Fracture Management for the Small Animal Practitioner

Anne M. Sylvestre DVM, DVSc, CCRP, Diplomate ACVS/ECVS has recently retired from referral practice in Oakville, Ontario and now focuses her time on offering continuing education for small animal practitioners.

List of Contributors xv


Preface xvii


Section 1 General Information 1


1 Fracture Identification 3
Anne M. Sylvestre


1.1 Number of Fragments 3


1.2 Fracture Configuration 3


1.3 Location on the Bone 7


1.4 Salter- Harris Fractures 7


2 Open Fractures 9
Anne M. Sylvestre


2.1 First Degree 9


2.2 Second Degree 9


2.3 Third Degree 9


Reference 10


3 Patient Management 11
Anne M. Sylvestre


3.1 The Patient 11


3.1.1 Upon Admission 11


3.1.2 Immediate Postoperative Care 11


3.1.3 Upon Discharge From Hospital 11


3.1.4 Outside and Walks 12


3.1.5 Follow?up Radiographs and Healing Times 13


3.1.6 Implant Removal 13


3.2 The Owner 14


3.2.1 Slippery Floors 14


3.2.2 Stairs 15


3.2.3 No Jumping 15


3.2.4 Common Stressors 15


3.2.5 Crates 15


3.2.6 Icing 15


3.2.7 Gentle Passive Range of Motion (PROM) 16


3.2.8 Urination and Bowel Movements 16


3.2.9 Food and Water 16


3.2.10 Cats 17


3.3 Managing Osteoarthritis (OA) 17


References 17


4 Bandages and Splints 19
Jennifer White and Anne M. Sylvestre


4.1 The Bandage 19


4.1.1 Layers of a Bandage 19


4.1.2 Creating the Bandage 19


4.2 Forelimb 27


4.2.1 Velpeau Sling 27


4.2.2 Spica Bandage 30


4.2.3 Antebrachial Bandages 31


4.2.4 Bandages for a Manus 37


4.2.5 Carpal Flexion Sling 37


4.3 Hind Limb 39


4.3.1 Ehmer Sling 39


4.3.2 Robert Jones Bandage 39


4.3.3 Crural and Tarsal Bandages 39


4.3.4 Bandages for a Pes 47


4.3.5 Robinson and 90?90 Slings 47


4.4 Bandage Care 47


4.4.1 Home Care Instructions 47


4.4.2 Bandage Changes 50


4.4.3 Bandage/Splint Complications 50


Reference 60


Section 2 The Forequarter 61


5 Mandible and Maxilla 63
Teresa Jacobson


5.1 Mandibular Fractures 63


5.1.1 Mandibular Symphyseal Separation 63


5.1.2 Rostral Mandibular Fractures 63


5.1.3 Fracture at the Level of the Mandibular First Molar 64


5.1.4 Temporomandibular Luxation 65


5.1.5 Other Mandibular Fractures 68


5.2 Maxillary Fractures 68


5.2.1 Fracture and/or Avulsion of the Incisive Bone 68


5.2.2 Fractures of the Maxillary Bone 68


5.3 Managing Expectations 68


5.4 Alternatives When the Treatment of Choice is Not an Option 68


5.5 Potential Complications of Maxillofacial Fracture Repair 69


References 74


6 Scapula 75
Anne M. Sylvestre


6.1 Fractures 75


6.1.1 Fractures Through the Body and Spine of the Scapula 75


6.1.2 Acromion Fractures 76


6.1.3 Fractures of the Neck of the Scapula 76


6.2 Managing Expectations with Recommended Treatments 78


6.3 Alternatives When Treatment of Choice is Not an Option 78


References 79


7 Shoulder Joint 81
Anne M. Sylvestre


7.1 Fractures and Luxations 82


7.1.1 Avulsion of the Supraglenoid Tuberosity 82


7.1.2 T or Y Fractures of the Scapular Neck and Glenoid Rim 82


7.1.3 Other Fractures Involving the Shoulder Joint 82


7.1.4 Medial Luxations 82


7.1.5 Lateral Luxations 84


7.2 Managing Expectations with Recommended Treatments 84


7.3 Alternatives When Treatment of Choice is Not an Option 86


7.3.1 Fractures 86


7.3.2 Luxations 86


References 86


8 Humerus 87
