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Locomotor > External coaptation of fractures - SA and LA > Flashcards

External coaptation of fractures - SA and LA Flashcards

1
Q

Roles of external coaptation

A
  • temporary support or first aid
  • secondary support after sx
  • primary support and stabilisation for selected fractures
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2
Q

What are the fracture forces? 4

A
  • bending
  • rotation
  • compression/ shear
  • distraction
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3
Q

List 6 different fracture configurations

A
  • transverse
  • oblique
  • comminuted
  • spiral
  • avulsion
  • compression
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4
Q

What to consider when deciding external coaptation

A
  • consider forces acting on fracture
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5
Q

How are bending and rotational forces neutralised?

A
  • by cast

- as long as the joints above and below the fx are immobilised

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6
Q

How can compression/ shear be neutralised??

A

difficult to neutralise with a cast

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7
Q

T/F: distraction forces are caused by mm tension and are poorly neutralised by external coaptation

A

True (e.g. olecranon fractures)

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8
Q

When - external coaptation

A
  • best for closed, minimally displaced stable fx
  • pair of bones (e.g. tibia/fibula)
  • young animal with high healing potential
  • 50% contact rule (i.e. bone fragments should be in contact at least 50%)
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9
Q

List steps of external coaptation

A
  • when
  • reduction
  • alignment
  • standing position
  • joint above and below
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10
Q

Outline reduction in process of external coaptation

A
  • heavy sedation or GA
  • repeat rads to ensure apposition remains for healing
  • adequate reduction varies b/w patients (juveniles tolerate greater displacement without developing delayed or non-union)
  • 50% contact rule
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11
Q

Describe alignment in process of external coaptation

A
  • perfect reduction often not achieved
  • proper joint alignment MUST be achieved
  • failure to align major bone fragments to joints of limbs –> rotational or angular malunion
  • cause functional gait abnormality, painful lameness from secondary OA
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12
Q

How should external coaptation be applied?

A
  • applied to maintain the limb in a normal standing positiion
  • allows animal to ‘bear weight’ when splint is in place and after removal
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13
Q

What are the guidelines for the joint above/below in external coaptation?

A
  • both must be immobilised
  • most conventional splints and casts cannot be used above stifle/elbow
  • spica splints can be constructed to immobilise the hip or shoulder
  • most are severely displaced
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14
Q

How often is external coaptation used?

A
  • infrequent in SA (difficult to manage, severe complications possible, often there is a better way to tx the patient)
  • it is only occasionally used to manage fx
  • fairly commonly used for support after sx, especially after arthrodesis
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15
Q

List 8 types of external coaptatin

A
  • Robert Jones bandage
  • Modified RJ bandage (less cotton padding used)
  • reinforced RJ bandage
  • splinted
  • bivalved cast (allows frequent changes without)
  • spica splint (shoulder, hip)
  • Schroeder-Thomas
  • Walking bar (aluminium bar at end of cast)
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16
Q

List components of the external coaptation dressing

A
  • primary layer
  • secondary layer
  • tertiary layer
  • +/- stirrups
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17
Q

Function - primary layer - example

A
  • to cover and protect skin
  • absorb discharge
  • variety: e.g. melolin
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18
Q

Function - secondary layer - example

A
  • absorption
  • provides support
  • provides pressure
  • keeps primary layer in one place
  • EXAMPLE:
  • roll cotton (don’t allow direct contact with wounds)
  • cast padding (less bulky, conforms better)
  • conforming gauze is wrapped over this ‘padding layer’ to provide stability and occasionally compression
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19
Q

Use - casting tape

A
  • applied over a light secondary layer
  • fine balance: too little padding may –> cast rubs/sores, too much padding will allow movement of bone fragments and delay healing
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20
Q

Function - tertiary layer - examples

A

FUNCTION
- holds inner layers together
- fixes inner layers to bandaged part
- barrier against physical abrasion
- barrier against environmental contaminants
EXAMPLE
- several types but elastic conforming bandage most common; allows application of consistent pressure to outer layer

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21
Q

When do you need to change a bandage?

A

when tertiary layer is wet as won’t keep the water out

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22
Q

Advantages - external coaptation - 2

A
  • relatively cheap (if no complications)

- avoids sx

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23
Q

Disadvantages - external coaptation

A
  • only appropriate for stable, minimally displaced fx
  • may result in bone/ limb malalingment
  • serious complications possible
  • complications are more expensive/ difficult to tx than original fx
  • difficult to manage (casts slip, get wet, animals remove them)
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24
Q

Complications - external coaptation

A
  • distal soft tissue swelling
  • distal limb oedema
  • skin rubs
  • skin ulceration
  • skin necrosis
  • soft tissue necrosis
  • slippage of cast
  • with severe complications, amputation often only option
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25
Q

How to minimise risk of complications of external coaptation

A
  • use coaptation only if necessary
  • plenty of padding (esp over bony prominences)
  • change dressing frequently
  • change or remove dressing if any concerns
  • educate owner to monitor dressing (smell)
  • avoid dressing if good alternative
26
Q

Is a transverse fx suitable for casting?

