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Fracture Management Flashcards

1
Q

what is the nurses role in fracture surgery?

A

analgesia provision and care of the patient prior to surgery
preparation for aseptic surgery
equipment gathering and set up for theatre
trolley assistant for surgery
post-op care
discharge of patient to the owner

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2
Q

when prepping the surgical trolly what should you consider?

A 
tidy
easy to find instruments
sharps tray
handles in the same direction
commonly used instruments in a tray or separate area
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3
Q

how should the patient be prepped for fracture surgery?

A

positioned correctly for the surgeons preferred approach
hanging limb used for scrub
clipping of limb but foot may not be necessary

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4
Q

how does hangling limb prep work?

A

limb is suspended from celing/IV stand by rope / chain attached to foot which is bandaged.
may be used for limb prep before surgery or limb may be hanging throughout

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5
Q

when will the foot need to be clipped?

A

if surgery is to be performed on the foot

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6
Q

if the foot has not been clipped how is contamination of the surgical site prevented?

A

foot should be covered with sterile vet wrap or draped

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7
Q

what specialised drapes may be used for fracture repair?

A

Opsite

Ioban

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8
Q

what is the purpose of Opsite or Ioban drapes?

A

minimise contact between the skin and the implant to reduce the risk of SSI

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9
Q

what is fracture reduction?

A

the process of replacing the fracture segments in their original anatomical position

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10
Q

what are the two overarching methods of fracture reduction?

A

closed

open

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11
Q

when can closed fracture repair be performed?

A

rare
recent fractures
stable fractures - once reduced they will stay in place
lower limb

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12
Q

why are lower limb fractures easier to reduce closed?

A

less soft tissue so easier to palpate

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13
Q

what is involved in closed fracture reduction?

A

traction
counter traction
manipulation
bending

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14
Q

what is the difference between traction and counter traction?

A

counter traction involves pulling another part of the body/ limb away so that the full effect of traction (pulling on the fracture to reduce) is utilised

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15
Q

what is the main method via which most fractures are surgically repaired?

A

open techniques

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16
Q

what is the main difficulty during open fracture reduction?

A

overcoming muscle contraction

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17
Q

what equipment can be used to overcome muscle contraction during open fracture repair?

A

levers e.g. hohmann retractor
bone holding forceps
muscle relaxants used occasionally

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18
Q

why are muscle relaxants often not that useful for fracture reduction?

A

muscle usually inflamed so abnormal and drugs may not have full effect

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19
Q

identify the 2 instruments in this image

A

L) reduction forceps

R) bone holders

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20
Q

what is involved in the process of toggling?

A

fracture is bent to around 180 degrees
ends of bone are engaged
limb straightened with bone in place

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21
Q

what fractures are most suited to reduction by toggling?

A

transverse fractures

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22
Q

describe a transverse fracture

A

at right angles to the long axis of the bone

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23
Q

is toggling more or less traumatic than traction?

A

less even though it looks awful!

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24
Q

what are the main choices for fracture fixation?

A 
conservative management
external coaptation
external skeletal fixation (ESF) with or without open fracture reduction and repair
internal fixation
combination of many
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25
Q

what equipment is involved in internal fixation?

A

pins, bone plates, interlocking nails

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26
Q

what are the main implants available for fracture repair?

A 
pins
wire
screws
ESF
plates (and screws)
combined or alone
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27
Q

what are pins mainly used for in fracture repair?

A

intramedullary pins

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28
Q

what is the function of intramedullary pins?

A

lie within the bone to line it up

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29
Q

describe an intramedullary pin

A

stainless steel smooth pins with trochar tip

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30
Q

are intramedullary pins often used on their own?

A

no

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31
Q

why are intramedullary pins rarely used on their own?

A

they don’t prevent rotation of fracture

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32
Q

what are intramedullary pins usually combined with?

A

plates or ESF

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33
Q

what are the main types of intramedullary pins?

A

Kirschner wires
Steinmann pins
arthrodesis wire

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34
Q

when are intramedullary pins used on their own?

A

in metacarpals or metatarsals as they are splinted on either side by other bones and so risk of rotation is reduced

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35
Q

how many cerclage wire be used alongside intramedullary pins to repair fractures?

A

cerclage wire can be placed around the fracture area while pins are placed down through the bone

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36
Q

what is the risk of using cerclage wire?

A

can loosen and interfere with fracture repair

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37
Q

what are the complications associated with intramedullary pins?

