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BSAVA Manual of
Small Animal
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Fracture Repair and


Management
Edited by

Andrew R. Coughlan
BVSc PhD CertV A CertS AO FRCVS
Animal Medical Centre
5 11 Wilbraham Road, Cha rlton
Manchester M2 1 I UF, UK
a nd

Andrew Miller
BVMS DSAO MRCVS
Willows Veterinary Centre, 78 Tanworth La ne
Shirl ey, Solih ull B90 4DF, UK

Publ ished by:

Britis h Small An imal Veterina ry Association


Kingsley House, Church Lane
ShurdinglOll, ChcllcnllHlll
GL51 5TQ, United Kin gdom

A Company Limited by Guarantee in England.


Registered Comp;my No. 2837793.
Registered as ,I eh"Tity.

Copyright © 1998 BSAVA

All rights reserved. No p.1rl Of lhis publication Inay be reproduced,


stored in a retrieval system, or tr;msmittcd, in fonn or by any means,
electronic, mechanic,ll , photocopying, recording or otherwise without
prior wriucn permission of the copyright holder.

All the colour illustrations in this book have been designed and created by
Vicki Martin [X--sign, Cambridge, UK and arc printed with their pcnn ission.

A cata logue record for this book is available from the Britis h Library

ISBN 0 9052 14374

The publishers ~nd cOlllributors cannot take responsibility for information


provided on dosages and mcthods of applic3lion of dru gs mcntioned in this
publication. Details o f this kind must be verifiL'd by individual uscrs from the
appropriate litera ture.

Typeset and printed by: Fusio n Design, Fordingbridge, Hampshire, UK _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

C.OLl h
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iii

Contents
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Contents iii

List of Contributors v

Foo'eword vi

Preface vii

PART 1 Background to Fracture Management

Fmcture Classification and Description 3


D. Gary Clayton Jones

2 History of Fracture T"eatment 9


Leslie C. Vaughan

3 Biomechanical Basis of Bone Fracture and Fracture Repair 17


Simon Roe

4 Fracture Healing 29
Tim M. Skerry

5 Imaging of Fracture Healing 35


D. Gary Clayton Jones

PART 2 Principles of Fracture Management

6 Evaluating the Fracture Patient 45


Ralph H. Abercromby

7 Non-surgical Management of Fractures 51


Jonathan Dyce

8 Instruments and Implants 57


John P. Lapish

9 Principles of Fracture Surgery 65


Andrew Miller

10 Complex, Open and Pathological Fractures 95


Chris May

II Fractures in Skeletally Immature Animals 103


Stuart Carmichael

PART 3 Management of Specific Fractures

12 The Skull and Mandible 115


Harry W. Scott

13 The Spine 133


W. Malcolm McKee

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iv
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14 The Scapula 161


Andy TorringTOn

15 The Humerus 171


Hamish R. Denny

16 Radius and Ulna 197


Warrick 1. Bruce

17 The Pelvis and Sacroiliac Joint 217


Marvin L. Olmstead

18 The Femur 229


A. Colin Stead

19 Tibia and Fibula 249


Steven J. Butterworth

20 Carpus and Tarsus 265


John E.F. HOltltoll

21 The Distal Limb 283


Jonathan Dyee

22 Patella and Fabellae 293


Ralph H. Abereromby

PART 4 Complications of Fracture Management

23 Fracture Disease 305


John F. Ferguson

24 Implant Failure 311


Malcolm C. Ness

25 Osteomyelitis 317
Angus A. Anderson

26 Complications of Fracture Healing 329


David Benneu

Index 341

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PART ONE - - - - - - - - - - - - - - -

Background to Fracture Management


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CHAPTER ONE

Fracture Classification and Description


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D. Gary Clayton Jones

INTRODUCTION becomes for the user to classify each fracture in the


same way as other workers and therefore the greater
A method for classifying fractures is needed to be is the opportunity fo r va riation and subsequentl y
able to describe fractures for a variety of reasons. An reduction in value of the data.
accurate descri ption of a fracture enables surgeons to For this reason no single system of fracture classi-
discuss methods of diagnosis, treatment and progno- fication or description has yet been adopted interna-
sis and to compare results, thus providing easier tionally for sma ll animals. A system of fracture
verbal and written communi cation. The use of a classification (Muller, 1990; AO/ASIF, 1996) has been
si milar fracture classification system for small ani- developed for use in human patients by the AO/ASIF
mals and for humans could provide a basis for com- (Arbeitsgemeinschaft fur Osteosynthesefragen/Asso-
parati ve studi es between spec ies. An accurate ciation for the Study oflnternal Fixation) Group using
classification could assist in pl anning for patient alphanumeric classifications combined with electroni-
requirements or ordering implants in quantity, which cally stored X-ray images. The central store can be
may be essential in a large hospital. remotely accessed but requires considerable computer
Many of the terms in current usage are man y power at the recording centre, although a PC, scanner
centuries old and relate to outmoded or superceded and modem are the only requirements at the hospital.
practices and problems. Initially fractures had to be Both recording of data and the requesting of data and
described verbally, as the only alternati ve would information can be made from a hospital office. A
have been to draw diagrams. The difficulty with computer-based CD-ROM or diskette system is now
verbal descriptions is that there is no internationall y available for equine fra ctures (Fackelman, 1993).
agreed definition for the terms that are commonly
employed. For example, how angulated maya frac-
ture plane be fo r the fracture still to be described as METHODS OF DESCRIPTION
' transverse'? The problem increases with the lack of
a common lang uage, as similar terms may ha ve dif- Earl y methods of describing fractures were based on
ferent meanings and therefore transmi ssion of data va ri ous anatom.ical features or on using eponymous
between countries is made even more difficult. The fracture descriptions, often named after the first ob-
value of exchange of data is obvious, as some fracture server (or sufferer) . The most commonly recognized of
types are rare and individual ex perience may be very such names are probably Colles, Potts and Monteggia.
limited, apart from the important needs of educa- These human medical terms are occasionally used in
tional exchange. veterinary practice but are of little va lue unless the
Prior to the advent of X-ray exa mination, photo- explanation is already known. Such eponymous de-
g raph y, fax trans mission and scanning, th e use of scriptions should therefore probably not be used in
prepared diagrams would ha ve been very laborious veterinary practice. The discovery of X-rays in the
and ineffici ent. C urrentlyit is becoming more possi- latter part of the nineteenth century allowed a more
ble to scan fracture images and transmit the informa- acc urate form of description based on the radiological
tion electronically to some central point for pictorial appearance of the fracture .
anal ysis and recording by computer, or possibly for The earliest description of a fracture was whether
rapid advice from a specialist. An alternati ve is to or not the fracture was 'simple' (closed) or 'com-
classify fractures into groups identified from a series pound' (open). This stems from the period prior to
of definitions that can be identified by various alpha- antibiotic therapy when an open fracture carried a high
numeric symbols. The problem is to decide at the risk of infection and potential loss of the limb or often
outset how much information is required from the of the patient. Today the words closed and open are
data and thence the complexity of any coding system. more commonly used to refer to the same clinical
The more complex the system, the more difficult it features .

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4 Manual of Small Anjmal Fracture Repair and M anagement

The ex pression 'simple' was used to imply ease or Specific


difficulty of treatment, but this was related to the
aspect of fracture infection. Some simple fractures Greater trochanter
may be very difficult to reconstruct, while some open Tibial tuberosity
fra ctures can be straightforward two-piece fractures Lateral condyle, etc.
that are mechanicall y easy tomend. Closed is now also
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used to describe a single circumferential disruption of


the diaphysis. (Small cortical fragments of less than Displacement of the fragments
10 % of the circumference are ignored as they probably
ha ve little significance for treatment or prognosis.) Greenstick Guvenile)
Open (compound) fractures are now generally Folded
classi fied into varioLis types which have a more mod- Fissure - undisplaced fragments which may
ern clini ca l significance from the point of view of displace at operation or under stress
treatment and prognosis. 'Compound ' does not indi- D epressed - fra gments in vade an underl ying
cate the number or type of fragmentation, though the cavity, es pecially parts of the slmll
wo rd is commonly misused to imply a difficult or Compression - of cancellous bone, often
fragmented fracture. vertebral body
Complex implies the difficulty or severity of the Impacted - cortical into cancellous bone.
fra cture, and ca n be defined as desc ribing a
multifragmented fracture of the diaphysis in which
there is no contact between the proximal and distal Nature of the fracture line
segments aft er reduction.
Pathological (or secondary) fractures are a par- Complete - all of the cortices are broken
ticular form, not related to trauma in every case, in with the separation of the fragm ents
which the fractures result from failure of bone strength Incomplete - part of the bone remains
from an underl ying cause such as bone tumour, infec- intact.
lion or osteodystrophy . The initiating defect may not
always be readil y identified by X-ray.
Compl icated fractures are those in which there Complete fractures ma y a lso be desc ribe d in
is major blood vessel, nerve or joint in vo lve ment. terms of:
Th e description is not so commonly used in veteri -
nary orthopaedics. These are often more serious in Di,.ectioll offractu,.e !ille
human patients, where loss of major arterial suppl y
may cause perman ent loss of functi on of a vital organ Transverse - the angle of the fracture line to
e.g. th e hand, or even result in an amputati on. a perpendicular to the long axis of the bone is
less than 30"
Closed (simple) fractures Oblique - the angle is equal or greater than 30".
There are various criteria that can be used to define Spiral - the result of torsion
different types of closed fracture: Longitudinal, Y or T fracture, saucer.

Anatomical location
The bone shaft (diaphysis) has been conventionall y Numbe,. 0,. type of fragments
divided into thirds: proximal (upper), middleanddistal
(lower). Two-fragment, three-fragment, comminuted
(many fragments, i.e. more than two);
Anatomical feature sometimes multi fragment is pre ferred.
Wedge fragments - the main fragments have
General some contact after reduction
Segmental - large one or more complete or
Capital almost complete fragments of shaft
Subcapital Butterfly (intermediate) fragment
Metaphyseal Irregular - a diaphysea l fracture with a
Diaphyseal (shaft) number of intermediate fragments with no
Sub trochanteric specific pattern, usuall y accompanied by
Physeal severe soft tissue lesions
Condylar Multiple - more than one fracture in same or
Articular. different bones.

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Fracture Classificati on and Description 5

Stability following retiuction AccessOlY carpal bOlle (JOhIlSOIl, 1987)

This has been termed the Charnley classification and Type I - intra-articular avulsion of the distal
was used to determine which fractures wo uld respond margin
to closed reduction and fixation. Type II - intra-articular fracture of the
proximal margin
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Stable after reduction - tends to remain in Type III - extra-articular avulsion of the
place without force distal margin
Unstable after reduction - fracture collapses Type IV - extra-articular avulsion of the
as soon as reducing force is removed. insertion of fl exor carpi ulnaris at proximal
palmar surface
Nature offractllre origin Type V - comm inuted fracture of the body
which may in vo lve the articular surface.
Avulsion/apophyseal - pulled by tendon or
ligament Central tarsal bone (Dee et aI., 1976)
Chip - small fragm ents at articular margin
followin g hyperextension injury Type I - small dorsal slab fracture with
Slab - larger fragment with a vertical or minimal displacement
very oblique fracture of a small cancellous Type II - dorsa l slab fracture with
bone which may extend into both articular displacement
surfaces. Type III - one-third to half of the bone
fractured in the median plane and displaced
Articular fractures mediall y or dorsa ll y
Type IV - combination of Types II and III
Extra-articular - not involving the joint Type V - severe comminution.
surface but may be intracapsular
Partial articular - involving only a part of Various combinations of fractures of the tarsus (see
the articular surface, with the remaining Chapter 20) are regularl y seen concurrently in the Grey-
articular cartilage surface being attached to hound, but are not classified, although they have been
the diaphysis described as triads (Newton and Nunamaker, 1985).
Complete articular - disrupting the articular
surface and separating it completely from the Metacmpal/metatarsalfract"res (Newtoll allti
diaphysis (e.g. Y or T fracture) . NllIzamakel; 1985)

Special classifications Type I - painful on palpation at the junction


of the proximal fourth/third and distal two-
Growth plate or epiphyseal fractures (separations) thirds/three-quarters of the bone; endosteal
The most commonl y used is the Salter-Harris system and cortical thickening of the bone on X-ray
(Salter and Harris, 1963) in which six types of injury Type II - hairline undisplaced fi ssure type
are recogni zed (see Chapter II): fracture
Type III - complete fracture with palmar/
Type I - complete, through the plantar displacement of distal fragment.
hypertrophied cartilage cell zone
Type II - partially includes the metaphysis Open fractures
Type III - intra-articular fracture to the Open fractures possess a wound which communicates
hypertrophied zone and then along the between the fracture bed and the outside environment.
epiphyseal plate to the edge Usually tltis is via a visible surface wound but could
Type IV - intra-articular fracture that describe a fracture of a skull bone which has penetrated
traverses the epiphysis, epiphysea l plate and the nose or a sinus cavity. Classification of open
metaphysis fractures is often he lpful in detennining optimal meth -
Type V - crushing injury that ca uses ods of treatment.
destruction of growing cells
Type VI - new bone bridges the growth plate. Type I - a fractur!' produced from inside to
outside by the penetration of a sharp fracture
Classifications of special joint fractures fragment end through the overlaying soft
Certain specific fractures (mainly because of their tissues. Such a fracture may become open
importance in the racing Greyhound) have been clas- some time following the initiating incident as
sified to aid prognosis and treatment. a result of uncontrolled or unsupported

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6 Manual of Small Animal Fracture Repair and Management

movement. There is usually limited soft tissue lag phase in which the bacteria become established, the
injury and the bone fragments are all present, organisms may begin to multiply, turning a contami-
often with out comminution. nated wound into an infected one. This is the concept
of a 'golden period' which should be taken into ac-
Type 2 - a fracture caused from outside to count but not relied upon implicitly.
inside by penetration of a foreign object. A system for classification of the soft tissue injury
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There is usuall y more soft tissue damage with has been developed for use in humans (Muller el al .,
contus ion around th e s kin wound and some 1992) (Table 1.1). Certain evaluations in human pa-
mainl y reversible muscle damage. Fractures ti ents are not made in veterinary patients and so the
may be more fragmented but there is little if system may be too complicated for animals, although
any loss of bone or soft tissue. it could probably be used with a little variation.

Type 3 - the most severe form of open Fracture classification suitable for
fracture in which loss of tissue fo llowing computer analysis
penetration by an outside object has resulted. The ability to classify fractures for computer analysis
Loss of skin, soft ti ssue and bone material is clearly the best method: it would readily allow
may have occurred and may be very severe. anal ys is and comparison of data as well as easily
Some workers recognize a s ubdivision in allowing worldwide cooperation. A number of meth-
which loss of the main arterial suppl y to the ods have been attempted but currently no single method
limb has occurred, as this indicates has gained acceptance.
mandatory amputation. A method of classification of femur fractures was
developed at the Uni versity of Michigan (Braden,
Although not offi cially recognized, an estimate of the 1995) following a general anal ysis of fractures by
time elapsed since the injury may be helpful in classi- Brinker (Brinker el al., 1990). This system is on ly
fying an open fracture. This acknowledges the dangers applicable to fractures of the femur and has a limited
of bacterial invas ion of a wound where, after an initial ability for fracture description. It is based on a paper

Illtegumellt Closed (IC)


[CI No injury
[C2 No laceration but contus ion
[C3 Circumscribed degloving
[C4 Extensive closed degloving
[C5 Necrosis from contusion

Illtegumellt Open (10)


[01 Skin breakage from inside out
[02 Skin breakage from outside in > 5 em, contused edges
[03 Skin breakage from outside in < 5cm, devitalized edges, circumscribed degloving
104 Full thickness contusion, abrasion, sldn loss
[05 Extensive degloving

Muscle/ Telldoll (MT)


MTl No injury
MT2 Circumscribed injury, one muscle group only
MT3 Extensive injury, two or more muscle groups
MT4 Avulsion or loss of entire muscle groups, tendon lacerations
MT5 Compartment syndrome / crush syndrome

Neurovascular (NY)
NVI No injury
NV2 [solated nerve injury
NV3 Localized vascular injury
NV4 Combined neurovascular injury
NV5 Subtotal/total amputation
Table 1.1: A system /or classification a/soft fiSSile injuries (designed/or lise in hUl1Ians).

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Fracture Classification and Description 7

fonn which can be an alysed by computer; thus no


computer eq uipment is required at the hospital.
General classification of fractures was developed by
Muller and others of the AO/ ASIF group for human
fractures (Muller, 1990; CCF, 1996) . Thi s has been
modified by various workers to create similar methods
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for small animals and the horse. Two systems for small
animals, the Prieur (Prieur et aI. , 1990) and the Unger Transve rse ~ <5% <25%
(Ungeretal., 1990), have been described in the literature
although neither has yet been accepted universally.
These classifications describe the bone, th e loca-
tion and the type of fracture . Each of the proposed
systems creates a four-digit record in a similar way to
the human AO system.
The Prieur and U nger fracture classification sys-
tems can only be used for fractures of the long bones Figure 1.1: Examples offemoral fractures alld their Ilumerical
and are not used for fractures in vo lving the s kull, identification using the Prieur classification system.
vertebral column, pelvis or small limb bones. Neither
system discusses the soft tissue problems, which may Proximal
well be of the greatest importance in determining segment
treatment and outcome.

The Prieur system Figure 1.2: The Prieur


This is the simpler system but it records slightly less 2 Middle classificatiol1 system:
information. Digits are allocated under each of four segment location of bone zones.
fi elds (bone; location; fracture area; fragment number)
(Table 1.2), so that each fracture is described by four
numbers (examples in Figure 1.1). The location zones
Distal
of each bone are determined by drawing a square segment
around the ends, of length and width equal to th e widest
dim ension of the bone end (Figure 1.2).

Field Number

Bone
Humerus 1
Radius/ulna 2
Femur 3
Tibia 4

Location
Proximal segment 1
Middle segment 2
Distal segment 3

Fracture area (percentage of bone length)


<5% (and/or not involving articular cartilage) 1
5-25% (specific fractures of femur neck) 2
> 25% (and/or involving articu lar surface) 3

Number of fragments _.
Two 2
Three 3
Four or more 4
Table 1.2: The Prieur system.

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8 Manual of Small Animal Fracture Repair and Management

The Unger system Dee JF, Dec J and Piemmttei DL (1976) Classification, management and
repair of ccntmltarsal fractures in the mcing Greyhound. Journal oj
This identifies fractures in a similarmannertotheabove the Americall Allimal Hospitals Associatioll 12,398-405.
but records somewhat more data by attem pting to iden- Fackelman GE, Peutz IP, Norris JC er al. (1993) 111edevelopment of an
equ ine fra cture documentation system. Veterillary alld Compara-
tify reducible or non-reducible wedges or the direction tive Orthopaedics and TrallmolOlogy 6, 47-52
of the fracture line. Charts of both letters and numbers Johnson KA ( 1987) Accessory carpal bone frac tures in the racing
for each bone and the codes aUocated for various frac- Greyhound classification and patho logy. Veterinary Surgery
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16. 60.
tures are required with this system, which attempts to Muller ME, Allgower M, Schneider R and Willenegger H ( 1992). In:
record the fractures in a clinically related manner. Manllal oj Jmemal Fixation, abridged 3rd edn, pp. 118- 158.
Springer Verlag, Berlin .
Mull er ME, Nazarian S, Koch P and Schalzker J (1990) The AO
Clw.sification oJFrac/lires oj Long BOlles. Springer Verlag, Berlin,
REFERENCES AND FURTHER READING Heidel be rg and New York.
Newton CD and Nunanwkcr OM (1985) Fract ures associated wi th the
mcing Greyhound. In : Textbook oj Small Anilll(ll Orthopaedics.
AO/AS IF ( 1996) Comprehellsive Classification oj Fractures. Pam - Lippincott, Philadelphia.
phlets l and II , Maurice E Muller Foundation, AO/AS IF Docu men- Prieur WO, Braden TD and von Rechcnberg B ( 1990) A suggested
tation Centre, Davos, C H-7270 Swi tzerland. rmcluTC classification of adu lt small animal frac tures. Veterinary
Braden T O, Eicker SW, Abdinoor D and Pricur WD (1995) Character- and COlllparath'e Orthopaedics and Trallllltltology 3, 11 1- 116.
istics or 1000 femur fr<lctu res in the dog and cat. Veterillaryalld Salter RBand Harris WR ( 1963) Injuries involving the epiphyseal plale.
Comparath'e Orthopaedics alld Traumatology 8, 203-209. JOllr/wl oj Bone and Joim Slirgery 45, 587-622.
Brinker WO, Hohn RB and Prieur WD ( t984) In : Mallual oj imemal Steadmall 's Medical Dictiollary. 25th edfl. Wi lliams and Wilkins,
Fixarioll ill Small Allimals, pp. 85-86. Springer Verlag, Berlin , Baltimore.
Heidelberg and New York. Unger M, Montavon PM and Hcim UFA (1990) Classification of
Brinker W, Piermattei D and Flo G (1990) Halldbook oJSmall Allilllal f"nlClures of long bones in the dog and cat, introducti on and clinical
Orthopaedics alld FraC/lire Treatment, 211d edll. WB Saundcrs, applicat ion. Veterillary alld COlllparative Orthopaedics and Trall -
Philadelphia . II/tltology 3, 41 - 50.

