Joint Fractures and Traumatic Luxations Flashcards
describe articular fractures
fractures involving the articular cartilage and subchondral bone
describe the diagnostic tools that may be indicated to make an accurate diagnosis and appropriate treatment plan
- radiographs! when stable, collimated, orthogonal views
- may augment orthogonal rads with stress views (helpful if suspicious of joint instability, if can open joint spaces may indicate ligament injury), oblique views (to combat superimposition), and contralateral (for comparison) views
- CT is more sensitive than rads
all may be required!
what are the 3 treatment options of articular fractures?
- fracture repair: ideal if possible
- salvage options: next best if repair not possible
- conservative/amputation: avoid if possible!
list the fundamental principles of articular fracture repair (4)
must achieve anatomic reduction AND RIGID internal fixation to:
-promote PRIMARY bone healing; don’t want callus formation!
-promote EARLY return to function
-and mitigate development of degenerative joint disease
describe methods of articular fracture repair (3)
interfragmentary compression can be helpful to minimize the fracture gap and optimize primary bone healing! achieve by
- manual compression with reduction forceps (skeletally immature animals, have softer bone so easier to achieve compression this way)
- screws place in lag fashion
- pin and tension band wire fixation; converts distractive forces from ligaments pulling on bone into compressive forces and rigid stability
describe considerations of articular fractures in juvelines (2)
- gentle tissue handling is key! minimize disruption of blood supply and minimize further injury to growth plate
- do NOT span physis with a rigid implant; prevents further growth! cross pins are often sufficient (smooth and as perpendicular as you can so growth plate can still grow around pins
what are the 3 salvage options if cannot achieve anatomic reduction and rigid fixation?
- joint replacement: provides optimal function
- joint fusion (arthrodesis): with a plate, no mobility in joint but usually good limb function and other joints compensate
- hip joint: femoral head ostectomy (excision arthroplasty); not as optimal function
describe post-traumatic osteoarthritis
- an inevitable consequence of articular fractures (cartilage injury)
minimize progression by:
1. limiting iatrogenic trauma (minimal invasive)
2. performing surgery early (within 3 days if possible)
3. adhering to fundamental principles of anatomic reduction and rigid fixation
4. promoting early return to function: controlled weight bearing, PROM, PT
5. initiate osteoarthritis management
describe the main complications and adverse sequelae associated with articular fractures
like with any fracture repair:
1. infection: can lead to septic arthritis!
2. implant failure/migration
3. delayed, mal, nonunion
for articular fractures specifically:
1. osteoarthritis
2. reduced ROM/joint function
describe traumatic joint luxations
- dislocation of a bone from a joint secondary to trauma
- describe the position of the distal bone in relation to proximal bone
- tyically involves joint capsule rupture and disruption of ligament(s)
describe joint laxatiy/subluxation
- used to describe partial dislocation
- soft tissue injury typically less severe than with complete luxation
describe presentation and diagnosis of traumatic luxation
presentation: acute onset +/- history of trauma, typically non weight bearing
diagnosis:
1. ortho exam; use anatomic landmarks! (pelvic triangle)
2. orthogonal radiographs: +/- stressed views for subluxation/instability
describe treatment principles of traumatic joint luxations (3)
- restore normal anatomic relationship
- provide stability to joint (NOT rigid!)
- preserve normal joint ROM
describe treatment options of traumatic joint luxations
preferred if possible:
1. closed reduction, no sx: attempted if acute (3-5 d)
2. open reduction and stabilization: if chronic (contracture), failed closed reduction or reluxation
salvage options: consider if severe OA, intra-articular fragments, and/or sx complications
1. joint replacement
2. arthrodesis
3. excision arthroplasty
not ideal but may be acceptable: if severe financial constraints and/or complications
1. amputation
2. medical management
what does treatment option of traumatic joint luxations depend on? prognosis?
- the joint involved
- the chronicity
- concurrent diseases/injuries
- owner and patient compliance
- owner expectations and finances
prognosis is similarly variable, dependent on severity, chronicity, and treatment option
describe shoulder luxation, preferred treatment options, salvage options, and post-reduction coaptation
can be in medial, lateral, caudal, or cranial direction; medial is most common, lateral is more likely in large breed dogs
preferred tx options:
1. closed reduction and coaptation: often successful if performed early
2. open reduction and stabilization: prosthetic ligaments, biceps tendon transposition
salvage options:
1. excision arthroplasty (glenoid excision, better in smaller dogs)
2. arthrodesis
post-reduction coaptation (2-4 weeks)
1. medial:
-velpeau sling forces humeral head lateral
-hobbles (immobilizes)
2. lateral:
-spica splint forces humeral head medial
-hobbles: immobilizes
describe elbow luxation, preferred treatment options, salvage options, and post-reduction coaptation
direction: most often (>90%) lateral, often with large breed dogs, see typical stance (elbow adducted and antebrachium externally rotated) on slide and orthogonal views are hella important!