A

if too long or too short they won’t effectively stabilise fractures, can be difficult to retrieve
if too long they can lead to seroma due to irritation or sciatic neuropathy if severe hindlimb damage
fracture non-union

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38
Q

what is an interlocking nail?

A

stainless steel pin used as intramedullary with holes in that is locked in place using screws or bolts

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39
Q

what is the purpose of interlocking nails for fracture fixation?

A

prevents rotation and axial collapse

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40
Q

when are interlocking nails most often used?

A

long bone fracture repair

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41
Q

what is a jig?

A

matches to intramedullary pin and sits on the outside of the limb
lines up with holes on the pin within the leg so that screws can be placed in ‘blind’

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42
Q

how can interlocking nails be inserted?

A 
insert nail into medullary cavity
attach jig
mark bone with awl where screws need to be placed
drill appropriate sized hole
measure depth
place screw/bolt
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43
Q

is interlocking nail fixation often performed?

A

no - useful but equipment is not commonly found in practice

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44
Q

what is a key benefit of interlocking nail fracture repair?

A

minimal interference with blood supply at the fracture site which aids healing
screws prevent collapse of limb as take some of the weight

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45
Q

what is the most common implant used to repair fracture?

A

bone plates and screws

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46
Q

what is the aim of using bone plates and screws?

A

restoring bone structure to restore weight bearing function and enable healing

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47
Q

what screws may be used with bone plates?

A

self-tpping or non-self tapping

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48
Q

what can bone plates be made of?

A 
stainless steel (most common)
titanium alloy
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49
Q

what are locking screws?

A

have a thread on the head which can lock into the thread on the bone plate to ensure they are held in firmly

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50
Q

what are the functions of bone plates?

A

compression of bone fragments
neutralisation of fracture forces
bridging a fracture

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51
Q

what is the effect of compression on fracture healing?

A

friction increases the stability of repair
creates primary bone healing
there is load sharing between the bone and the implant which reduces implant failure

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52
Q

how are bone plates used to neutralise fracture forces?

A

bone is reconstructed to anatomical shape by lag shoes or wire
plate is applied to support the bone after reconstruction by contouring it to the bone

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53
Q

when are bone plates used to bridge fractures?

A

unreconstructable (comminuted) fractures - bones in small pieces

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54
Q

how is a plate used to bridge a fracture?

A

used to shore up / support fragments

either large plate or multiple

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55
Q

where is weight borne when bone plates are used to bridge fractures?

A

all weight on plate

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56
Q

when are bone screws used?

A

combined with a plate or interlocking nail

used in isolation for fractures of cancellous bone

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57
Q

when are bone screws never used in isolation?

A

for diaphyseal fractures

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58
Q

why are bone screws never used for diaphyseal fractures?

A

slower healing and greater forces through bone

screws alone are not strong enough

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59
Q

what are the main types of bone screws?

A

locking
self tapping
non-self tapping

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60
Q

what are the functions of bone screws?

A

secure a plate to the bone to support a fracture during healing
to compress fragments together in lag fashion to enable rapid healing without a callus

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61
Q

when are lag screws especially useful?

A

near a joint as callus is reduced

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62
Q

how are lag screws placed?

A

drill a hole that is the size of the screw threads in the near or cis cortex and then insert a guide in this hole to drill a hole in the far or trans cortex with a drill bit the size of the core diameter of the screw.
When the screw is inserted it engages with the far cortex but not with the near cortex so it tightens the two pieces of bone together

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63
Q

how can you prevent lag screws from cutting the bone cortex when inserted?

A

a washer (small metal disc with a hole in it) is used around the screw head to distribute the force more evenly

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64
Q

what is the aim when repairing articular fractures?

A

perfect reduction

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65
Q

why is perfect reduction of articular fractures required?

A

to reduce the risk of arthritis and maintain joint mobility

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66
Q

how articular fractures treated?

A

open reduction and internal fixation (ORIF)

compression

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67
Q

how does external fixation work?

A

pass through the skin into the bone

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68
Q

what is full pin ESF?

A

pin goes right through bone and out to skin on other side

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69
Q

what is half pin ESF?

A

pin only protrudes from the skin on one side of the bone

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70
Q

what pins can be used for ESF?

A

smooth

threaded

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71
Q

what are smooth ESF pins used for?

A

very small fractures

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72
Q

what are the most often used ESF pins?

