Post Op Managment Flashcards
What 3 things do we look at in a post fracture repair radiological assessment?
- Alignment >50% ESF
- Assess for any rotation that has occurred as implants tightened
- Implant positioning avoiding joints, fracture site and on occasions growth plates (unless you have lag screwed it)
What is the allignment in “open but do not touch” fractures?
At least 50% overlap
in both planes. Doesn’t have to be perfectly aligned.
Do you deserve cereal in melted chocolate?
Yes.
What is the allignment in ‘ORIF’ (open reduction, internal fixation)?
Must be near 100%
What can be seen in relation to the fracture on a radiograph of a fracture repair with an external fixator?
the fracture lines
What are the 3 major causes of inappropriate fixation?
- Implants too small or too large
- Fail to address forces applied
- Too rigid, especially external fixator
What is the consensus about using casts in veterinary?
- Many complications, e.g. pressure sores and loss of digits
- Avoid this method of immobilization
Where are pressure sores most common with robert Jones dressings?
- Accessory carpal bone
- Calcaneus
Post fracture repair what rrestrictions should we give tto dogs in general?
Garden on lead for 3 weeks and then to lead for another 8 weeks
How long should we restrict cats
8 weeks
When are antibiotics recommended on fracture discharge?
60-90mins + surgery
What instructions do we give to owners for dressing management?
- Keep dry. Heavy duty polythene protected with sock only when outside
- Check toes and top of dressing twice daily
- Any smell to bring to surgery
- If off colour, bring to surgery
- If veterinary surgeon in any doubt remove dressing or cast
What fixation failure do we have with pins?
Fracture rotates or collapses
What fixation failure do we have with cerclage wires?
Loosen and fail to maintain reduction of fragments resulting in instability
What fixation failure do we have with a plate?
- Loss of trans cortex with cyclical loading results in plate breaking
- If too strong, stress protection of the bone
- Stress riser – rigid piece of bone next to area of bone not plated and can break
What fixation failure do we have with an ESF?
- Pin tract infection common
- Fracture through pin tract
- If too strong get delayed healing of fracture
What is a common IM pin failure in a cat femur?
Damages sciatic nerve especially in the cat
•an affected animal will show a great degree of pain – you have to do something straight away otherwise you get neuropathy
What failure is common if there is a retrograde placement of an IM Pin?
Can enter a joint
What happens if there is eccentric loading of bones during weight bearing + muscle contraction?
Bending
What happens if there is a defect in compression surface +/- weak implants with the plates and screws?
Angulation of bone
When are plates weak against bending?
If cyclically loaded
What are the threee options for a buttress fixation?
- Very strong broad DCP plate
- Bridging plate – strong central section without screw holes
- Combination fixation; pin-plate
What are problems with placing an external skeletal fixator?
- Failing to place pins within safe corridors
- Pin tract sepsis and premature pin loosening
- Iatrogenic bone fracture (pins > 25-30% of bone diameter, or close to fracture lines)
- Placing clamps / bars too close to skin = pressure necrosis
- Using too weak / strong a frame
How do we know this is loosening?
Start to see radiolucency
Where is fractur disease more common?
The young animal
Name 3 possible fracture diseases (5)
- Joint stiffness
- Osteoporosis
- Stress protection
- Infection
- Quadriceps contracture
What is seen in distal femoral fracture? (3)
Muscle atrophy
Joint stiffness
Muscle contracture (quadriceps tie-down)= stifle hyperextension
What might be the only treatment for quadriceps contracture?
Amputation
Other than amputation what might treat quadriceps contracture?
- Avoid external coaption
- Rigid internal fixation
- Encourage early use of the limb – appropriate use of analgesia
- Early physio- and hydrotherapy
What is involved with acute osteomyelitis?
Soft tissue and associated periosteum
How can you treat osteomyelitiis?
Antibiotics
What is chronic osteomyelitis?
Primarily bone infection and established around implants
What radiographic changes are seen with fracture disease? (5)
- Proliferative changes to the periosteum
- Sclerotic margin to infected area
- Bone lysis, particularly around implants
- Development of involucrum and sequestrum
- Soft tissue swelling
What can be seen here?
What is Involucrum?
Pus filled in bone
How can we treat fracture disease?
- Remove necrotic bone and sequestrum (a dead fragment of bone)
- Appropriate antibiotics – swab taken at surgery not from any discharging sinus
- Stabilise the fracture – it will heal in the presence of infection if no movement
- When fracture healed remove implants
When will fractures heal in the prescence of infection?
If rigid stability is ensured
When we have secondary bone healing with instability?
If mild
What happens if forces at the fracture site exceed the tolerance of granulation tissue?
This will result in tearing of the blood vessels that are bridging the fracture site, preventing the sequential deposition of cartilage and eventually bone = delayed or non-union.
What is the blood supply to the inner 2/3 of cortex in a normal bone?
Endosteal origin
What is the blood supply to the outer 1/3 of cortex in a normal bone?
Periosteal
What happens to the blood supply with a fracture?
Normal blood supply is disrupted and initial vascular supply required for fracture healing comes from the surrounding soft tissues, such as muscles – extraosseus blood supply.
How can we manage a delayed healing fracture?
- Patience
- Stage down fixator to encourage bone loading
- Physiotherapy to encourage weight bearing
What is atrophic non-unions and what may it require?
Non-viable – may require amputation
What is hypertropic non-unions? How can we treat?
Viable
Treat
- Debride fracture ends and open medullary cavity
- Compress fracture
- Apply cancellous bone graft or equivalent
Where is the most common sites for non-unions? (2)
Radius and femur
What age and weight is non-unions most common?
- 2-7 years old
- Weighing between 7-14 kg
When is the best oppurtunity to heal a fracture?
The first attempt
What is the main complication of a fracture?
Instability
What is mal-union?
Fracture does not heal in the correct allignment
When is mal-union bad?
When there is rotation
When is mal-union fine?
A cranialcaudal bend
When is a mal-union maybe ok but depends on severiy?
If it heals in a medial-lateral plane
When is fracture scoring done and what is it?
Done before fracture repair
A means by which the fracture is given a score to determine the likelihood of uneventful healing
What does a high fracture score mean in general?
Guarded prognosis
What factors are considered for fracture scoring?
Patient factors
- Weight of animal: heavier have a higher score
- Age: younger animals lower score
- Boisterousness and ability to manage cage rest
- Concurrent illnesses
Fracture
- Type of fracture: does it allow compression plating or require
external fixator, etc. If you can get a plate on it – lower the score. EF – higher score. Open – higher (contamination and infection affects healing) - Open or closed?
- Associated soft tissue injuries
- Single or one of several – multiple limbs – higher score
Owner factors
- Will they comply with post-op instructions?
- Finances – if they have no money don’t start
Surgeon
- Are they able to manage this fracture?
Is the correct equipment available?
What can we do for a fracture in an aggressive animal?
Use plates - don’t need to see the animal again
What age is this animal?
Young
Discuss
Air gun + debris
comminuted fracture
What is the cause of this fracture?
Pathology