A

Yes - it is stable to compression

27
Q

How long will fx in young animal take to heal?

A

3-4 wks (check with repeat rads.)

28
Q

How long do you leave a cast on a fracture?

A

until the bone has healed

29
Q

How are fractures that extend into a joint classified?

A

Salter-Harris classification

30
Q

How can you manage a fracture that requires sx prior to sx?

A
  • rest
  • restrict activity (cage)
  • NSAIDs
  • opioid analgesia
  • +/- cold compress (if tolerated)
  • +/- sling
31
Q

What causes carpal hyperextension?

A

rupture of the palmar fibrocartilage

32
Q

What is the tx for carpal hyperextension?

A

pancarpal arthrodesis (i.e. fuse all the joints in the carpus) e.g. via plates and screws on carpus

33
Q

What aspect of a fracture should a plate be applied?

A
  • dorsal aspect?
  • place on the compression aspect
  • don’t place on the tension aspect (as tension can break the plate)
34
Q

How can you prevent plate breakage?

A
  • use external coaptation to protect implant/reduce forces

- CONCERNS: = cast related sores, cast slippage

35
Q

How can you reduce risk of complications associated with external coaptation for a plated fracture?

A
  • don’t place cast immediately postop
  • place RJ dressing for 3-5 days to allow swelling to reuce
  • place cast
  • monitor for 24h before sending patient home
  • ask owners to monitor cast carefully (written instructions)
  • keep cast dry
  • change cast weekly
  • remove if there are cast-related complications
  • remove cast at 6 wks postop
36
Q

Why might you place a needle in a metacarpal pad which has been distal to an external cast?

A
  • to determine if blood present (avascular?)

- to determine if pad necrosis

37
Q

List the 4 points of equine orthopaedic emergency

A
  • exam
  • triage
  • immobilisation of unstable joint
  • transport
38
Q

Purpose - bandages

A
  • cover wounds protected by dressing
  • prevent swelling/ oedema formation
  • immobilisation (with splinting)
39
Q

Describe an equine lower limb bandage

A
  • INNER LAYER: apply wound dressing, cover with orthopaedic padding
  • PADDING LAYER: apply padding, conform to limb with conforming gauze
  • OUTER (SHELL) LAYER: apply cohesive bandaging tape, seal to and bottom with adhesive bandage and white tape
40
Q

Describe a lower limb cast (equine)

A
  • minimal orthopaedic padding
  • apply cotton stockinet
  • fix cast felt to proximal margin
  • apply casting tape
  • apply heal wedge
  • incorporation of Gigli wires (facilitates cast removal)
41
Q

Indication - equine transfixing casting - 2

A
  • repaired or conservatively treated distal limb fracture that is unstable under axial loading
  • fetlock breakdown injuries
42
Q

What hx do you need when approaching the fracture patient?

A
  • what happened? how long ago?
  • was the trauma observed?
  • has the horse been moved since the trauma?
  • did the horse have to be caught after the trauma?
  • did the horse loose a lot of blood?
  • did the horse sweat excessively?
  • has any medication been given?
43
Q

What equipment do you need for equine fracture emergencies?

A
  • bandage material (wound dressing, conforming gauze, sheet cotton, casting tape, duct tape)
  • splints (slats, boards, light metal rods, PVC pipes, Kimzey leg saver splint)
  • Chemical restraint (xylazine HCl, detomidine HCl, romifidine HCl, butorphanol tartrate)
  • ABs (procaine penicillin G, K-penicillin, gentamicin sulphate)
  • OTHER (flunixin meglumine, phenylbutazone, tetanus toxoid vaccine, IV fluids)
44
Q

What should you immediately asses the equine fracture patient for? 2

A
  • shock presentation
  • blood loss
  • localise and assess degree of damage (decide tx or euthanasia)
45
Q

How can you chemically restrain a fractured horse?

A
  • ALPHA-2 AGONIST: xylazine HCl, detomidine HCl, romifidine HCl
  • ALPHA-2 AGONIST/ NARCOTIC COMBINATION: detomidine HCl, butorphanol tartrate, never use narcotics alone as this causes excitement
  • AVOID PHENOTHIAZINE TRANQUILISERS: acepromazine maleate etc, hypotensive effects in the presence of circulating catecholamines
46
Q

What should you visually inspect an injured equine limb for?

A
  • deviation in abnormal axial/abaxial position
  • hyperextension
  • swelling/ haematoma
  • open wound
47
Q

What should you palpate an equine injured limb for?

A
  • crepitus
  • fracture fragments
  • open wound/ moist spot
  • stress tests
48
Q

How can a fracture be classified?