A

threaded

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73
Q

what are the 2 main ways that ESF pins can be threaded?

A 
negative profile (Ellis)
positive profile (Imex)
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74
Q

what are negative profile (Ellis) pins like?

A

thread is cut out of the pin itself

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75
Q

what are positive profile (Imex) ESF pins like?

A

thread is laid on top of the pin

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76
Q

what types of ESF pins can be positively or negatively threaded?

A

end threaded

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77
Q

what types of ESF pins can be positively threaded only?

A

centrally threaded

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78
Q

what is the role of interface ESF pins?

A

end is roughened to help stick to putty

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79
Q

on negative profile (Ellis) ESF pins where must the junction between screw and thread be located?

A

in the medullary cavity of the bone as this is a weak point on the screw

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80
Q

identify the two ESF pins in this image

A

top: positive profile (Imex)
bottom: negative profile (Ellis)

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81
Q

why are connecting bars needed in ESF?

A

connexts pins

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82
Q

what can connecting bars for ESF be made from?

A

stainless steel / carbon

acrylic / putty

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83
Q

what is the benefit of stainless steel / carbon connecting bars for ESF?

A

reusable

rounded ends

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84
Q

what is the benefit of acrylic / putty connecting bars for ESF?

A

light
no limit to pin size
no limit to pin closeness
no protruding ends to irritate

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85
Q

what is the disadvantage of stainless steel / carbon connecting bars for ESF?

A

heavy (although carbon is lighter)

all clamps need to be in a straight line and so pins must be as well

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86
Q

what is the disadvantage of acrylic / putty connecting bars for ESF?

A

removal and adjustment is more difficult

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87
Q

what is the role of clamps in ESF?

A

connection of pins to bars

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88
Q

what are the 2 main makes of ESF clamps?

A

SK

KE

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89
Q

what are the advantages of clamps for ESF?

A

adjustment and pin removal is generally easier

reusable (although may deform)

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90
Q

what are the disadvantages of clamps for ESF?

A

need to be carefully constructed otherwise they won’t work
limit to pin size
limit to bar size

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91
Q

what is a tied in intramedullary pin?

A

IM pin is left long and connected to ESF via seperate connecting bar or by bending the bar

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92
Q

what is useful about a tied in IM pin?

A

prevents migration of IM pin and increases stability

useful at joints

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93
Q

what is used to surgically repair avulsion fractures?

A

pin and tension band

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94
Q

what are avulsion fractures?

A

those pulled by tendons or ligament attachment

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95
Q

what bones are at risk of avulsion fracture?

A 
olecranon - triceps
greater trochanter - gluteals
medial malleolus - medial collateral lig
acromion of scapula - deltoid
calcaneus - gastrocnemius
tibial tuberosity - quads
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96
Q

why are IM pins no good for avulsion fractures?

A

pin will be bent due to pressure of triceps

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97
Q

how can an olecranon avulsion fracture be treated?

A

figure of 8 tension band applied

pull of triceps is offset by tension band

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98
Q

what is the principle of tension band wire?

A

active distracting forces are counteracted and converted into compressive forces

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99
Q

how can a tibial tuberosity avulsion fracture be treated?

A

reduce fracture
place 2 K wires perpendicular to fracture
drill hole through bone distal to fracture
place cerclage wire in figure of 8 pattern around K wires
bend K wire and cut ends

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100
Q

how does tension band wire work?

A

pins hold the fracture in place
wire attaches to the pins on either side and moves through a hole created distally to the fracture site
when tension is applied to the fracture this then pulls on the wires which then pull the fracture repair even closer together

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101
Q

why should the surgical assistant be familiar with each procedure?

A

so they may participate in surgery

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102
Q

what is the benefit of knowing the sequence of events involved in a surgery?

A

allows the assistant to ensure that instruments are available and presented to the surgeon in an orderly fashion

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103
Q

what is the main role of the surgical assistant during orthopedic procedures?

A

managing surgical table and passing instruments correctly
assisting with surgical retraction and haemostasis
ensuring that diagnostic samples are not lost and transferred appropriately to sample pots
keeping bone grafts safe and reminding the surgeon to use it
swab count
running a continuous suture and cutting sutures

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104
Q

describe how to correctly pass a surgical instrument

A

in a decisive manner
tip of instrument visible and handles placed in surgeons waiting hand
slap instrument firmly into the palm of the surgeon in proper position of use

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105
Q

how should instructions for fracture post-op care be given?