Catherine Popovitch, Thomas W.G. Gibson, and Anne M. Sylvestre


8.1 Fractures 88


8.1.1 Physeal Fractures of the Proximal Humerus 88


8.1.2 Two?Piece Humeral Shaft Fractures 88


8.1.3 Multifragmented Humeral Shaft and/or Supracondylar Fractures 89


8.2 Managing Expectations with Recommended Treatments 90


8.3 Alternatives When Treatment of Choice is Not an Option 90


References 91


9 Elbow Joint 93
Anne M. Sylvestre


9.1 Fractures and Luxations 94


9.1.1 Condylar Fractures 94


9.1.2 Bicondylar Fractures 94


9.1.3 Acute Luxations 94


9.1.4 Chronic Luxations 99


9.1.5 Proximal Ulnar Fractures 100


9.1.6 Monteggia Fractures 100


9.2 Managing Expectations with Recommended Treatments 101


9.3 Alternatives When Treatment of Choice is Not an Option 101


9.3.1 For Patients with a Fracture 101


9.3.2 For Patients with a Luxation 102


References 102


10 Radius and Ulna 105
Catherine Popovitch, Thomas W.G. Gibson, and Anne M. Sylvestre


10.1 Fractures 106


10.1.1 Fractures of the Proximal Ulna 106


10.1.2 Fractures of the Proximal Radius 106


10.1.3 Fractures of the Radius in Toy Breed Dogs 106


10.1.4 Fractures of the Radius and Ulna in Non?Toy Breed Dogs and Cats 107


10.1.5 Isolated Fractures of the Shaft of the Ulna 112


10.1.6 Physeal Fractures of the Distal Radius 112


10.2 Managing Expectations with Recommended Treatments 114


10.3 Alternatives When Treatment of Choice is Not an Option 114


References 117


11 Carpal Joint 119
Anne M. Sylvestre


11.1 Fractures and Ligamentous Injuries 120


11.1.1 Fractures of the Styloid Process of the Radius or Distal Ulna 120


11.1.2 Fractures of the Radial Carpal Bone 120


11.1.3 Fractures of the Accessory Carpal Bone 122


11.1.4 Fractures of the Ulnar Carpal Bone 123


11.1.5 Collateral Ligament Injuries 123


11.1.6 Shearing Injuries 124


11.1.7 Hyperextension Injuries 125


11.1.8 Luxation of the Antebrachiaocarpal Joint 125


11.1.9 Luxation of the Accessory Carpal Bone 125


11.1.10 Luxation of the Radiocarpal Bone 126


11.2 Managing Expectations with Recommended Treatments 127


11.3 Alternatives When Treatment of Choice is Not an Option 127


11.3.1 For Patients with a Fracture 127


11.3.2 For Patients with Ligamentous Injuries 128


11.4 About Pancarpal Arthrodesis 128


11.5 About Partial Carpal Arthrodesis 128


References 129


Section 3 The Hindquarter 131


12 Pelvis 133
Anne M. Sylvestre


12.1 Co?morbidities 134


12.2 Fractures 134


12.2.1 SI Luxations/Fractures 134


12.2.2 Fractures of the Ilial Shaft or Wing 134


12.2.3 Acetabular Fractures 137


12.2.4 Ischial Fractures 137


12.2.5 Fractures of the Pelvic Floor 137


12.2.6 Summary of Indications for Surgical Repair of Pelvic Fractures 138


12.3 Managing Expectations with Recommended Treatments 139


12.4 Alternatives When Treatment of Choice is Not an Option 139


References 140


13 Coxofemoral Joint 141
Thomas W.G. Gibson and Anne M. Sylvestre


13.1 Fractures and Luxations 141


13.1.1 Acetabular Fractures 141


13.1.2 Hip Luxations 142


13.1.3 Alternative Treatment of Choice: Open Reduction 146


13.1.4 Capital Physeal Fractures of the Proximal Femur 148


13.1.5 Fractures of the Femoral Neck 149


13.2 Managing Expectations with Recommended Treatments 150


13.3 Alternatives When Treatment of Choice is Not an Option 150


13.3.1 Acetabular Fractures 150


13.3.2 Luxations 150


