External coaptation.

The goal of any method of fracture repair should be the early return of total limb function and the prevention of fracture disease. This can be accomplished through adhering to the basic principles of good patient and fracture assessment, choosing the correct method of fracture repair, and appropriate patient care. The complications of external coaptation can be minimized by appropriate patient and fracture assessment as well as correct cast and splint application. Choosing external coaptation as a method of fracture repair can be rewarding as long as the appropriate steps are taken to ensure success.     

Fracture complications. An overview

No surgical procedure is free of complications. Determining the reason that a complication of a fracture repair occurred and developing a treatment plan are important if the objectives of fracture treatment are to be met. It is also necessary to deal with owners, and, sometimes, other veterinarians in meeting these objectives.     

Femoral Head and Neck Fractures in the Dog and Cat: A Review of 115 Cases

Case histories of 115 dogs and cats with fractures of the femoral head or neck, were reviewed; these animals had been presented to the Ohio State University Veterinary Hospital between 1969 and 1976. Signalment, fracture type by anatomic location, fracture to fixation interval, surgical approaches used, methods of surgical repair, surgical complications, and final results of surgical repair were examined. Avascular necrosis of the femoral head was not a clinically significant problem following internal fixation in this study. Most animals had very good to excellent limb function following fracture repair.     

Fractures of the radius and ulna.

Fractures of the radius and ulna are common in the dog and cat. If treated inappropriately, complications may result. These include delayed union, nonunion, malunion, and growth deformities. ESF is a versatile method of fixation for fractures of the radius and ulna. Types that are applicable range from the simple type I to the complex type III fixator. In general, the more unstable the fracture, the more rigid the assembly must be to counteract fracture forces. There are three basic phases to consider when using ESF: (1) preoperative planning, (2) application of the ESF, and (3) long-term management. A deficiency in any one of these phases can lead to complications and an unsatisfactory clinical outcome. Although ESF can be used on many types of fractures, the technique is especially well suited for open or highly comminuted fractures when internal fixation is not applicable. In these cases, close attention must be paid to the integrity of the soft tissues. In addition, cancellous bone grafts should be placed either at the time of initial repair or in a delayed fashion after adequate vascularity has been established. Staged or complete removal of the ESF should be individualized to each fracture case. In general, staged disassembly or "dynamization" can begin when the bone and fixator begin to function as a composite as determined by radiographs. Complete fixator removal should be considered when the fracture exhibits clinical and radiographic evidences of union.     

Basic mammalian bone anatomy and healing.

The goal of any method of fracture repair should be the early return to function of the patient with minimum postoperative morbidity. This is accomplished most optimally by having a basic understanding of the biology of bone healing and by being familiar with the musculoskeletal system of the species before attempting fracture repair. Applying the fundamental principles of mammalian bone anatomy and physiology to the bird ensures the best prognosis possible and minimizes postoperative complications in the avian patient.     

A Fresh Look at the Process of Arriving at a Clinical Prognosis Part 4: Fractures

Equine bone and biomechanics research continues to provide us with sound and practical concepts for preventing fractures in equine athletes, accelerating a safe return to training and competition, and avoiding recurrence. Bone is a living, dynamic tissue that is constantly in a state of turnover as part of its ongoing maintenance, and is constantly responding to the various forces it experiences, from within and without. Even the seemingly inert, acellular components of bone are in a perpetual state of flux under both biomechanical and metabolic/nutritional influences. Homeostasis in bone involves both modeling and remodeling; modeling is bone's adaptive response to increases or decreases in load that are of insufficient magnitude to damage the bone. It involves the addition or removal of existing bone, changing the shape and loading capacity of the bone as needed. Remodeling is bone's reparative response to injury; it involves the removal and replacement of bone in the area of damage. Fractured bone needs the following conditions for best repair: protection—remove the primary cause of bone injury and prevention of further such injury; stability—depends on the type and site of fracture; blood flow—bone is dependent on good blood supply for repair; competent immune response—a robust white cell response is necessary both for tissue repair and for prevention/resolution of bacterial infection at the site; nutrients—all living tissues need adequate calories, and protein, minerals (including trace minerals), and vitamin D are of primary importance for optimal bone repair; and load—after fracture healing, increasing the loading capacity of the bone directs further bone repair and modeling. The prognosis may be adversely affected when any of these conditions are not met adequately. Generally, fractures in horses are not fatal injuries by themselves but most often prompted by a poor prognosis for return to soundness because of the fracture type, the development of serious complications, and the economic investment required for adequate repair. Factors that determine the prognosis for survival are degree of structural failure, ease of fixation and potential for complications, adequacy of stabilization, concurrent and complicating conditions, owner's wishes, and prognosis for return to athletic performance. Fractures of the metacarpus and metatarsus are used to illustrate the aforementioned principles.     