A

written and verbal

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106
Q

what should be discussed with the owner on discharge of the surgical fracture patient?

A 
age related implications
when post op x-rays are needed
cage rest?
time frame for weight bearing
suture removal date
buster collar
if physio needed
prognosis
signs of wound infection
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107
Q

what effect can age have on fracture healing?

A

there is possibility of premature closure of the growth plate in young animals

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108
Q

what are the potential complications following fracture surgery?

A

fracture instability
loosening or breakage of implants
delayed or non union
infection

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109
Q

what must you and clients be looking out for following fracture surgery?

A 
lameness
change in limb use
change in shape
swelling
discharge
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110
Q

what are the considerations for cage rest?

A 
suggest books that may help owners if they like
size of cage
what to have in cage
bedding needed
anything to relieve boredom
decreased food intake
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4
5
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111
Q

what can be done to relieve boredom on cage rest?

A 
games
training
music
sitting with dog
grooming / stroking
give food toys and decrease meal size to take up time eating
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112
Q

why is triage so crucial in ortho trauma patients?

A

ortho injuries are usually obvious but can hide less obvious, more serious, injuries

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113
Q

what is first aid?

A

emergency care given immediately to an injured individual

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114
Q

what is the purpose of first aid?

A

minimise injury and future disability

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115
Q

what may first aid be required to do in severe cases?

A

may be necessary to keep the victim alive

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116
Q

what are the aims of first aid?

A

preserve life
prevent suffering
prevent deterioration

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117
Q

where do the majority of traumatic fractures/luxations result from?

A

RTAs - especially cats

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118
Q

what percentage of dogs with forelimb injury also have thoracic / abdominal injury?

A

up to 79%

119
Q

what percentage of dogs with hindlimb injury also have thoracic / abdominal injury?

A

51%

120
Q

is fracture / luxation or thoracic / abdominal injury likely to be more severe?

A

thoracic or abdominal injuries are likely to be more immediately life threatening

121
Q

what does the primary survey consist of?

A

methodical initial assessment to rapidly identify the major life threatening injuries

122
Q

what does ABC stand for?

A

airway
breathing
circulation

123
Q

what else should be assessed during the primary survey after ABCs?

A

external haemorrhage

CNS

124
Q

what possible oral/skull reasons could there be for a patient having breathing difficulties following trauma?

A

head trauma
fractures (skull, maxillary)
blood clots
ruptured trachea

125
Q

what must be checked when looking at the airway?

A

patancy

126
Q

during the primary survey of the airway what should you check for?

A

check mouth for obstruction (e.g. blood clot, FB)
are nostrils blocked
tongue swollen or lacerated
hard palate split
swelling around larynx (e.g. after dog bite)
crepitis

127
Q

what about a patients breathing should be assessed in the primary survey?

A

rate
effort
adequacy

128
Q

what may indicate a broken jaw?

A

blood around nose, saliva, unable to close mouth

129
Q

what can be used to assess circulation during the primary survey?

A 
MM
CRT
HR and pulse quality
any pulse deficits
pulse in extremities
rectal temp
temperature of extremities
130
Q

what may be indicated by cold extremities?

A

peripheral shut down

131
Q

what circulation parameters can indicate shock?

A

MM colour

CRT

132
Q

what are the main types of patient management of shock?

A

compensated
decompensated (early)
decompensated (late)

133
Q

what are the signs of compensated shock?

A 
tachycardia (mild)
tachypnoea (mild)
slightly darker MM
CRT <1 second
normal mentation and BP
134
Q

why does compensated shock present the way it does?

A

increased CO, HR and systemic resistance to maintain blood pressure and perfusion

135
Q

what are the signs of decompensated (early) shock?

A 
tachycardia
tachypnoea
pale MM
slow CRT
weak pulse
poor mentation
hypotension
136
Q

what is happening during early decompensated shock?

A

peripheral vasoconstriction to reduce blood flow to peripheral organs, essential organ BP preserved and lactic acid accumulation

137
Q

what must be done if a patient has decompensated (early) shock?

A

give fluids

138
Q

what are the signs of decompensated (late) shock?

A 
bradycardia
absent CRT
severe hypotension
cheyne stokes breathing
death
139
Q

what is Cheyne Stokes breathing?

A

deep and fast breaths followed by apnoea

140
Q

what should you assume about the injury of RTA patients until proven otherwise?