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II
CHAPTER TWO

History of Fracture Treatment


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Leslie C. Vaughan

INTRODUCTION Rome incurred a loss of original medica l thought; and


then, during the thousand or so years of the Dark Ages,
Evidence that s urvives about life in ancient civili za- learning was positively discouraged. It was not until
tions shows that their people were aware of the effects the Renaissance in the fifteenth and sixteenth centuries
of trauma. Fractures caused by accidents or combative that scientific enlightenment was revived in Europe.
violence were treated using principles which remain Interest in anatomy and surgery was rekindled but the
valid today. The bone setters appreciated that fracture real renaissance in surgery had to wait until the nine-
healing depended on the broken bone being kept im- teenth century. This is not to say that the intervening
mobile for a long enough period, and splints were used years were devoid of originality in fracture manage-
to achieve this. Elliot Smith (1908) examined two sets ment. Guthrie cites Guy de Chauli ac ( 1300- 1367) as
of splints from Egyptian graves which had been ap- possibly the first to employ extension and shows an
plied to a fractured femur and forearm , respectively, extension device from Gersdoff (1517) that works on
about 5000 years ago. They were made of rough wood modern principles (Figure 2.1).
wrapped in linen and, together with pieces of bark,
completely invested the limb, the whole held in place
with linen bandages. Elliot Smith studied healed femo-
ral fractures, many of which were shortened due to
fragment displacement, and 100 forearm fractures,
of which on ly one had not united while one had
suppurated.
Egyptian papyri from about 1500 BC, found in
Thebes in 1862, illustrate the treatment given to the
injured and deformed (Guthrie, 1958). The Ebers pa-
pyrus deals with surgery, anatomy and pharmacy while
the Edwin Smith papyrus describes fracture treatment
with splints.
Other civilizations of similar lineage also practised Figure 2.1: Gersdoff's (1517) application of extension
fracture management. In India the Hindus employed apparatus to a/ractured arm. (Reproduced/rom Guthrie,
/958 with permission.)
bamboo for splints.
From writings and relics more is known about the As ever, war was a teacher of surgery, and military
physicians of many centuries later. Hippocrates (460- surgeons became skilled in fracture care. Amputation
375 BC) wrote books on fractures and dislocations, was routine for open fractures but the mortality was
using terms which are still familiar, and distinguished high.
between open and closed fractures. Rigid support was In the eighteenth cenn. ry, among many distin-
provided with bandages impregnated with wheat glue, guished surgeons, John Hunter (1728-1793) had a
wax or resin, which set hard. great impact. His work on fracture healing and bone
Celsus, remembered for describing the cardinal growth, much of it learned from animal studies, estab-
signs of inflammation, wrote a book in AD 30 detailing lished him as a pioneer of orthopaedics. About this
fracture treatment with splints fastened to limbs with time the term 'orthopaedic' was coined by Nic holas
bandages stiffened by starch. Andry, from the Greek orlhos (straight) and pais
After such early enterprise, fracture treatment might (child), to describe the teacliing of methods oftreating
have been expected to progress at a greater pace in the and preventing deformities in children. It was not
fo llowing centuries than was the case. As Guthrie appropriated for use in a veterinary context until two
(1958) ex plained when tracing the development of centuries later.
human medicine, the decline of culture in Greece and The nineteenth century is particularly notable for

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10 Manual of Small Animal Fracture Repair and Management

the many innovations that were introduced to avoid the transformed the study of horse lameness and described
untoward sequelae of closed reduction methods, such the pathology and treatment of most common limb
as joint stiffness and limb deformity. Attention began disorders, including fractures. In dogs, Blaine (1824)
to be paid to the soft tissues and the development of treated femoral fractures with a pitch plaster, spread on
means offixation that enabled the limb to bear weight. leather, and a wooden splint. Pliable wood was used to
By the close of that century, three discoveries had support the forearm. For open fractures the bone ends
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been made which profoundly influenced surgery and were sawn off, loose pieces were removed, the wound
fracture treatment. Morton (1846) demonstrated an- was closed and a splint was applied. Blaine blamed non-
aesthesia with ether, and Liston (1846) performed the union on 'neglect of proper attention in the first place'
first operation using ether: an amputation through the and removed the soft bone ends with a fine saw.
thigh. In 1865 Lister demonstrated an antiseptic sys- Limb operations were performed on horses and
tem, employing carbolic acid, in a case of open fracture dogs before anaesthesia and antisepsis were known,
of the leg and 2 years later he recorded 11 such cases, but with these aids this field expanded. The potential of
with 9 complete recoveries. radiography was immediately recognized and Hobday
The discovery of X-rays by Rontgen (1895) ena- (1896) published probably the first veterinary skia-
bled fractures to be characterized and the efficacy of graph, of a eat's leg. The skiagraphs of canine fractures
manual reduction and external fixation to be evaluated. published by Hobday (1906) showed their value in
Poor results could now be explained, and improved diagnosis and for assessment of healing.
means of external and internal fixation were sought. The trend of human surgery towards specialisms
was evident in the late nineteenth century, and the
recognition of orthopaedic surgery provided an impe-
ANIMAL FRACTURES tus to promote the subject. Early in the twentieth
century the work of Hey Groves, Lane and Sherman
For lack of evidence, it is not possible to determine indicated the direction that advances in fracture treat-
what was known about animal fractures before the ment might take, but progress was slow. For example,
eighteenth century. Through the ages, the horse was in World War I the prompt application of a Thomas
depended on for labour, travel, sport and war and splint instead of a crude splint reduced mortality from
consequently its health and welfare received more femoral fractures to 20% from 80%, an indication that
attention than that of the other domesticated species. old methods needed to be changed. Even so, repair
The need for hoof care was evident from the time when results were often unsatisfactory, as Robert Jones
horses in the annies of Alexander (356-323 Be) were (1925) complained in a lecture, 'Crippling due to
abandoned because of hoof wear. Ways of protecting fractures'. Fai lure to achieve anatomical alignment,
the hoof were attempted with woven grass shoes, and or to avoid injury to soft parts, was too conunon. The
later with leather or metal plates. The Romans used a remedy, he believed, was to have special units run by
'hipposandal ' , a metal device strapped to the hoof, and surgeons skilled in this work.
by the fifth century in Europe metal shoes were fixed In the veterinary field a similar cri de coeur in the
with nails. 1950s changed attitudes to speciali zation and resulted
The term 'farrier' was introduced in about 1562 and in veterinary orthopaedics developing along similar
farriers, apart from shoeing, also dealt with general lines to those in human medicine.
ailments of horses and other animals. Blundeville Such has been the revolution in the theory and
(1609) wrote the first English text of note on shoeing, practice of fracture treatment in modern times that the
under the influence ofItalian and French works. Much main categories under which this has occurred demand
of the early literature lacked a scientific basis but, even separate consideration. In animals, for practical rea-
so, many of the terms used are still common. sons, it is the dog and cat that have benefited most from
Concern about farriery training standards led to the these advances.
formation of the London Company of Blacksmiths in
1356 and this was the forerunner of the Worshipful
Company of Farriers, which received its Charter in EXTERNAL FIXATION
1674.
The position of the treatment of fractures may be Rigid external limb support has been provided with
judged from the opinion in Bartlet's Farriery (1756) many different materials. For humans, splints ha ve
that there was 'no purpose in keeping horses who have been made of wood and metal, and casts of bandages
any fracture except in the foot '. Nevertheless, Gibson impregnated with substances that harden, such as
(1729) treated fractures with splints while supporting resin, starch, sodium siJjcate and plaster of Paris.
the horse in slings. Munro (1935) traced the early use of plaster of Paris to
The building of the first veterinary schools in Europe Arabia, and showed how cast application changed over
late in the eighteenth century marks the origin of veteri- many years, eventually to allow weightbearing and to
nary science. Veterinary surgeons emerged who soon avoid confinement to bed.

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History of Fracture Treatment 11

In animals, wood, metal, g utta pereha, leather, McCulU1 (1933) and Wright (1937) a lso made use of
cardboard and poroplastic felt have been used for the Scluoeder-type splint. Gunn (1936) ach ieved con-
splints, and casts were moulded with bandages soaked tinued traction with an apparatus in volving the inser-
in starch or pitch. Williams (1 893) and Hobday (1900) tion of pins into both bone ends (Figure 2.3).
advocated plaster of Paris fo r dogs. Lacroix and Cozart
(1924) preferred soaked wood because of its lightness
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and Ehmer (1925) employed yucca board attached


with bandages soaked in sodium silicate. Barrett (1936)
and Wright (1937) conformed unpadded strips of pIas-
ter of Paris to the s hape of the limb (Fig ure 2.2).

So.,n A.' "


I .. ,",·" T.","
I'u,".

Figure 2.3: Mechal1ical jracture traclion apparatlls jor


overridingjractllres ill dogs. (Reproducedjrom GUill!, 1936,
Australian Veterinary Journal, 12, /39.) ..

Figure 2.2: Method of applying plaster slabs. (Reproduced Coaptation splinting and casting remained the main
jrolll Wright, 1937, with permission a/The Veterinary
Record.) o ption for fracture treatment un til s uperseded by inter-
nal fi xation . Whi le the Thomas splint has become
In dogs, adequate results could be achieved with outmoded except as a fi rst aid measure, casts sti ll ha ve
extern al supports for fractures which were read ily an important role in the treatment of minor injuries and
reduced, especiall y those distal to the elbow and stitle in s upp lementing surgica l repairs. Plaster of Paris has
joints. The method proved less satisfactory for the been replaced with synthetic materials such as fibre-
humerus and femur, where muscle mass and limb glass and resin, which have the adva ntages of being
shape made reduction and support difficult. In hu- light, waterproof and resistant to self-mu tilation.
mans, red uction could be achieved with mechanical
traction but, due to lack of patient cooperat ion, it was
not practi cal in animals. Steiner (1928) treated 40 dogs EXTERNAL SKELETAL FIXATION
with femoral fractures by suspending them by their
hindlegs and found the results satisfactory but the The advantages of stabi lizing a fracture wit1lOUt expos-
humanity of this is doubtful. Dibbell (1930) provided ing the site or burying foreign material have long been
traction with a wire splint devised for humans by recognized. In 1849 Malgaigne (Venable and Stuck,
Thomas (1875), and he checked the red ucti on by 1947) devised adjustable me ra l hooks that pierced frac-
fluoroscopy before incorporating tongs attached to the ture fragments close to the skin surface (Figure 2.4).
bone end in an external s upport (Dibbell, 193 1). Parkhill (1897) inserted fo ur pins at right angles into the
Schroeder (1933a,b, 1934) employed s kin and ske letal bone and secured them extern all y with bolts and clamps
traction and developed the Thomas splint for dogs. (Figure 2.5). Lambotte (1907) used a half-pin apparatus.

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12 Manual of Small Animal Fracture Repair and Management

Hey Groves (1916) employed a double transfixation Anderson (1934) inserted half-pins under local
device to treat open and comminuted fracnlres, which anaesthesia for radius/ulna fractures and embedded
allowed ambulation and avoided confinement to bed their ends in a plaster cast after mechanical reduction.
(Figure 2.6). In the 1920s various attempts were made to Later he modified this method to include clamps and
control reduction and fixation externally. cOIlllecting rods in various configurations.
For dogs, Stader (1934) described a fu ll -pin
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transfixation splint, with K-wires embedded exter-


nally in a wooden strip, while Self (1934) used steel
wires and fastened them to a metal splint. Stader
(1937) next introduced a half-pin device to provide
reduction and fixation. By 1939 the Stader Reduction
Splint was available in three sizes (and was also used
in US servicemen in World War II). Ehmer (1947)
developed a half-pin splint (Kirschner-Ehmer) which
allowed flexibility of pin angles and which, after
attachment of a reduction gear, allowed the
Figure 2.4: Malgaiglle 's clamp (1849) IIsed jor fractures of fragments to be manoeuvred - a design that is still
the patella and olecranon. The prongs projected through the manufactured.
skin. (Reproducedjrolll Venable and Stuck, 1947, with Such apparanls gained popularity in North America
permission of Blackwell Science. Originally printed in
Stimson, Fractures and Dislocations, 1910.)
but not in the UK. The risk of tracking infection and pin
loosening were common fears. Knight (1949) found
that results were not consistent but Turnbull (1951),
Weipers (1951) and Kirk (1952) reported favourably
on them. At tltis time internal fixation was being
perfected; antibiotics had overcome the fear of surgi-
cal infection and it was inevitable that intramedullary
Figure 2.5: A new apparatus for the fixation of bones after
fi xation and plating would become the chosen
resection and ill fractures with a tendency to displacement, methods.
(Reproduced/rom Parkhill, 1897, American Surgery In the 1970s interest in external skeleta l fixati on
Association Transactions, 15, 251.) was revived, particularly for open and comminuted
fractures, shearing injuries and mandibular fractures.
The results achieved were better than previously, due
to the upgrading of methods of application and after-
care. There is now a burgeoning literature on this
subject which reflects a worldwide acceptance of these
techniques. Sophisticated systems may be purchased
or home-made devices constructed to suit the indi-
vidual case (Carmichael, 1991; Harari, 1992).

INTERNAL FIXATION

The advantages of maintaining fracture components in


apposition by mechanical means were appreciated
long before this became possible practically. The in-
troduction of aseptic surgery and of radiography ena-
bled such techniques to advance, though the concept
was not immediately accepted. The early implants
were similar to those in present use but experience has
brought about changes in their design, the materials of
which they are made and the manner of their insertion.

Wire
The apposition of bone ends with wire is probably the
oldest ofthe internal fixation methods (Figure 2.7). In
humans, silver was used first but in 1883 Lister
Figure 2.6: Double tral1~fixiol1 apparatlls. (Reproduced/rom
Hey Groves, 1916, On Modem Methods of Treating Fractures, repaired a fractured patella with iron wire and
published by John Wright Gnd SOliS.) Lambotte employed annealed iron wire. Hey Groves

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History of Fracture Treatment 13

(1916) preferred iron to si lver and believed that the more satisfactory results were achieved when cerclage
wire shou ld perforate rather than encircle the bone, application improved (Hinko and Rhinelander, 1975).
though he thought wiring was unsatisfactory. Despite A more recent innovation using wire is the tension-
the relative weakness of wire and its inability to band technique, which converts a distracting or tension
overcome angulation forces, it found favour over the force into a compressive one. It has special advantages
next 20 years because it meant introducing less metal for treating avulsions and allows an early return to
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into the wound than did a plate. This is an indication weightbearing, which is beneficial for animals.
of the fear of complications that plating had engen-
dered, which did not abate until the introduction of Intramedullary devices
biologically inert metals. Short pegs that crossed the fracture line and impacted
in the medullary cavity were used in the late nineteenth
century, especially for delayed unions. Hey Groves
(1912, 1916) tried pegs of ivory, bone and nickel-
plated steel, 1.5-2.0 inches (38-51 em) long, for
recent fractures. They were difficult to insert, they
were limited to simple transverse fractures and they
failed to provide rigid alignment. When he introduced
full-length pinning for femoral fractures, his critics
believed this would cause marrow destruction, fat
embolism and sepsis. According to Hobday (1906)
pegs were used to treat non-union fractures in dogs.
( e?:._ The concept of intramedullary fixation was revived
'f".. when Kuntscher (1940) successfully repaired experi-
mental fractures in dogs with V-or trefoil-shaped
Figure 2.7: Types of wire 'bone sutures' devised to provide nails. By 1950 nailing was routine in humans (Watson-
more rigid internal fixatiol1. (Reproduced from Venable Gild
Jones, 1950) and it proved satisfactory in dogs (Jenny
Stuck, 1947, lVith the permission o/Blackwell Science. Redrawn
from Seer's Practical Surgery, 1901.) et ai., 1946; Marcenac et ai., 1947; Griesmann, 1948;
Moltzen-Nielsen, 1949; Schebitz, 1949; Jenny, 1950).
Metal bands were stronger than wire loops and It was, however, the round section Steinman pin rather
various designs were made, the most notable being by than the nail that found favour for long bone fractures
Parham and Martin in 1916. Erosion tended to occur in dogs and cats, possibly because it was easierto insert
beneath bands and this could so weaken the bone that and cost less. Its early advocates were Bernard (1948),
it fractured; such changes were attributed to pressure Brinker (1948), Frick et al. (1948), Knight (1949),
necrosis before the destructive effects of electrolysis Knowles (1949), Lauder (1949), Moltzen-Nielsen
were reali zed. (1949), Turnbull (1949), Henderson (1950), Leighton
In dogs, Hobday (1906) mentioned the union of (1950) and Weipers (1951). The canine femur p;oved
fractures with silver wire inserted in hemi-cerclage not to be ideally suited for pinning because its medul-
fashion, while French (1906) treated pseudarthroses lary cavity varies in width along its length, making it
with silver wire sutures. Ehmer (1925) plated and difficult to achieve adequate bone/pin contact. Conse-
wired dog fractures but found after-care with external quently fragment rotation or even non-union might
supports was unsatisfactory. Perrin (1923) repaired a occur unless the repair were supplemented. Dbel (1951)
dog 's femur with wire but it became infected. A impacted the medulla with two or more pins. Pins with
fractured calcaneum was wired by McCunn (1933), a threaded end were thought to give a better grip. The
and Weipers (1951) had used silver and phosphorbronze addition of cerclage wires oran external skeletal fixator
wire in the 1930s. Larsen (1927) and Moltzen-Nielsen could also resist rotation.
(1949) used Parham bands and Knight (1949) em- An intramedullary extension splint was devised by
ployed silver wire for some years. Jonas and Jonas (1953) which included a spring-
Cerclage wiring gained popularity for small ani- loaded device intended to make insertion easier. En-
mals largely as an adjunct to intramedullary pinning, to thusiasm for the splint waned when it was associated
secure long oblique bone ends and to hold fragments in with untoward reactions and proved difficult to re-
place (Turnbull, 1951). Repair failures were not un- move.
common, due to wires loosening or breaking, which A round-section pin which has a sledge-runner tip
sometimes led to non-union or osteomyelitis, and this at one end and a hook at tlWother relies on its spring-
provoked a controversy about the hazards of cerclage like action to contact the inner wall of the cortex.
(Newton and Hohn 1974). Interference with blood Although initially developed for humans (Rush and
supply was thought to be responsible for some of these Rush, 1949), it was adapted for small animals (Carney,
failures, though a narrow loop was less likely to reduce 1952) and remains popular, especially for condylar
vascularity than a band. Bands were discarded and fractures in lniniature breeds of dog.

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14 Manual of Small Animal Fracture Repair and Management

Plates and screws


The first metal bone plates and screws were devised by
Hansmann (1886). Made of nickel-plate, they were
inserted in such a way that the screws and one end of the
plate protruded through the skin to make removal easy
(Figure 2.8). Trials with plates in the late nineteenth
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century led Lane (1907) to design a pattern of steel plate


that remained standard for many years. Lane's belief
that success depended on strict antisepsis caused him to
reconunend a 'non-touch' technique. Lambotte (1907)
preferred plates of soft steel plated with gold or nickel,
having tried aluminium, silver and brass. As experience
with plating grew, it was reported that Lane plates
tended to break at the junction of the bar and first screw
hole (Figures 2.9 and 2.10). The plates were 1/ 16-3/16
of an inch (1.6-4.8 mm) thick and 1/4 of an inch
(6.3 mrn) wide. Since the screws penetrated only one
cortex, the repair was wea k. Sherman (1912), advised
by engineers, introduced a substantially stronger plate
that was slightly curved and had fewer screw holes. It
was made of vanadium steel, which was twice as tough
as the tool steel in Lane 's plates; the screws were
machine type with self-cutting threads, which provided
greater holding power than wood-type screws.

n-;:-
I ",j I~ Figure 2.9: Lane bone plates broken at their weakest poim.
(Reproducedjrom Shennan, 1912, Surgery, Gynecology and
o Obstetrics, 14, 629.)
. ,I,
!
. o
o
"
~

C
\
Figure 2.10: Lalle bone plates appLied to a fracrured femur.
(Reproducedfrom Venable and Stllck, 1947, wirh the
I permission of Blackwell Science. Originally primed in Lalle,
Operative Treatment of Fractures.)
L together with bolts. He was ahead of his time in
stressing the importance of fracture planning and the
value of motor-driven drills.
)0;; 000 0 0 000 0 o~ Over the next two decades, plating became associ-
ated with an unacceptable level of complications such
as plate loosening, wound breakdown and failure of
= :so i .....
:::'
union. The severe bone reactions (,rarefying osteitis' )
that developed were attributed to infection or faulty
Figure 2.8: Hansmann's bone plate (1886). The end of rhe
plate and tile screws protruded from the wound. (Reproduced technique until Venable et at. (1937) showed that the
jrom Venable and Stllck, 1947, with the permission of problem was due to the metals used. Metals could
Blackwell Science. Originally printed ill A. Hansmanll's A disintegrate in tissues through electrolys is, but this
new method of fixation of fragments in compli cated could be avoided by using metals that are biologically
fractures, Verll. d. Deutsch Gesellsch. f. Chir, 1886.)
inert. The inert alloy, vita Ilium, was introduced to bone
Hey Groves (1912, 1916) experimentally tested the surgery (Venable and Stuck, 1941) and stainless steel
efficacy of plating in cats and rabbits and found that was modified to improve its inertness. The qualities of
short plates attac hed with screws through one cortex 18-8 S Mo steel in this respect led to its universal
were unable to retain the bones in position. He advo- acceptance in implant manufacture. The lesson regard-
cated longer, thicker plates fixed with screws or cotter ing metal corrosion was learned slowly and it was
pins through the full width of the bone. For some some years before old stocks of inferior implants were
fractures a plate was applied to each cortex, both held discarded from hospitals (Cater and Hicks, 1956).

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History of Fracture Treatment 15

In dogs, Larsen (1927) reported the repair of frac- of this vigorous reappraisal. At first compression was
tures with Lane plates, the first being in 1910 (Figure achieved with a plate attached to the bone using a
2.11). Chambers (1932) and Stainton (1932) referred to compression device, but in 1969 Perren et al. tested in
plating but gave no clinical details. Moltzen-Nielsen animals a new style of '''dynamic compression plate'
(1949) described 30 repairs with Lane plates between (DCP), which relies on the geometry of the holes and
1928 and 1939. Bateman (1948) repaired calcaneal eccentric placement of the screws to produce compres-
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fractures in Greyhounds with a slotted plate fixed to the sion. It was successfully used in humans by Allgower
tibia and tuber calcis. Sherman plates of vita Ilium were et al. (1969) and is arguably the outstanding ilillovation
used by Knight (1949), Chappel and Archibald (1951) in bone plating in th e last half-century.
and Kirk (1952). Two steel plates were used in tandem The various systems now commercially available
to repair a fracnlred calcaneum in a bull (Kirk and provide implants of high quality but also require prac-
Ferll1ell, 1951). The plating of long bone fractures tical ski lls of equal quality fortheir correct insertion. In
became increasingly cOirunon in the 1960s, tending to 1970 an international veterinary association for the
replace intramedullary pinning in large dogs. The type study of internal fixation was formed, with similar
of plate depended on the size and shape of the bones, aims to those of the original organization. Implicit in
which vary greatly in the different breeds, unlike the the ethos is the acquisition of skills to the benefit of
standard morphology of bones in humans. Sherman fracture treatment and many veterinary surgeons world-
plates were inherently weak at the screw holes and so the wide take advantage of the courses that are available
straight-edged Venable plate was indicated for large and where practical knowhow may be learned.
heavy dogs. The Bums plate combined features of the The fact that rigid fixation tends to overprotect
latter two, while the Eggers Contact plate had long slots bone union has led to the introduction of plates made
instead of screw holes and was claimed to provide of materials that allow some flexibility, such as carbon
compression of the fracture during weightbearing. The fibre. Biodegradable materials might answer some of
finger plates designed for human phalanges were suit- the problems created by metals, and plates with low
able for long bones in the miniature breeds. contact interfere less with vascularity. These and many
other developments are being tested in response to
clinical challenges and are part of a never ending
process which began when the first attempts were
made to assist nature in the healing of fracnlfes many
• centuries ago.

