Orthopaedics III Basic Fracture Management · 2 The fracture patient Causes Management...
Transcript of Orthopaedics III Basic Fracture Management · 2 The fracture patient Causes Management...
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Faculty of Health and Medical Sciences
Orthopaedics IIIBasic Fracture Management
James MilesUniversity Hospital for Companion Animals
1.12.15Slide 1/110
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Outline
1 Aims2 The fracture patient
CausesManagementImmobilisation
3 Specific fracture problemsPolytraumaOpen fractures
Pelvic fractures4 Fracture management
principlesFracture scoringAims of fracture repairFractures and healingFixation techniques
5 Fracture knowledgeapplied
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Intended Learning Outcomes
• Make a plan for initial management of the fracturepatient
• Differentiate between fractures that require specialistattention and those that can be managed in generalpractice
• Explain the role of different fracture treatment options(surgical and non-surgical)
• Understand the concept of fracture scoring and how itcan guide the treatment plan
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What causes a fracture?
Fracturecauses
Extrinsic(outside the patient)
Intrinsic(inside the patient)
Directtrauma
Indirecttrauma
Musclerepetitive loading
Pathologicweakness
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Triage
Identify conditions which:
• Will kill in minutes
• Will kill in hours
• Will kill in days
• Are a bit annoying
◦ Bladder rupture
◦ Arterial bleeding
◦ Diaphragmrupture
◦ Rib fracture
◦ Skin lacerations
◦ Liver bleeding
◦ Pneumothorax
◦ Tibial fracture
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Priorities
FAST scan
Supportivecare
Clinicalassessment
ImmobilisationTraumaseries
Orthoexam
Fractureseries
Neuroexam Cardio
exam
Respexam
Bleeding
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Initial steps in clinical assessment
1 Alert colleagues
2 Obtain short, relevant history
3 Move patient to suitable treatment area
4 Assess ABCD
5 Assess other clinical parameters
6 Collect minimum database
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Fracture first-aid
• Supportive treatment
• Clinical assessment
• Immobilisation• Radiography
• Trauma series• Fracture site
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A B C DAirway Patency
Oxygen supplementation (avoid stress)
Breathing Symmetry of ventilationBilateral lung soundsPalpate for emphysema, fractured ribsPulse oximetry
Circulation Mental statusMM/CRTPulse character and rateECG
Disabilities Neurological statusCranial and peripheral reflexes
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Minimum database
• Haematocrit (PCV)
• Total protein
• Blood glucose
• Activated clotting time
• Urine specific gravity
There is no specific test for trauma!Initial profiles rarely influence management
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Fluid support in trauma
Volumes (ml/kg) Dogs Cats
Total body water 700 600Red blood cells 40 20Plasma 50 40Total blood 90 60
• Rates equivalent to plasma volume per hour areprobably sufficient
• Only 20% of infused crystalloids remains intravascularafter 1 hour
• Hypertonic saline may produce the same effect withless risk of oedema
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Colloid support in trauma
• Colloids remain intravascular*
• Small volumes are effective in increasing circulatingvolume
• No survival advantage in human studies
• Human meta-study suggests crystalloids better withpulmonary contusions
*if there is capillary damage, colloids will leak out
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Fluid rescuscitation
• Use at least one large bore IV catheter• Cephalic• Saphenous (lateral - dog, medial - cat)
• Monitoring• Maintain Hct >20%• Mainain TP >50% of initial value• Urine output (place catheter)• Peripheral pulse• Skin perfusion• Lactate
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Why immobilise?
• Analgesia• Prevent further damage
• Fracture fragments• Surrounding soft tissues
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Immobilisation
Green: reasonable expectationBlue: possible, with specialised splintsRed: not usually possible with bandages
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Casts
• Simple to apply
• Resists bendingand rotation
• Useful fortemporarystabilisation
• Does not resistaxial forces
• Complicationsmay limit longerterm use
• Stable, rapidlyhealing fracturesonly
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Fracture healing times
0
10
20
30
40
50
3 6 12 12+
Hea
ling
tim
e (w
eeks
)
Patient age (months)
ESF or IM pin
bone plate
Casts have similar healing properties as ESF/IM pin butrely more on inherent fracture stability
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Cast and splint principles
• Immobilise the joint above and below the fracture
• Use appropriate amounts and type of padding
• Pay attention to bony prominences or high pressureareas
• Place the limb in a neutral position
• Avoid tension and wrinkling of materials
• Avoid excessive moulding and indentations
Casts provide more support than splintsToo loose is almost as bad as too tight!