A

severe injury

141
Q

how should mobile trauma patients be handled?

A

minimal restraint

142
Q

how should recumbent trauma patients be transported?

A

on an improvised / proper stretcher to prevent further injury

143
Q

what should you do with a patient with a suspected vertebral column fracture?

A

restrain

144
Q

what is involved in a secondary survey?

A

through check of whole animal after primary survey and stabilisation of patient

145
Q

what acronym can be used for the secondary survey?

A

A CRASH PLAN

146
Q

what does A CRASH PLAN stand for?

A

A - airway – nose, larynx, neck thoracic inlet
C - cardiovascular - CRT, pulse, BP
R - respiratory - chest wall and lungs
A - abdomen - diaphragm, inguinal, flank, paracostal
S - spine
H - head - eyes, ears, mouth, teeth, tongue
P - pelvis - rectume, perineum, scrotum, vulva
L - limbs
A - arteries and veins
N - nerves - cranial and peripheral

147
Q

what is the aim of the primary survey?

A

identify and treat serious / life threatening injury

148
Q

when is a secondary survey performed?

A

only after successful resuscitation and stabilisation of life threatening injuries

149
Q

what is involved in the secondary survey?

A

history from owner

thorough physical exam

150
Q

what are the signs of orthopedic injury?

A 
recumbency (spinal injury) or severe lameness
limb wound(s) with pain and swelling
deformity
abnormal mobility / instability of limb
crepitation
151
Q

what are the major orthopedic injuries?

A 
fractures
luxations
subluxations
wounds penetrating joints
tendon laceration / avulsion
ligament strain
muscle lacerations
152
Q

define fracture?

A

disruption in cortical continuity of the bone

153
Q

what is an incomplete fracture?

A

fracture of only one cortex of the bone

154
Q

where are incomplete fractures seen?

A

young animals due to the flexibility of bones

155
Q

what is a complete fracture?

A

both cortexes of bone affected

156
Q

what is luxation?

A

dislocation - complete disruption of normal relationship between the articular surfaces of the joint

157
Q

what is sub-luxation?

A

partial disruption of relationship between articular surfaces of joint

158
Q

what are the signs of luxation?

A

may still weight bear

abnormal gait and anatomy

159
Q

what is the contact between articular surfaces like in subluxation?

A

still some contact but abnormal and unstable

160
Q

what order should processes take place during wound management?

A 
analgesia
water soluble jelly
clip
flush
debride
bandage
161
Q

how much saline should wounds be flushed with?

A

at least 500ml

162
Q

what is the role of water soluble jelly in wound management?

A

protects wound from hairs / further contamination while clipping ocurs

163
Q

what is the main first aid for open fractures / luxation?

A

treat as for laceration
apply sterile hydrogel to exposed articular cartilage or bone
moist wound management

164
Q

how should open fractures / luxations be dressed?

A

supportively to attempt to restore normal anatomy - use of a splint
sterile dressing of wounds unless minor grazes

165
Q

how should the patient be prevented from injuring themselves further?

A

cage confinement to prevent/restrict movement

166
Q

when may fracture / luxation patient not be cage confined?

A

if injuries are only minor

167
Q

what should not be attempted in the conscious patient?

A

reduction of luxations / fractures

stabilisation of proximal limb injuries

168
Q

why should fractures / luxations not be reduced in the conscious patient?

A

too painful

169
Q

when should fractures / luxations reduction be performed?

A

under GA

170
Q

is stabilisation of proximal limb fractures possible with external coaptation?

A

no

171
Q

what injuries may be stabilised in the conscious patient?

A

distal limb (below elbow/knee)

172
Q

why can proximal limb fractures not be stabilised?

A

difficult to support joints above and below fracture

muscles will stabilise

173
Q

what is required for all cases with suspected major orthopedic injury?

A

anaesthesia for radiographic assessment of injury

174
Q

when may a displaced fracture or luxation be reduced?

A

when patient under GA for radiograph of area

175
Q

what does reduction of fracture / luxation do?

A

promotes comfort and helps prevent further tissue injury

176
Q

what are orthogonal radiographic views?

A

views at 90 degrees to each other

177
Q

what can be performed while the patient is under GA for imaging of ortho injury?

A

wound care
splint / bandage application
reduction of luxation

178
Q

how should first aid be provided for closed fractures / luxations?