REFERENCES
9 Allgower M, Ehrsam R, Ganz R ef 01. (1969) Clinical experience with
a new compression plate 'DCP' . Acta Orthopaedica Scal1dinavica
(Supplement) 125, 45.
Anderson R ( 1934) Fractures of the radius and ulna. A new anatomica l
method of treatment. JOllmal of Balle alld Joim Surgery 16, 379.
5 Barrett EP (1936) The treatment offracturcs in small animal s by means
6 of the unpadded cast. Veterinary Record 48, 1086.
8 Bartlet (1756) A Gem/eman's Farriery or, a Practical Treatise 01/ 'he
7 2 Diseases oj Horses, 3rd edn. Nourse, London.
Bateman lK (1948) A fresh approach to the repair of the os cal cis in the
Figure 2.11: BOlle plating equipmellt llsed ill dogs. (From Greyhound. Veterinary Record 60, 674.
Larsen, 1927, Maanedsskrift fUr Dyrlaeger, 39, 337.) Bemanl BW (1948) Method of repair offemoral and humeral fractures.
JOllmal ofrile American Veterinary Medical Association 113, 134.
In 1958 a group of Swiss surgeons formed an Blaine D (1824) Callille Pathology,2 nd edn. Boosey and Sons, London.
association for the study of the problems of internal Brinker WO (1948) The use of intramedu llary pins in sma ll animal
fractures. North American Veterinarian 29, 292.
fixation with a view to evaluating the operative treat- Cannichael S (1991) The external fixator in sma ll animal orthopaedics.
ment of fractures in humans. The research undertaken Joumal oj Small Animal Practice 32 , 486.
Camey lP (1952) Rush intramedullary fixation oflong bones as applied
in their laboratories at Davos had far-reaching effects to veterinary surgery . Veterinary Medicine 47, 43 .
on fracture repair in humans and animals. Attention Cater WH and Hicks JH (1956) The recent history of corrosion in metal
used for internal fixation. Lancet 2, 871.
was focused on achieving a mechanically stable unit Chambers F (1932) Fractureof the femu r in the dog . Veterinary Record
with lag screws, compression plates and intramedul- 12,9 1.
lary nails, in order to allow early, pain-free limb use Chappel CI and Archibald J (1951) Vita Il ium bone plating in dogs.
Description of a practical technique and clinical observations.
and thus avoid some of the serious joint and soft tissue Veterinary Medicine 46, 291. ~.
complications. Primary bone healing was said to fol - Dibbell EB (1930) Splints for fixation of fractures and dislocations in
small animals. North American Veferinariall 11, 29.
low such a fixation although more probably the im- Dibbell EB ( 1931) Lowerthird femoral fractures in dogs. North Ameri-
proved healing was promoted by rigid immobilization can Veterillarian12 , 37.
of the bone fragments. Ehmer EA ( 1925) Our method of handling fractures. North American
Veterinarian 6, 47 .
Implant development has been an important aspect Ehmer EA (1947) Bone pinning of fractures of small ani mals. JOllmal

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Itra

16 Manual of Small Animal Fracture Repair and Management

a/the Americoll Veterinary Medical Association 110, 14. Moltzcn-Nielsen H ( 1949) Recent experi ences in the treatment of
Elliot Smith G (1908) The mosl ancien( splints. British Medical Jourl/al fractures by s urgical methods. Veterinllry Record 61 ,79 1.
t ,732. Munro IK (1935) The history of plaster-of-Paris in the treatment of
French C (1906) Surgical Diseases alld Surgery oflhe Dog. French, fractu res. British Joumal of Surgery 23, 257.
Washi ngton, DC. Newton CD and Holm RB ( 1974) Fracture nonun ion resu lting from
Frick EJ, Witter RE and Mosier JE (1948) Treatment of fract ures by cerclage appliances. Joumal of/he AmeriClln Veterinary Medical
intnuncdullary pinning . North American Veterinarian 29, 95. Association 164, 503.
Gibson W ( 1729) Tlte Farrier's New Guide, 6th cdn . Osbom and Obel N ( 1951) lntramed ullar fi xation med rastfria sta var vid fraktur pa
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Longman. London. femu rdiafysen nos hund. Nordisk Veterinarmedicin 3, 723.


Gricsmann H ( 1948) Marknagclung cines Oberschcnkclbruc hcs bc im Parkhill C (1 897) A new apparatus for the fi xation of bones aft er
Hund. Deutsch tierarzlliche Wo chellschrift 55, 275. resection and in frac tures with a tcndcncy to displacement. Ameri-
Gun n RM C ( 1936) The treatment of limb bone fra ctures in nnimals. call Surgery Associafioll Transactions IS, 25 1.
AIISlralitlll Velerilla ry Jollma/12 , 139. Perren SM, Russenberger M, Stcinemann S e/ al. ( 1969) A dynamic
Guthrie D ( 1958) A History of Medicine (lVith supplcmclIIs). Thomas compression plate. Acra Orthopaedica ScO/ulinavica (S upplement)
Nelson and Sons, London. 125,3 1.
Harmi J (1992) The Veterinary Clinics of North America 22 , I. Perrin F ( 1923) The treatment of fra ctures. North AmericclII Veterinar-
Henderson W ( 1950) Intramedu llary repair of femo ral fractures in the iall 4, 490.
dog and cat. Veterinary Record 62, 168. Rush LV and Rush HL ( 1949) Evolution of medullary fixati on of
Hey Groves EW ( 1912) Some clinical and experimental observations frac tures by longitudinal pin . American J ournal of Surgery 78 ,
on the operati ve treatment of fractures. Brifish Medical Journal S, 324.
1102. Sehebitz H (1949) Die Marknagelung bei Haus tieren. MOlllllshefiefiir
Hey Groves EW ( 191 6) On Modem Methods o/Treating Fracfures. Veterinarmed;zill 4, 27.
John Wright and Sons, Bristol. Sch roeder EF ( 1933a) The traction principle in treating fractures and
Hinko PJ and Rhinelander FW (1975) Effective use of cerclage in thc disloeations in the dog and cat. North Americall Veterillarian 14,
trcat mcnt of long bone fractu res in dogs. Journal of the American 32.
Veterinary Medical Association 166, 520. Schroeder EF (1933b) Fract ures of the femoral shaft of dogs. North
Hobday FTG ( 1896) The new photography in vctcrinary practice. The American Veterillariall 14, 38.
Journal o/Comparative Pathologyalld Therapeutics 9, 58. Schroeder EF (1934) Fractures of the humerus in dogs. North American
Hobday FrG (1900) Canine alld Feline Surgery. Wand AK Johnston, Veterinarian IS, 3 1.
Edinburgh and London. Self RA (1934) Open reduction and mechuniea l devices in treating
HobdllY FrG (1906) Surgical Diseases of the Dog and Car, 2nd edn. fract ures in small animals. Veterinary Medicine 29, 120.
Ba illi ere, Tindall and Cox, London. Shennan WO (1912) Vanadium steel bone plates and screws. Surgery,
Jenny J ( 1950) Ku ntscher's medu llary nailing in fcmur fractu res of the Gy necology alld Obstetrics 14, 629.
dog. Joumal of/h e American Veterinary Medical Associ(l(ioll 117, Stader 0 (1934) A method of treating femora l fractures in dogs. North
38 1. American Veterinarian 15, 25.
Jenn y J, Kanter U and Knoll H ( 1946) Die Behandlun g von Stader 0 ( 1937) A preliminary announcement of a new method of
Femurfrakt uren des H undes durch Marknagelung. Schweizer A rchi v treating fractures. North American Veterinarian 18,37.
flir Tierheiikullde 88, 547. Stader 0 (1939) Treating fractures of long bones with the reduction
Jonas S and Jonas AM ( 1953) Self-retaining medullary extension spli nt. splint. North American Veterinarian 20, 55.
Joumal ofthe American Veterinary Medical Associatioll122 , 26 1. Stainton H (1932) The fractured canine femur. Veterinary Record 12,
Jones R (1925) Crippling due to fractures: its prevention and remedy. 187.
British Medical Jouma/ l , 909. Steiner AJ ( 1928) Treating femur and pelvic fmct urcs. J ournal of the
Kirk H ( 1952) Modem methods of fracture repair in large and s mall American Veterinary Medical Association 73, 3 14.
an imals. Veterinary Record 64,3 19. Thomas HO ( 1875) Diseaseso/the Hip, KlleealUJAllkleJ oims. T. Dobb
Kirk H and Fennell C (195 1) Treatment of fracture of os calcisofa bull and Co., Li verpool.
by plating. Veterinary Record 63,363. Turnbull NR (1949) Fractures of the huments and fem ur re ~lired by
Knight GC ( 1949) A report on the use of stainless steel intramedu llary intramedullary pins. Veterinary Record 61 , 476.
pins and Shennan type vitallium plates in the treatment of small Turnbull NR ( 1951 ) The problems of the dis placed epiphysis. Veteri-
animal fractures. British Veterinary Joumal lOS, 294 . nary Record 63, 678.
Knowles JO ( 1949) Fracture repair by bone pinning. Veterinary Record Venable CS and Stuck WG (194 1) Three years experience with Vita Ilium
6t , 648. in bone surgery. Annals of Surgery 114,390.
KuntscherG ( 1940) Di e Behandlung von Knochenbruechen bei Tieren Venable CS and Stuck WG (1 947) Th e Imernal Fixatioll of Fractures.
durch Marknagelung. Archiv Jiir lVissenschaftliche praktische Blackwell Science, Oxford.
Tierileilk llllde 7S , 262. Venable CS, Stuck WO and Beach A ( 1937) The effects on bone of the
ulcroix JV und Cozart JM (J 924) Wood splints and the treatment of presence of metals: based on electrolysis. AIII/ais ofSllrgery 105,
fract ures of long bones. Nortll American Veterinarian 5, 408. 917.
Lambotle A (1907) L 'lmerl'enrioll Operaroire dans les Frac/eurs. Wutson-Jones R (1950) Medullary nailing o ffra ctures after fift y years.
Lamartins, Brussels. Joumal of Bone and J oint Surgery 328, 694.
Lane WA ( 1907) Cli ni cal remarks on the operative treatment of frac - Weipcrs WL ( 1951) Mailers canine. Veterinary Record 63, 659.
tures. Brirish Medical Jot/mall, 1037. Williams W ( 1893) The Prillciplesalld Practice of Veterilwry Surgery.
Larsen S ( 1927) Operativ Frakturbehandling . Ma cmedsskrift flir John Menzies and Co. , Edinburgh.
Dyrlaeger 39, 337. Wright JO (1937) Some observations on the incidencc, causes and
Lauder JSJ (1949) Fracture repair by bone pinning. Veterillary Record treatment of bone fractures in the dog. Veterillary Record 49,2 .
6t 866.
Leighton RL (1950) A new method of pemlanent intramedullary
pinn ing. Joumal of tile American Veterinary Medical Associatioll
117, 202.
Marccnac N, Bordet R and Jenny J (1947) Osteosynthese femoral par Note 011 Illustrations : The BSA V A has been unable to
cnclo uage metallique centromedu ll aire. Bulletill Academie contact the original publishers for Figures 2.3, 2.5, 2.6,
Viterbwire France 20, 6 1.
McCu lll) J ( 1933) Fractures and disloeations in small anima ls. Veteri - 2.9 and 2.11. We are pleased to acknowledge the
nary Record 13, 1236. source and apologize for any unintended discourtesy.

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CHAPTERTHREE-----------------------------------

Biomechanical Basis of Bone Fracture


and Fracture Repair
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Simon Roe

INTRODUCTION parameter is used to compare different material s, not


different structures.
Every aspect of fracture management is influenced by Bone is a complex material composed mostly of
extrinsic or intrinsic forces. It is therefore essential for organized collagen fibrils and a hydroxyapatite min-
successful orthopaedists to appreciate the mechanical eral matrix. Although many other components are
natureoftheart offracture repair and to meld it with their present, these two contribute most significantly to the
understanding of the biological aspects of the tissue and mechanical behaviour of bone. At a very basic level,
its response to trauma. This chapter addresses the cortical and cancellous bone are quite similar.
mechanics of bone as a material and a structure, of When a material is not homogeneous, its mechani-
fractures and fracture healing, and of implants used to cal behaviour is influenced by the direction of loading
impart stability. Terms in bold type are dermed further relative to its orientation and it is termed anisotropic.
in the Glossary at the end of the chapter. A graphic depiction of how bone properties are influ-
enced by specimen orientation is presented in Figure
3.1. The response also varies with the type of load
MECHANICS OF BONE applied. Due to the organization of the mineral phase,
bone is very resistant to compression in all directions.
Bone as a material The interaction of the mineral crystals causes it to fail
It is often helpful to understand a material before by shear, usually at 45° to the long axis. Because the
considering the structure that it builds. An engineer mineral crystals are much more resistant to compres-
must be familiar with how steel behaves before build- sion than the collagen fibres are to tension, peak
ing a bridge. When he looks at the bridge, he considers compressive loads are much greater than failure loads
the loads that are likely to be borne and then decides if measured in tens ile eva luations.
the structure and the material it is made of are strong
enough. In a similar way, a surgeon must assess a
fracture and its repair. The loads that must be consid-
ered are discussed later in this chapter. This section
considers the stress and strain that might be ex pected
within the material with which the surgeon is working.
Appreciating these internal forces and deformations is
important in understanding the limits of bone as a
mechanical material.
A common approach to understanding mechanical
materials is to subject them to a load while measuring
the resulting deformation. For simple materials (which
includes most of those associated with fracture me-
chanics), the response is linear and the slope ofthe line
represents the stiffness of the structure tested. This is
often the most important parameter as it conveys how
much movement will occur for a certain load. In
fracture repair mechanics, it relates directly to the
amount of movement that might be expected at the
fracture site. If the specimen being tested is a pure
Figure 3.1: The tensile strength offour specimens prepared
material that has known dimensions, then the stress from the same piece of corticaL bone is recorded on the graph.
versus strain response can also be produced. The slope Specimens oriented other than in line with the osteolls were
of this line is termed the modulus of the material. This weaker ill tension, demonstrating the allisotrophy of bone.

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18 Manual of Small Animal Fracture Repair and Management

Cancellous
The properties of cancellous bone are determined by

~Q •
its density and by its architecture. It also displays
anisotropy. There are few conditions in animals in
which the mechanics of cancellous bone need to be
considered. The primary concern is its ability to hold
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implants when fractures occur in the metaphysis or


(a)
epiphysis, particularly in the young and very old. Some
Figure 3.2: (a) Section through a radills and ulna to
specific conditions (beyond the scope of this chapter)
demol/strate the cross-sectional area that bears the load ill that have stimulated considerable research into cancel-
the limb. (b) After removal a/the ulna, the dimensions, cross- lous bone mechanics are osteoarthritis, osteoporosis
sectional area and area (A MI) and polar moments a/inertia and joint replacement.
(PM!) increase. If a diaphysis responds /0 load by il/creasillg
its cortical thickl1ess by 20%, the cross-sectional area
increases by 90% and the AMI alld the PMI increase by
Fracture of bone
250%, to produce a Sfrllcture with grea/ly el1hanced
resistance to bending and rotation. Cortical
The majority of fractures involve primarily cortical bone.
The way in which a cortical shaft breaks will be deter-
mined by the type of loading and the rate at which the load
Bone as a structure is applied. It is easiest to consider the specific patterns
The structural arrangement of bone (as a material) has created by simple loads applied slowly (Figure 3.3):
both microscopic and macroscopic components. The
two primary types of bone when considering fracture Compression results in fracrure lines 45° to the axis
management are cortical and cancellous. Tension produces a straight separation of the
material
Cortical Rotation results in a spiral fracture line
On a microscopic level, cortical bone is very dense and Bending is more complex as it produces tension
very regularly aligned, thus imparting considerable on one side of the cylinder and compression on
strength to diaphyses of long bones. The arrangement the other. A simple transverse fracrure begins on
of bone in the diaphysis demonstrates a major me- the tension side (because bone is weaker in
chanical concept, area moment of inertia (AMI), that tension). As the forces become compressive, the
applies to many aspects of fracture management and weakest plane is at 45° and often two fracture
will be the basis of understanding many situations lines diverge and a 'butterfly' fragment develops.
described in this chapter.
The cylindrical structure of the diaphysis provides In clinical situations, loading is usuall y very complex.
resistance to bending and rotation forces while Weight bearing and muscle contraction in anticipation
optimizing the mass of the bone. The dynamic nature of a trauma often create large compressive forces
of the response of bone to its mechanical environment within a bone that ma y be subject to rotation, bending
is revea led by the way in which it responds to increases or a combination of both.
in load (Figure 3.2). If a portion of the ulna of yo ung Another factor of the fracture process that influ-
pigs is removed, the load borne through the radius ences the final degree of damage is the rate of load ing.
increases. The radius responds by increasing in thick- The process of development and propagation of frac-
ness and in outer diameter, greatly increasing its AMI. ture lines is very complex and the following discussion
The dimensions of the structure also determine is a simplification to high light the major principles
the polar moment of inertia (PMI), which influ- involved. When a load is applied relatively slowly, a
ences the resistance to torsional load. PMI reflects the fracture begins in the material at the weakest point. As
di stribution of the structure around the central axis of more energy is applied to the bone, the fracture line
rotation . Material further from the axis will increase follows the weakest path through the material. A single
this parameter and produce a structure with superior line of fracture occurs and its configuration is influ-
resistance to rotation. enced by the type of load applied and any inherent
An important point to remember is that the bending weaknesses in the structure. However, if load is ap-
and torsional strengths of a structure are determined by plied rapidly to bone, the energy stored in the structure
the strength of the material as well as AMI and PM!. can cause multiple sites of disruption of the material.
Mineralized disorgani zed callus is not as strong as As these develop into fracture lines, the large amount of
cortical bone and so, during healing, the amount and energy being rapidly applied to the structure may be
dimensions of callus tissue are increased to provide dissipated in multiple directions, and not necessarily
bending and torsional strengths that are able to wi th- along the weakest plane. In the clinical situation, high
stand the loads applied. energy trauma is associated with a high degree of

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Biomechanica l Basis of Bone Fracture and Fracture Repair 19

~
t
c=::::> :::;
c ~
c:::::> ~
, .....
c:::::>::: r
,+ .....
c=::::>-"
,
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J
J

J
, J

.. ..
".

..... ./ ~
".
/

:> ? ?

({I) t (b) ~ (e)


~
(d) (e)

Figure 3.3: Thefracture configuration is afunction oftlle/orces acting all tile bone. (a ) Compression: the minerat struclllre
+
shears at 45 0 to the long axis, producing oblique fraclUre lines. (b) Tension: bone is weaker ill tellsion because the mineral
crystals contribute little. failure occurs by separation ill a straight tille. (c) Rotation: shear fo rces create a spiral /racture
pattern. (d) Bendillg: tension develops on the convex sill/ace alld compression on the concave surftlce as the bone bellds.
Because the bOlle is weaker intension. Ihe/raclure begins transversely. As il travels across the bone, the forces change to
compression Gild Ihe fracture often progresses ill bOlh 45 0 directions to create a 'butterfly' Jragmem. (e) Combined bending and
compression: all increase in the compressive stress resulrs ill shear failure ear/ier and a larger 'butterfly' Jragmem results.

comminution. The highly comminuted femur fracture stress and strain ex peri enced by th e tiss ues wit11in the
in Figure 3.4 occurred when the dog leapt from a truck fracture influence the ir develo pment and d ifferentia-
travelling at 35 mph. When the dog's foot contacted the tion. The ty pes of tiss ue prese nt in vari o us regions of
ground and stopped moving forward, his body contin- the ca llus are often dictated by their tolerance of the
ued, creatin g a massive torsional load in the limb. This loca l deformation s.
was combined with a massive compressive load from Early in the healing process, th e fracture gap fills
the landing body and the contraction of the tlligh mus- wi th granulation tiss ue. The loose, fibrous nature of
cles in an attempt to prevent falling. this tissue allows it to tolerate strains in the region of
40%. Because strain is calcul ated fro m the ori ginal
Cancellous length of th e tissue being loaded, one way that nature
Fracture of cancellous structures follo ws some of th e is able to reduce tissue strain is by increasing the width
patterns seen for cortical bone. In compression, how- of the fracture gap. Resorption of fracture ends occurs
ever, collapse and compaction occur. It is important when large motions are present (Fig ure 3.5).
that this type of change be noted when evaluating a A5 the biological processes drive callus differentia-
fracture as it will influence the ability to reconstruct th e tion, regions with less strain become more fibrous and
bone and to appl y an implant to it. Tilis type of fracture cartilaginous matrix is deposited. This tissue is stiffer -
is most commonl y seen in vertebrae. less movement of the fracture frag ments will occur with
the same load. However, it is also less tolerant of strain.
Ifit is distorted by more than5 %, tissue injury will occur,
MECHANICAL ASPECTS OF differentiation will be reta~ded, and more granulation
FRACTURE HEALING tissue will be laid down. If the stiffening of the callus does
control movement, mineralization and woven bone for-
The various stages of callus maturation are influ- mation begin. Again, this corrunences first in regions of
enced by local humoral and physical fac to rs. The the callus with the least motion. The tissue is stiffbutmore

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20 Manual of Small Animal Fracture Repair and Management

susceptible to injury - more than 0.2 %strain will damage


Pelvis the mineralized matrix. If tissue strain is minimal during
the bridging period, the newly fomled bone can provide
sufficient strength to join the fracture ends.
The final maturation process is also influenced by
the mechanical environment of the bone. Loading is
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sensed by the osteocytes of the inunature callus and


remodelling by 'cutter cones' and the development of
an Haversian system result in re-establishment o f
cortica l structure. In a fracture in which the implant
eliminates fracture fragment movement, the earlier
phases of tissue differentiation may be bypassed, and
primary bone healing by the cutter cones and gap
filling will combine to repair the bone.