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Cast complications
• Bandage or cast slipping
• Pressure sores
• Ischaemia
• Dermatitis
• Joint stiffness (possibly permanent)
• Patient interference (chewing, poor tolerance)
• Owner compliance
Incidence can be reduced by proper bandaging technique.However, with prolonged use (>6-8 weeks), some level ofcomplications is almost inevitable.
Swaim, Renberg and Shike: Small animal bandaging, casting and splinting techniques. Wiley-Blackwell 2011
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Why take a trauma series?Dogs with limb fractures:
• % with thoracic trauma
• % with overt signs
6020
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Polytrauma
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What is polytrauma?
• Significant injuries to >1 major bodysystem, eg:
• Respiratory• Cardiovascular• Nervous (central, peripheral)• Excretory (biliary, renal)• Integumentary• Musculoskeletal
• Our patients typically havepolytrauma
• Maintain a high index of suspicion
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Why worry about polytrauma?
• Multiple problems increase management complexity
• Increased risk of complications
• Increased financial costs
• Implications for surgical intervention
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Human perspective - polytrauma
Early Total Care
• Popularised in the 1980s• Fracture fixation in <24hrs reduced
• Pneumonia• Respiratory distress syndrome• ICU and hospitalisation times
• Controversies• Increased mortality in severely injured patients?
Nicola: Early total care versus damage control: current concepts in the orthopedic care of polytrauma patients. ISRNOrtho 2013;329452:1-9
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Human perspective - polytrauma
Damage Control Orthopaedics
• Currently popular (from 2000)• Divides treatment into 4 phases
• Acute life-saving• Haemorrage control and fracture immobilisation• Monitoring• Definitive fracture fixation
• Controversies• Timing of definitive fixation• Days 2-4 seem ’bad’
Nicola: Early total care versus damage control: current concepts in the orthopedic care of polytrauma patients. ISRNOrtho 2013;329452:1-9
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Human perspective - why the change inapproach?
• Severe trauma induces SIRS• Severe SIRS can produce organ failure
• SIRS is mediated by CARS• Mild SIRS + excessive CARS induces prolonged
immunosuppression• Mild SIRS = ’first hit’• Surgery =’second hit’• Surgery may worsen initial SIRS• Surgery during excessive CARS induces organ failure
Systemic Inflammatory Response SyndromeCounter-regulatory Anti-inflammatory Response Syndrome
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Human perspective - timing
• Initial SIRS phase ≈ 24 hours• CARS phase ≈ 48-96 hours
• Stable or borderline patients→ ETC• Unstable or critical patients→ DCO
• How do these timings relate to dogs and cats?
• Could monitoring of eg IL-6 aid decision making?
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Open fractures - decision making
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Incidence
• Of all traumatic fracture patients:• 14% dogs• 29% cats
• Particular risk factors:• Young (<16 months)• Distal to tibiotarsal joint• Increasing body size• Comminution• Hit by car
Millard and Weng: Proportion of and risk factors for open fractures of the appendicular skeleton in dogs and cats.JAVMA 2014;245:663-668
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Classification
Grade Wound Description Infection
1 <1cm Clean wound 0-12%
2 1-10cm No extensive skin loss or avulsion 2-12%
3A >10cm, orextensive damage,or loss of skin
Periosteal coverage of bone intact9-55%3B Periosteal stripping, bone damage, extensive contamination
3C Vascular compromise requiring surgery
Gustilo-Anderson open fracture classification, see J Bone Joint Surg Am 1976; 58:453-458
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Assessment
• Can the limb be salvaged? (ie: 1-3B)
• Will limb function be acceptable?• Arthrodesis• Reconstructive surgery
• Financial and emotional cost
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Treatment
• Prevent further contamination• Cover wound immediately• Standard sterile precautions whenever uncovered
• Decontaminate wound• Prepare surrounding skin• Irrigation• Debridement
• Antibiotic therapy• IV broad spectrum ASAP• Consider post-debridement culture and sensitivity
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Preventing contamination
• A dirty wound is noexcuse for a dirtysurgeon
• Maintain normalsterile precautions
• Protect the woundfrom the hospital
• Take a swab!
• Give antibiotics early
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Wound plan
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Reduce contaminationLavage
• effectively reduces bacterialnumbers and removes debris
• is dependent on adequate pressure• 60ml syringe with 18g needle• specialised lavage equipment
• is dependent on adequate volume• at least 250ml• 50ml/cm2 wound?
• use isotonic fluids• LRS better than saline?• tap water acceptable?• not hydrogen peroxide or other
chemicals
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Debridement• Carefully remove necrotic tissue• Sharp dissection best• Stage removal (don’t remove tissue unless you know
it is dead)• May need to repeat as extent of injury becomes
apparent
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Culture and antibioticsSensitivity Specificity
Pre-debridement culture 88% 43%Post-debridememt culture 63% 50%
• Infecting organism found:• 8-29% pre-debridement cultures• 42-60% post-debridement cultures
• Negative culture has a good predictive value• Antibiotic choice
• IV 1st or 2nd gen. cephalosporin TID-QID 48-72hrs• Veterinary data lacking!