13.3.3 Femoral Head and Neck Fractures 151


13.4 About the FHO 151


References 152


14 Femur 153
Thomas W.G. Gibson and Anne M. Sylvestre


14.1 Fractures 154


14.1.1 Avulsion Fractures of the Greater Trochanter 154


14.1.2 Fractures of the Femoral Shaft 154


14.1.3 Physeal Fractures of the Distal Femur 157


14.2 Managing Expectations with Recommended Treatments 159


14.3 Alternatives When Treatment of Choice is Not an Option 159


References 161


15 Stifle Joint 163
Anne M. Sylvestre


15.1 Fractures and Luxations 164


15.1.1 Articular Distal Femoral Fractures 164


15.1.2 Patellar Fractures 164


15.1.3 Traumatic Patellar Luxations 166


15.1.4 Collateral Ligament Damage 166


15.1.5 Luxation of the Stifle Joint 166


15.1.6 Articular Proximal Tibial Fractures 169


15.2 Managing Expectations with Recommended Treatments 170


15.3 Alternatives Treatment When Surgery is Not an Option 170


References 170


16 Tibia and Fibula 171
Thomas W.G. Gibson and Anne M. Sylvestre


16.1 Fractures 172


16.1.1 Tibial Tuberosity Avulsion Fractures 172


16.1.2 Tibial Plateau Physeal Fractures 172


16.1.3 Proximal Tibial Shaft Fractures 173


16.1.4 Fractures of the Mid? and Mid?to?Distal Portions of the Tibial Shaft 173


16.1.5 Fractures of the Distal Tibial Shaft 177


16.1.6 Physeal Fractures of the Distal Tibia/Fibula 177


16.1.7 Fractures of the Fibular Shaft Alone 177


16.2 Managing Expectations with Recommended Treatments 178


16.3 Alternatives When Treatment of Choice is Not an Option 178


References 181


17 Tarsal Joint 183
Anne M. Sylvestre


17.1 Fractures and Ligamentous Injuries 184


17.1.1 Articular Distal Tibial Fractures 184


17.1.2 Fractures of the Medial Malleolus or the Lateral Malleolus 184


17.1.3 Medial or Lateral Collateral Ligament Injuries 186


17.1.4 Luxations of the Tarsocrural Joint 186


17.1.5 Shearing Injuries 186


17.1.6 Fractures of the Calcaneus 188


17.1.7 Fractures/Luxations of the Talus 192


17.1.8 Fractures/Luxations of the Central Tarsal Bone 193


17.1.9 Fractures of the Numbered Tarsal Bones 193


17.1.10 Luxation of the Intertarsal and/or Tarsometatarsal Joints 194


17.2 Managing Expectations with Recommended Treatments 194


17.3 Alternatives When Treatment of Choice is Not an Option 195


17.4 About Pantarsal Arthrodesis 195


17.5 About Partial Tarsal Arthrodesis 195


References 197


18 Paw (Manus and Pes) 199
Anne M. Sylvestre


18.1 Fractures and Luxations 199


18.1.1 MC/MT Fractures 199


18.1.2 Phalangeal Fractures 202


18.1.3 Luxations of the Inter?Phalangeal or MC/MT?Phalangeal Joints 203


18.2 Managing Expectation with Recommended Treatments 204


18.3 Alternatives When Treatment of Choice is Not an Option 204


References 204


Section 4 Fracture Repair Techniques 205


19 Essential Information on Fracture Repair 207
Anne M. Sylvestre


19.1 Forces Applied to a Bone 208


19.2 Techniques for Reducing a Fracture 208


19.2.1 Distraction 209


19.2.2 Lever 209


19.2.3 Toggle 209


19.2.4 Oblique Fractures 210


19.2.5 Using the Plate 211


19.3 Instrumentation 211


19.3.1 Drills 211


19.3.2 Fracture Repair General Instruments 213


References 214


20 Pins and Wires 215
Catherine Popovitch


20.1 Case Selection 215


20.2 Instrumentation 215


20.3 Fundamentals of Application 215


20.3.1 Cerclage Wires 215


20.3.2 Pins 216