Os Penis
MECHANICS OF FIXATION
TECHNIQUES

An understanding of the mechanical characteristics of the


implants commonly employed in fracture repair is neces-
sary if a surgeon plans to minimize the strain in tile
fracture callus so that healing can occur. TillS section will
begin by presenting a method used by the author to assess
implants in general and individual fracture repairs. TillS
method simplifies the likely forces acting on an implant
and provides a basis for evaluating stability of a repair.
Figure 3.4: Litle drawing oj a radiograph of a highly
comminuted Jemurfraclllre that occurred when the dog leapt
Jrom the back of a truck moving at 35 mph. When the fool Forces acting on an implant
lallded alld stopped and Ihe body comil1ued moving, massive During a gait cycle, weight bearing and muscle con-
torsionalJorces were applied. These com billed with Ihe traction result in a complex array of forces within a
compressive forces of body weight and of the thigh muscles.
bone or bone-implant construct. Studies of these forces
The fraclllre developed II/any cOlllminutions because of the
large amoullt oj energy alld the rapid rale of loading. are difficult and have provided limited data, but for
improvin g clinical judgement in orthopaedics it is
Narrow fracture gap Large usually sufficient to take a much more simplistic
'>., tissue strain approach. The forces acting on a bone or implant are a
combination of ax ial compression, bending and rota-
tion (Figure3.6) . In some specific instances, fragments
associated with the origin or insertion of major muscle
f I groups may experience mostly tension. This scenario
will be addressed in a separate subsection.
(a) _ _....LL--_ _ Axial compression is the component of the forces
aligned down the shaft of the bone. When acting on a
fracture, it causes collapse and shortening. Weight
TI
Wide fracture gap Smaller bearing and muscle contraction will contribute to this
~ tissue strain
component. When evaluating an implant for its ability
I-Ll- to counter this force, the purchase obtained in the
major proximal and distal fragments must be consid-

i i
ered. The ability of a fracture repair to resist compres-
sion will also be influenced by the completeness of
reconstruction.
I-rr- Bending is present whenever a bone is bearing load
(b) and it is not perpendicular to the ground. Eccentric
Figure 3.5: (a) Wh en the fracture gap is small, the muscle contractions can also apply bending forces in
tissues withill the gap experience a large amOUII! ojstrain any direction. An implant's resistance to bending is
because a smail all/oulll oj 1Il0vemel1f is distributed over a
short length of tissue. (b) Wh en theJracw re gap is wider, the
deternlined by the elastic modulus of the material it is
strain is reduced as the same amount oj de/ormation is made of and its area moment of inertia (AMI). Im-
distributed over a longer length. plants made from 316L stainless steel can be generally

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Biomechanica l Basis of Bone Fracture and Fracture Repa ir 21

Axial compression It is also necessary to determine the AMI at the


wea kest point of the structure that wi ll be loaded. It is
easy to calculate the AMI for circular or rectangular
structures but, if a hole in a bone plate or interlocking
nail is bearing load, then this will be the weakest point.
The AMI of the solid portion of a 3.5 mm plate is
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29.9 mm' while tllrough a hole it is 14.8 mm' - a 50%


reduction. If a screw hole in an interlocki ng nail is
located close to a fracture, it should also be considered
a weak point in the construct. For the 8 mm nail, the
AMI drops from an impressive 201 mm' for the solid
section to 64.7 mm' in the weakest di rection.
Torsion is induced by changes in the direction of
the body while the limb is bearing weig ht. Assessment
of rotational stability is often more complex than
compression or bending. The polar moment of inertia
Torsion Bending (PM!) of the implant is not usually a weak point in the
construct. Stabi lity is estimated by how well the im-
plant engages the primary fracture fragments. Rota-
: tional stability may also be im parted by interaction of
the fracture fragments. The way in which different
systems are assessed wi ll be discussed in the specific
sections below.

External coaptation
Splints and casts provide immobi li zation of fracnIre
ends by encasing the limb. They do not directly contact
bone and so must act tllrough the skin and muscles of
the limb. The cast or splint material is the most rigid

t
portion and it must be built wit h sufficient strength to
withstand the forces that will be applied to it for the
appropriate duration. Bending forces are the most
significant forces because casts span joints and there is
Figure 3.6: Diagrammatic representation of the three force a great propensity for the limb to want to bend at the
categories considered when evaluating a fracture. CljixCltioll level of the joint. There are a number of ways of
method. or a repairedfractllre. Weight bearing alld muscle improving cast design and construction to counteract
COl/tractions contribllte to compressive forces down the 10l/g the bending forces. Thickness ofthe wall of the cast is
axis. Wh ell the bone is at all angle to the ground or when the the most obvious approach but the disadvantage is that
muscles pull more 011 one side thall 011 the other, belldillg will
be indllced. This lIIay be ill allY direction. Torsion will occllr the cast becomes heavier. If the primary bending
when the mass of tlte body changes direction while the lim b direction is known , th e cast ma y be reinforced in that
is bearing weight. specific plane. This wi ll increase the AMI (because the
added dimension is in the plane of bending) without
compared based on their AMIs. Titanium has a lower adding too much weight. It is also beneficial to form a
modulus and implants of similar AMI wi ll be less stiff. cast that is relatively straight but this tends to lengthen
However, titanium resists fati gue damage under re- the limb and is more awkward fo r the patient.
peated loading better than stainless steel. Since most The interface between the cast and the bone will
implants fai l by fatigue rather than from a single also influence the ability of the cast to immobilize the
excessive loading event, this property must also be fracture fragments. The greater the stiffness of this
allowed for when assessing an implant's suitability to interface, the better wi ll the rigid cast material sup-
maintain fracture stability until healing has occurred. port the fracture. High stiffness is produced by using
Because calculation of the AMI of a structure is little or no cast padding and by applying the cast wrap
based on the direction of bending, it is necessary to with pressure. Both these approaches increase the
estimate this for a repair. In most bo nes, a primary likelihood of pressure injury to the skin and soft
direction is not evident and the smallest AMI, which tissues between the cast and the bone. The surgeon
determines the weakest direction, is used to character- must therefore judge the correct amount of padding
ize the weakest point in bending. In the femur, the and cast wrap pressure that wi ll avoid soft tissue
eccentric location of loading through the femoral head injury but will still provide adeq uate immobilization
dictates a lateral to medial bendi ng direction. of the fracture fragments.

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22 Manual of Small Animal Fracture Repair and Management

External skeletal fixators that the clamping bolt is closest to the skin. Sufficient
distance must be left between the clamp and the skin to
P in factors allow for some swelling. The surgeon can reduce the
The strength of the purchase of the pins in the fract ure length of the pin by selecting a location with the least
fragments is an important factor in the success of soft tissue. This also reduces the tissue irritation caused
external fixation (Figure 3.7). Indi viduall y, smooth by the pin and appears to reduce the incidence of pin
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pins rely on compression of the bone against the pin track drainage and infection.
shaft to resist pull-out. In most frames, multiple pins In the beginning of this section, the advantages of
are placed and they are purposefull y angled to each threaded pins in increasing the immediate strength of
other so that they brace each other. Threaded pins are the pin-bone interface was described. It is of eq ual
more secure ly anchored in bone. Negative thread pro- importance for the surgeon to consider the long-term
files were used initially because they are easier to stability of the pin -bone interface. Loosening o f pins
manllfactllre~ however, they are weak at the point is the most common complication of external fixa-
where the shaft and threads meet and pin breakage was tion. It causes discomfort for the patient and ma y
frequently seen. The Ellis pin was designed with a affect the hea li ng process. The mechanica l aspects of
short negatively threaded portion so that only the fa r pin placement feature heavily in the maintenance of
cortex was engaged with thread and the thread-shaft a stable interface. Threaded pins loosen less fre-
junction was protected by being inside the bone. Break- quently, because they mechanicall y lock into the
age was seen occasionally following resorption of the bone. The more pins that are present in a fragm ent, the
bone of the near cortex . less is the load at each interface and, therefore, the
Positive profile threaded pins are now available. less likely is loosening.
The threads are created by a lathing or ro ll ing proc- The amount of bone injury that occurs during pin
ess. The shaft diameter is not significantly reduced place ment is also a major determinant of how the
and therefore the bending strength of the pin is not bone around the pin will change during hea ling.
compromised. Because the thread diameter is greater, Significant thermal injury causes bone necrosis.
the purchase of the pin is also greater than for nega-
ti ve profile pins. This larger diameter does make
these pins a little more awkward to place as the /" ~
tlueaded portion does not fit through the hole in the
external fixator clamp. ~ _k
The surgeon must select the appropriate diameter (a)
pin for each situation. The larger the diameter, the
stronger the pin wi ll be in bending and the stiffer the
Weak p a i n t ,
frame will be, overall. This must be countered by the
size of the bone into which the pin must be placed. As c,
(b) \ 1 .1111 11111 , 111 .111"
a general ru le, the diameter of the pin should not
exceed 30 % of the diameter of the bone so as not to
weaken the bone. This may be difficult to comply with Weak point protected
when placing pins in the mediolatera l plane of the
radius or in the metacarpals or metatarsals.
The rigidity of a fixator is increased by increasing
(e)
.
.1 , 111 .1 11"

the number of pins in each fragment. Two is a mini-


mum and four is considered the maximum in most t .t
small animal applications. Obviously, pin diameter
and frag ment size wi ll dictate what can actuall y be
(d) \'.\ \ \ \ \\\\\' \\ \ \' .\ \\'
acllieved. Pins shou ld be spaced evenly over each Shaft diameter-1
not reduced
fragment, as this increases torsional ri gidity of a fram e.
They should be placed as close to the fracture as is - Lar9 er ma'or diameter
considered safe. This is detennined by the possible
presence of fissures and the size of the bone. If there are Figure 3. 7: Types oj pillS Jar external jixators. (a) Smooth
pillS rely ol/frictioll \\lith rhe bone or bracing against other
no fissures, an estimate of this safe dista nce is three pillS in rheframe. (b) Negative-profile threaded pillS engage
times the diameter of the pin being used. Because the bone more securely bw are sllsceptible to Jailure at the
stiffness of a structure is influenced by its length, the shaft- thread jUllction. (c) Ellis pins have a small length of
pins closest to the fracture should be angled towards negative-profile thread, designed to engage only one cortex.
each other so that the span of the connecting bar that The \\leak point a/the pill is protectedfrom bending forces.
(d) Positive-profile threaded pillS have a larger major
bridges the fracture is minimized. diameter, so holdillg strength is increased. Becallse the sllaft
A final factor that influences the stiffness of a diameter is flot reduced, (h ey are better able to resist tile
fixator is the length of the pin. Clamps are oriented so cyclic bendillg forces associated witll weight bearing.

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Biomechanica l Basis of Bone Fracture and Fracture Repair 23

+ ~ +
t~ t
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-,-

(b) (e)
Figure 3.8: (a) Axial compression dOlVn lhe shaft 0/ a/raclllred bone supported by a unilateral external fixator results ill
bending 0/ llie pins and lhe connecting bar. (b) Axial compression 0/ a bilateraL /rame results ill bending o/the exposed lengths
0/ rlie pills. (c) Bending/orces directed Ollt 0/ the plane 0/ a bilateraLframe result in bending 0/ the cOllnectillg /XII"S. By addillg a
third IXII' ill a nother plane, the frame is beller able 10 resislthese forces.

Microcracking reduces the strength of the support- complex frame should be applied. A bi latera l frame
ing bone and stimulates a repair respo nse. Resorption e mploys connecting bars on each side of the bone.
to re move the dead and damaged bone ma y reduce Axial compressive forces will now be resisted by the
the strength of the interaction between the bone and pins (Figure 3.8b): their diamete r, numbe r and ex-
pin . Movement at the interface wi ll prevent new posed length will determine the stiffness . Bending
bone formation and a fibrous interface will develop. in the plane of the fi xator is also well resisted
Movement will al so injure these tissues, causing because the connecting bars protect each other.
pain and stimulat ing an inflammatory res po nse . Bending in the plane perpendicular to the fixator is
Once it starts, the process often becom es self-per- resisted by the connectin g bars on ly: their exposed
petuatin g. To reduce thermal injury to bone, pin length and diameter are determining factors of ri gid-
tracks should be pre-drilled with a drill onl y s lightly ity. Torsional forces also are better resisted by
smaller than the shaft diameter, or pins with effi- bilatera l frames as the connecting bars are distrib-
cient cutting tips should be used. Pre-drilling also uted around the axis of rotation.
reduces the amount of microcracking in the s ur- Triangular configurations are selected to improve
rounding bone. the bending stiffness of a frame (Figure 3.8c). The
connecting bar in the second plane imparts resistance
Frame configuration to bending perpendicular to the plane of the bilateral
The forces that act on a fracture - axial compression, portion of the fixator. A multi-planar fixator may also
bending and torsion - must be considered when be indicated when the primary fragments are small.
assessing the suitability of a fi xator fram e configura- When only two pins are possible in one plane, a third
tion. The simplest frame is a unilateral design. Com- pin may be placed in a different plane to improve
pression will cause bending of the connecting bar fragment purchase.
(Figure 3.8a). Thediameterofthe bar and the size and Complex, multi-p lanar fixators have been criti-
number of pins will influence the performance of the cized as potentially being too rigid. They may signifi-
frame. The inherent stability of the fracture must also cantly reduce the load being borne by the callus and
be considered. If the fracture is transverse, it will not thus reduce the stimulus for callus development and
be able to collapse and the bone will reduce the load maturation. To counter this effect, destabilization of
placed on the fi xator. Ifthe fracture fragments do not the frame should be considered once ca llus develop-
interact, the frame must bear all of the load through ment has begun. The optimal time at Wllich to increase
the limb. Bending forces will be resisted similarl y by the load borne by the callus has not been detennined.
a unilateral frame. To increase the res istance of a In a large gap fracture model, s ix weeks of healing
unilateral frame to bending, a second connecting bar seems most advantageous. The extent of the bone and
will increase the AMI. Torsional forces are resisted soft tissue injury should be taken into account for each
by friction between the e1amp and connecting bar in case. Destabilization is preferably achieved by remov-
a unilateral frame. Theelamp bolt must be very firm ly ing connecting bars from a frame but can also be
tightened to ensure that it is secure. achieved by removing pins.
If the surgeon feels that a unilateral fram e will Fixator frames can be constructed with acrylic or
not be able to provide sufficient resistance to the epoxy materials. They have the advantage that pins can
bending forces in a particular patient, then a more be pos itioned in any plane; soft tissue interference can

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24 Manual of Small Animal Fracture Repair and Management

be minimized and wo unds can be avoided. This is Interlocking nails


particularl y helpFul for shearing injuries and for frac- Interlocking nails resist a ll three of the forces acting
tures of the jaw. Acrylic connections can also be used on a fracture. The screws that lock the proximal and
when the small metal system is too large, such as in toy distal fragm ents to the nail prevent collapse under
breeds and birds. Polymethylmethacrylate is the most compressive forces and prevent rotation when tor-
common material used. One commercial system sup- sional forces are app lied (Figure 3.9). The central
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plies tubing and prepackaged methacrylate for con- location of the nail and its large AMI provide good
necting bars similar in strength to the small and medium resistance to bendin g. Interlocking nai ls are weak-
metal systems. The acrylic can also be nnixed to its ened at the screw holes and this weakening is not
dough state and applied without tubing. Epoxy putty is reduced by placing a screw in the hole. It is there fore
of similar strength to the acrylics and is easier to use for important to position the nai l so that screw holes are
small fi xators. not close to the fracture. In some situations, this ma y
mean selecting a nail wi th onl y one lockin g screw.
Points to remember New nail systems are being developed for veterinary
use. The influence of factors such as screw size,
Maximize pin diameter number of holes and nail diameter will need to be
Maximize pin number per fragment determined to guide the surgeon in the selection ofthe
Reduce pin length appropriate nail for each case.
Add more cOIUlecting bars
Reduce connecting bar span Orthopaedic wire and cerclage
Use full pins and bilateral frames when possible. Orthopaedic wire is malleable stainless steel that is
formed into cerclage, henni-cerclage, interfragmentary
Intramedullary pins and interlocking nails or tension-band wires. The wire is often stressed dur-
ing placement and tying, and is susceptible to fatigue
Pins failure. Small nicks and notches in the wire also
Intramedullary pins provide little resistance to axial weaken its resistance to repetiti ve loading.
compression . If the fracture configuration is not
inherentl y stable (i.e. simple, transverse), collapse
will occur. Intramedullary pins are able to resist
bending forc es because of the ir large AMI. They are
c.
not able to resist torsional forces and, again , must
re ly on interdi gitati on of fracture frag ments to be
stable as a single device. Stacked pinning increases
the rotational stability only very sli ghtl y and should
not be re lied upon if the fracture is not inherentl y
stable. Because of these defici encies, intramedul-
lary pinning as the only fi xa tion method is onl y
indicated in simple fractures in which there is good
interdigitati on of fragments. If this is not the case,
adjunct fixati on must be added or another fixation
method chosen.
Pins can often be used for metaphyseal and epi-
physeal fractures, particularly if they are placed dy-
namically. These fractures are often quite transverse
and so they ha ve inherent resistance to collapse. Two
small pins placed on either side of a fragm ent will
impart rotational stability if they engage well proxi-
mally. Dynamic placement entails directing the pins
into the medullary cavity and having them deflect off
the inner wall of the cortex and continue up the
medullary canal into the far metaph ysis. The interac-
tion of the pin with the cortical wall provides a stable
anchorage against rotational forces. The crossed pin
technique can also be used: these pins begin on one
side of the bone and penetrate the cortex on the other
t
Figure 3.9: Interlocking nails provide good stability because
lhe primary fraclurefragmel1ls are 'locked ' to lhe device.
side. For optimal rotational stability, the pins should Compressive and rotational/orees are resisted by the screws.
be directed so that the point at which they cross is Because tlte naiL has a large area moment of inertia, it resists
above the fracture line. belldillg forces well.

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Biomechanical Basis of Bone Fracture and Fracture Repair 25

Untwists especially in conjunction with one or two skewer pins


so that their line of action is directed more perpendicu-
Unbends ~
lar to the fracture line.

(b)
~ Hemi-cerclage is chosen when the cylindrical na-
ture of the diaphysis can not be rebuilt. When used in
conjunction with an intramedu llary pin , the wires
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should also encircle the pin. Interfragmentary wires


Both unbend ~
are used to appose fragments in flat bone fractures,
===-- JBc:: particularly those of the mandible. Twist knots are the
most common.
(e) Tension-band wires are employed to counter bend-
ing forces on pins or screws used to attach avu lsed bone
Figure 3. 10: The three COIIIIllOIl cerclage kllots. (a) ,/ivist fragments. They should be positioned opposite the
knot. When loaded past its yield POilll, the kilO! Illltwists.
(b) Single loop. Greater tension is generated thall for a {wist direction of pull on the fragment. Although they are
kllot. The loop yields at a similar load to twist kllots by the passive structures, the cyclic stresses are reduced if
free arll1l1llbelldillg. (c) Double loop. A greater tellsioll is they are tightened firm ly. The wires are frequently
generated alld it resists a lIluch greater load before yield. placed in a figure-of-eight configuration and tied with
Both arms unbend during this process.
one or two twist knots (Figure 3.11).

Full cerclage acts to compress fragm ents of the Bone screws and plates
diaphysis together. The complete circumference must
be rebuilt and fragments accurately reduced because Screws
the wire will no longer be tight ifthere is any reduction Screws convert the torque of insertion into compression
of the circumference around which they are tied. Cer- along theirshaft. They are used individually to compress
clage comparisons are based on the tension that is or hold fragments, or in conj unction with a bone plate.
generated when they are formed and the resistance of In most instances of individual use, they are applied in
the knot to loosening. lag fashion so that fragments are compressed together.
The near fragment is drilled to the diameter of the
Twist knots must be formed by evenl y wrapping threads while the far fragment is drilled to the core
both wire strands around one another (Figure diameter and, for most screws, threads are cut with a tap.
3.10). This knot is used conun onl y because it can As the screw is tightened, the head of the screw com-
be formed with inexpensive equipment. When presses the near fragment on to the far fragment. The
loaded past their yield point, the wires untwist amount of compression that can be achieved is dictated
The single loop knot is formed using a wire with
a loop made in one end: the free end passes ~tl of the triceps ...
around the bone and through the loop. The wire
is tensioned in a wire tightener wit h a rotating
crank. Once tight, the free end is bent over, cut
and fl attened. The single loop cerclage generates
greater tension than the twist cerclage but has
similar yield properties - the free arm unbends as
the wire yields
The double loop cerclage is formed from a piece
of wire bent double in the middle: both ends are
passed around the bone and back through the
bend. Both anns are tightened using a w ire
.. is countered
tightener with two cranks and bent, cut and by the tension
flattened in a similar fashion to the single loop band wire
cerclage. This cerclage generates three times the
tension o f the single loop cerclage and resists
twice the distracting load.

A minimum of two cerclages should always be used;


otherwise bending forces are not countered. Long
oblique fractures of two or three segments are the most
suited to their use but they are not considered strong Figure 3.11: A tension bal1d wire is a passive structu re that
enough to be the only means of fixation of a fracture. resists the pull of a distracting muscle that is actillg all the \ i\.'.
They can be used in some shorter oblique fractures, elld of a pill or screw. ...:!' I/)
;:.- "7

.-,-
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26 Manual of Small Animal Fractu re Repair and Management

Line perpendicular to I n a number of instances the screw must resist


long axis of the bone bendi ng and the surgeon must select the appropri ate
Line
perpendicular Thread s DO NOT sized implant. The bending strength of a screw is
to fracture lin e engage in co rtex
determined by the AMI of its core diameter. This
relationship involves raising the radius to the fourth
power. A 4.5 mm cortical screw is 2.5 times as strong
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as a 3.5 mm screw .

Plates
Bone plates are effecti ve in resisting all three of the
forces that must be countered - compression, bending
and torsion. They are most susceptible to bending
forces because of their eccentric position relati ve to the
ax is of the bone. Their mode of placement dictates the
Threads
engage in level of risk associated with a repai r. If a fracture is
far cortex anatomicall y reduced and the fragments are com-
Figure 3.12: A screw placed illiag/ashion is used to pressed by the plate, the bone and plate share the load,
compress two /ragmellls together. Screw threads engage the their combined AMI is large, and the construct is
far cortex but /lot the /l ear cortex. As rhe screw is (igh/elled, strong (Figure 3.1 3a) . If the bone is not reconstructed,
compression is achieved. The optimal orielllarioli/or the particularl y the cortex away from the plate, the plate
screw ill sharrer oblique fractures is half way between a line
drawn perpendiclliar to rhefracrure line alld a line drawll
alone must resist bendi ng fo rces. The solid section of
perpendiclliar to the long a.xis of the bone. a plate is usuall y strong enough but if a screw hole is
located within the fracture the screw hole is the weak-
by the strength of the bone threads in the far cortex. For est point. The AMI is greatly red uced and there is a
optimal compression, the screw is ideally placed per- concentration of stress (Figure 3. 13c).
pendicularto the fracture line. When the fracture is short To reduce the stress concentration effect, the lim-
and oblique, this is not feasible and will often result in ited contact plate (LCP) was designed with a scalloped
sliding of the fracture fragments. The optimal angle is profi Ie to the surface that is in contact with the bone.
then half-way between perpendicular to the fracture and Because the AMI is similar over the length of the plate,
perpendiculartothe axis of the bone (Figure 3.12) . (The there is little concentrat ing effect of the stress. The
same principle holds if skewer pins and cerclage wires solid section of the LCP is significantly weaker than
are used for a similar purpose.) the solid section of the regular dynamic compression

(a ) - (b ) r- «) ,- (d)

'"
'C

fI
~

fI
··· Q ~
0,»
'" 0S.~
@~~
"
- r3 ;&:;
'" ~ .... /

Screw
{(1
II hole hole
"
'-- '-- -
Complete Some No contact Pin supports
bone contact bone contact Plate alone the plate by
increasing the AM I

Figure 3.13: The bending strength of a fractured bone repaired with a bone plate is affected by the integrity of the bOlle after tlie
repair. (a ) If the bone is fulLy rebuilt, its dimensions call be inclllded ill the estimation 0/ the AMI at the weakest poim o/tlie
repair. The bone protects the plate/rom belldillg loads. (b) I/th e/ar cortex makes comact, this will also cOllfribute 10 the AMI at
the weakest poim. Because the bone comact is some distance from the plate, th is provides some mechanical advantage. (c) If
there is no cOlllact between tile bonefragmellfs, the pfate mllst resist all the bending/orces. The AMI of the lVeakest point mllst be
considered when assessing the stability 0/ the repair. (d) By com billing a plate with all intramedullary pill, the AMI of the
comminuted area is greatly enhanced.

