Surgery: Feet/Claw/Teat/Tail Flashcards
what are the indications for a digit amputation
Toe necrosis
Non-healing ulcer
White line disease
Septic arthritis of distal interphalangeal joint
Osteomyelitis of distal phalanx (P3) or navicular bone
Tenosynovitis of deep flexor tendon
A lot of these end stage of common foot lesions
what questions should be asked when determining whether or not to amputate a digit
Other claw on same foot has no lesions/not lame?
- No lesions at all because there will be more weight put on it
Other hind foot has no lesions/not lame?
Infection NOT tracked above level of surgical incision?
Cow otherwise well, good BCS, not freshly calved
Can farmer cope with post op wound management?
- Not suited to every farm
Slats?
One narrow claw can get stuck
Animal welfare most important?
- Sometimes culling is best for welfare
Realistic expectations (12-24 months max)
- 55% survival at 1 year post surgery in hind-limbs, and 84% survival in forelimbs
what are pre-op preparations for digit amputation
Antibiotics (broad spectrum)
NSAID ‘wind up’
Suitable crush (or down under sedation)
Lift foot, tourniquet
Clip and surgical prep
IV regional anesthesia , 20-30ml convenient superficial vein (licence IV?)
Check it worked!
+/- local infiltration
Lasts about 90 mins but tourniquet should only be on about 60 mins
how do you do an IV regional amputation for digit amputation
Lateral digital vein probably best
Wait 10 mins (block other side?)
Diffuses out of the vein and anesthetize the surrounding structures
what are the 3 potential sites for digit amputations
Distal part of P1
Proximal interphalangeal (PIP) joint (cartilage)
Distal interphalangeal (DIP) joint (cartilage)
how is a digit amputation done
If you expose cartilage you need to use a curette to scrape the cartilage off
Aided by scalpel incision in ID space to ‘seat’ the embryotomy wire
- 90º
Make an assessment for ascending infection
Twist and pull any blood vessels (tourniquet so won’t bleed)
No skin closure, heals by secondary intention so needs to be kept clean and dry
- Rely on granulation bed forming
what are the post op procedures following a digit amputation and how do you bandage it
Bandage before removing tourniquet
Apply pressure:
- Melonin contact layer
- Cotton wool
- Knit firm
- Vet wrap (quite tight)
- Duct tape (water proof)
Change after 2 days then twice/week until full bed of granulation tissue
- Poorly managed manage worse than no bandage at all!
Continue meds — 4 more days of antibiotics and NSAID
- At least of 5 day course of antibiotics
- NSAIDs are not really licensed for long term use — extend withdrawal periods
how do you remove a interdigital growth/hyperplasia
Prep and anesthesia same as digit amputation
Get hold of mass with allis tissue forceps
Incise skin around mass and dissect below
+/- suture
Bandage
Alternative = electrocautery
what are the 3 layers of the teat
- mucosa
- submucosa
- skin
name the important teat anatomy
why is the distal end of the teat important
Streak canal is where the teat seals off from environment
Teat cistern — if there is a full thickness wound it is a route of infection into the udder or can end up with fistula formation
what is the venus plexus of the teat
If there is a wound at the top it can affect blood supply to the distal teat
how does blood supply run in the teat
Blood supply runs in a vertical direction so vertical wounds > horizontal wounds (necrosis)
how should you restrain for teat surgery
Kick zone
Sedation (watch don’t go down or big dose so stays down)
Crush
- +/- kick bar
- +/- lift leg
- Awkward height
Parlour:
- Rope behind
- +/- kick bar
- Good height
- Assistant hold tail
what are further investigations that can be done to examine the teats
Palpate (roll between fingers)
- Polyps or scar tissue
Probe
- Narrow
- Obstruction
Ultrasound
Theloscope (endoscopy, not a day 1 skill)
Very precious part of anatomy
what are the local anesthesia blocks for teat surgery
Local (try to avoid adrenaline)
Ring block, 20ml, 23g 1.5cm needle
- Small needle
OR
Inverted V (depends on wound orientation
Tourniquet/clamps and IVRA
Teat cistern infusion 10ml (if polyp)
what other pre op procedures for teat surgery are done
California milk test (CMT)
- Is there mastitis? (subclinical)
Antibiotics
- Intra-mammary vs parenteral
- Both if full thickness wound