20.4 Pinning Techniques for Various Long Bones 218


20.4.1 Humerus 218


20.4.2 Radius 218


20.4.3 Femur 218


20.4.4 Tibia 220


References 221


21 Plating 223
Anne M. Sylvestre


21.1 Case Selection 223


21.2 Instrumentation 223


21.2.1 Bone Screws 223


21.2.2 Bone Plates 224


21.2.3 Plating?specific Instruments 225


21.3 Fundamentals of Application 226


21.3.1 Selecting a Plate 226


21.3.2 At Surgery 227


21.3.3 Pin-Plate Combination 228


21.3.4 Stack Plating 230


21.4 Postoperative Care 230


21.5 Plating Techniques for Various Long Bones 230


21.5.1 Humerus 230


21.5.2 Radius 230


21.5.3 Femur 230


21.5.4 Tibia 232


References 233


22 External Fixators 235
Kathryn Wander


22.1 Case Selection 235


22.2 Basic Rules of External Fixation 235


22.2.1 Pins 235


22.2.2 Connecting Bars 236


22.2.3 Clamps 236


22.3 Fundamentals of Application 237


22.4 Fixators: Biomechanics/Constructs 237


22.4.1 Acrylic Splints/Constructs 238


22.4.2 Circular External Fixators 239


22.5 Postoperative Care 239


22.6 Complications 241


22.7 Preferred Technique for Various Long Bones 242


22.7.1 Tibial Fractures 242


22.7.2 Humeral Fractures 242


22.7.3 Femoral Fractures 242


22.7.4 Radial Fractures 242


References 243


23 Repair of Physeal Fractures 245
Thomas W.G. Gibson


23.1 Physeal Fractures 245


23.1.1 Crossed Pin Technique 246


23.2 Avulsion Type Physeal Fractures 247


23.2.1 Tension Band Wiring Technique 247


23.3 Repair Techniques for Various Physeal Fractures 247


23.3.1 Proximal Humerus 247


23.3.2 Proximal Ulna 247


23.3.3 Proximal Radius 247


23.3.4 Distal Radius 247


23.3.5 Greater Trochanter 248


23.3.6 Distal Femur 248


23.3.7 Tibial Tuberosity 248


23.3.8 Proximal Tibial Physis 248


23.3.9 Distal Tibial Physis 248


References 248


24 Fractures of the Jaw 251
Teresa Jacobson


24.1 Anatomical Considerations 251


24.2 Jaw Fracture Management 251


24.2.1 The Principles of Jaw Fracture Management 252


24.2.2 Intubation Considerations for the Fracture Repair 253


24.2.3 Feeding Plan Post Jaw Fracture Repair 253


24.3 Pain Management 254


24.4 Maxillofacial Fracture Repair 255


24.5 Methods of Maxillofacial Fracture Stabilization 257


24.5.1 Tape or Nylon Muzzles 257


24.5.2 Osseous Wiring Techniques for Maxillofacial Fracture Repair 257


24.5.3 Intra?Dental Wiring Techniques with Acrylic Reinforcement 260


24.5.4 Bonding the Maxillary to the Mandibular Canines 265


24.6 Bone Grafts 266


24.7 Teeth in the Fracture Line 266


24.8 Antibiotic Therapy in Maxillofacial Fracture Repair 267


24.9 Irrigation of the Appliance 267


24.10 Recheck Examinations 267


References 267


25 Approaches to the Long Bones 269
Anne M. Sylvestre


25.1 Approach to the Diaphysis of the Humerus 269


25.1.1 Patient Position 269


25.1.2 The Surgical Approach 269


25.2 Approach to the Diaphysis of the Radius 271


25.2.1 Patient Position 271


25.2.2 Surgical Approach 271


25.3 Approach to the Femoral Diaphysis 271


25.3.1 Patient Position 271


25.3.2 The Surgical Approach 272


25.4 Approach to the Tibial Diaphysis 272


25.4.1 Patient Position 272


25.4.2 The Surgical Approach 272


Reference 274


26 Implants 275
Harold Wotton


26.1 Maneuvering Orthopedic Implants 275


26.2 Quality Implants: Essential Information on Quality Implants 276


26.3 Titanium vs Stainless Steel 276


Index 279