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Biomechanical Basis of Bone Fracture and Fracture Repair 27

plate (DCP). LCPs rely on the presumption that, when percentage. Strain, like stress, is complex within com-
the solid section is bearing the load alone, the bone will plex structures and similar techniques are used to sim-
usuall y also contribute to the strength of the repair. If plify their understanding. For example, if a piece of
a hole does need to be left unfilled, the plate is only as cortical bone 10 !TUn long is compressed, it will shorten
strong as its weakest point and the reduced strength of as the load increases. Because we know that the failure
the solid section will have little effect on outcome. strain of bone in compression is approximately 2%, we
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Also, the original LCPs were made of pure titanium, know that if the load applied reduces the height of our
which, though weaker and less stiff, has superior piece of bone to 9.8 mm, it will probably break.
fatigue resistance. The scalloped contour also reduces
the amount of cortical bone that is devitalized by the Stiffness
plate ' s interference with periosteal blood supply. When a load is applied to a structure and it defonns, the
Plates may still be used for repair in fractures in relationship between tl,e load and deformation repre-
which it is not possible to reconstruct portions of the sents the stiffness of the structure. In most simple cases,
shaft or in which it is felt that the extensive dissection stiffness is assumed to be linear and is denoted by a
necessary to incorporate all fragments into a repair single number with ullits of Newtons/mm. It is repre-
would compromise healing. Lengthening plates, sented graphically by the slope of the load versus
which come with a range of lengths of the solid defonnation curve. In fracture mechanics this is often an
section, can be used in bones that are large enough to important parameter to consider: the stiffer the struc-
accommodate a 4.5 mm screw. Another approach ture, the less motion will be present at the fracture site.
that can be used in bones of all sizes combines a plate
applied to the primary proximal and distal fragments Modulus
with an intramedullary pin (Figure 3.13d). The plate If the stress and strain are calculated for a structure that
effective ly prevents fragment collapse and rotation had a load versus deformation test, the slope of that
but, without the pin, the central span that is unat- curve is termed the modulus. It denotes the stiffness of
tached to the bone is subjected to bending. By adding the material, in contrast to the stiffness of a structure.
the intramedullary pin to the repair, the AMI of the Its units are the same as stress - Newtons/mm' or
implants is greatly increased and the risk of plate Pascals. Modulus is useful for comparing materials
failure greatly reduced. and making assumptions about how structures might
behave based on their material. An example would be
the comparison of a bone plate made of stainless steel
GLOSSARY versus one made of titanium. The modulus of steel is
greater than tl,at of titanium; so, for a similar load and
This section gives more detail of terms highlighted in given that the plates have the same dimensions, there
bold earlier in the chapter, in the order in which they would be less movement with a steel plate.
first appeared.
Isotropic and anisotropic
Stress If a material is homogeneous, the expected response
When an external load is resisted by a structure, internal will be the same, no matter what is the direction of the
forces are generated. These internal forces are termed applied load. This material is isotropic. The steel of
stress. In complex structures with complex forces (such implants is isotropic.
as bones), the stress is also complex. Two approaches When a material or a structure has a direction in
are used to simplify the understanding of stress. The how it is put together, its response to a load will depend
forces can be simplified to a single important direction on the direction from which the load is applied. This
or the stresses can be considered only in certain impor- material is anisotropic. Most biological materials are
tant directions. One important point to remember is that anisotropic and to appreciate the properties of the
stress is distributed over the cross-sectional area of a material fully it is important to denote its orientation
stmcture, and so the magnitude at anyone point will be relative to the forces impacting it.
influenced by this dimension. The usual units for stress
are Newtons/mm' CN/mm') or Pascals (pa). Shear
Shear is generated when an applied force causes two parts
Strain ofthe structure to want to slide past one another. This is
When an external load is resisted by a structure, the most easily demonstrated at interfaces between two ob-
structure defonns. Often, the internal defonnations that jects when one goes one way and tlle other another, but is
compound to produce the overall change in shape must also present within a stmctiire when the base is held firm
be considered. These internal defonnations are termed and the top is pushed. Shear can refer to a way in which
strain. Because they describe deformation within a a force is applied and to tl,e types of stress that are present
material, they are expressed as a ratio of the change in within a material. Shear stress is created when torsional
length to the original length; the usual terminology is forces are applied to bone.

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28 Manual of Small Animal Fracture Repair and Management

Area moment of inertia the lateral aspect of the femur would be ex pected to fa il
Area moment of inertia (AMI) is a structural param eter in medi olateral bending before crani ocaudal bending,
important in assessing resistance to bendin g. It because the AMI in the mediolateral directio n is
quantitates not only the cross-sectional area, but also 29.9 mm' and in thecrani ocaudal directi on is250 mm' .
ho w the material is distributed. In pure compression or It is also important to realize that AMI is influenced by
tension, cross-sectional area alone provides an esti- the plane chosen in measuring the dimensions. When
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mate of a stru cture's strength. In bending, one s ide of analysing an implant o r fracture repair, consider the
a structure experiences tension and the other compres- weakest po rti on. Using the 3.5 mm bone plate exam-
sion . There is a plane along the structural centre that ple, the AMI in th e medi olateral direction th rough a
ex peri ences no force; tllis is termed the neutra l plane. ho le is only 14.8 mm'.
Material further from the neutral plane is better able to
resist the forces in the structure, and so the fo rmula e for Polar moment of inertia
calculati on of this parameter emphas ize this distance. Polar moment of inertia is a similar concept to area
For a circul ar structure, the formula is (n .r')/4 , w here moment of inertia except th at it defines the dim ension
r is the radius. The influence of increas ing the diameter of a structure at a certain plane relati ve to its ability to
on a structu re's abili ty to resist bendin g is easil y resist torsio nal forces. Tllis parameter quantitates th e
appreciated. For a rectangular stru cture, the equation is way in which th e structure is distributed around th e
(b.h3)/ 12 , where b is the width and It is the height. centre of the torsional effect. This is obvio us ly easy for
Because the terms width and height relate to the circular structures but becomes more complex with
orientation of the rectangle re lative to th e bendin g complex shapes. For a hollow cylinder (li ke a bone)
force, it is important fi rst to determine in which direc- be ing twisted around its longitudinal ax is, the equatio n
ti on bending will occur before computing this param- is '/2 .n.(r' - 1"'), where r is the outer radius and r' is th e
eter. For example, a 3.5 mm bone plate (10 x 3 mm) on inner fadi us.

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CHAPTER FOUR

Fracture Healing
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Tim M. Skerry

INTRODUC TION Wounding

Fracture healing is a speciali zed fo rm of wound repair


in which there is regeneration of the injured issue Coagulation Acute Phase
without scar formation. The mechanisms behind such Platelets Inflammation Response
a remarkable response involve bone growth, model- PDGF IL-1
ling and remodelling. The control of fracture repair
therefore in volves the same loca l and systemic influ-
TGF ~
ECF (TG Fo.)
( \ IL-6
IFGy
ences capable of affecting bone in other circum-
stances. Lymphocytes
TGFp
The purpose of this chapter is to provide a brief IL·2
introduction to the cellular processes that are acti vated IL·S
when bone fractures, and to explain:

The implications of concurrent injury, disease


or treatment on the progress of a healing
fracture Repair
The mechanisms behind the novel treatments
Fig ure 4.1 The inflammatory cascade. The consequences oj
for enhancement of healing which are
injury include tile dijferellf stages of the inflammatory
begitming to appear in the clinics. process ;n which are expressed mOllY a/the same cytokines
as those with effects 011 bone physiology.

ACUTE EVENTS AFTER BONE ing, progressing through organization of tbe clot, ang-
FRAC TURE iogenesis and fibrosis. At this stage, events in bone
begin to differ from other tissues, as the fibrous callus
In addition to the local events that occur immediately is replaced by cartilage which undergoes endochon-
after fracture, there is an acute inflammatory response dral ossification and eventually remodelling.
to the injury. The major systemic effect of this inflam- It is important to consider the mechanisms of
mation is the acute phase response (APR), a process these acute changes, because the so-called inflamma-
that appea rs to have a protecti ve fun ction for the tory cytokines (Figure 4.1) are in many cases regula-
organism (for reviews see Lewis, 1986; McGlave, tors of normal bone fun ction (Table 4.1 ). This is
1990). Local inflammation associated with injury entirely in accordance with the needs of an earl y
causes changes in the circulating concentrations of the inflammatory response to injury. However, persist-
acute phase proteins. These include proteins with ent inflammation (as a sequel to infection, for exam-
coagulation and complement system functions, their ple) may cause aberrant or inappropriate effects by
inhibitors, transport proteins and C-reacti ve protein . direct actions on the cells that are attempting to repair
The APR is also associated with changes in hormones the fracture.
(insulin, glucocorticoids and catecholamines), vita-
mins and minerals - primarily iron and zinc. There is
also acti vation of proteolytic enzyme cascades con- TYPES OF FRACTURE HEALING
nected with clotting, complement, kinin and fi brino-
lytic pathways, and a change in amino acid metabolism, Indirect fracture healing
with breakdown of muscle protein. In normal circumstances after a fracture, there will be
Locally, the acute events after fracture follow the some degree of instability of the bone ends. The
same initial sequence seen in other tissues, with bleed- movement between the bones will not support imme-

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30 Manual of Small Ani ma l Fracture Repa ir and Management

Cytokine Osteoclast Osteoblast Resorption Formation


formation/activity growth/activity ill vivo in vivo

IL- I ~ +/ + +/ - + +
TNFu + /+ + /- +
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IFNy -/ -/ - -
IL-6 +/ -/-
GM-CSF -/ +/
TGF~ -/- +/+ - +
FGF -/-
PDGF -/-
Ta ble 4. 1: Cyrokilles implicated ill bone formation (Ind resorpliol1. Mas! of the cytokines ill rliis table are also implicated ill (lie
illjlallll/1atOlY response, showing rite pleiotropic actiolls of these agents. The compLex actions oj cytokilles are iilustrated by the
divergence between actions of illdividual age Ills all specific cells in vitro, seell as - which denotes differem results by di/ferellf
workers. /" additioll, the fack a/correlation ber-ween in vitro {md in vivo actiolls, or stimulatioll a/both/ormation Gild resorpri all
by a sillgle agent, suggest tltat the p icture presellfed by these data are far /rolll complete. + = expression; - = 110 expression;
space = 110 data.

diate formation of new bone, and a tissue with the ble for trabeculae to regenerate directl y. This can occ ur
ability to deform more than bone must be made as an by axial growth of new elements along collagen alld
intermediate. Fibrous tissue is therefore produced by elastin fibres which form within the defect (Aaron arlei
fibroblasts in the organizing clot aro und the fracture. In Skerry, 1994).
the orga ni zation process, capillary invasion and angio- Direct fracture healing does not occur witho ut
genesis occur so that the clot becomes accessible to surgical intervention. The ASIF developed the ideas th at
other precursor cells via the circulation. The fibrous anatomical reduction, rigid fi xation and rapid return to
tissue stabilizes the fracture enough to permit cartilage normal function were the ideal goals of treatment (see
surviva l, and a wave of metaplasia passes fro m each Chapter 9). In many fractures, perfect anatomica l
side of the periosteal cuff of the ca llus ac ross the reduction is not necessary for good function, and ri g id
fracture gap. The cartilage is then replaced by bone in fi xation can have adverse effects on the rate of healin g.
endochondrial fas hion. Fractures flXed with plates, which heal by direct unio n,
Biologicall y, this indirect fracture hea ling is a are wea ker than the surrounding bone and take mu ch
sensible process. Since the clot forms a mass aro und longer to unite than those that heal by indirect union. It
the fracture site, the ensuing callus fo rms a large cuff is tempting to assemble the 'jigsaw' in order to obtain a
around the bone enels so that, as the organization satisfactory postoperati ve radiograph, but the reducti on
process occurs, the sequential stiffening of the tissues of use of plate fi xation in human orthopaedics, and tlle
provides good mechanical stability. When the bones increase of use of intramedullary nai ls and extern al
have uni ted, the fracture is stronger than the surround- fixators, implies that other considerations may be more
ing norma l bone, and remodelling (see below) reduces important (see Chapter 10).
the superfluous mass so that eventually complete res-
toration of normal function and strength can occur.
FRACTURE REPAIR, BONE GROWTH
Direct fracture healing AND REMODELLING
There are circumstances in which the presence of
fracture ca llus is a serious obstacle to a return to When the processes in vol ved in fracture repair a re
function. This is rarely the case in midshaft fractures of dissected into their component parts, there are man y
long bones, but where a fracture incl udes part of an similarities with bone growth and remodelling (Tab Ie
articular surface, rapid anatomical realigrunent of the 4.2) . In both growth and fracture repair, endocho 11-
fragments is the primary consideration. If this is per- dral ossification occurs to convert a minerali zed
fo rmed and the fragments are held ri gidly, direct frac - cartilage template into new bone tissue, using th e
ture healing can occur with littleornocallus fo rmation. same regulated chondrocyte differentiation pathwa y.
In this circumstance, Haversian systems can cross the Because of these similarities, understanding of fra c-
fracture gap and repair the cortical bone directl y with- ture hea ling is simpli fied if the controlling influenc es
out any endochondral processes. Where defects exist of the indi vidua l component processes are consid-
in cancellous bone, with sufficient stability, it is possi- ered separate ly.

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Fracture Healing 31

Growth Growth Remodelling FractUl'e


(endochondral) (apposition) I·epair

Chondrocyte + +
differentiation
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Cartilage resorption + +

Bone formati on + + + +

Bone resorption + + + +

Table 4.2: Similar component cellula r processes are comhi/led differently to give rise to such diverse tissile actiolls as
longiTudinal hone growth Qlldjraclllre healing.

Endochondral ossification and appositional surface, so that no osteocytes are formed. This sug-
growth gests that mammalian osteocytes are osteoblasts that
During the no rmal endochondral ossification process, made a committed step to stop advancing by substitut-
chondrocytes in the growth plate undergo an ordered ing polarized secretion with a generali zed secretion of
developmental sequence. Chondrocytes in callus, prob· matri x proteins.
ably originating from cells within the periosteum or Bone fonnation during fracture healing, whether
from differentiating cells in the organi zing haematoma, endochondral or appositional, results in replacement
undergo th e same sequence of events. of the large mass of the soft periosteal and endosteal
After mineralizati on of carti lage, there is capillary callus wi th bone. However, atthisstage,although there
invasion and recruitment of cells resembling osteoclasts. is restoration of function in that the bone is ab le to
Since they resorb cartilage, not bone, they are termed withstand loading, the mass of th e callus is excessive.
chondroclasts, but there is no evidence that they are a In addition, the bulk of the callus may interfere with
separate cell type. The cells resorb crescent-shaped norm al muscle and tendon movements . To convert the
pieces of calcified cartilage matri x, analogous to the relatively disorgani zed bony callus into a restored
Howships' lacunae resorbed from bo ne by osteoclasts. cortical tube, the callus must be remodelled - a
New bone is then fonned in those defects. process entailing bone resorption.
New bone formation at this stage is similar to the
appositional formation that occurs with periosteal ex- Bone resorption and callus remodelling
pansion durin g growth. Mature osteoblasts line the Bone resorption is accomplished by osteoclasts, which
surfaces, and secrete matrix in a highly polarized must perform two roles: removal of th e hydroxyapatite
fashion , so that it is deposited on the s ide nearest to the mineral phase of th e bone wi th acid; and degradation
bone. This hi ghly regulated polarization is controlled of the collageno us and non-collagenous proteins with
by specific cytokines and moderators of their functi on enzymes. Osteoclasts are hi ghl y polarized cells that
at diffe rent levels in the periosteum. For example, initiate resorption after attaclling to the bone surface at
transforming growth factor 6 (TGF6) is ex pressed by the peri phery of th eir zone of contact. This sea ling or
osteoblasts on th e bone surface and in a more periph- c lear zone contains contractile proteins including
era l zone two or three cell layers further away from th e osteopontin, which are secreted by the osteoclast to
surface. Interestingly, the zone between th ese two faci li tate attachment. Osteoclast attachment to bone
layers does not contain TGF6, and in th e more periph - matri x is also facilitated by integrins - a class of cell
eral zone the act ions of th e peptide are moderated by matrix attachment mo lecules found in many tissues.
expression of the latent TGF6-binding protein, which Interestingly osteoclast attachment is mediated by an
is absent on the bone surface. a.V63 integrin, whose 63 s ubunit appears to be exclu-
The new bone matrix differs from carti lage in that sive to these cells and is different from the 62 s ubunit
the predominant collagen is type I (type II is the ex pressed by closely related cells of the monocyte
predominant fibrill ar collagen in carti lage), although macrophage lineage. This specificity may have thera-
th e same chondroitin sulphate and some keratan sul- peutic implications, as neutralizing antibodies to the
phate proteoglycans are also present. Mineralization osteoclast integrins inhi bit bone resorpti on (Horton et
of this osteoid proceeds with focal calcifications oc- aI., 1991).
curring around matrix vesicles. While most osteoblasts Tight attaclunent allows the osteoclast to maintain
advance with th e deposition of matri x, some remain specific conditions in the resorption space where the
and become incorporated in the new boneasosteocytes. pH may drop as low as 3 (Sil ver et al. , 1988). Acidifi-
It was tho ught that this was a passive process. How- cation of the resorpti on space is the res ult of secreti on
ever, durin g the development of fi sh bone, all the of hydrogen ions, prod uced by the action of carbonic
osteoblasts continue to advance with th e periosteal an hyd rase and transported across the osteoclast's ' ruf-

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32 Manual of Small Animal Fracture Repair and Management

fled border' cell membrane by a specific proton pump. Secondary osteon s or Haversian systems are suo
This appears to be uniquely expressed in osteoclasts perficially similar to primary osteons, but arise when
and different from the classical vacuolar and potas- a group of osteoclasts tunnel into a surface and
sium ATPase pumps found in other cells. A chloride! proceed along the length of the bone (Figure 4.3). At
bicarbonate exchanger in the basal membrane of the the same time as the tunnelling is proceeding, capi l-
cell maintains the osteoclast's intracellular pH, which lary growth occurs to maintain supplies to the cells,
wo uld otherwise rise with acidi fication of the resorption and to bring in osteoblast precursors. The osteoblasts
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space. Degradation of matrix proteins is accomplished fill in the tunnel concentrically as the osteoclasts
by neutral protease enzymes such as cathepsins, which continue to resorb bone, so that in cross-section a
are secreted into the resorption space. Haversian system, like a primary osteon, contains
Bone resorption in remodelling is responsible for concentric lamellae. However, the concentric lamel-
remova l of the now superfluous mass of periosteal and lae of the Haversian system cut through the pre-
endosteal callus. At the same time, Haversian remod- ex isting lamellae of the bone.
elling occurs in the intracortical callus to restore nor-
mal compact bone structure.
ENHANCEMENT OF FRACTURE
Haversian remodelling HEALING
Haversian remodelling is an ordered process of bone
resorption and formation within the cortex, which Increased understanding of the control of bone cells
gives the classical histological appearance of concen- and the way that loca l interactions occur has led to
tric lamellae inadult bone. It is importanttodistinguish some exciting new ideas w ith direct relevance to the
this from the primary osteonal bone seen in yo unger clinician. The idea of using biological materials to
animals, which is a feature only of rapid growth and not enhance fra cture healing or to stimulate filling of
previous resorpti on. defects has progressed beyond bone graftin g, and
Primary osteons arise w hen a periosteal bone sur- may explain some of the mechanisms by which that
face expands rapidly in young growing animals. The technique can be so effecti ve. Experiments have
osteoblasts in periosteum form osteoid matri x, as de- shown the profound effects of deminera lized bone
scribed previously, but in an irregular way so that some matrix in stimulating bone fonnation ill vivo (Syftestad
areas of the advancing front proceed faster than others. et aI., 1984), and this appears to be due to stimulatory
The conseq uence of this is that gaps lined with effects of some of the extracellular matrix compo-
osteoblasts are left in the new bone surface and these nents as well as mitogenic growth factors such as the
fi ll in concentrically. Primary osteons are therefore insulin -like growth factors, transforming growth fac -
characterized by concentric lamellae of bone, which tor B (TGFB) and the bone morphogenetic proteins
do not interrupt the more linear lamellae that represent (BMPs) which are present in large quantities in bone.
the line of the advancing mineralizing front (Figure Direct application of exogenous TGFB or BMPs have
4.2). In appeara nce they are not dissimilar from knots been shown to stimulate profound bone formation in
in wood. hea ling fractures (Bolander, 1992). The actions of
these agents may be related to their roles in develop-
ment, where limb morphogenesis is linked to BMP
ex pression (Jones et al., 1991). Such therapies are not
confined to the laboratory. Growth factor-loaded
bone cements and bone substitutes are in develop-
.. . ....... ... . ..... ment for clinical use, and may offer radical advances
5 for treatment of inactive non-unions, where bi ologi-
........ ,- 6 ~ "
\. " cal activity has ceased.
4 Finally, it is appropriate to consider mechanical
loading as a method of effecti ng fracture healing.
. -' " Bone cells are rapidly res ponsive to strain in the
o 3
c matrix (Skerry et aI., 1989), and interfragmentary
.Q
l3 2 -.. -.~.
movement has been shown to stimulate more rapid
i" ... - .... - ... -'-- .....
(5 1 progression of indirect healing than totally rigid fixa-
tion (Goodship and Kenwright, 1985). It is of extreme
importance to distinguish these micromovement re-
Figll re 4.2: As osteoblasts appose new bone 011 a periosteal gimes from the gross movements that occur at inad-
sllrface, primary os/eolls result from concentric infilling of equatel y fixed fracture sites. The latter will not enhance
spaces left as the developingjront of/ormation advances
unevenly. The lamellae between the primary osteons are
hea ling! The use of controlled micromovement has
continuous and are not imerrupted by the osteollS. Numbers become accepted to the degree that fixators are now
show fhe order of deposition of lamellae. dynamized to allow small movements at the fracture

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Fracture Healing 33

-A ____ ------ -------- __ _

------ ~
-----------------
~~---- --------

-------
o -------
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- S --- - - - - --------- - - ---- --------------------

'Cutting co ne'
of osteoclasts

Osteoblasts
laying down.~::::==-_ _+:-'I:-~
new bone :::

New osteocytes
embe dded in
bone matrix - - - - --.¥::t:(

Surface
lining ce lls ------++,i.!.-::::c::~

-':;';~=\=;t:::::'" Classical
co ncentric
lamellae of
Haversian
bone

Figure 4.3: Cel1lrai figure: Haversian or secondary osreolls are the result of tUl1nelling ilUO the bone cortex by a 'cutting cone'
composed of osteoclasts. immediately behind the osteoclasts, populatiolls of acti ve osteoblasts lay dOlVll llCIV bone Gnd graduaiLy
become less active as Lining cells which cover the swiaee. Some osteoblasts becollle incorporated illra the new bone matrix as
osteocytes. (A)-(C) Cross-sections show progressive expansion oflhe resorbing Haversian cGnal as the clltting COile 0/
osteoclasts erode oul a/the plal1e o/the diagram. (D) - (F) Osteoblastsjill in the defect, resulting ill the classical cOllcentric
lamellae o/secondarily remodelled Haversian bOl/e. These lamellae interrupt the original lamellae a/the primary bone.

site, in order to stimulate the cells and enhance the movement is imprac tical. The discovery that bone
healing_Recent research into the earl y consequences cells communicate via exCitatory amino ac ids, previ-
of loading on bone cell gene expression has already ously thought to be involved onl y in intercellular
led to the identification of a number of possible communication w ithin the eNS , is one example of a
pharmacological targets which could mimic the ef- route by which the healing of fractures might be
fects of loading in situa ti ons where the application of enhanced (Mason et at., 1997).

