Distal Hind Limb

Question 1

Proximal Tibial Fractures

Answer 1

Generally seen in skeletally immature dogs.
Avulsion fractures of the tibial tuberosity.
Salter Harris type 1 or 2 of the proximal tibial physis.

Question 2

Tibial tuberosity avulsion

Answer 2

Growth plate doesn’t fuse before 18 months.
Minimally displaced fractures can be managed with coaptation in a craniolateral splint maintaining the stifle and hock in extension.
Requires reduction and stabilization- pin and tension band fixation

Question 3

Proximal physeal fractures

Answer 3

Worry about future predilection for cruciate tears.
Physeal-metaphyseal component: cross pins, stress, Im, external coadaptation. Tibial tuberosity: tension band or lag screw fixation
A lot of soft tissue contracture

Question 4

Diaphyseal tibial fractures

Answer 4

Open fractures are common. Open approach via medial aspect of the tibia to spare the medial and saphenous nerve and vein.
External coadaptation- use with high fracture scores (transverse or incomplete fractures). Intact fibula act as an internal splint. Must immobilize both stifle and hock

Question 5

Coadaptation principles

Answer 5

Rigid preformed splints: pad depression
Malleable splints: pad protuberances
Always leave the digits exposed

Question 6

Diaphyseal tibial fractures: IM pin

Answer 6

Normograde in dogs. Craniomedial aspect of tibial plateau. Extra articular and cranial to mensici
Do not enter the hock distally. (cut off the tip of the pin)
Cat tibia is much straighter than the dog’s which makes it simpler. IM pins can be inserted retrograde. Must protect patellar ligament.
Hybrid fixators extremely useful. Consider type 1b constructs

Question 7

Linear external fixators- tibia

Answer 7

Can use type 1,2, or 3. Sole or adjunctive fixation. Proximal full-pin splintage pins associated with considerable post-op morbidity

Question 8

Interlocking nail stabilization- tibia

Answer 8

Can be placed via open, limited open or closed reduction. Placed normograde similar to IM pin. Sigmoid conformation of some dog’s tibia may preclude nail placement

Question 9

Plating of tibial fractures

Answer 9

Medial plate. Open, limited open, or MIPO application. Contouring important. Consider plate/rod construct
Avoid medial saphenous neurovascular complex

Question 10

MIPO: Minimally Invasive Plate Osteosynthesis

Answer 10

Accurate reduction is dependent of precise contouring of the plate.
Determine the location for insertion incisions. Develop the epiperiosteal tunnel. Slide plate through the tunnel.

Question 11

Distal tibial physeal fractures

Answer 11

Salter Harris 1 or 2. Closed reduction and external coadaptation (Reduction can be difficult). Open reduction and internal fixation- medial or lateral approach. Manual reduction. Cross pins, stress pinning, IM pin
Advocate limited open or closed reduction. Irregular conformation of the physis confirms stability if reduced anatomically. External coadapt for 2-3 weeks.

Question 12

Malleolar Fractures

Answer 12

Use fluoroscopic aid. Pin and tension band stabilization of malleolar fractures. Arthrodesis a consideration

Question 13

Calcaneal Fractures

Answer 13

Plantigrade stance- debilitating lameness. Resembles achilles tendon injury.
Surgery necessary due to distractive forces.
Pin and band fixation in small dogs and cats if too small too plate. Lateral plate fixation in larger dogs and dogs with concurrent intertarsal fractures/luxation
Caudolateral or lateral approach: reflect the superficial digital flexor tendon. Plating HIGHLY ADVOCATED

Question 14

Metatarsal fractures

Answer 14

Occur as single or multiple. Treatment depends on which bone and how many. 3 and 4 metatarsal are weight bearing. Intact bones can act as a splint.
Many can be managed with coadaptation in a mason-meta splint
IM pins, plates or external fixators can be used for stabilization