SA Fractures 1 Flashcards
Fractures clinical signs.
Lameness - usually, but not always, severe.
Pain on palpation/manipulation.
Swelling.
If unstable:
- deformity.
- abnormal mobility.
- crepitus.
Triage and assessment of thoracic trauma.
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).
Signalment and fractures.
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.
Aetiology of SA fractures.
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.
Ortho and neuro exam.
Multiple injuries often present.
Neuro exam - for brain or spinal injury.
Repeat exam daily and under GA.
Dx.
Imaging - radiography.
– orthogonal views.
– multiple views?
- do opposite leg for comparison.
- CT.
– faster.
– assess thorax.
– 3D imaging.
How can fractures be classified?
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.
Classifying fracture by its cause.
Extrinsic:
- direct trauma.
– car bumper.
- indirect trauma.
– bump or fall.
Intrinsic.
- muscular.
- pathological.
- stress.
- Classification by communication with the environment.
- Classification by extent of bony damage.
- Closed.
Open. - Incomplete.
- greenstick.
- fissure.
- depressed.
Complete.
- Classification by number and position of fragments.
- Classification by direction of the fracture lines.
- Simple.
Comminuted.
Segmental. - Transverse - tension / avulsion.
Oblique - compression force.
Spiral - torque.
Butterflying - bending (tension and compression).
- Classification of fracture by location.
- Classification by forces on the fracture.
- Diaphyseal - proximal / midshaft / distal.
Metaphyseal - compression fractures.
Epiphyseal.
Condylar.
Articular. - 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.
- Classification of fracture by stability?
- Classification of fractures by tissue involvement.
- 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. - Muscle damage.
Nerve damage.
Blood vessel damage.
- Classification by age of fracture.
- Recent / fresh.
- sharper and cleaner break and bone fragmentation.
- easier to fix.
Older.
- smoother and more won edges.
- more difficult to fix.
Emergency fracture management.
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).
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.
- Cage rest and analgesia.
- Cage rest and analgesia.
- Cage rest and analgesia / spica splint.
- Splinted bandage and analgesia.
- Support bandage / splinted bandage / analgesia.
Support bandage / splint / analgesia.
- Aims of fracture management.
- What is fracture disease?
- To create an optimal environment for fracture healing and return the patient to normal function ASAP. Avoid fracture disease.
- Occurs during bone healing as a result of immobilisation of the limb.
- joint stiffness, muscle atrophy, osteoporosis, muscle contracture and fibrosis.
Decision making in fracture reconstruction.
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.
Fracture fixation choices.
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.
Conservative management.
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.
External coaptation management.
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.
Advantages of non-surgical management.
Reduce / avoid anaesthesia.
Avoid need for open surgery.
No disruption of blood supply.
Cheaper materials.
Cheaper overall? - maybe not.
Disadvantages of non-surgical management.
Fracture disease.
Insufficient stability leading to a delayed or non-union.
Cast sores.
Malunion.
External coaptation - suitable fractures.
Lower limb.
Simple stable fractures.
Transverse / interdigitating.
Radius with intact ulnar.
Tibia w/ intact fibula.
Fractures w/ overlap >50%.
Good healing potential - young.
Aims of surgical management?
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.
Fracture reduction.
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.
Cancellous bone grafts.
Stimulate bone healing.
Sites of harvest:
- proximal lateral humerus.
- iliac crest (cats).
Uses:
- stimulate bony union on fracture repair.
- arthrodesis.
- delayed / non-union fractures.