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34 Manual of Small Animal Fracture Repair and Management

CONCLUSIONS Goodship AE and Kenwright J ( 1985) The innuence of induced


micromovemelll upon the healing of experimental tibial fractures.
JOl/rnal oj BOlle alld Joilll Surgery 678, 650.
Fracture hea ling is a remarkable process in that it is one Horton MA, Taylor ML, Amell TR and Helfrich MH (1991) Arg-G ly-
Asp (RG D) pcptides and the anti-vitroncctin receptor antibody
of the most successful repair mechanisms in the body. 23C6 inhibit dentine resorption ,lIId cell spreading by osteoclasts.
When one considers the immense complex ity of the £rperimellw/ Cell Research 195, 368.
cel lular interactions thatoccurto restore the continuity Jones eM, Lyons KM and Hogan BLM (199 1) Involvement of bone
morphogenetic protein-4 (BMP-4) and Vgr-I in morphogenesis
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offractured bones, it is surprising that so few problems and ncurogcncsis in the mouse. Deve/opmelll Ill, 531.
occur. Increased understanding of the fundamenta l Lewis GP ( 1986) Mediators of IlIjl(//lIl11atioll , Wright, Bristol.
Mason DJ , Suva U, Gencver PG et al. (1997) Mechanically regulated
physical and biochemical influences on bone is having expression of a neural glutamate transporter in bone. A role for
a considerable im pact on clinical treatments, and will exci tatory amino acids as osteotropic agents. BOlle 20, 4-9.
continue to do so. The relative ease of production of McGlave P ( 1990) Bone marrow transplants in chronic myelogcnous
leukaemia: an overview of determinants of s urvival. Semillars ill
recombinant osteotropic biochemicals and the devel- HaelllGtology 27, 23-30.
opment of novel methods of app lication and delivery Nathan CF and Spom M8 (199 1) Cytoki nes in context. Journal oJCel!
Biology 113, 98 1.
mean that fracture treatments are likely to advance Rosat i R, Homn GSB, Pinero OJ et al. (1994) Nonnal long bone
beyond recognition in a short time. Since technologi- growt h and dcvelopmen t in type X co llagen-null mice. Namre
cal advances invariably appear to exceed predictions, Genetics 8, 129.
Silver lA , Murrills RJ and Etherington DJ (1988) Microclectro<le
the only certainty about the future is that it wi ll be even studieson thc<lcid microenvironment beneath adherent rnacrophages
more exciting than anytiling which is currently per- and osteoelasts. £rperimelllal Cell Research 175,266.
Skerry TM and Fennor B ( 1993) Mcchanical and honnonal influences
ceived to be possible. il/ vil'o cause regional differences in bone remodelling. In Mechalli~
cal ill/eractiolls with Cells. cd. F Lya ll and AJ EI Haj , p. 97.
Cambridge University Press, Cambridge.
Skerry TM , Bitens ky L, Chayen J and Lanyon LE (1989) Early strain -
REFERENCES AND FURTHER READING related changes in enzyme acti vity in osteocytes fo llowing bone
loading ill vivo. Journal of BOlle alld Milleral Researcll 4, 783.
Syfteslad GT, Trimu JT, Urist MR and CaphHl AI ( 1984) An osteo-
Aaron JE and Skcrry TM (1994) Intramembranous trabecu lar gcnern~
inductive bone matrix extrnct stimulates the il/ vitro conversion of
tion in normal bone. BOlle alld MilleraI25(3), 211.
mesenchyme into chondrocytes. Calcified Tisslle Intematiollal36,
Bolander ME (1992) Regulat ion of frac ture repair by growth factors.
625.
Proceedillgs ofthe Societyfor E:cperimelluli Biology and Medicine
Vaes G ( 1988) Cell ular biology and biochemi cal mechanism of bone
200, 165.
resorption. A review of recent developmcnts on the fonna lion.
Currey JD (1984) What should bones be designed to do? Calcified
activation, and mode of ilction of osteoc lasts. Clinical Orthopaed-
Tissue IllIernalional 36(S I), 7.
ics 231, 239.

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CHAPTER FIVE

Imaging of Fracture Healing


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D. Gary Clayton Jones

INTRODUC TION Immediate post-oper ative


Tllis study provides the base line for further examina-
The monitoring of the heaLing of fractu res is based tion and indicates the quality of the reduction and the
upon both the clinical progression of the patient and the position of any implants (Figures 5. 1 and 5.2).
evaluation of the process by ancillary examination. By
far the most common meth od of examination is radio-
graphy and this is likely to be the situation fo r the
foreseeable future in veterinary practice. The initia l
diagnosis of fractures and the planning of trea tment
methods is generally based on the X-ray examinations
and therefore an initial base line of in formation is
already available to enable comparison with thesubse-
quent healing process.
Standard views should be made during any subse-
quent examination, generally using two views at right
angles. Occasionall y other views may be indicated to
examine a particular feature of the fracture process,
e.g. oblique or stressed views. If all ex posure factors
are recorded and kept constant along w'ith the other
radiograpllic parameters, then useful comparisons may
also be made later in tenns of bone density/calcifica-
tion. When large metallic implants are present then
they may obscure the fracture line in one view and this
can make for more diffi cult interpretation as only one
view may be possible. Similarly, allowances need to be
made when radiographs are taken tllrough a cast or
splint, particularl y if the cast or splint is only partiall y
radiolucent.
It must be remembered that radiographic changes
of bone will often appear to lag behind changes that
may be perceived clinically and that the rate of radio-
graphic change will depend on:

Age of the patient


Method of repair
Type of fracture
Associated soft tissue injury.

TIMING OF RADIOGRAPHS Figllre 5.1: Immediate post-operative films oj a Bernese


MOlillfaill Dog's tibia'fracfllre~ ireared Ilsillg lag screws and
Films may usefully be obtained at a number of time a plate alld screws. These films allowed evaluatioll of overall
reduction a/the fracture fragmellfs, size of the fracture gaps,
periods following a fracture. However, economics or effectiveness a/contouring o/Ihe plate wilh re.speCIIO file
the condition/nature of the patient may preclude some bone sllr/ace and rhe length al1d position oj the lag screws
of these examinati ons. and the plate screws.

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36 Manual of Small Animal Fracture Repair and Management

Figure 5.2: may be noted that an apparently healed fracture is less


Immediate post- well repaired than expected, indicating that some sec-
operative film 0/
illframedullary
ondary treatment may be required.
pinning 0/ a non-
ullion, s/towing At secondary procedures
failure a/ the When a fracture has not healed by the fi rst procedure
implant 10 engage
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and furth er treatments have to be made, or when


ill the distal femoral
segmellf. The dog
fracture repair progresses more slowly than normal,
had 10 return 10 rhe then furth er radiographic examinations may be re-
theatre fo r quired, as indicated by the particular features of the
repositioning of indi vidual case.
the pin.

EXAMINATION OF THE FILM


All of the visible structures on the film should be
examined systematica ll y to obtain the maximum infor-
mation. These include:

Skin
Soft tissues - muscle planes, li gaments, tendons,
lymph nodes
Joints - articular surfaces, joint space, regions of
attachment of ligaments and joint capsule
Ten to 14 days Bone - periosteum, cortex, endosteum,
This will be at around the time of suture and soft medullary cavity and fracture ends
dressing removal and would be the period when soft Implants - shape and position and the bone/
tissue changes should be resolving, or commencing if implant interface.
a post-operative infection is establishing.
The possible changes that can be seen in bone are quite
Four to 6 weeks limited and will involve loss of bone, production of
Fracture hea ling is generall y advancing significantly bone or no change in the bone.
by this time. Where callus is ex pected or required it
wi ll normally be adequately calcified at this stage to be Bone loss (resorption or loss of density/fine
readil y visible. There may be little to see sooner than structure)
this, especially in adult animals, even when fracture Loss of bone is generally associated with hyper-
repair is progressing well. Implant failures due to vascularity and may be the result of motion, infection,
cyclic loading will often be noted at about this time. dystrophy, allergy, metalosis or tumour.

Towards the end of healing At the fracture line a small amount of resorption
This is the time at which a decision will be made as to is probably norma l, even when there is rigid
whether the animal can be allowed more normal activ- internal fi xation. However, when significant it
ity and whether implant removal is to be considered. indicates instability, infection or corrosion
The time taken to reach this point will vary. (Figures 5.3 and 5.10).
At the bone implant junction it usually indicates
Prior to implant retdeval motion, infection, corrosion or early stress
It is always better to make a radiographic assessment protection (see Figure 5.8) .
of healing rather than to rely on an elapsed calendar Beneath the implant it indicates established
period to determine implant remova l. This assessment infection/neoplasia or stress protection.
is often complicated by poor visua lization of the frac- All of the complicating conditions mentioned
ture because of overlay of the image of a plate. The may ultimately involve the bone substance at
nature of the region around the fracture is also exam- some distance from the vicinity of the fracture.
ined as extensive covering of implants by new bone Disuse osteoporosis is usually noted distal to
formation may complicate the retrieval operation. the fracture, often involving the smaller bones
of the carpus or tarsus (Figures 5.4 and 5.5).
After removal of implants Severe progressive resorption of fracture ends is
This is the examination that may now allow assess- seen in the uncommon atrophic non-union (see
ment of the fracture line on all views and sometimes it Chapter 26).

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Imaging of Fracture Hea ling 37


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Figure 5.3: Mastiff, 18momhs old. (a) Widened osteotomy


line, one month after osteotomy afthe ulnar shaft/or
treatment of 11llllllited anconeus. The osteotomy is olliy
supported by the radial shaft and so there is //lovell/em at the
fracture plane. Note the hypertrophic bOlle/ormation alld the
irregular periosteal reaction of active irritation callus Figure 5.5a, b: Yorkshire terrier with a distal hUlllerallloll-
extending proximally alld distally 011 the ulnar shaft. (b) The ulliol1. Note the loss of density of the humeral condylar
same case 3 lIIomhs later lIIith bridging oflhe gap Gnd fragments as well as the loss of dellsity alld coarse trabecular
infilling with woven bOlle, almost complete resolution oflhe appearance in the bones of the forearm belol\! the fracture.
periosteal reactioll alld remodelling a/the callus. The opposite leg contrasts the loss of density and bone
structure with all identical radiographic exposure.

Bone production
At the fracture line, bone production may indicate
primary union if the gap is filled evenly and at right
angles to the fracture line. Gap healing is seen when the
bone is formed parallel to the fracture line. When bone
fonn s parallel to the fracture gap but fa ils to bridge the
gap, this may progress so as to seal the medullary
cavity and indicates there is motion in the fracture gap
and a non-union is developing.
At the bone/implant junction, motion may result in
formation of a sclerotic line ata slight distance from the
surface ofthe implant. Althe junction of the end of the
implant and the bone a small mound of bone can be
formed because of the sudden difference in rigidity
between the bone/implant montage and the bone alone
(stress riser).
At the periosteum level, bone production is either
periostitis or the natural healing response at a fracture,
termed periosteal callus. New bone may form below
the periosteum or above the surface.

Periostitis (irritation callus) (Figure 5.3)


develops as the result of infection or instability,
Figure 5.4: Immediate post-operative film of long-standing or following trauma due to surgery. It tends to be
/lOIl-Ullioll of metatarsal fractures treated with more obviolls in younger patients, in which it
illlrQmedullary pinning. The ends a/the bones a/digit III (the
may be difficult to avoid entirely. It is rapid in
ullsupported digit) show a long-standing resorption of the
fracture ends bur no evidence of allY callus formation, in development and has an irregular, poorly defined
spite of previous external support trearll/em. surface. The density and the fine structure are

-
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38 Manual of Small Animal Fracture Repair and Management

also irregular. It may be very large in problems, so that the requirement of radiography is not
hypertrophic non-unions. Periosteal reacti on is just to monitor the state of union but to try to assist in
also seen in pathological fractures associated determining whether or not any further intervention is
with neoplasia as well as being a reaction to the required from the surgeon. The age of the patient will
neoplastic process itself. have considerable effect on the rate of normal union:
Bridging callus is the combination of periosteal fractures injuvenile animals may heal to radiographic
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reaction, endosteal reacti on and ca llus induced union within as little as 3 weeks, whereas they may
within the fracture gap. It bridges the fracture take two or three times as long in an old animal. The
ends and is noted most frequently in cases treated ability of bone to develop a profuse periosteal callus is
by unstable methods such as external coaptation frequently noted in juvenile patients but the develop-
using casts and spUnts. It is a less irregular ment of a similar callus in an older animal would
reaction than periostitis. Once the gap has been signify some major problem.
bridged and the fracture is stable, the surface of When internal fi xation has been performed the
the reaction becomes smooth and the density and ' quality' of the operation will have a direct bearing on
fine structure are more even. the repair. The manner of soft tissue and bone handling
Involu crum is a specifi c type of periosteal callus will affect periosteal reaction, interference with blood
that endeavours to surround the dead bone of supply may significantly delay healing and the method
sequestra. of repair will determine the type of healing process to
Endosteal callus is formed in similar be expected.
circumstances to periosteal reactions but at a
slower rate. Healing of bone under stable conditions
This type of healing is noted in bone fragm ents that are
No change in bone in contact and usually supported by a plate and/or
Apparentl y inert bone is noted occasionally during screw fixation so that there is no movement of the
fracture repair, and repeated radiographs over a period fracture ends in relation to one another - so-called rigid
of weeks or months will usually show that there is in internal fixation. This type of repair is often promoted
fact some very gradual change taking place (Figure by compression of the fracture fragments and is some-
5.4). For bony change to occur there must be a viable times calledprimoryordirectunion. Theonly require-
blood suppl y or nearby cellular activity. Thus inert ment is for there to be good vascularity of the fragments.
bone indicates loss of blood suppl y or absence of In the laboratory under experimental conditions this
cellular activity in the neighbourhood. type of repair can be demonstrated reasonably easily.
Avascular fragments or bone ends will remain In practice it is rare that true accurate apposition of the
apparentl y inert until revascularization occurs. fracture ends is achieved perfectly by the surgeon; by
Biologically inactive non-unions are occasionally the time surgery is performed the fracture fragments
noted that show inactivity that is marked by the ab- will almost always be deformed by splintering, rub-
sence of callus fo rmation at the bone ends or of any bing or the initiating trauma itself, so that there is
change in cortical density or finestructure (see Chapter almost always a combination of gap healing and con-
26). Bone ends of a fracture supported by a large plate tact healing along various parts of the fracture line.
or pin may also be inert if no load bearing is passed Immediately post-operatively, fine lines or small
through the bone substance (stress protection). pockets of air from the surgical procedure can be seen
Sequestra are by definiti on dead bone fragments in the soft tissues. These often tend to follow the tissue
separated from a blood supply, usually in association planes and they should disappear within one or two
with infection. Initi ally they are not always separated days. Soft tissue swelling is variable: in cases where
physically from the original bone. They remain as there was pre-operati ve oedema there will usually be a
radiodense fragments (often appearing more dense significant reduction in soft tissue swelling within a
than surrounding inflamed bone that loses density week as circulation is re-established.
because of hypervasc ularity) and they only gradually The initial fine lines of the fracture gap and ends
become devoured by phagocytic activity (see Figure remain relatively unchanged for I to 2 weeks and may
5.10). They then become ragged in outline and have a even appear clearer after this time. This is the result of
moth-eaten appearan ce. loss of blood supply from the fracture Line back to the
nearest intact Haversian/Volkmann system, so the
bon e remains inert until revasc ulariza tion. Once
RADIOGRAPHIC APPEARANCE OF revascularization has developed, there is a progressive
HEALING FRACTURES remodelling of the fracture ends by regrowth ofHa ver-
sian systems by invasion of new osteones. As remod-
It is difficult to provide hard and fast rules as to when elling is a combination of osteoclastic and osteoblastic
a fracture is hea ling normally. The healingofa fracture acti vity there may be removal of some bony cortex
may occur and be successful in spite of therapy or close to the fracture ends so that there may be a

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Imaging of Fracture Hea ling 39

transient apparent slight widening of the fracture ga p. may be noted within a few weeks of the fracture repair.
The gap becomes more hazy due to new bone produc- This may be as early as 3 to 4 weeks in younger
tion so that by 8 to 12 weeks the fracture lines are filled. patients. This is the result of vascular changes in the
Remodelling of the repaired cortex res ults in virtual cortex beneath the plate and also a possible stress
absence of the fracture lines after a few months protection effect. The vasc ular changes can be mini-
(Figure 5.6). mi zed by the use of low contact dynamic compression
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(LCDC) plates, but the cost of such implants and the


apparent unimportance of such changes clinically means
that they are rarely used. A small mo und of periosteal
bone, forming next to the ends of th e plate, is noted
after a few weeks because of the stress change occur-
ring in the bone at this level. This can be observed to
consist of an elevated margin all around the plate when
it is removed. However, the new bone on th e lateral
s ides ofthe plate is difficult to display radiogra phicall y.
The cortex beneath this periostea l reacti on may a lso
become slightly sclerosed (Figure 5.7).

Figure 5.6: Fracture of the femoral IIeek ill all adult


Weimaraller treated by a lag screw and allfi-fotatiollal wires
via trochanteric osteoromy repaired with pins and tellsioll·
balld wire. (a) Immediate posl-operarivejilm showing fhe
fracture lille with clearly defined margills. (b) After 6 weeks
thefraclIl re line is still evident bllt is 110W hazy, with less lVell
defined margins, and no callus is seell. (e) Fijreelllllonths
later tfle whole regioll is repaired, with well orgallized bOlly
bridging {mel /10 excess callus, indicating that the repair was
stable durillg the healing period. Clinically the dog made
good lise a/the limb at all times.

Fracture callus is said not to develop in fractures


successfull y managed by this method. In practice tllis
is largely true, altho ugh a small periosteal callus is
sometimes seen. This may be more a reflection of the
Figure 5.7: DC plate repair of a radius alld uilla !raclIlre ill
development of periosteal reaction seconda ry to the a Poodle. (a) Immediate post·operativefiJm shows a good
inevitable handling necessary for fracture reduction reduction of the radius a lld slight displacemelll a/the uilio. A
and the separation of periosteum from the cortex in the small corrica/fragment is visible between rlie radius alld
region of the fracture by the original trauma, rather uillo. (b) Al 4 l1lomhs the/ractllres are healed: the corric'"es of
than a requirement on the part of the body for a the radius are cominuous, with re-establishment of a 1I0rmal
medullary cavity. No callus/armed ill this bOlle but callus
periostea l bridge to be created. Thus onl y minimal formation has llnited the ulna, which needs relllodel1ing. The
amounts of periosteal new bone should be expected corticaL/ragment has been resorbed. Smail mOllnds 0/
and excessive amounts should be eva luated as indicat- periosteal bOl1e are presem at the ellds oJtfl e plate alld the
ing some form of fracture complication . Some callus cortex beneath the plate proximalfy appears slightly sclerotic
new bone will be produced in those parts of the fracture because 0/ the bone /ormatioll alol/g flie sides oj the plate.
DistaLLy ajine lucent line is seell between the plate alld (he
line where there is a need for gap healing. This initially bone, indicating millor cortical resorption/rom mild stress
has an amorphous dense appearance; it fills the gap, protection or vascular inhibitioll. The trabeculae ill file
and may even be seen to project a little way into the medullary cavity are more dellse alld hazy af the levels oJlhe
medullary region as endosteal new bone until it remod- proximal and distal screws because a/the extra stress being
els to develop a more conventional cortical pattern in trallsmitledjrom plate and screws to unsupported bOlle.
later months.
If a gap is present in the cortex opposite the plate Healing after partial reduction with minor
then a small bridging callus will often be seen here instability
which develops following micro-movement in this This type of healing is to be ex pected with repairs using
region. When greater than 1 mm, gaps may become intramedullary (IM) pins and wi res and the external
fill ed by fibrous tissue or cartilage rather than bone and fixator. In these circumstances there is little or no
remain radiographically apparent until they finally fill dynamic or static compression at the fracture surface
with bone. and some minor movem ents of the fracture fragments
When a plate has been used for the fracture repair may be expected. Reduction is often less well achieved
there will be some localized change beneath and near than when compression plates and screws are used.
the ends of the plate. Some reduction of bone dens ity The radiographic changes wi ll then depend on the

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40 Manual of Small Animal Fracture Repair and Management

degree of stability of the fracture site and the size of any Extemal fi xators are often used for extensively
gaps or defects. Callus form ation is therefore to be comminuted or open fractures. In these cases soft
expected, and both periosteal and endosteal callus will tissue trauma may be extreme; reduction may be in-
be noted. 1M pin placement may damage the endosteal complete or im possible and this will influence the
blood supply so a preponderance of periostea l callus is hea ling noted. Callus formation is usually essential for
more like ly, especially in those animals where a large the repair of such fractures and will be a combination
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diameter pin which almost fill s the cavity has been of periosteal , endosteal and induced call us. The callus
used. The amount of callus depends on the amount of is often irregular as infection comes under control and
fragm ent movement and the age of the animal. As IM because of defects and periostea l damage. Where frag-
pins are often used by inexperienced surgeons, the ments are displaced from the fracture bed or are sepa-
amount of iatrogenic periosteal trauma may al so be rated from their attachments, little change may be
quite large and tlus can contribute to the periosteal noted until the fragm ents are eitl,er revasculari zed or
reaction that is seen. Sinli larly the placement of cer- incorporated into a callus process. Fragments at a
clage wires often results in circumferential stripping of
soft tissue attachments w ith a resultant reaction.
When healing is progressing norma ll y the callus
production wi ll be noted to be fairl y limited to the
fracture region, to bridge the gap and to ha ve a smooth
remodelling outline withi n a few weeks. A profuse
callus, with extension some distance above and below
the fracture level, that fails to bridge the fracture gap
and has a rough exterior surface suggests an irritation
call us secondary to infection or movement. Infection
tends to cause a more widespread reactive appearan ce
than movement, which is limited to the ends of the
bone near the fracture gap. However, infection and
movement are often present simultaneously in the
same fra cture so that the distinction may be blurred
both radiographically and clinically (Figure 5.8).

