of infection was becoming apparent again and another sample was submitted for further culture and sensitivity testing. Enrofloxacin antibiotic was started empirically at this point. The sensitivity study showed a Cellulomonas spp/Microbacterium spp population resistant to sulphatrimethoprim.
We were still worried we weren’t going to win with this conservative approach and surgical referral was discussed with the wonderfully patient owner. He agreed to visit a specialist surgeon on our advice.
There were delays in this process and by the time he was presented to the surgeon (Figure 5), there was sufficient improvement that the specialist surgeon chose to keep treating Jimmy’s wound conservatively.
After a week we took over primary care of Jimmy again. At this point we transitioned to duoderm-based dressings as Manuka honey is better suited to early stage and more contaminated wounds.
Finally, at this point things started to go to plan (Figure 6), if slowly. Progressively the granulation bed filled in the wound and the surface eventually fully epithelised four months after the original bandage wound was sustained.
While it is the case that greyhound skin is especially prone to iatrogenic bandage damage, we were upfront about the fact that it was our bandage that had caused the initial problem. We cut all billing to just consumables and the owner was quite marvellous throughout the whole process.
A lack of infection control was obviously a big part of the delay in healing. However, joint mobility and bandage design appeared to make the biggest difference overall to the capacity of this very difficult wound to heal.
Jimmy is now bandage free (Figures 7, 8) and his wound is gathering strength. He is still on restricted exercise as we are aware greyhound goofiness could see this large area of exposed scar tissue being damaged again.
Dr Gary Beilby BSc BVMS MVS (Conservation Medicine)
Dr Gary Beilby is a Murdoch graduate from 1989. After a hiatus from vet practice, he returned in 2007 and completed a Masters in conservation medicine. In addition, he has a focus on behaviour medicine but will likely remain a GP.
Born and raised in Perth, Dr Beilby has travelled extensively throughout Australia from a young age. He has a deep love of the West Australian bush—from the deserts to the tall forests—and draws enormous nourishment from camping out under the stars or sitting quietly waiting for wildlife to pass in front of his camera lens.
Today he runs Animal Happiness Vet—comprising a hospital and ambulatory service based in Perth—and sits on the board of Veterinarians for Climate Action.