A
  • incomplete/ complete fracture
  • simple/ comminuted
  • closed/ open
  • articular/ non-articular
  • tendon/ ligament
  • status surrounding soft tissue
49
Q

Outline biomechanics post-fracture

A
  • mm acting over a fractured bone exert a different action than what they are intended to
  • passive action structures counter their action (suspensory apparatus and reciprocal apparatus)
50
Q

Features of an ideal splint

A
  • neutralises damaging forces
  • not too cumbersome (pendulum effect)
  • applicable under different circumstances (minimal assistance, no anaesthesia)
  • economical and accessible (boards, slats, light metal rods, PVC pipes, casting material)
51
Q

What are the functional division of the equine TL? 4

A

4 - elbow to distal scapula
3 - distal radius to elbow
2 - distal Mc to distal radius
1 - coronary band to distal Mc

52
Q

What are the functional divisions of the equine HL? 4

A

4 - stifle to hip
3 - proximal Mt to stifle
2 - distal Mt to proximal Mt
1 - coronary band to distal Mt

53
Q

What determines the angle of the fetlock? 2

A
  • suspensory apparatus
  • flexor tendons
  • both lead to bending focus over fracture site if fracture is in TL division 1 (coronary band to distal Mc)
54
Q

How to deal with a fracture in TL division 1

A
  • IMMOBILISATION: padded bandage/ cast bandage with dorsal splint, Kimzey leg saver splint, ideal technique under debate, some clinicians argue that immobilising the fetlock in flexion is counterproductive as this can result in displacement of a fracture that is otherwise stable under axial loading (weight bearing). rigid external coatation with the weight bearing limb preferred
  • AVOID EXCESSIVE PADDING: slipping, pendulum effect
55
Q

How to deal with a fracture in TL division 2 (distal Mc to distal radius)?

A
  • Robert Jones Bandage (RJB) with rigid splints up to elbow
  • lateral and caudal
  • RJB is 2-3 x diameter of limb at fx site, multiple layers of individually conformed padding
56
Q

How to deal with a fracture in TL division 3 (distal radius to elbow)

A

BIOMECHANICAL FACTOR: inadequate stabilisation with RJB splints up to elbow, digital extensors and flexors act as abductors of the limb

  • GOAL OF IMMOBILISATION: prevent abduction and soft tissue damage on medial aspect of the limb
  • IMMOBILISATION TECHNIQUE: RJB with extended lateral splint
57
Q

How to deal with a fracture in TL division 4 (elbow to scapula)

A
  • BIOMECHANICAL FACTOR: triceps apparatus disabled, elbow cannot be fixed for weight-bearing, ‘dropped elbow’
  • HUMERUS/ ULNA/ SCAPULA: well protected by soft tissues, no need for direct protection
  • GOAL OF IMMOBILISATION: splint carps in extended position to allow for weight-bearing and balance
  • IMMOBILISATION TECHNIQUE: padded bandage with splint caudally or cranially over carpus, walking may be difficult, foals may be too weak to ambulate OR no immobilisation
58
Q

How to deal with a fracture in HL division 1 (coronary band to distal metacarpus)

A
  • BIOMECHANICAL FACTOR: reciprocal apparatus, plantar cortices easier aligned
  • IMMOBILISATION TECHNIQUE: bandage/ cast bandage with plantar splint or angled Kimzey leg saver splint. Ideal technique is debated. some argue that immobilising the fetllock in flexion is counterproductive as can result in displacement of a fracture that is otehrwise stable under axial loading (weight-bearing); condylar fx third Mc/Mt, P1 fx. Rigid external coaptation with limb weight-bearing preferred.
59
Q

How to deal with fracture in HL division 2 (distal to proximal Mt)

A
  • PROBLEM: angulation at tarsus, proximal tarsus difficult to bandage, splints difficult to apply
  • IMMOBILISAITON TECHNIQUE: RJB with splints up to tuber calcaneus (lateral and plantar), usually less voluminous than on TL
60
Q

How to deal with a fracture in a HL division 3 (proximal Mt to stifle)

A
  • BIOMECHANICAL FACTOR: reciprocal apparatus components are peroneus tertius mm, flexor digitalis superficialis mm, gastrocnemius mm (overriding at fx site instead of hock flexion, stifle joint cannot be immobilised, mm laterally over tibia act as abductors)
  • IMMOBILISATION TECHNIQUE: RJB with extended lateral splint up to coxofemoral joint, wide board splint, light metal (modified Schroeder Thomas - without groin bar) to prevent
61
Q

How to deal with a fracture in a HL division 4 (stifle to coxofemoral joint)

A

FRACTURES OF FEMUR AND PELVIS:

  • limb remains controllable d/t more distal mm insertions
  • impossible to stabilise by external means
  • non-weight bearing lameness
  • poor prognosis (unstable fx, fractures involving acetabulum)
62
Q

How can you transport the fx patietn?

A
  • SHORT DISTANCE: bring trailer as close to patient as possible, foals may be carried
  • USE LARGE VANS or GOOSENECK TRAILERS: for TL fx, transport patient facing backwards, for HL fx transport patient facing forwards, THUS weight is thrown on 2 sound legs when vehicle stops.
  • LIMIT STALL SPACE within vehicle with trailer partitions, adult horses will normally not travel recumbent, horse can lean on support to maintain balance
  • LEAVE HEAD AND NECK FREE (long lead) as head acts as a counterweight to maintain balance, less anxiety
  • FOALS: young foals will travel recumbent, partitioned area next to mare, attendant if possible

Locomotor (31 decks)

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