Internal fixation of a proximal metatarsal fracture in a calf

An open proximal metatarsal fracture was identified in a 9-month-old calf. Open reduction, internal fixation, and external coaptation were used to repair the fracture. The calf recovered without complications and was reported to be sound 6 months after surgery.     

Principles of long bone fracture management.

The fixation of fractures in which one of the following primary devices is used: IM pins, bone plates, external skeletal fixators, can benefit from the additional application of any number of secondary devices. The secondary devices include cerclage, hemicerclage, or interfragmentary wires, skewer-pins, screws, and external skeletal fixators. These are indicated to facilitate the repair and eliminate the forces acting on the fracture site. A complete understanding of all the methods of fixation facilitates the selection of the proper implant or combination of implants. This information must be combined with the knowledge of how each device is most appropriately used depending on both the fracture type and fracture location. Taking into consideration all of these factors helps ensure that fracture healing occurs in the shortest possible time with the fewest complications. The ultimate goal of obtaining a full return to function may thereby be achieved.     

Complications after orthopedic surgery in alpacas and llamas: 24 cases (2000-2006)

Objective— To report complications associated with orthopedic surgery in alpacas and llamas.
Study Design— Retrospective study.
Animals— Alpacas (n=18) and llamas (n=6) that orthopedic surgery using internal or external fixation.
Methods— Medical records (January 2000–December 2006) and radiographs were reviewed and owners contacted for follow-up information for alpacas and llamas that had orthopedic surgery involving internal or external fixation. Fourteen camelids had internal fixation, 7 had external fixation, and 3 had a combination of internal and external fixation.
Results— Twenty-two animals (92%) were discharged after surgery (mean hospitalization, 15 days). Of 20 animals with ≥1 year follow-up information, 18 were alive (82%). Postoperative complications related to fracture healing, infection, soft tissue structures, or joints occurred in 21 camelids (87%). Thirteen animals returned to their intended use, 4 animals returned to breeding but not their intended use, 4 were euthanatized, and 3 were only able to be used as pets.
Conclusions— Fixation type (internal, external) did not have any significant effect on complications involving fracture healing, infection, soft tissue structures, or chronic lameness. Camelids with open fractures were more likely to have complications associated with fracture healing, repair, and infection than closed fractures.
Clinical Relevance— Complications after orthopedic surgery in alpacas and llamas are more common than previously reported and may result in chronic lameness or prevent return to their intended use.     

Fractures of the rostral portion of the mandible and maxilla in horses: 89 cases (1979-1997).

OBJECTIVE: To compare fracture locations, repair methods, complications, and outcomes of horses with fractures of the rostral portions of the mandible and maxilla. DESIGN: Retrospective study. ANIMALS: 89 horses with fractures of the rostral portions of the mandible and maxilla. PROCEDURE: Medical records and radiographs were reviewed. Fractures were categorized by fracture location and stability. Postoperative complications and long-term outcome were determined by clinical examination and telephone interviews with horse owners. RESULTS: 4 fracture types were recognized. Fractures involving just the alveolar plate (33%) and those involving the alveolar plate and the body of the bone (32%) were most common and were often repaired by interdental wiring. Unilateral fractures of the mandible (11%) were managed without surgery if stable. Unstable fractures were repaired with wires, a U-shaped bar (U-bar), or a bone plate. Bilateral fractures (24%) were often repaired with orthopedic wires in foals or with a U-bar, acrylic splint, wires, or bone plate in adult horses. In 2 horses, bilateral fractures were managed conservatively. Short-term complications developed in 24 of 89 (27%) horses. Soft tissue infections and wire loosening or failure were the most common short-term and long-term complications. Wire replacement was not required in any horses after release from hospital. Persistent draining tracts were most often associated with bone sequestration. Long-term functional and cosmetic outcomes were favorable for all fracture types and repair methods. CLINICAL IMPLICATIONS: Although complications in horses with fractures of the mandible and maxilla are common, long-term prognoses for functional and cosmetic outcome are favorable.     

Multiple rib fracture in a neonatal foal using a nylon strand suture repair technique

OBJECTIVES: To report rib fracture repair using the Securos Cranial Cruciate Ligament Repair System (SCCLRS; Securos Veterinary Orthopedics, Charlton, MA) in a neonatal foal. STUDY DESIGN: Case report. ANIMALS: A 1-day-old Standardbred foal with fracture of left ribs 2-9. METHODS: Four days after admission the foal was anesthetized and rib fractures were repaired using open reduction and the SCCLRS. RESULTS: Rib fractures were successfully stabilized and the foal was discharged 7 days postoperatively without further complications. CONCLUSIONS: The SCCLRS provided a straightforward, effective method of rib fracture repair in neonatal foals. CLINICAL RELEVANCE: Effective rib fracture repair in neonatal foals can be achieved with the SCCLRS.     

