SA Fractures 1

Question 1

Fractures clinical signs.

Answer 1

Lameness - usually, but not always, severe.
Pain on palpation/manipulation.
Swelling.
If unstable:
- deformity.
- abnormal mobility.
- crepitus.

Question 2

Triage and assessment of thoracic trauma.

Answer 2

Airway, breathing, circulation (A,B,C) and deal with life threatening injuries.
After a traumatic fracture, thoracic imaging should be assessed for the following:
- pulmonary contusions.
- pneumothorax.
- fractured ribs.
- other thoracic problems (e.g. ruptured diaphragm).

Question 3

Signalment and fractures.

Answer 3

Age: young = fracture > luxation.
Sex: male cats roam more.
Breed: Springer spaniels - humeral stress fractures.
Size: small breeds distal radial and ulnar fractures.
Occupation: greyhounds fracture accessory carpal bones and central tarsal bones.

Question 4

Aetiology of SA fractures.

Answer 4

Usually direct trauma e.g. RTA.
Indirect fracture - landing injury.
– fracture higher up leg.
High energy - high damage (comminuted) and soft tissue damage.
Fracture after minor trauma
- consider pathological.
Prior hx of lameness e.g. stress fracture?
Concurrent disease/meds
- osteopenia.

Question 5

Ortho and neuro exam.

Answer 5

Multiple injuries often present.
Neuro exam - for brain or spinal injury.
Repeat exam daily and under GA.

Question 6

Dx.

Answer 6

Imaging - radiography.
– orthogonal views.
– multiple views?
- do opposite leg for comparison.
- CT.
– faster.
– assess thorax.
– 3D imaging.

Question 7

How can fractures be classified?

Answer 7

By cause of fracture.
By communication w/ ext. environment.
By extent of bony damage.
By number and position of fragments.
By direction of fracture lines.
By location of fracture.
By forces acting on fracture / displacement.
By stability.
By degree of complexity and involvement of other tissues.
By age of fracture.

Question 8

Classifying fracture by its cause.

Answer 8

Extrinsic:
- direct trauma.
– car bumper.
- indirect trauma.
– bump or fall.
Intrinsic.
- muscular.
- pathological.
- stress.

Question 9

1. Classification by communication with the environment.
2. Classification by extent of bony damage.

Answer 9

1. Closed.
   Open.
2. Incomplete.
   - greenstick.
   - fissure.
   - depressed.
   Complete.

Question 10

1. Classification by number and position of fragments.
2. Classification by direction of the fracture lines.

Answer 10

1. Simple.
   Comminuted.
   Segmental.
2. Transverse - tension / avulsion.
   Oblique - compression force.
   Spiral - torque.
   Butterflying - bending (tension and compression).

Question 11

1. Classification of fracture by location.
2. Classification by forces on the fracture.

Answer 11

1. Diaphyseal - proximal / midshaft / distal.
   Metaphyseal - compression fractures.
   Epiphyseal.
   Condylar.
   Articular.
2. Avulsion - pulling of bone by tendons.
   Impaction - affect articular surface, quite stable fractures.
   Compression - in cancellous bone e.g. spine.
   Over-riding - muscles around bone all contract as soon as the bone breaks.

Question 12

1. Classification of fracture by stability?
2. Classification of fractures by tissue involvement.

Answer 12

1. Stable - contact between 2 bone ends, load-sharing across bone.
   Unstable - e.g. lots of fragments, possibly unreconstructible, implants take all load until healing occurs.
2. Muscle damage.
   Nerve damage.
   Blood vessel damage.

Question 13

1. Classification by age of fracture.

Answer 13

1. Recent / fresh.
   - sharper and cleaner break and bone fragmentation.
   - easier to fix.
   Older.
   - smoother and more won edges.
   - more difficult to fix.

Question 14

Emergency fracture management.

Answer 14

Treat the whole patient:
- A,B,C.
- IV catheter.
- fluids.
- analgesia.
- open fracture management.
- immobilise / cover.
When to repair - when patient stable for GA - in order of priority:
- skull and spinal fractures (w/in 24hrs, neuro status dependent).
- open fractures (6hrs – wound management).
- articular fractures and dislocations (1-2d).
- long bone fractures (1-5d).