Kreder and Armstrong: The significance of perioperative cultures in open pediatric lower-extremity fractures. ClinOrthop Rel Res 1994;302:206-212, and Lee: Efficacy of cultures in the management of open fractures. Clin OrthopRel Res 1997;339:71-75
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Fracture fixation
• Stabilise as soon as possible
• Infection does not stop bone healing• Options:
• Internal fixation• Titanium better than steel• Reserve for Grade 1?
• External fixation• Combine with open wound management• Consider conversion once infection controlled?• Use alone may be successful
Ness : Treatment of inherently unstable open or infected fractures by open wound management and external skeletalfixation. JSAP 2006;47:83-88
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Case - initial presentation
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Case - post-operative
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Case - progress
• ESF removed at 6 weeks
• Open wound management at carpus continued• At check-up 20 weeks after injury
• Wound healed• Residual instability at the carpus• Arthrodesis recommended
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Summary
• Evaluate fracture in terms of potential for recovery
• Consider amputation if:• Limb function likely to be poor• Patient will not tolerate intensive management• Financial constraints
• Start antibiotic therapy early
• Minimise infection risk• Prevent further contamination• Aggressive debridement and lavage• Early stabilisation
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Pelvic fractures - decision making
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Pelvic structure
• Box-like
• Extremely rigid
• Fracture=large force
• Multiple fractures
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Pelvic fractures
• Common• ≈ 25% of fracture patients
• Frequently complicated• thoracic injuries (≈ 30%)• urinary tract injuries (≈ 40%)• neurological (lumbosacral, sacrococcygeal)• spinal fractures• vascular
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Triage
• Full clinical examination
• Trauma series• Thorax and abdomen
• Ultrasonography• Thorax and abdomen• FAST scan
Abdominal and Thoracic Focused Assessment with Sonography in Trauma, Lisciandro (2011) J Vet Emerg Crit Care
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Pelvic fractures - functional significance
• Green areas• Painful• Rarely need
stabilisation
• Red areas• Affect function• Surgery often
indicated
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Pelvic fracture Decision Tree
Assess width
% overlap at SI joint
Intact mechanical axes
Pain control
Try conservative management
Surgicaltreatment
<50%≥50%
0≥1
<67%≥67%
UnacceptableAcceptable
Acetabular fracture
No Yes
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Case - Ziuta
• 2 year old, F, domestic cat
• 3.3 kg
• Not walking following fall from1st floor window
• Trauma series – normal
• Blood loss treated withtransfusion
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Case - radiographs
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Case - fracture tracing
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Case - iliac plating
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Case - external fixator
Reported for use in cats and small dogs. Complianceproblems. Acute stabilisation (humans).
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Case - conservative management
• Acceptable only if pelvic width >67%
• Painful – cage rest for 4–6 weeks
• Suboptimal treatment if weight-bearing zones areinvolved
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Case - actual surgery
Slide 57/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Summary
• Evaluate fractures in terms of function
• Determine if conservative management is sufficient• Consider repeat radiography after 4-5 days
• Stabilise
• If surgical:• Aim for surgery within 5-7 days (max)• Neurological recovery may be uncertain
Slide 58/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Slide 59/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture scoring - concept
• What is it?
• Why do it?
• How do we do it?
Slide 60/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture scoring
Mechanical
Fracturetype
Otherinjuries
Patientsize
Slide 61/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture scoring
Biological
Patientage
Healthstatus
Tissuedamage
Slide 62/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture scoring
Clinical
Ownertype
Patienttype
Slide 63/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture scoring - summary
Fracture scoring gives us an idea of how:
• Fast it will heal
• Strong the repair must be
• Compliant the owner (patient) will be
Checklist - the actual ’score is less relevant
Slide 64/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture scoring – appliedSnoop 20167, 11 months old M Affenpinscher (3kg)Non-weightbearing on both fore limbs after fall frombalcony:
• Mechanical?
• Biological?
• Clinical?
Slide 65/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture scoring – applied
Louis 19929, 18 months old M Welsh Springer (20 kg)Hit by car, no other injuries:
• Mechanical?
• Biological?
• Clinical?
Slide 66/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
What do we want?
• Anatomical reduction vsalignment
• Stable fixation
• Preservation of blood-supply
• Early mobilisation
Slide 67/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
What happens next?