A

support dressing of limb into reduction or near reduction

179
Q

when may support dressing of the limb in reduction or near reduction be possible?

A

if distal injury has torn ligaments or tissues resulting in marked laxity

180
Q

when should conscious manual reduction of closed fractures/luxations not be attempted?

A

if the limb is not obviously markedly unstable

181
Q

how should unstable fractures be supported?

A

use soft padding
splinting material
conforming and outer protective layer

182
Q

what are the available splinting materials?

A

fibreglass resin
orthoboard
thermoplastic
plaster of paris

183
Q

how is fibreglass resin activated?

A

by water

184
Q

how long does hardening of fibreglass resin take?

A

5 mins

185
Q

what happens during hardening of fibreglass resin?

A

exothermic reaction

186
Q

what is orthoboard?

A

plasticised cardboard

187
Q

how is orthoboard moulded?

A

in hot water

188
Q

what is the benefit of orthoboard?

A

cheap

189
Q

how is thermoplastic used to create splints?

A

heat in water or use heat gun

190
Q

what is plaster of paris activated by?

A

heat

191
Q

what is the benefit of plaster of paris?

A

cheap

192
Q

what is the disadvantage of plaster of paris?

A

long time to set and heavy

193
Q

what is needed for long term splinting of injuries?

A

custom splint to reduce irritation and ensure adequate support

194
Q

what are the 4 layers used for bandaging?

A

dressing
softban
conforming layer
vet wrap

195
Q

what are the functions of a bandage?

A

protects wounds and fractures from self-trauma and contamination
supports fracture / luxation pre and post surgery
pressure to aid haemostasis and control swelling
immobilisation for comfort, movement restriction and prevention of further damage

196
Q

when are support dressings used in first aid?

A

to support the distal limb only (below elbow and stifle)

197
Q

how many layers of bandage should be applied to support fracture / luxation?

A

all 3 (4 - not always dressing) layers

198
Q

what joints should be supported when applying supportive bandages?

A

joints proximal and distal to injury

199
Q

should the foot be included within bandages?

A

yes to ensure prevention of swelling

nails should be visible

200
Q

what is required when placing splints?

A

careful application and adequate padding

201
Q

what type of bandage is a splint preferrable to?

A

padded bandage

202
Q

why is a splint better than a padded bandage?

A

provide better immobilisation

203
Q

what are the main types of splint?

A

off the shelf or customised

204
Q

what is required for upper limb fractures?

A

cage rest prior to repair - no bandaging

205
Q

what are the main off the shelf splints available?

A

green gutter

206
Q

what is the issue with green gutter splints?

A

likely to buckle

rubbing likely

207
Q

what are the main custom splint types?

A

those using cast material

tongue depressor / other available material

208
Q

what is the purpose of a robert jones bandage?

A

immobilise fracture /luxation
controls swelling / oedema
comfort

209
Q

what is the role of a robert jones bandage post op?

A

support

controls swelling

210
Q

when may a robert jones bandage be especially useful?

A

haemorrhage

211
Q

what drugs should be supplied to the fracture / luxation patient?

A

analgesia (NSAID or opioid)

antibacterial if open fracture

212
Q

how should bleeding be treated in first aid?

A

as for laceration

apply sterile contact layer then generous padding using absorbant layer

213
Q

what can an absorbant layer for the control of haemorrhage be made from?

A

cotton

214
Q

how long should pressure be applied to haemorrhage via a bandage?

A

30 mins to 1hr

215
Q

how can severe bleeding be managed?

A

GA for ligation of bleeder

216
Q

what are the 2 main options for fracture fixation?

A

non - surgical management

surgical management

217
Q

what are the non-surgical management options for fracture fixation?

A

external coaptation

conservative

218
Q

what are the main surgical options for fracture fixation?

A

pin and wire
ESF
internal fixation
plate and screws

219
Q

what are the principles of fracture fixation?

A

return patient to normal function as soon as possible

create circumstances which allow bon healing to be optimal

220
Q

can fractures be healed non-surgically?

A

yes - some will heal with this method

221
Q

what are the potential advantages of non-surgical fracture management?

A

reduce or avoid anaesthesia
avoid the need for open surgical approach and the potential risks
cheaper materials
can be cheaper overall if no complications

222
Q

what are the disadvantages of non-surgical fracture management?

A

fracture disease
insufficient stability leading to delayed or malunion
malunion
cast sores leading to iscchemia

223
Q

how does conservative management provide stability for bones to heal?