Tibial fractures

Tibial fractures are common in small animal practice. As with other appendicular fractures, the patient's age, fracture location, and fracture type must be considered thoroughly. While methods for tibial fracture repair are similar to those used for appendicular fractures elsewhere, there are some unique considerations, both anatomically and functionally, that must be contemplated before repair. The following article will review the incidence of tibial fractures, tibial fracture types, and options for tibial fracture management and treatment. The use of external fixators, orthopedic bone plates, open reduction with internal fixation (ORIF), and external coaptation will be discussed. An emphasis will be placed on the most common types of tibial fractures, as well as those best suited for repair by general practitioners of veterinary medicine. Three case based examples will follow the overview.     

Standing surgical repair of propagating metacarpal and metatarsal condylar fractures in racehorses

REASONS FOR PERFORMING STUDY: Repair of spiral and long diaphyseal metacarpal and metatarsal fractures under anaesthesia can be problematic and associated with a high incidence of complications, including fracture propagation necessitating euthanasia. OBJECTIVE: To report on a practical repair technique for which general anaesthesia is not required. METHODS: Thirteen racehorses with a spiral/propagating condylar fracture had the fracture repaired using local anaesthesia and sedation, without the need for general anaesthetic. RESULTS: Ten of the horses returned to training and 8 raced again. Two horses were retired directly to stud. One horse had propagation of the fracture 3 days post surgery, and was subjected to euthanasia. CONCLUSIONS AND POTENTIAL RELEVANCE: Results achieved were comparable to those gained using standard repair techniques under general anaesthesia. The described technique removes the need for general anaesthesia for repair of selected condylar fractures.     

Use of a double-hook plate to repair a subtrochanteric femoral fracture in an immature dog

A subtrochanteric femoral fracture in a 5-month-old Doberman Pinscher was repaired by use of a 5-hole, 3.5-mm, double-hook plate. The double-hook plate afforded rigid 3-point fixation of the short proximal metaphyseal segment without impingement of the proximal femoral physis and allowed compression of the fracture fragments by placement of an interfragmentary screw through its pendulum hole. The fracture healed without complications, and the dog had a rapid return to function. Although designed for use in performing femoral osteotomies in dogs afflicted with hip dysplasia, the double-hook plate can be used to repair fractures with short proximal or distal segments.     

Management of limb fractures in wapiti (Cervus elaphus): 22 cases (1993-1997).

OBJECTIVE: To determine treatment and outcome of a series of wapiti (elk) with fractures of the limbs. DESIGN: Retrospective study. ANIMALS: 22 wapiti. PROCEDURE: Medical records were reviewed to determine affected limb and bone, fracture configuration, method of treatment, outcome, and complications. RESULTS: 2 animals had fractures of the humerus; 8 had fractures of the radius, ulna, or both; 5 had fractures of the third metacarpal bone; 3 had fractures of the tibia; 2 had fractures of the femur; and 2 had fractures of the tarsal bones. Most fractures (n = 11) were closed, displaced, nonarticular fractures; 6 fractures were open. Four animals died or were euthanatized prior to fracture treatment, 2 were not treated because fractures had already healed, and 14 underwent fracture repair. In the remaining 2 animals, the affected limb was amputated. Five animals developed nonfatal complications (wound dehiscence, osteomyelitis [2 animals], delayed union, and malunion) and 2 developed fatal complications (gastrocnemius rupture and femoral fracture during recovery). Overall, 16 animals were discharged from the hospital, and all were doing well at follow-up, 2 months to 4 years after discharge. CLINICAL IMPLICATIONS: In wapiti, limb fractures can be successfully treated by means of internal or external fixation. The high rate of fracture healing, even among wapiti with open fractures, should encourage veterinarians to repair limb fractures in wapiti.     

Neuromuscular blocking agents in equine anesthesia

In summary, neuromuscular blocking agents can be used safely and to advantage in equine anesthesia. Muscle-relaxant use in equine anesthesia has been helped by the development of new relaxants such as atracurium, which has a reliable and reproducible duration of action. There are certain cases that benefit particularly by the use of relaxants but their use is not limited to these cases. These cases involve horses that experience persistent movement and hypotension during anesthesia, are undergoing ophthalmic or abdominal surgery or fracture repair, or are severely ill. Horses receiving muscle relaxants during anesthesia require mechanical ventilation, and neuromuscular blockade should be monitored with a peripheral-nerve stimulator.     