100% 100% 20% 10% 2%
The different tissues involved in healing have differentstrain tolerances.
Slide 68/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Bone healing in action
Compare these films with the abnormal healing on slide 82
Slide 69/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Fracture healing times
0
10
20
30
40
50
3 6 12 12+
Hea
ling
tim
e (w
eeks
)
Patient age (months)
ESF or IM pin
bone plate
...can we relate these healing times to fracture stability?Slide 70/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Why the difference?
30 min 2 days 4 days
Frac
ture
rig
idit
y
Removed
Intact • Rat model
• Bilateral femoral fracture+ IM pin
• Haematoma removed at30min, 2d or 4d
• Fracture rigidity testedat 4 weeks
From: Grundnes (1993) in Acta Orthop 64(3):340–342
Slide 71/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Timing of repair
Depends on several factors:
• Patient stability (DCO vs ETC)
• Fracture severity
• Possible wait for equipment/surgeon
In general:
• Joint fractures – within 24 hours
• Salter Harris/immature animals – within 24–48 hours
• Other – within 2–3 days
Slide 72/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
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Casts
• Simple to apply
• Resists bendingand rotation
• Stable fracturesonly
• Does not resistaxial forces
• Complicationslimit use
Slide 73/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Intramedullary pins
• Simple surgery
• Minimalequipment
• Resists bending
• Not for radius
• Does not resistrotation or axialforces
Slide 74/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
External fixation
• Simple tocomplex surgery
• Moderateequipment
• Resists all forces
• MIO possible
• Owner +/orpatientcompliance
• Post-op care
• Pin tracts
Slide 75/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Plating systems
• Minimal post-opcare
• Resists all forces
• MIO possible
• Complex surgery
• Training required
• Risk of failure
• Expensiveequipment
Slide 76/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Plate-rod combinations
• Minimal post-opcare
• Resists all forces
• MIO possible
• Complex surgery
• Training required
• Risk of failure
• Expensiveequipment
Slide 77/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Interlocking nails
• Minimal post-opcare
• Resists all forces
• MIO possible
• Complex surgery
• Training required
• Risk of failure
• Expensiveequipment
Slide 78/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Screws
• Anatomicalreduction
• Fragmentcompression
• Complex surgery
• Expensiveequipment
Slide 79/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Pin and tension band
• Simple surgery
• Minimalequipment
• Fragmentcompression
• Cerclage twistingrequires practice
Slide 80/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
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Stabilisation - aims
• Anatomical reduction
• Stable fixation
• Preservation of blood-supply
• Early mobilisation
• Compatible with skill level – refer?
Slide 81/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
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Post-operative management
• Rest!
• Regularcheck-ups
• Clinical• Radiographic
• Look out for• Healing• Progress• Complications
Compare these films with the normal healing on slide 69
Slide 82/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Infections
• ESF pin tractinfections arecommon but minor
• ESF is a goodchoice for revisionor primary repair ofinfected fractures
• Fractures will heal ifstable
Clinical signs
Radiographic signs
Fracture andimplantsunstable
Fracture andimplantsstable
Revise repair& antibiotics
Removeimplants when
healed
Antibiotics
Slide 83/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Looking at radiographs
So far, you have not had any teaching in radiology. Lookingat the following case radiographs may therefore seemimpossible.
Try to think of the radiographs as black and whitephotographs of the bones you have seen in your anatomybooks and as skeletons.
Remember that (for our purposes) the only things that canbe seen on a radiograph are – in increasing order ofdensity – air, fat, soft tissue (or fluid) and bone.
Slide 85/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Looking at radiographs
Working in small groups, look at the radiographs and try to:
• identify which bone it is
• identify the joints above and below the bone
• follow the cortices (denser white) and see where theystart or end
• identify where the main fragments are
• decide if the fracture is ’reconstructable’ (like a jigsawor puslespil) or not
• think about what forces are working on this fracture(from muscles, ground, body mass)
Slide 86/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Case 1 - Jonesy
• 1 year old, F, domestic cat
• 3.3 kg
• Acutely lame on the right hindlimb following fall from 4thfloor window
• Trauma series – normal
Slide 87/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Case 1 - radiographs
Slide 88/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
U N I V E R S I T Y O F C O P E N H A G E N U N I V E R S I T Y H O S P I T A L F O R C O M P A N I O N A N I M A L S
Case 2 - Hilde
• 9 year old, F, British shorthaircat
• 4.5 kg
• Lame right hind – no knowntrauma (indoor/outdoor cat)
• Clinical examinationunremarkable apart frommetatarsal pain
Slide 100/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15
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Case 2 - radiographs
Slide 101/110 — James Miles — Orthopaedics III: Basic Fracture Management — 1.12.15