A

surrounding soft tissue (muscle, periosteum, adjacent bones)provides sufficient stability to keep bones aligned whilst healing

224
Q

what must be minimised while fractures are healing with conservative management?

A

movement

225
Q

how can movement be minimised while healing a fracture using conservative management?

A 
restrict exercise (cage rest / lead walking only)
provide analgesia (NSAIDs)
prevent weight bearing
226
Q

what fractures are suitable for conservative management?

A

selected fractures of pelvis, scapula or vertebrae

stable minimally displaced fractures

227
Q

what is involved in cage management of the fracture patient?

A

restricted activity

confinement in a room or cage

228
Q

how long should cage rest last for if fracture is being managed conservatively?

A

4-6 weeks

229
Q

what does the length of cage rest for conservative fracture management depend on?

A

age of patient

fracture type

230
Q

where is weightbearing prevented in conservative fracture management?

A

on affected limb

231
Q

what bone fractures are often managed with prevention of weightbearing?

A

scapula

232
Q

what methods can be used to prevent weight bearing on a scapula fracture?

A

carpal flexion bandage

velpeau sling

233
Q

what is the risk with using slings to prevent weight bearing?

A

sores

234
Q

what information do owners need about a cage when their pets are undergoing conservative fracture management?

A 
size
contents
boredom reduction techniques
nursing care
bed sores and regular turining
235
Q

how may patients having conservative fracture management have ambulation assisted?

A

hoist
belly band
harness - forelimb fractures
sling- hindlimb fractures

236
Q

what must be considered about the home environment for conservative fracture management patients?

A

non-slip rugs

ramps where needed

237
Q

where are pressure sores likely?

A

bony areas (e.g. olecranon, greater trochanter, medial maleolus)

238
Q

what should be included in a care sheet for cage rest?

A 
length of confinement and why
requirements
food needs
toys
toiletting
suture removal 
follow up checks
recovery and expected time frames
any issues don't hesitate to contact
239
Q

what happens during external coaptation?

A

compressive forces are transmitted to bones by means of interposed soft tissues

240
Q

what is crucial about the application of casts or splints used for external coaptation?

A

pressure is evenly distributed

241
Q

why do casts or splints used for external coaptation need to have pressure evenly distributed?

A

to avoid circulatory stasis

242
Q

where should be stabilised during external coaptation?

A

joints should be immobilised above and below the fracture

243
Q

what should happen to joints distal to the fracture?

A

should be immobilised - inculding foot

244
Q

why should all joints distal to the fracture be immobilised?

A

to avoid foot swelling

245
Q

what fractures are suitable for external coaptation?

A

fractures distal to elbow or stifle
stable fractures
those with 50% overlap of fracture fragments on orthogonal radiographs
fracture of one bone of a 2 bone segment (e.g. radius or ulna fracture)
2 or fewer metacarpal or metatarsal fractures

246
Q

is external coaptation widely used?

A

yes

247
Q

what are the issues with external coaptation?

A

high number of complications which can be worse than original complaint

248
Q

what must you do before using external coaptation?

A

careful case selection
careful application
good post op care

249
Q

what can be used for external coaptation?

A 
splint
cast
preformed splint (e.g. green gutter)
custom made splint
250
Q

what is the first layer of the cast?

A

stockinette

251
Q

how many layers of stockinette should be applied?

A

double layer

252
Q

how long should the stockinette applied as the first cast layer be?

A

long enough to overlap top and bottom

253
Q

what is crucial when laying the stockinette layer of a cast?

A

hold taut so there are no creases

254
Q

what is the primary layer of the cast?

A

water repellent, conformable bandage e.g. softban

255
Q

how may layers should be used for the primary cast layer?

A

one to 2 layers of 50% overlap

256
Q

where should padding be placed on the primary cast layer?

A

not too much over bony prominences due to risk of sores and likelihood of cast slipping
can be placed above and below for a donut effect

257
Q

what should be allowed at the top and bottom of the primary cast layer?

A

excess for overlap

258
Q

what cast material can be used?

A

fibreglass impregnated polyurethane cast material (Vetcast)

259
Q

what are the benefits of fibreglass impregnated polyurethane cast material (Vetcast)?

A 
light weight
comfortable
waterproof
radiolucent
fast setting
260
Q

what should be worn when applying cast material?

