Appendicular fracture repair Flashcards

1
Q

Approach to fracture management

A

Establish the location and the nature of the fracture

Fracture assessment

List all possible methods of fracture repair

Weigh up advantages and disadvantages of each method

Establish best options

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Fracture classification

A
  1. Cause of fracture
  2. Communication with external environment
  3. Extent of bony damage
  4. Number and position of fragments
  5. Direction of fracture lines
  6. Location
  7. Forces acting on the fracture/displacement
  8. Stability
  9. Degree of complexity and involvement of other tissues
  10. Age
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Forces acting on transverse fractures

A

Shear +
Compression +++

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Forces acting on oblique/spiral fractures

A

Bending +
Torsion +

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

High risk fractures based on biologic fracture assessment

A

Old patient

Poor health

Poor soft tissue envelope

Cortical bone

High velocity injury

Extensive approach

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Mechanical fracture assessment

A

Caution:
- butress fracture
- multiple limb injury
- giant breed

In the middle:
- contact fracture
- pre-existing clinical disease
- large dog

Little risk:
- compression fracture
- single limb
- toy dog

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

High risk fractures according to clinical fracture assessment

A

Poor client compliance

Poor patient compliance

Wimp

High comfort level required

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Aim of diaphyseal fracture repair

A

To repair it with as simple and as reliable a method as possible.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Articular fractures

A

Disruption of the articular surface will inevitably lead to some degree of degenerative change

Goal of surgery is to slow the onset/progression of arthritis, and reduce the impact on quality of life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Principles of articular fracture repair

A

Perfect reduction of the articular surface

Use rigid internal fixation

And interfragmentary compression of the fracture gap - using lag screws (+/- plates)

Early mobilisation and use of the joint is important to minimise stiffness.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Avulsion fractures

A

An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment.

Accurate anatomical reduction of the fracture

Rigid internal fixation (beware can be tiny fragments)

Implants must resist the tensile forces that caused the fracture in the first place

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Principles of avulsion fracture repair

A

Counteract active distracting forces and convert them into compressive forces using the tension band principle.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Humeral diaphyseal fractures

A

Frequently distal half to third

Cast fixation not appropriate (upper limb)

IM pin fixation can be used but the bone narrows significantly distally restricting the size of pin that can be used. In dogs the IM pin should be angled so it sits in the medial epicondylar ridge.

Plate fixation is often an appropriate choice but both the surgical approach and the shape of the bone do not make this an easy option. Tension side of the humerus is the cranial or lateral. However applying a plate on the medial surface is acceptable practice.

ESF fixation should be avoided in the upper limb if a simpler option is appropriate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Radial diaphyseal fractures

A

Distal diaphyseal fractures are most common.

Surgical approaches – medial or lateral.

External coaptation is suitable for simple fractures with stability and good apposition of fracture ends.

IM pins and interlocking nails are NOT suitable as there is no safe area for placement of these implants that will not cause damage to the articular surfaces.

Plate and screw repair on the cranial or medial aspect is best for simple fractures.

In large dogs it may be necessary or preferable to plate both the radius and ulna.

If fracture is comminuted then ESF should be considered, although placement of pins in the radius, which is quite a narrow bone, can be a frustrating job. Consider a type Ib ESF construct (2 unilateral frames)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Distal Radial and Ulna Fractures – metaphyseal or epiphyseal

A

Fractures proximal to the growth plate are common especially in small or toy breeds of dog.

These fractures are prone to non-union, most commonly atrophic, if treated sub-optimally.

External coaptation is not advised.

Rigid stabilisation with ORIF using a bone plate and screws is recommended or use of external skeletal fixation may also be suitable.

Short plates risk implant related fracture due to ‘stress-riser’ effect.

Risk of osteopenia of the bone underneath plate, leading to secondary fractures.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Femoral diaphyseal fractures

A

One of the most commonly fractured bones.

Surgical access will be from lateral

Repair options include:
○ External coaptation / cast – NOT appropriate for upper limb bone
○ IM pins – usually combined with cerclage wires for a long oblique fracture or an ESF (cats). The IM pin should be inserted in a normograde manner to avoid any damage to the sciatic nerve if it loosens and migrates.
○ Interlocking nail – for mid diaphyseal fractures
○ Plate and screws – place on lateral aspect of the bone
○ ESF – to be avoided if possible as large muscle mass for pins to go through which will cause patient some morbidity – especially in dogs. With severely comminuted unreconstructable fractures may be most appropriate option.

17
Q

Tibial diaphyseal fractures

A

Surgical Approach – medial (easy approach). Medial side is tension side of bone and gives best surgical access for plate fixation.

Remember to assess whether fibula is intact when assessing fracture.

Tibial tuberosity avulsion fracture - consider signalment and history - don’t be misled by milk lameness.

Repair methods –
○ External coaptation,
○ IM pinning. Pin size dictated by distal tibia (narrow). Care not to leave pin long as may cause damage in stifle and care not too insert too far down bone or can enter hock joint, distal tibial epiphysis is thin. Pin placed in a normo-grade fashion from starting on the craniomedial aspect of the tibia.
○ Interlocking nails can also be used – narrow size of tibia may restrict use.
○ ORIF with plates and screws
○ Closed reduction and application of an ESF -unilateral or bilateral or bilateral biplanar all possible