- Duration depends on infection risks (cascade)
NSAID
- Painful
- Inflammation
- Cascade for long term use
Cannula
- Allows drainage of milk but to infection if used long term post op
- Prone to mastitis if not milking
- Dirty and can introduce infection but helpful to relieve of milk
how do you assess teat wounds
Age
- >12hrs not good
Orientation
- Horizontal not good
Structures involved
- End = streak canal = teat not sealed 😔
- Milk visible = cistern = fistula 😔
- Base = blood supply = necrosis 😔
Pain
Farmers expectations (cull cow vs peak lactation)
assess this teat injury
Horizontal component but vertical as well
Not involving the distal anatomy
Superficial
Might be okay
Worry about necrosis
assess this teat injury
Dry and old, need to debride it
Looks full thickness at distal end
Likely going thru streak canal
Poor prognosis
assess this teat injury
Fresh
Horizontal direction
Near base of teat but there is the venus plexus here
how do you treat a skin only teat wound
no milk
teat bandage (? abs and NSAID)
cold compress helps with swelling
how do you treat a full thickness teat wounds
Consider drying off quarter
Debride dead/necrotic tissue
how do you close a full thickness teat wounds
Mucosa
Submucosa/connective tissue/muscle:
- Both small diameter absorbable
- Ex. Vicryl 4-0, 1.5 metric (ie small)
- Vertical = continuous
- Horizontal = interrupted (tension)
Skin:
- Simple interrupted
- Not too much tension
- Non-absorbable, monofilament, smallish diameter
- Ex. Proline 3-0, 2 metric
what is the wound post op care for teat injuries
+/- teat bandage to protect outside of wound in between milkings
Milk as normal
- Not by hand as pressure not even and puts tension on suture or cannula
Start milking when swelling decreased and healing started (sooner the better)
On-going antibiotics/NSAID
what are teat injury wound complications
Mastitis
Fistula formation
- Non-healing leads to a hole
- Bacteria entry
Wound breakdown
Fibrosis/narrowing of canal
Edema
what are teat obstructions (aka slow milkers)
Congenital, teat peas, neoplasia
Ultrasound useful but underutilized (endoscopy in EU)
what are the treatments teat obstructions in heifers (aka slow milkers)
Narrow/atresia of streak canal
Perforate with needle/small scalpel, daily manipulation to avoid adhesions
what are the treatments for teat obstructions in adults
More complex, underlying issue or polyp
Base:
- Teat spiral slowly into canal to ‘catch’ tissue then apply traction to pull out
Mid:
- Dilate teat and remove with forceps
End:
- Try plug or teat knife
Open teat surgery EU
how is teat amputation of supernumerary teats done
Ideally before 4 weeks old
>3 months = vet
Heritable
Get the right teat!
Local anesthetic around teat
Forceps on base cranial caudal direction
Orientation of skin
Burdizzo if large
Scalpel
+/- suture
how is teat removal due to injury done
Local anesthesia using ring block + sedation
Junction proximal 1/3 + mid 1/3 (blood vessel at base of teat)
Clamp forceps or burdizzo
Scalpel
Tie off any blood vessels (if no burdizzo)
Open — drainage
If toxic mastitis
If for a wound you might close it
what are the indications for enucleation
Neoplasia,
Severe non-responsive infection
describe how to do 4 point retrobulbar block
Gently curved 22-gauge 3.5” spinal needle, directed through the conjunctival fornix and along the sclera (not penetrating the globe) at 10 o’clock, 2 o’clock, 4 o’clock and 8 o’clock
At each site the needle is inserted to a depth of 6-10cm and 5-8ml is injected
describe the basic steps of enucleation
Clip/clean (dilute iodine)
Suture/allis tissue forceps eyelids shut
Circular incision right around the eyelid margin (1cm)
Allis tissue onto eyelid
Traction but watch!!
Dissect muscle and CT — ligament (close to orbit)
Dissect through optic nerve and blood vessel
- Very difficult to tie off blood vessel because its so deep
+/- pack globe with swabs
Stich margin
Continuous suture pattern
Tighter then normal and close together
what are the indications for tail amputation
Trauma, tourniquet feces
how is a tail amputation done
Sedate
Caudal epidural
Tourniquet proximal to site of amputation
Rubber ring for castration
Flutter valve for calcium
Clip and surgical prep
Double V shaped skin incision (10cm above issue)
Undermine flap
Disarticulation of vertebrae
Ligate blood vessels
Stitch skin