A

gloves

261
Q

how is fibreglass impregnated polyurethane cast material (Vetcast) activated?

A

immerse in water (hot or cold - if not experienced) and squeeze 6 times

262
Q

how should the cast ‘Vetcast’ be applied?

A

under a little tension
average of 6 layers (3 up and down)
more layers at bends
avoid wrinkles

263
Q

what should be done once the cast has set?

A

cast is cut on 2 sides (bivalve) using a cast saw

264
Q

when is cast cutting performed?

A

when the patient is still under GA or sedation

265
Q

what is the purpose of cutting the cast?

A

ease of removal if problems

id another vet does not have a cast saw

266
Q

where are cast cuts often performed?

A

medial and lateral most common

cranial and caudal may be stronger

267
Q

what may dictate the location of cast cuts?

A

if the cast is likely to be used as a splint at a later date

268
Q

how should the bivalved cast be secured once it is cut?

A

tape together firmly using strips of non stretchy tape

269
Q

what tape can be used to secure the bivalved (cut) cast?

A

zinc oxide

270
Q

what can be done to avoid sharp cast edges?

A

fold softban and stockinette over the ends and apply extra padding as necessary

271
Q

where should the extra padding and softban / stockinette be secured?

A

with tape once folded over and padding added

272
Q

how should the foot of a cast be reinforced to prevent wear?

A

use extra tape

273
Q

what should the outside of the cast be covered in?

A

cohesive bandage such as vetwrap

274
Q

what should be visible from the bottom of the bandage?

A

toes and central pads visible but not protruding

275
Q

what can indicate that the foot in a cast is swollen?

A

nails will splay out

276
Q

how is a cast removed?

A 
easy if bivalved
remove outer layer
cut tape
change padding
check for sores
reapply cast/splint if necessary
277
Q

what is the complication rate for external coaptation like?

A

high - 63%

278
Q

when can external coaptation complications occur?

A

owner compliance low
difficulties in management
inappropriate case selection
even can occur in cases where selection and management is optimal

279
Q

what soft tissue injury can occur from external coaptation?

A

ischemic injury ranging from mild dermatitis to avascular necrosis

280
Q

what animals are particularly prone to external coaptation soft tissue injury?

A

sight hounds

281
Q

how can external coaptation soft tissue injury be prevented?

A

weekly cast changes
owner compliance
correct amount of cast padding (not too much or too little)

282
Q

what can be the cost of soft tissue injury from external coaptation?

A

more expensive than original injury

loss of limb

283
Q

what are the complications with healing of fractures treated with external coaptation?

A

malunion, delayed union or nonunion
rotation, angulation or shortening
may be functional or non-functional depending on severity

284
Q

what dogs have a high chance of malunion, delayed union or nonunion of fractures repaired with external coaptation?

A

toy breeds

285
Q

when does fracture disease occur?

A

during the time necessary for the bone to heal

286
Q

what is fracture disease a result of?

A

fracture management (immobilisation or decreased weight bearing)

287
Q

what is typically seen with fracture disease?

A 
joint stiffness
muscle atrophy
osteoporosis
muscle contracture and fibrosis
adhesions
288
Q

why can osteoporosis occur with external coaptation of fractures?

A

loss of bone density due to reduction in force through bone

289
Q

how can fracture disease be avoided?

A

aim for rapid return to weight bearing
avoid unnecessary immobilisation of joints by external coaptation
consider other options that cause less fracture disease e.g. ESF or internal fixation

290
Q

do all patients tolerate external coaptation?

A

no!

291
Q

what discharge instructions should owners of patients with casts be sent home with?

A

complications that are possible
instructions for care of cast/patient
onus on owner to bring dog/cat back if they are at all concerned

292
Q

what signs indicate that a patient should be returned to the practice?

A
  1. Any change in shape of the splint or cast on the limb.
  2. Any excessive chewing of the splint or cast by the animal.
  3. Any sign of excessive discomfort.
  4. Any unusual or bad odours coming from the splint or cast.
  5. Any unexplained soiling of the splint or cast that was not present before.
  6. Any pronounced sores that develop at the top of the splint or cast that do not respond to talcum powder application.
  7. Swelling of the toes, or the leg above the splint.
  8. Inappetance, depression or fever in your pet.
293
Q

how can the owner check the health of the cast limb?

A

pinch toes

check for sensation, temperature and comfort

294
Q

what must not happen to a cast?

A

become wet

JJ (33 decks)

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