Figure 5.8: Femoralfracture ill adulT Boxer Dog treated by


intramedullary pill alld cerclage wires 8 weeks previously.
(a) There is a delayed Illlion, wiTh the /racture gap stili evident
lind mineralized callus/ormation that has flOt bridged 'he
gap. The callus is large on the caudal cortex and /lIrther Figure 5.9: Commillllfed grade 2 open fracture of mid-shaft
mineralization is presellf ill tile soft tisslles. The wires lie i/1 a tibia ill Dobermallfl treated with type 2 eXlemaljixator.
lucent region, possibly indicatillg a low-grade ill/ection. (a) Immediate post-reducliolljilm shows soft tisslle swellillg
Periosteal reactioll is evident along the shaft of the bOlle, alld gas shadows close to the fracture. Smail, separated,
almost reachillg the metaphysis proximally alld distaJly. dellse fragmems are visible caudally, {evelwith the distal
(b) Six weeks later thefraclure has progressed to IInioll, with fracture line. (b) Six weeks later there is extensive periosteal,
healillg by caliusformation. Milch o/the periosteal reaction endosteal and medullary callus engulfing alld almost
is 1I0W smooth alld wellmineraiized alld will gradua"y resorb. obscuring the comminutedjragmellfs. The smail dense
fragments are 110 W illcorporated infhe callus alld some have
The callus wi ll rapidly remodel once bridging has been resorbed. Bridging o/the fracture is almost complete.
The circumscribed naTUre of the ca llus suggests that little
been achieved, leavingjust a small bulge in the outline 1II0tioll is presel1l in the /racture region. (Delise Linear
of the bone and a more dense sclerotic scar that can streaks parallel to the connecting bars are layers of dressing
persist for months or years (Figure 5.8). covering the clamps.)

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Imaging of Fracture Healing 41

significant distance from the fracture bed may not ing in a delayed union or non-union or to replace a
become incorporated into the healing process but may comminuted segment of bone. In either circumstance
actually graduall y become resorbed. This is a sterile it is intended to promote callus. Initiall y it is relatively
process which is normal if the fragment is no longer radiolucent and may be almost invisible or appear as
req uired for weight bearing, and does not signify an poorly defined radio-dense fragments at the fracture
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infection (Figure 5.9). site on the post-operative film. This may reduce in
At the implant/bone junction there is normally a density over the first 2 weeks but then be replaced by
small amount of peri osteal and endosteal bone produc- a more widespread amorphous shadow within and
tion around the pins, especially at the cortex closest to aro und the defect which increases in density and size
the connecting bar. A small halo of lysis is often noted so as to become a bridging callus. This will consist of
next to the pin but this wi ll us ually extend to the full a combination of periosteal callus as well as new bone
thickness of the cortex on ly if the pins are loosening induced within the graft itself.
due to movement. Ring sequestra are rarely noted at Co rlicalgrafts are less commonly used and consist
the implants but, if present, may also indicate loosen- of fragments of cortical bone usuall y separated from
ing of the implants. There is usually some soft tissue their blood suppl y. In general they are radiographicall y
swelling around the pin tracks which persists while the inert for long periods oftime, provided that they are not
implants are in place. In cases treated by external infected. Callus formation is usually seen at the bone
fixator, soft tissue swelling of the limb is often exten- ends of the host bone as they become incorporated. It
sive at the time of original surgery ; a general reduction has been shown that cortical grafts may not develop
in the overall soft tissue swelling around the limb is a vascularity fo r a number of years so they function as a
feature of successful repair and may be noted with in physical strut rather than being truly incorporated.
two weeks of surgery. Cancellous bone is often placed around the ends and it
is probably this that largely contributes to any radio-
Healing by spontaneous repair with graphic change.
moderate instability
Cases treated by conservative methods or by use of
coaptation with splints or casts may be considered to be DISTURBANCES OF UNION
of this type. These will usually be closed fractures and
are often on ly partially reduced. Healing is thus en- These may be the result of delayed union ar non-union,
tirely as the result of callus formation without the infection or implant failure . The radiographic identifi-
presence of implants. In these cases there is a gradual cation of impending problems is important in fracture
formation of periosteal and endosteal callus and it is to management and will often be pre-empted by clinical
be expected that the amount of callus wi ll be greatest signs. Interpretation is often made because of a depar-
in these cases. The callus may often appear to obstruct ture from what would be expected to be the normal
the medullary canal partially orcompletely. Theamount process, which is determined by the mode oftreatment
of callus depends on the amount of fracture movement that was originally selected (see Chapters 25 and 26).
and the effecti veness of the reduction. The callus is
often radiographically visible by 1 to 2 weeks after Acute infection
reduction and bridging is usuall y complete by 2 to 4 Acute infection is very important but has few obvious
weeks. Soft tissue swelling ma y be slower to reduce rad iographic signs. Soft tissue swelling and possible
than may be noted in a fracture treated by open reduc- gas shadows in the soft tissues may be the only earl y
tion, as movement offracture ends (even within a cast) signs during the first few days. This will usually
will continue to induce soft tissue inflammation. The become associated with a faint palisade periosteal
large bridging callus often has a smooth outline and reaction which may be quite extensive along the shaft
may be seen to be remodelling and reducing in volume of the bone within 2 to 3 weeks. In a young animal
at its limits while continuing to enlarge in the region of infection can track between the periosteum and the
the fracture gap. Remodelling of the callus is relatively cortex so that the cortex remains smooth, with a lucent
rapid once union has occurred but some change in bone line between it and the periosteal shadow. Extension of
outline may persist for the rest ofthe life of the animal, the periosteal reaction, continuing soft tissue swelling
though re-establishment of the medullary cavity will and the development of sequestra are the sequelae as
often occur. Synostosis of paired bones (e.g. radius and the infection becomes fully established.
ulna) is common with th is method of repair and med-
ullary canal re-establishment may not occur in these Chronic infection
cases. This may be of no clinical significance. The changes described for acute infection become
established and more radiographically apparent and
Healing of bone graft either continue with an extendi ng bony destruction and
Cancellous bOlle graft is the type of graft most com- periosteal reaction or develop to a condition which no
monly employed in clinical practice, to stimulate heal- longer progresses but remains established with

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42 Manual of Small Animal Fracture Repair and Management

draining tracks, sequestra and involucra I new bone animal is presented normal progress for a mature
around the frag ments and dra in ing tracks. There is patient becomes diagnosed as delayed union. In a true
usually a halo of lysis around any im plants which delayed union the fracture will go on and repair with-
become progressively loose and have a gradually di- out alteration of the treatment method.
minishing function. An im plant in effect becomes a
Non-union
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metall ic sequestrum (Figure 5. 10).


Non-union is a pathological process which requires
treatment. The diagnostic features radiographically
are that bridging of the fracture does not occur and the
fragments remain separate. Various types of non-
union occur with atrophy of the bone ends, minimal
callus, or hypen rophic callus, as well as signs of
infection in some cases. The medullary cavities be-
come closed by new bone and develop well-defined
sclerotic ends. In long-standing cases a pseudanhrosis
develops, in which the ends of the bone remodel until
they form a crude bal1-and-socket type joint. In the
distal limb the socket is distal and the bal1 is proximal.
These features may be reversed in the upper limb.

Stress protection
Tins process is not wel1 defined and is not often noted
in small animals. It occurs when the implants are
strong enough to unload the underlying bone so that
most or al1 of the weight bearing is through the implant
(usual1y a plate) and not through the bone. This results
Figure 5.10: Mature Greyhound pet witll ill/eeted /lOIl-lillion
in atrophy of the unloaded pan of the bone. It is
of tibia previollsly treated by all extemaljixaror. (a,b) The
jraclltre region is surrounded by soft fisSile swelling which sometimes noted in radius and ulna fractures after
contains hazy milleralization of ecropic bOlle/armario1/. The synostosis has occurred between the proximal frag-
fracture line is poorly marginated, irregular alld widened ments and the distal radial fragment, but in Wllich the
wirh woolly periosteal reaction. Sequestra are seen ill the dista l fragment of the ulna is not united and gradual1y
fracture gap with a brokelljragmenr of cerclage wire. Some
resorbs. Fractures have general1y united but the corti-
resorption a/the cortices is evidel11 ill {he region a/the
jracrure alld /licem tracks/rom previolls extemaljixator pillS ces beneath the plate undergo a progressive reduction
are visible ill the distal segmellf. (e) Six weeks later the in density as wel1 as a reduction in thickness. A gap
jixator has beel! removed, leaving large lucent tracks. The may develop beneath the implant and the bone. Careful
original pillt racks have healed. Callus is /lOW partially bridging removal of implants with temporary protection of the
the/racture caudally, and the bone ends alld margins are more
clearly defined. The sequestra have been removed. Soft tissue
weakened bone until it regains its strength is indicated.
sweliing is flOW IIl11ch less evident. FlI rtherextemalsllfJport was
provided and the fracture went all to heal.
FURTHER READING
Delayed union Brinker wo, Holm R8 and Prieur WD (1984) Mallllal of Imernal
A delayed union is one in which the anticipated changes Fixation III Smal/ Animals. Springer Verlag, Berlinl Heidelberg!
New York.
of repair are not as rapid as expected and it has no Morgan lP and Leighton RL ( 1995) Rndiology ofSmal/ Allimal Frac-
specific radiographic signs. As most fractures occur in tllre Managemem. WB Saunders, Philadelphia.
Ri ttmann WWand Perrcn SM ( 1974) Cortical BOlle Healing after
young immature animals there is a general expectation Internal Fixatioll alld Injectiol/. Biomechanicsalld Biology. Springer
that all fractures heal rapidl y, so that when an older Verlag, Berlin.

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PART TWO

Principles of Fracture Management


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CHAPTER SIX - - - - - - - - - - - - - - - - - - - -

Evaluating the Fracture Patient


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Ralph H. Abercromby

INTRODUCTION patient survival. Only once the ABC (airway, breath-


ing, circulation) of emergency medicine has been dealt
To the biased observer, fracture management is one of with can a full examination be performed. A patent
the most exciting and rewarding disciplines of veteri- airway must be confirmed or established (suction or an
nary surgery. However, care must be taken not to emergency tracheotomy may be required), haemosta-
become preoccupied with the obvious fracture, thereby sis must be established (using either pressure or Iigationj
neglecting the remainder of the patient. stapling) and the circulation may require support.
Frequently tissues other than bone, and often unre- Fluid therapy at this stage is usually given to reverse
lated to the musculoskeletal system, are injured. The hypovolaemic shock, perhaps caused by obvious haem-
entire patient must therefore be examined and as- orrhage or less apparent loss of circulating blood
sessed, and in vestigations and treatments prioritized. volume into a potentially massive fracture haematoma.
Definitive fracture management may have to be de- Fluid therapy is indicated in the shocked patient.
layed should it prove of less critical concern. Blood volume expansion will increase cardiac output,
Assessment ofthe patient is made in several phases: systemic blood pressure and tissue perfusion. Isotonic
crystalloid solutions such as 0.9% saline or Ringers are
Telephone advice useful but high volumes are required to maintain circu-
Initial examination of the patient lating blood volume (CBV) because of fluid redistribu-
Detailed examination of body systems. tion. Alternatives include hypertonic saline, which has
a profound effect on CBV for a relatively small amount
Telephone advice ofi.v. fluid, orthe use of colloid solutions, either plasma
Fracture evaluation and management may begin at the or synthetic plasma expanders. Whole blood should be
time of the initial phone call from a distressed owner. administered when blood loss is great.
First aid advice, such as clearing airways, stenuning Cranial trauma or shock must be considered if the
haemorrhage or temporary splinting, can be given by patient is unconsciolls.
phone and may be life saving or may limit further
damage to osseous or soft tissues. It must be judged Detailed examination of body systems
whether it is in the interests of the patient for a veteri- Once obvious life-threatening conditions have been
nary surgeon to attend althe site of injury, with limited dealt with, a more thorough examination must be
facilities, or whether the patient should be transferred given . Analgesics may be required on humane grounds
urgently to a well equipped, prepared clinic having and the calming effect of reduction of pain may facili-
previously advised the owner with regard to covering tate a more efficient further examination.
open wounds, control of haemorrhage and temporary A protocol should be established which is memora-
stabilization of lower limb fractures. Conclusions will ble and comprehensive, ensuring that all body systems
have to be drawn from information provided by un- are examined and assessed. This may be a systemj
trained and perhaps distressed personnel as to the organ-based examination (heart, lungs, intestines, eyes)
presence oflife-threatening injuries or whether irrepa- or a regional one beginning, say, cranially and extend-
rabledamage may occur to vital structures if the patient ing caudally and distally. The author considers a sys-
is moved by such persons. tem-based examination less likely to result in omissions.
For example, when examining the neurological sys-
Initial examination ofthe patient tem, the effects and responses of the brain, spinal cord
A rapid but careful initial assessment of the patient is and nerves are considered, which includes assessment
made and a thorough history taken when the patient is of structures such as the eyes and muscles which, in
first encountered. Priority is given to life-threatening turn, demand their own examination - so ensuring that
injuries. An accurate patient assessment completed in tissues are assessed from at least one perspective, and
the first few minutes after arrival is often pivotal to probably two or more.

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46 Manual of Small Animal Fracture Rcpair and Management

A full examination requires a variety of ski lls and Although the major tra uma may be apparently
equi pment. Experience and well trained senses can be unconnected with the thora x, the pati ent should re-
more va luable than expensive monitoring or diagnos- ceive careful thoracic auscultation and radiography,
tic equi pment. Observation and regular reassessments ECG examination and perhaps ultrasonography.
are paramount. Essential equipment includes stetho- Needle thoracocentesis, in addition to being easily
scope, torch, perclission hamm eror simiiar, and steri le performed, can provide rapid confirmation of clinical
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needles/catheters and syringes (for detection of free suspicions of pneumo/haemothorax and allow earl y
fl uid or air within the thorax or abdomen). (perhaps life-saving) management before results of
Trul y life-sav ing findin gs and decisions are likely more invol ved tests are available.
to be made within the consulting room. Subsequent to Cond itions o f concern include pne umothora x,
stabili zatio n and thorough cl inical examinati on, fur- pneum omedi astinum , haemothorax , pu lmonary
ther investigations may req uire tec hniques such as pa re nc hy ma l hae mo rrh age, frac ture d ribs,
radiography, ultrasonography, endoscopy, electro- diaphragmatic rupture, haemopericardiulTI, traumatic
cardiography and laboratory facilities. myocarditis and neurogenic pulmonary oedema.
Surgeons are sufficiently aware of the majority of
the above to estab lish their presence or absence. The
THORACIC EXAMINATION possibi lity of traumatic myocarditis is, however, quite
often overlooked and may explain otherwise unex-
The respiratory and cardiovascular systems should be pected sudden anaesthetic or post-surgical deaths. Blunt
assessed in their entirety, not just those parts contained trauma to the heart results in areas of cardiac contusion
within the limits of the thorax (Figure 6.1). +/- myocardia l infarction which are conducive to the

Tr.I1II11 01 suspected I

Assess pu lse and mucous membra nes I I Assess rcspi r.ltion-l


j .---' '----0
Circulation abnonnal ICirculm ion nonnall Respiration nonnal Resoiration abnonnal l
begin i/v nilid therapy j
Perform I TIlOr,lcic wound? I
IObvious site of haemorrhage I · full clinical examilllition
· thordcic radiognlphy I I
I · ECG Yo; No
Yes · +1- thoracocentesis I
,0
I j
Seal and treat
j
It Perfonn ;
thoracocentesis
I Con~ Normal?
--'
IOral/pharyngeal/airway I
Haemothornx?
I y:" I
No , obstruction?

I ~o
~o .'
Yj I Assess cause I
and treat
Yi
IClear/intubate/ I
I tracheostomy
I TIlOracic /
radiography
I Chcst drain I --'
I Rib fracture or nail chest? I
I
~ Bleeding? I
Haemopcricardium? Uself-limiting? r
YIs No
~o Y;".I ..1 1Place affected I
T ~ 0
1 Y~
I.
sidedowlI

Auscul!atc/pcrcuss
I ,I
Ii Examinesource
al!emative
for : I Identify source
Arrest haemorrhage
ThoracocenlesisjradiograDhv I
j
of haemorrhage Provide blood
replacemem Air or blood pTCSCnt?
1
~o
Source found?

.!

T
Y;"

~ ~Drain

Self limitin/.:?
IImanagement
Empirical supportivc( I
for shock IManage thoracic problems ~ .!
Investigate/manage other ~es ~o
body systems
IImanage
Identi fy and ; I
source

? Diaphragmatic rup1Ure I
? Luns! contusion

Figure 6.1: Algorithmfor initiaL management oftllOracic trauma .

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Evaluating the Fracture Patient 47

development of cardiac arrhythmias. Most are evident nation are unlikely to identify a specific lesion: they are
within the first 48 hours but may not be apparent at the more likely to localize and grade the severity of any
time of presentation or for some time thereafter. A wide problem. Assessment of gait, mental status, posture,
variety of arrhytlunias may present but the most com- cranial nerve reflexes, proprioception and local spinal
mon ones are relatively non-specific ST segment and T- reflexes enables identification of the presence or ab-
wave changes. The majority of patients will be clinically sence of a neurological problem and typing of it as
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unaffected but some may progress to conditions slIch as upper or lower motor neuron. The area affected may be
ventricular tachycardia or ventricular fibrillation, and localized to a general region, e.g. to the head or spine
death, if appropriate management is not instigated. For between T3 and L3, or to a more specific site, e.g. a
this reason it is probably advisable to arrange for a lead fibular nerve injury.
2 ECG to be performed several times on the day of Some injuries, such as those causing increased in-
admission and occasionally thereafter and to delay tracranial pressure, may require inunediate investiga-
surgery until theECG reading is normal, unless there are tion and management, whilst others may significantly
very good reasons to do otherwise. affect the prognosis for a return to acceptable post-
treatment quality of life. Injuries to the neurological
system may present with signs suggestive of muscu-
ABDOMINAL EXAMINATION loskeletal injury, and vice versa. Careful assessment is
required to prevent treatment of the wrong body system.
The organs or muscles of the abdomen are not uncom- A critical neurological examination can be difficult
monly damaged in conjunction with musculoskeletal to perform in the severely traumatized patient. Abnor-
injuries. Plain radiography (indicated in virtnally all mal signs noted may be transient, reflecting swelling or
cases oftraumatic injury), ultrasonography and perito- contusion rather than anatomical disruption, or may be
neal lavage may be useful in identifying abdominal static or progressive. Repeat examinations at regu-
haemorrhage or rupture of viscera. More extensive lar intervals are therefore essential.
investigations of organ integrity or function may re- Ophthalmic examination is likely to be performed
quire contrast studies. in conjunction with the neural system.
The ability of an animal to pass urine or faeces does Clinical findings may suggest that more extensive
not eliminate the possibility of injuries to the relevant examination is required, e.g. myelography or MRl
system. Animals with ruptured bladders, ureters or scan. Electrodiagnostics such as electromyography
urethra will regularly pass relatively normal urine in an can be useful but valid conclusions may require a delay
acceptable fashion. With the exception of urinary of 3-7 days.
obstruction, ruptures of the gastrointestinal tract tend
to be of more pressing importance than are injuries to
the lower urinary tract. ORTHOPAEDIC EXAMINATION
As far as is practicable an animal's ability to pass
urine or faeces under control should be assessed. The Examination and management of the
cause and implications of any problem must be consid- fracture site, with the exception of early
ered. management of haemorrhage and covering
Extensive abdominal or retroperitoneal haemor- open wounds, is likely to be of lower
rhage may prove rapidly fatal. When treatment can be priority than that of most other systems.
given, the patient may benefit more from supportive
care and abdominal compression to limit further bleed- To limit further skeletal or associated soft tissue injury,
ing than from immediate and heroic surgical interven- however, examination of these should not be allowed
tion . The latter may merely facilitate iatrogenic to cause unnecessary movement of the patient.
exsanguination of the patient unless large amounts of Temporary support (e.g. splints such as rolled-up news-
replacement blood are immediately available. papers, gutter splints or binding to the contralateral
The integrity ofthe diaphragm must be established, limb) may be applied to damaged areas (Figure 6.2).
especially if anaesthesia is being considered. Early appl ication of splints and support bandages, both
before and after critical limb examination, has the
following advantages:
NEUROLOGICAL EXAMINATION
Fracture stabilization
Critical assessment of the neurological system is vital Reduces pain
and the reader should consult standard texts for details Reduces further soft tissue damage
on examining this system. (The BSA VA Manual of Prevents or reduces oedema
Small Animal Neurology gives an excellent descrip- Reduces periosteal strip
tion of the requirements and the interpretation of a Reduces self-inflicted trauma
neurological examination.) The results of the exami- Helps to reduce overriding.

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48 Manual of Small Animal Fracture Repair and Management

Fracture type

C losed Open

Assess neurological/vascular Cover with sterile dressing


status of limb
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Assess neurological/vascular status of limb


normalf abnormal
acceptable
nonnal/ abnonnal
I J llcceptable

Y es
j j
Cage
confinement
Apply spHnt
or support
I
or spica bandage Yes No
splint
I j j
I
I Patient's condition stable?
IIAPPly suppon
bandage/spli11l
II' Cage
confinement!
I spica splint
,,+ .!
Y I
I ~o IPatient stable for anaesthesia? r-
Perfonn definitive Continue supponive
radiography
and fracture
care and investigations
+/- sub optimum
..'
y~s ~o
repair/management radiography I
Continue
Sedate/loeul
supportive
anaes!hetic care and
investigation
Local w ound
managemen! Consider initial wound management
+/- sub under sedation + analgesia
aplinmm or local anaesthesia
radiog raphs

General anaesthesia

Wound and fracture


management

Figure 6.2: Algorithm for fracture management foLlowing stabilization of life-threatening injuries.