Question 15

Temporary fracture management prior to referral or definitive management for:
1. pelvic fracture.
2. femur fracture.
3. humeral fracture.
4. radius and ulnar.
5. tibial.
6. hock, carpus, foot.

Answer 15

1. Cage rest and analgesia.
2. Cage rest and analgesia.
3. Cage rest and analgesia / spica splint.
4. Splinted bandage and analgesia.
5. Support bandage / splinted bandage / analgesia.
   Support bandage / splint / analgesia.

Question 16

1. Aims of fracture management.
2. What is fracture disease?

Answer 16

1. To create an optimal environment for fracture healing and return the patient to normal function ASAP. Avoid fracture disease.
2. Occurs during bone healing as a result of immobilisation of the limb.
   - joint stiffness, muscle atrophy, osteoporosis, muscle contracture and fibrosis.

Question 17

Decision making in fracture reconstruction.

Answer 17

Whole animal:
- single/multiple bones.
- single/multiple limbs.
- size, age and nature of animal.
Fracture:
- forces acting on fracture.
- type and quantity of bone.
- involvement of joints.
- open or closed.
Owner and vet:
- client/post op care.
- experience of surgeon.
- availability of equipment.
- expense of procedure.
Fracture assessment score (BMC):
- Mechanical – fracture and patient type.
- Biological – speed of healing.
- Clinical - client and patient compliance.

Question 18

Fracture fixation choices.

Answer 18

Healing requires adequate bone reconstruction, stability and vascularity - need balance between these.
Conservative management - e.g. cage rest.
External coaptation - e.g. splints / cast / bandage.
Surgical management:
- external skeletal fixation +/- IM pin.
- internal fixation – pins, screws, bone plates, interlocking nails.

Question 19

Conservative management.

Answer 19

Good for fracture with lots of surrounding soft tissue (muscle, periosteum, adjacent bones) provides sufficient stability to keep bones aligned whilst healing.
Minimise movement whilst healing:
- restrict exercise (cage rest).
- provide pain relief (NSAIDs).
- duration age dependent (2-4w).
For fractures that are:
- pelvic.
- mandibular.
- spinal.
- scapula.
- minimally displaced.
- cancellous bone.
- on non load bearing bones.

Question 20

External coaptation management.

Answer 20

Splint or cast or bandage.
Fractures below elbow/stifle.
Young animals.
Minimal displacement.
One bone only of a 2 bone area.
Stable fractures.
Cast or customised splint best.
Off the shelf splint and bandage for temporary use.
Careful case selection needed.
May NOT be the cheapest option.
- complications possible and sometimes severe.

Question 21

Advantages of non-surgical management.

Answer 21

Reduce / avoid anaesthesia.
Avoid need for open surgery.
No disruption of blood supply.
Cheaper materials.
Cheaper overall? - maybe not.

Question 22

Disadvantages of non-surgical management.

Answer 22

Fracture disease.
Insufficient stability leading to a delayed or non-union.
Cast sores.
Malunion.

Question 23

External coaptation - suitable fractures.

Answer 23

Lower limb.
Simple stable fractures.
Transverse / interdigitating.
Radius with intact ulnar.
Tibia w/ intact fibula.
Fractures w/ overlap >50%.
Good healing potential - young.

Question 24

Aims of surgical management?

Answer 24

Place implants between fracture fragments to hold them securely while fracture heals.
Implants must withstand forces that are trying to separate fracture fragments and disrupt healing.
- rotation and tension especially.
Can use implants in isolation or in combination e.g. pin and plate.

Question 25

Fracture reduction.

Answer 25

Process of replacing the fracture segments in original anatomical position.
- closed – recent, stable, lower limb.
– can cause soft tissue damage.
- open – most fractures, instruments, toggling.

Question 26

Cancellous bone grafts.

Answer 26

Stimulate bone healing.
Sites of harvest:
- proximal lateral humerus.
- iliac crest (cats).
Uses:
- stimulate bony union on fracture repair.
- arthrodesis.
- delayed / non-union fractures.