preferred:
1. closed reduction and coaptation: often successful if performed early, lower success in cats (higher chance to reluxate, probs just go straight to sx) than dogs
2. open reduction and stabilization: prosthetic ligaments
salvage:
1. athrodesis
post-reduction coaptation: 2-4 weeks
spica splint, maintains elbow in extension
describe antebrachiocarpal luxation, preferred treatment options, salvage options, and post-reduction coaptation
direction: dorsal or palmar;
-usually due to major trauma in dogs, both collateral ligaments as well as the palmar support structures if hyperextension
-often due to less severe trauma in cats, can occur due to rupture of the medial collateral ligament alone! often results in palmar luxation
preferred treatment options:
(a note): closed reduction and coaptation is often unsuccessful
1. open reduction and stabilization: prosthetic ligaments can be successful IF injury is isolated to collateral ligaments (more common in cats than dogs)
2. pancarpal arthrodesis: required if palmar support structures are affected (most dogs)
post-op copatation: 2-4 weeks
palmar splint bandage
describe sacroiliac luxation, preferred treatment options, salvage options, and post-reduction coaptation
direction: craniodorsal; typically associated with 2 or more pelvic fractures
radiographs: need to see straight! VD pelvis is most helpful, follow medial contour of ilial wing
treatment options:
1. open reduction and stabilization: use a sacroiliac screw (lag or positional)
2. conservative management: strict crate rest (6-8 weeks)
when do you recommend surgery for a sacroiliac luxation? how?
when: decision should be made within 5-7d of injury bc over time sx becomes significantly more challenging bc so much muscle around pelvis = lots of contracture
how:
1. >50% displaced or highly unstable
2. >50% pelvic canal narrowing, especially in cats concernec about ability to defecate
3. neuro status: if present, operate
4. pain: severe pain or unwilling to use limb after 3-5 days operate
5. polytrauma: affecting ability to ambulate (case-dependent)
describe hip luxation, preferred treatment options, salvage options, and post-reduction coaptation
direction: craniodorsal (75%) or caudoventral (15%)
-caudoventral luxations occur due to forced limb abduciton (splayed); associated with fracture of greater trochanter; femoral head can be displaced in obturator foramen = painful!
diagnosis:
1. thumb test: stick thumb in depression behind greater trochanter, externally rotate greater trochanter and thumb should get pushed out, if not is luxated
2. pelvic triangle
preferred treatment:
1. closed reduction +/- coaptation: successful if perform early, more success if caudoventral than craniodorsal
2. open reduction and stabilization: toggle rod
salvage: both indicated if underlying hip disease
1. total hip replacement: large breed dogs, when owner expects normal hip function, dog is active, sport/working
2. FHO (excisional arthroplasty): financial constraints, companion pets (small breed dogs cope better with this); some large breed dogs can tolerate
post-op coaptation: 4-6!!! weeks
1. ehmer sling: craniodorsal luxation
2. hobbles (prevent splaying): caudoventral luxation
describe stifle luxation, preferred treatment options, salvage options, and post-reduction coaptation
deranged stifle: disruption of at least 2 major ligaments (collaterals, cruciates)
complete luxation: hella rare, more likely in cats, requires disruption of all 4 ligaments, vascular integrity of distal limb must be carefully evaluated (often compromised)
preferred treatment options:
1. open reduction and stabilization: prosthetic ligaments, extracapsular suture, temp immobilization with trans-articular ESF
salvage: arthrodesis
describe tarsocrural luxation, preferred treatment options, salvage options, and post-reduction coaptation
typically involved disruption of both medial and lateral supporting structures (malleolar fracture, collateral ligament rupture(s), shearing injury, medial side more commonly affected)
preferred treatment:
1. closed reduction and coaptation: often unsuccessful
2. open reduction and stabilization: prosthetic ligaments, malleolar fracture repair, transarticualr ESF (if severe shearing injury)
salvage: arthrodesis
post-op copatation 2-4 weeks:
lateral splint bandage
describe digit luxation, preferred treatment options, salvage options, and post-reduction coaptation
relatively common
preferred treatment options:
1. closed reduction and coaptation: often unsuccessful
2. open reduction and stabilization: may be preferred over closed in working dogs, suture repair +/- prosthetic ligament
salvage: arthrodesis
post-reduction coaptation: palmar/plantar splint bandage
compare and contrast the common preferred treatments (2) to the salvage treatments (3) for all the joints
preferred:
1. closed reduction: reasonable first line treatment for acute luxations of shoulders, hips, elbows, and digits
- open reduction and stabilization: reasonable for all joints (if no severe underlying disease)
salvage:
1. joint replacement: reasonable salvage option for hips
- arthrodesis: very reasonable salvage option for carpus and tarsus
-shoulders, elbows, and stifles can do okay but will have mechanical lameness - excision arthroplasty: very reasonable salvage option for hips, shoulders can do okay