Surgical management of complete diaphyseal third metacarpal and metatarsal bone fractures: Clinical outcome in 10 mature horses and 11 foals

Reasons for performing study: Osteosynthesis of third metacarpal (McIII) and third metatarsal (MtIII) bone fractures in horses is a surgical challenge and complications surrounding the repair are common. Retrospective studies evaluating surgical repair, complications and outcome are necessary to increase knowledge and improve success of long bone fracture repair in the horse. Objectives: To evaluate clinical findings, surgical repair, post operative complications and outcome of 10 mature horses and 11 foals with McIII or MtIII fractures that were treated with open reduction and internal fixation (ORIF). Methods: Medical records were reviewed and follow‐up information obtained by means of radiographs and/or telephone questionnaire. Results: Survival was achieved in 62% of the horses (3 mature/10 foals). On long‐term evaluation (>6 months) 11 horses (2 mature/9 foals) were fit for their intended activity, one mature horse had a chronic low grade lameness, and one foal was lost to follow‐up because it was sold. The main fracture types were simple transverse (33.3%) or simple oblique (28.6%) and 71.4% of the fractures were open, 3 Type I (one mature/2 foals) and 12 type II (7 mature/5 foals). The preoperative assessment revealed inadequate emergency treatment in 10 horses (5 mature/5 foals; 47.6%). Survival rate of horses with open fractures was 12.5% (1/8) in mature and 85.7% (6/7) in foals. Post operative incisional infection (4 mature, 3 foals) was only managed successfully in 2 foals. Fracture instability related to inadequate fracture fixation technique occurred in 4 horses (all mature) and was always associated with unsuccessful outcome. Conclusions: Age, bodyweight and infection are strongly associated with outcome in treatment of complete McIII/MtIII fractures. Clinical relevance: Rigid fixation using plates and screws can be successful in treatment of closed or open, complete diaphyseal McIII/MtIII fractures in mature horses and foals. Instable fixation, infection and a bodyweight >320 kg are major risk factors for unsuccessful outcome.     

Use of a plate-rod construct and principles of biological osteosynthesis for repair of diaphyseal fractures in dogs and cats: 47 cases (1994-2001)

OBJECTIVE: To determine outcome for dogs and cats with diaphyseal fractures in which a plate-rod construct was used for fracture repair. DESIGN: Retrospective study. ANIMALS: 35 dogs and 12 cats. PROCEDURES: Medical records and radiographs were reviewed to obtain information concerning signalment, fracture severity, construct design, time to radiographic union, complications, and outcome. Clients were contacted by telephone to obtain information on complications, limb usage, and overall satisfaction with the procedure. RESULTS: 31 femoral, 9 humeral, and 7 tibial fractures were assessed. Thirteen fractures consisted of 2 fragments, 22 consisted of 3 to 5 fragments, and 12 consisted of > 5 fragments. Forty-six of 47 (98%) fractures reached union. Mean +/- SD times to radiographic union were 7.5 +/- 2.7 weeks for the dogs and 4.8 +/- 1.3 weeks for the cats. There were 4 short-term, minor complications and 15 long-term complications (2 major and 13 minor). Owners of 21 of 30 dogs (70%) and 9 of 12 cats reported that their animals had normal limb function. Twenty-six of 28 dog owners (93%) and 12 of 12 cat owners indicated that they were satisfied with results of the procedure. As surgery time increased, time to union also increased. Time to union for fractures with > 5 fragments was significantly shorter than time to union for fractures with < or = 5 fragments. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that plate-rod constructs can successfully be used for repair of diaphyseal fractures of a wide range of severity in dogs and cats.     

Use of a new investigational interlocking nail supplement in the repair of comminuted diaphyseal tibia fractures in two dogs

Two dogs were diagnosed with highly comminuted diaphyseal tibial fractures following traumatic incidents. Investigational hybrid interlocking nail (ILN) bolt/external skeletal fixator (ESF) pins were used to repair both fractures. The surgery was successful, and fractures healed without complications by 6 weeks (case no. 1) and 17 weeks (case no. 2) after surgery. This article describes the application and the advantages of a new, investigational ILN supplement that was specifically designed to accomplish initial rigid stability and allow progressive destabilization to the fracture repair. The authors are continuing to study the biomechanical properties of this procedure in order to accurately establish clear recommendations for its use in certain fracture situations.     

Clinical considerations of the thoracic limb.

The avian skeleton is significantly different from the mammalian skeleton, and these differences are important when providing fracture repair and postoperative care for the avian patient. Successful repair depends on an understanding of fracture management and healing and of the anatomical, physiologic, and behavioral concerns of avian patients. Having knowledge of fracture repair without an understanding of the unique needs of avian patients' results in a disappointing treatment response.