Emergency fractures Flashcards
How are fractures classified?
- Location (which bone involved, and where, e.g. metaphysis, diaphysis, epiphysis)
- Structures involved (articular vs non articular)
- Contamination (open vs closed)
- Extent of damage (complete vs incomplete, simple vs comminuted)
- Size of fragment (chip vs slab vs shaft fracture)
- Fracture configuration (transverse, oblique, spiral, avulsion, growth plate)
- Displacement, fracture fragments and margins
Describe this fracture. How would you manage it?
- Simple transverse fracture of accessory carpal bone.
- Non-articular and no evidence of external communication.
- Moderate displacement, at least two fragments and irregular poorly defined margins
- No joint effusion, swelling on palmar aspect of limb.
- Chronic fracture, recommend ultrasound to check carpal sheath and flexor structures. Internal fixation challenging, may have to manage conservatively but guarded prognosis for return to work
Describe this fracture. How would you manage it?
- Complete, comminuted fracture of the olecranon.
- Communicates with elbow joint, no evidence of external communication.
- Minimal displacement, multiple fragments, butterfly configuration, sharply defined margins
- Acute fracture. Articular involvement and pull of triceps means internal fixation recommended. Good prognosis with internal fixation depending on repair and anaesthetic recovery outcomes
What are the possible causes of fractures in horses?
Trauma – most common cause, can be acute trauma (e.g. kick, fall) or chronic repetitive trauma (e.g. stress fractures in racehorses, general wear and tear in any horse)
Developmental – most commonly fragments due to OCD or other developmental orthopaedic disease
Secondary to other disease conditions, e.g. neoplasia or infection – uncommon in the horse, but keep on differential list
What are the most common sites of fractures in the horse?
Kick injuries – splint bones, stifle bones (tibia, patella), olecranon, head
Trauma/falls – head, vertebrae, long bones (femoral or cannon fractures in anaesthetic recovery), joints during competitions (patella fractures from hitting fences)
Repetitive injury / wear and tear – distal phalangeal (pedal) bone, middle phalangeal (pastern) bone, distal sesamoidean (navicular) bone
Stress fractures in racehorses – anywhere, but most common are carpal bones (radius, radiocarpal and third carpal), third metacarpal bone, middle phalangeal (pastern) bone, proximal sesamoid bones, radius, tibia, pelvis, vertebrae
What clinical signs are associated with fractures in the horse?
- Range from mild / subtle to marked / severe!
- Acute, severe or displaced fractures will have obvious conformational abnormalities, severe lameness, pain and crepitus at the fracture site
- Non-displaced fractures (including stress fractures) and small chip fractures may have minimal lameness and localising signs
- Articular fractures normally have joint effusion
- Know your anatomy, palpate carefully!
This stallion galloped through a gateway and sustained this wound over the lateral aspect of his pelvis. On examination with a sterile gloved hand, there is a first-sized hole through the muscles, with palpable crepitus of the underlying bone. What anatomical structure on the pelvis has been fractured?
Tuber coxae
What are the red flags in the history that warn you the horse may have a fracture?
- Major red flags for fractures are history of trauma (e.g. kick or fall), acute onset severe lameness, acute onset joint effusion, heat, pain, swelling and palpable crepitus
- Non-displaced stress fractures may present as acute onset lameness following exercise, which resolves over a few days
- Non-displaced, repairable fractures can progress to catastrophic irreparable fractures if not recognised and treated appropriately
What are the key aspects of physical exam in a fracture diagnosis?
- Careful and detailed palpation for heat, pain, swelling and crepitus.
- Crepitus due to air/gas under skin is usually diffuse and non painful. Crepitus due to bone fragments is painful and localised.
- Administer sedation and analgesia as needed until horse is calm and can be examined thoroughly
- If attending event / accident and examine immediately, then consider re-examining later. Exhausted or excited horses may mask some of the signs initially. Swelling and heat can take a few hours to appear.
- Consider what underlying / associated structures may be affected
What diagnostic tests would you do when investigating a fracture?
- Nerve or joint blocks – avoid if possible, only use is in chronic, mild, small fractures
- Radiography – first line approach for most fractures
- Minimum of two views
- Some regions may not be accessible for radiography
- Non-displaced fractures may not show any radiographic changes
- Ultrasound – main use is in pelvic fractures in racehorses
- Gamma scintigraphy – valuable for non-displaced stress fractures (e.g. tibia, radius, humerus) and regions which cannot be accessed / imaged well with radiography (e.g. vertebrae, ribs, scapula, pelvis)
- CT – gold standard but availability of facilities and cost limits use, esp useful in imaging complicated fractures and neck lesions
This horse pulled up acutely lame following ridden work. What diagnostic test would you do?
- antebrachial carpal
- x-ray (4 views)
Acute onset severe lameness is a common emergency call out in equine practice.
You receive a phone call from an owner who has just found her horse in the field severely lame, and unable to bear weight on its right forelimb. The horse is kept with several others in the field, was sound when ridden a week ago, and the owner said it was fine yesterday. The owner thinks it may have fractured its shoulder based on the way it is trying to walk.
What is most common cause of acute onset severe lameness in the horse?
A. Fracture
B. Tendon rupture
C. Septic synovial cavity
D. Pus in the foot
E. Mud fever
F. Arthritis
Pus in the foot
What are possible fracture complications?
- Articular involvement –> degenerative joint disease
- Contamination -> osteomyelitis, synovial sepsis, soft tissue infection
- Soft tissue involvement -> tendon, ligament, muscle or neurovascular damage
- Unstable -> non-healing or malunion
- Damage to periosteal vascular supply -> sequestrum formation
- Mechanical overload of contralateral limb -> laminitis
how can you avoid fracture complication?
At first examination
Recognise fracture promptly and provide adequate stabilisation
* Do not nerve block or exercise if risk of fracture
* Provide adequate support / splinting to prevent further damage
* Provide adequate support / splinting if moving or transporting the horse for further assessment
* Cover and protect open wounds
At first diagnostics
* Assess carefully for involvement of other structures
* Radiography for articular involvement
* Ultrasound to assess soft tissues
* Neuro exam for suspected nerve damage
* Further diagnostic as required
* Get the full picture to enable you to plan treatment options and advise on prognosis
How can you avoid fracture complications in articular fractures?
- Lots of resources describe options for different fracture types across the joints, however the principle is very simple:
- Remove small unstable articular fragments which are not an integral part of the articular surface and will cause trauma if left
- Stabilise large fragments which are an integral part of the articular surface (screw, plate etc)
- Arthrodesis is a viable option for low option joints (pastern, carpometacarpal, and distal tarsal joints)
What tendons are damaged here?
SDFT, DDFT, suspensory
What is the correct term for this radiographic view?
A. dorsolateral palmaromedial oblique
B. flexed dorsopalmar
C. flexed lateromedial
D. dorsomedial palmarolateral oblique
E. skyline oblique
flexed lateromedial
What is the correct description for this olecranon fracture?
A. Closed, comminuted, non-articular
B. Closed, simple, non-articular
C. Closed, comminuted, articular
D. Open, simple, non-articular
E. Open, comminuted, articular
F. Open, comminuted, non-articular
Open, comminuted, articular