Care must be taken to prevent further soft tissue injury clinical examination may increase the index of suspi-
and compromise of blood supply. Regular re-examin- cion. This is especially so with undisplaced fractures or
ations are essential to ensure that such complications, or where only one of a pair or group of bones is injured
the conversion of a closed fracture into an open one, (e.g. radius/ulna or tarsal bones) and adjacent struc-
have not occurred. Splints are usually only applied to tures give reasonable support. In such cases it is likely
fractures distal to the stifle or elbow, to the spine, or to that subtle signs such as localized swelling or bruising
the mandible. Humeral or femoral fractures are usually or exquisite pain on examination/palpation wi ll have
best left unsplinted, relying instead on restriction of to be relied on.
movement of the animal and inherent muscle support to On identification or exclusion of grossly unstable
protect the damaged tissues. Splinting of such fractures fractures the remainder of the musculoskeletal system
often results merely in support of the lower limb and (as far as is practical) should be examined. Range of
immobilization of joints distal to the fracture and places movement and stability of all joints, deep palpation of
a fulcrum with increased motion at the fracture site, the bones and soft tissues and assessment of the integrity
very area at which one wishes to limit movement. of all structures - not just bone - should be performed.
Effective splinting of such fractures requires a spica Where concurrent injuries allow, the patient should be
splint or a correctly applied Thomas extension splint examined at rest, on rising and at various forms of
The presence of a fracture may not be in dispute, exercise. Multiple long bone fractures are likely to
only the extent and type. Proper assessment and clas- preclude such an examination but an undisplaced frac-
sification generally requires radiography but timing ture may only become evident on a more critica l
varies (see below) . The area should be protected until evaluation following observation of a relatively mild
radiography is deemed advisable or appropriate. Frac- lameness at exercise. The presence of such fractures in
tures are not always evident, though resu lts of a careful the presence of more severe injuries will always be a

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Eva luating the Fracture Patient 49

test of clinical ability but emphasizes the importance of graphs of lower quality (perhaps with regard to posi-
a thorough eva luation of the entire patient. tioning and number of projections) taken of the con-
The integrity of both neural (see above) and vasc u- scious or lightly sedated animal may suffice, but
lar structures require to be confirmed. Excellent frac- unnecessary patient pain or discomfort should be
turerepair is oflittle value if the distal limb is avascular avoided.
or acceptable limb function is not possible because of Such radiographs are of use in confirming the
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spinal or peripheral nerve injury. Uncertainties of presence but not necessarily the absence of fractures.
tissue viability or future function may be extremely They should not be relied upon for formulation of the
important factors in the owner's decision whether to final pre-operative treatment plan as features such as
pursue trea tm ent. fine cortical fi ssures or alterations in bone quality may
Should the distal limb be warm and soft tissues be overlooked or may not be apparent, resulting in
bleed when pricked with a needle, the blood supply to catastrophic fracture fragmentati on at the time of
the limb is generally assumed to be adequate. Shock surgery or inappropriate treatment of pathological
and peripheral vasoconstriction, however, reduce the fra ctures.
value of such tests. Correction of circulating blood Delay in perfonning any fracture radiography until
volume and treatment of shock may make assessment immediately prior to treatment may be justified in
easier but uncertainty as to tissue/limb viability may some instances on clinical, humane, ioni zin g rad iation
persist. Further in vestigation with arterial contrast protection or fmancial grounds. If delay is to be of
studies, Doppler ultrasound or injection of intravascu- more than a day or so from the time of admission, good
lar fluoroscein dyes may assist detection of blood client communication and rapport are essential.
supply to a specific part of a limb. It would appear that
even these tests have limitations and that the use of
scintigraphy, where available, is a more reliable asses- FRACTURE PLANNING
sor of vascular integrity.
An increase in interna l pressure within anatomi- A treatment plan fo llows full clinical examination and
cally restricted regions (compartment syndrome) may fracture diagnosis. Repair technique decisions should
require fasciotomy to prevent permanent vascular or not be delayed until fragments are exposed at surgery;
neural damage. neither should surgery be commenced with only one
planned procedure. Complications may be encoun-
tered that will require modification of plan A or indeed
RADIOGRAPHY OF THE FRACTURE change to plan B, C, or D, etc.
REGION Depending on the complexity of the fracture and
the methods of repair considered, the level of planning
High quality radiographs in at least two planes are may vary. The AO/ASIF courses teach the value of
required to confinn and further evaluate the extent of tracing all fragments from both orthogonal views on
fractures. They provide information that is vital in separate sheets of clear acetate to allow reconstruction
producing definitive diagnosis and primary and sec- of the bone. By so doing it is possible to ascertain the
ondary treatment plans. They therefore assist in fo rmu- size and number of implants required and how they
lating a prognosis as to expected return to function and relate to one another. This technique may seem rather
estimating possible costs of therapy. laborious and time consuming but it is an excellent
Heavy sedation or, more conunon ly, genera l an - exercise in planning and often allows identification of
aesthesia is usually necessary to produce the quality of potential problems, such as the proposed site of a plate
radiograph required for treatment planning. This is of screw coinciding with fracture lines.
little consequence when the intention is to proceed Proper planning reduces both decision time and
with definitive treatment under the same anaesthetic iatrogenic soft tissue injury at surgery. Surgical/anaes-
but often carmot be justified, on medical grounds, thetic times should be reduced and clinical results
merely to confirm a provisional diagnosis knowing improved. It must be possible to alter teclmique
that surgery will be delayed, that further radiographs according to circumstances (equipment and informa-
will be required and that information gleaned from tion must be available) but the better the pre-surgical
interim radiographs is unlikely to alter the temporal assessment and planning, the less likely it is that
management of the situation. In such cases radio- unex pected surprises will be encountered at surgery.

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CHAPTER SEVEN-------------------------------------

N on-surgical Management of Fractures


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Jonathan Dyce

INTRODUCTION T he presence of large muscle masses about the


humerus and fem ur precludes cast management of
Historically, the management of long bone fractures fractures proxima l to the e lbow and stifle, because of
using casts and splints pre-dates oth er means of repair. poor mechanical coupling between the cast and bone.
With appropriate case selecti on th e results achieved by Excessive cast paddin g will produce a similar effect.
such ri gid bandaging, oth erwise known as external The fracture sho ul d be located centrall y within the
coaptation, could be very good. However, it should be cast as cast purchase on the proximal and distal li mb is
appreciated that, with the advent of more sophisti cated necessary for stabil izati on. T he ax iom that the joint
fixation techniques, optimal fracture management is proximal and d istal to the fracture should be immobi-
now unlike ly to in vo lve primary coaptation. The aim lized is a useful guide, but fractures with considerable
of this chapter is to rev iew th e principles of non- intrinsic stability (e.g. iso lated distal rad ial or ulnar
s urgical fracture management, with particular empha- fractures) may not require extension of the cast proxi-
s is on castin g. It does not give a comprehens ive list of mal to the elbow.
fractures suitable for non-surgical management, and
the reader is d irected to the chapters on specific frac-
tures for guidance in the indi vidua l case. INDIC ATIONS FOR CASTING
T he following criteria should be cons idered when as-
CAST BIOMECHANICS sessing the suitability of a fracture for cast management.

Cast management of fractures does not result Fracture configuration


in rigid immobility but should impart suffi- Re latively stable fractures - for example, those with
cient stability for fracture healing to occur. greenstick (incomplete) and interdigitatin g transverse
config uration - are the most suitable fo r casting. If a
As ri gid bone fixation is not achieved, healing will frac ture is minimall y displaced, particul arly in the
proceed by secondary bone uni on, with obvious call us immature animal, the peri osteum is mo re li ke ly to be
formation. Therefore, aspects of the local fracture intact, and to contribute to fracture stabili ty.
environment that favour callus fo rm ati on will signifi- Casting may be appropriate for those cases where
cantl y influence selection for cast management. one member of paired bones is fractured and th e intact
The ability of a cast to immobili ze a fracture de- bone contributes s igni fica nt support - for example,
pends on th e stiffness of the cast, the intimacy of the frac ture of the radius with an intact uln a, or fewer than
cast layer to the bone, and the locatio n of the fracture three metapodal fractures. Simple oblique or spiral
within the cast (Tobias, \995). fractures, which are stab le on mani pul ation fo llowing
The stiffness, or resistance to bending, is determined reducti on, may also be good candidates.
by the choice of cast material and the application tech- Comminuted fractures are rare ly suitable fo r cast-
nique. Of the fo rces acting at the fracture site, bending ing as subsequent deformati on of the frac tu re plane is
is neutralized well by a cylinder cast, but compressive, likely to occur.
rotational. shearing and distracti ve forces are countered
relatively poorly. Consequently, inherently unstable Fracture location
fractures (including avulsion frac tures) are not suitable The biomechani cs of cast application and the d ifficul ty
for coaptation. Casting materials are stronger in tension of mani pul ative reduction'precl ude satisfactory coap-
than com pression, and so cast fai Iure is Ii kely to occur on tatio n of proximal lim b fractures.
the compression aspect of any angulation, but this Intra-articular fractures proximal to the carpus and
vulnerable aspect may be reinforced by appl ying a spine tarsus almost in variably dictate open reduction and
moulded from the cast material. internal fixa tion; coaptation should not be cons idered .

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52 Manual of Small Animal Fracture Repair and Management

However, selected fractures of the carpus and tarsus can Intended role of the patient
have a good clinical outcome without anatomical recon- While casting is frequently possible, it is unlikely to be
stmction, and coaptation may therefore be appropriate. the optimal management for athletic and working
Growth plate fractu res occur in young dogs with animals. Expectations of function must be discussed
good osteogenic potential, but the advantage of an with owners prior to fracture coaptation.
ea rl y return to weight bearing offered by internal
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fixation and the likelihood of complications of cast Cost


management of such juxta-articular fractures make Economy is frequently cited as an indication for cast
cast management a poor option. Salter-Harris Type I management of frachlres. However, the cost of materials
fractures of the distal radius are a special case and used in cast application is likely to exceed that of dispos-
may be managed by casting alone or by cross-pin able materials used in simple external skeletal fixation.
fixation and adjunctive coaptation. The latter tech- The incidence of complications leading to additional
nique, where an intrinsically weak repair is protected expense (e.g. cast replacement) should also be consid-
by a secondary fixation, is referred to as adaptation ered. The time commitment to fracture management and
osteosynthesis. aftercare is similar for both treatment regimens.

Fracture reduction
Reduction should be performed without an open surgi- CAST CONSTRUCTION
cal approach, to conserve the periosteal envelope and
limit vascu lar compromise to the fracture site. The A cast typically comprises several layers: a contact
fracture is reduced with care, using a combination of layer (generally stockingette), a padding layer, a com-
linear traction and toggling of the bone ends. Follow- pression layer and the circumferential cast material.
ing manipulation of transverse fractures, the fracture
should appear more than 50% red uced in two radio- Casting materials
graphic planes. Although anatomical reduction is the For lIlany decades, plaster of Paris (POP) was the only
ideal, it is rarely achieved and is certainly not a pre- available casting material (Hohn, 1975). POP products
requisite for success. are still produced, but are messy to apply, take many
Muscle masses in the proximal limb and soft tissue hours to reach weight bearing strength, deteriorate when
swelling may preclude fracture palpation and therefore wet, and are relatively heavy and brittle. Excellent
adequate manipulative reduction. conformability, radiolucency and economy are redeem-
If there is a delay to fracture management, muscle ing qualities, but a number of alternative casting mate-
contracture and callus formation will progressively rials are now available that are superior in key respects.
impede reduction. If adequate reduction is not possible Predictably, none is ideal (see below). For reviews of
then open reduction and alternative fixation must be casting materials see Houlton and Brearley (1985) and
considered. Langley-Hobbs et at. (1996). Currently, the author uses
resin-impregnated fibreglass for all small animal cast
Signalment applications, and also finds this a versatile splinting
In general, limbs can be mainta ined comfortably in material. This consistently makes well tolerated, strong
casts for 4 to 6 weeks. Candidates for coaptation and durable casts. Although such products are not
should therefore produce adequate bridging callus cheap, the cost is justified by the likelihood ofthe initial
within this period. Younger animals form callus more cast delivering bone union without complication.
readi ly and on this criteria are good subjects for cast- Properties of the ideal casting material include:
ing, but the rapidly growing juvenile is more likely to
encounter complications associated with restricted limb High strength/weight ratio
growth within the cast. Easy to apply
The specific physiology of distal radial/ulnar frac- Short time to reach maximum strength after
tures in toy breed dogs res ults in an unacceptably high application
incidence offailure following cast management. Such Conformable
fractures dictate surgical intervention. Durable
Radiolucent
WARNING Water resistant but ' breathable'
Distal radial/ulnar fractures should not be Easy and safe to remove
cast. Reusable
Economical.
C hondrodystrophic and obese dogs are difficult to cast
effecti vely, because of limb conformation, and there- Cast application
fore alternative methods of fracture management are If there is significant soft tissue swelling at the time of
generally indicated. initial examination, casting shou ld be delayed and a

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Non-surgica l Management of Fractures 53

non-rigid compressive (Roben Jones) bandage should ends of the tapes are temporaril y secured to a tongue
be applied to the reduced fracture, until this swelling depressor. Stockingette is rolled up the limb to incor-
has subsided. Typically, tltis will take 2 to 3 days. porate any wou nd dressing, and is tensioned to elinti-
Any skin wounds should be debrided and, when nate creases (Figure 7. 1b). Cast padding, such as
necessary, closed. The haircoat is clipped if it would Soffban (Sntith & Nephew), is wound on to the limb
interfere with cast application. The limb should be with a 50% overlap on each turn. Two layers are
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clean and dry. Following appropriate preparation, ad- generally indicated. Panicular care is taken to ensure
hesive tape stirrups (e.g. zinc oxide tape) are applied to even padding over pressure points. Excessive padding
the limb to prevent distal migration of the cast (Figure about pressure points should be avoided and consid-
7.1a). Tapes placed on the dorsal and palmar aspects of eration should be given to increasing the padding in
the limb are preferred, as medial and lateral tapes may adjacent depressed regions with, for example, dough-
cause squeezing of the toes within the cast. The free nuts of onhopaedic foam.

Figure 7. J: Cast application (see text jor details).

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54 Manual of Small Animal Fracture Repair and Management

Next, a compressive layer is applied in a similar deteriorating weightbearing function of the cast limb
manner to compact the padding. and signs of general ill health (inappetence, dullness,
The cast material is applied with appropriate ten- etc.) may suggest the development of complications
sion, again with a 50 % overlap on each tum (Figure within the cast. It is sensible to schedule routine
7.1c). Care is taken to maintain this overlap over the wee kly appointments for cast assessment for the dura-
convex aspect of joints. A 1-2 cm margin of cast tion of casting. Rapidly growing dogs and other high-
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padding is left exposed proximal and distal to the cast risk patients may require more frequent assessment.
(Figure 7.1d). Two or three layers of cast material are Excessive exercise while cast will compromise
generally applied. Manufacturers' recommendations cast survival and predispose to complications; there-
regarding wetting and handling should be followed. fore pen rest is recommended, with minimal leash
Tension is increased as the cast is applied proximal to exercise to toilet. The cast must be kept clean and dry.
the elbow or stifle to give a snug fit about the muscle While outside, a polythene footbag is applied and
masses and to prevent loosening. secured using rubber bands or clothes peg.
It is important that an appropriate limb posture is
maintained during casting and that indentations are not WARNING
produced in the cast by the fingers. Once the cast has The hag should he removed at all other times
hardened, thestockingette and padding are rolled down to prevent moisture build-up within the cast.
and secured to the cast with adhesive tape (Figure
7.le). The stirrups are peeled apart, twisted through Bedding materials such as straw can migrate between
1800 and bound to the distal cast (Figure 7.lf, g). The cast and skin, and should be excluded. Kennelled dogs
pads and nails of the axial digits should remain can be successfully managed in casts provided that
exposed (Figure 7.1h). monitoring is diligent and hygiene good.
To facilitate removal, the cast may be cut along its
cranial and caudal aspect and then bandaged with
strong adhesive tape. However, this will affect some of CAST REMOVAL
the material properties of the cast, and this approach is
not recommended. The time course for development of clinical union will
With the resin-embedded fibreglass materials, be around 3 to 6 weeks, depending on individual
weight-bearing strength will have been reached by the patient and fracture factors. Radiography should be
time of recovery from anaesthesia. performed (Chapter 5) to confirm adequate fracture
Medication with non-steroidal anti-inflannnatory healing, prior to cast removal. Although plaster shears
drugs is useful to limit soft tissue swelling and to can be used to remove most casting materials, an
provide analgesia. The requirement for ongoing treat- oscillating circular saw is most suitable. Bilateral
ment should be reassessed after 3 to 5 days. incisions are made in the cast (Figure 7 .2a), taking care
not to damage underlying tissue. The two halves are
then prised apart using cast spreaders (Figure 7.2b),
CAST MAINTENANCE and the underlying bandage materials are removed
(Figure 7.2c).
WARNING After cast removal it is important that a regimen of
Amputation may be the price paid for poor progressively increasing controlled exercise is en-
cast management. forced. The goal is stimulation of callus remodelling
without jeopardi zing fracture repair.
The majority of patients managed in a cast will be
discharged to the care of their owners until cast re-
moval. It is therefore essential that owners are edu- COMPLICATIONS
cated in daily cast monitoring, and that the development
of complications is reported at the earliest opportunity. Joint stiffness
It is a sobering fact that a significant amount of litiga- Limb immobilization will cause progressive joint stiff-
tion arises from poorly managed casts. Written instruc- ness and this is an inevitable consequence of cast man-
tions should always be given out at discharge and agement. It is most marked in those patients with
owners must understand their responsibility in cast periarticular soft tissue damage, which exacerbates peri-
maintenance. articular fibrosis and adhesion. It is normal to cast joints
Points to monitor are swelling of the toes or proxi- in extension and, therefore, compromised joint flexion
mal limb, toe discolouration and COO~lesS, skin abra- is to be expected following cast removal. The degree of
sion about the toes or proximal cast, cast loosening, compromise may be overcome (for example, in the
angular deformity , damage, breakage, discharge or carpus) by immobilizing the joint in a mild degree of
foul odour. Chewing at the cast may be a response to flexion. At worst, fracture disease - a syndrome of
discomfort and should be investigated. In addition, stiffness, periarticular fibrosis, cartilage degeneration,

J
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Non-surgical Management of Fractures S5

seen within hours of cast application . It is therefore


sensible to hospita lize the patient overni ght to observe
any earl y complications of casting. Ongoing soft tissue
swelling within a properly pressuri zed cast will also
cause dista l limb oedema, but this will manifest later
after application. Limb swelling isa potentiall y serious
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complication and req uires diligent monitorin g and


appropriately rapid intervention.

Pressure sores
Bony prominences such as the olecranon, accessory
carpal bone and calcaneus are particularl y vulnerable
to s kin trauma. Two mechanisms are responsible:
pressure necrosis and abrasion. Good application tech-
nique and appropriate cast monitorin g will signifi-
cantly reduce the incidence and severity of s uch
complications. Direct skin traumaanda moist environ-
ment within the cast predispose to bacterial dermatitis.
Staphylococcal organisms are generall y responsible.
The development of full thickness s kin wounds can
permit extension of infection to underl ying tissues, and
necroti zing cellulitis can become established. There
may be few systemic clinical signs of deterioration and
a purulent discharge staining the cast may be the first
obvious sign . Unfortunately, amputation may be the
only appropriate management in the severe case.
Abrasion of the toes caused by too short a cast
should be managed by cast replacement rather than
piecemeal reconstruction or local trimtning.

Cast loosening
As the acute soft tissue swelling about the fracture
subsides, the snug fit of the cast is lost. Tllis will
predispose to fracture instability and abrasion within
Figure 7.2: Cast removal. and about the cast. Long-term casting will be inevitably
associated with muscle atrophy and similar loosening.
muscle atrophy and osteoporosis - can occur. This is
seen particularly following cast application to the proxi- Delayed union, ma lunion and non-union
mal hindlimb in young dogs, where quadriceps contrac- Correct case selection and good casting technique
ture and the resultant genu recurvatuITI are devastating should prevent fra cture repair failure. Compromised
complications (Chapter 21). fracture healing is more li kely to be seen in association
with any of the above complications. The frequent
WARNING removal and reapplication of a cast may contribute to
Avoid stifle immobilization in skeletally im- movement at the fracture plane and therefore fa ilure of
mature animals. repair. Delayed union, ma lunion and non-union are
discussed in detail in Chapter 24.
Joint laxity
Laxity is a particular complication in rapidly growing Refracture
young dogs of large breeds. Carpa l hyperextension, Refracture rarely occurs following cast removal if there
associated with palmar carpal liga ment laxity is most is radiographic evidence of bridging callus fo m18tion.
commonly seen. Further coaptation is not appropriate
and the majority of such cases will resolve spontane-
ously with controlled weightbearing. SPLINTED BANDAGES
Limb swelling Splinted bandages are useful in the management of
Excessive tension durin g cast applicati on will cause fractures distal to the metacarpus/metatarsus as all toes
attenuation of lymphatic and venous drainage and are supported and not subjected to weight bearing.
consequentl y distal limb oedema. This is likely to be Ready-made plastic and metal ' metasplints' are ava il-


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S6 Manual of Small Animal Fracture Repair and Management

able. Customized splints are readily made from casting EXTERNAL COAPTATION IN
materials and have the advantage of better conform- FRACTURES OFTHE SKULL AND SPINE
ability. Metacarpal fracnrres managed with non-mould-
able splints are more likely to develop palmar bowing Specific issues relating to the management of skull and
during fracture healing. Thecomponentsofthesplinted spinal fractures are covered in Chapters 12 and 13,
bandage are essentially the same as the cast, but with- respectively.
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out a rigid circumferential external layer. Padding is


placed between the toes before bandaging to prevent
interdigital sores. The s plint is enclosed in the CONSERVATIVE MANAGEMENT
compressive layer and this is then covered with a
flex ible cohesive bandage. Splinted bandages are not A number of fractures - for example, of the pelvis
as rigid as tubular casts and tend to be less suitable for caudal to the acetabulum - are best managed without
fracture management. Phalangeal fractures are readily any additional support beyond the local muscle bulk.
managed in splints. Management invol ves attention to ongoing analgesia,
Fractures of the tarsus may be immobilized by rest in an appropriately sized pen with flooring that offers
cranial or lateral half casts made from casting materials a sure footing, and provision of comfortable bedding. In
or thermall y sensitive plastic. all cases in which ambulation is difficult, particular
attention should be directed toward supervision of
defaecation and urination. Consider the use of a beUy
OTHER BANDAGES band to support dogs when they are taken out to toilet.

Support bandages such as the Spica splint and


Schroeder- Thomas extension splint may be used for REFERENCES AND FURTHER READING
primary fracture management, but invariably they are
not the first choice. Similarly, non-weightbearing slings Hohn RB (1975) Principl es and application ofplastcr casts. Veterinary
such as the Velpeau, carpal and Ehmer should be Clinics of North America 5, 291.
Houlton JEF and Brearley MJ ( 1985) A comparison of some casting
considered on ly as adjunctive means to protect rela- malerials. Veterillary Record 117, 55.
tively fragil e internal fixation, or reduced luxation. L. . nglcy-Hobbs SJ, Abercromby RH and Pead MJ ( 1996) Comparison
and assessmcnt of casting materials in small animals. Veterinary
In cases such as scapular and pelvic fractures that Record 139, 258.
are not candidates for s urgical intervention, it is rare Swaim SF (1970) Body casts. Techniqucs of application to the dog.
Veterinary Medicille Small Animal Clinician 65, 1179.
that such bandage support will improve the prognosis Tobias TA ( 1995) Slings, p'ldded bandages, splinted b.:'lndages, and casts.
or time of conva lescence compared with more con- In: Small AI/imal Orthopaedics, ed. ML Olmstead. Mosby, SI Louis.
serva ti ve management (see below). The likely inci- Tomlinson J ( 1991 ) Complications of fractures repaired with casts and
splints. Veterillary Clinics of North America 21 , 735.
dence of complications of bandaging should also be Withrow SJ ( 198 1) Taping of the mandible in trcatmeTll of mandibular
considered. fractures. JOllrnal ofthe American Anillwl Hospital Association 17,
27.

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CHAPTER EIGHT - - - - - - - - - - - - - - - - - -

Instruments and Implants


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John P. Lapish

Fracture repair in small animals using internal or Ma nufacture of surgical instruments


external fixation is very dependent on corrosion-resist- The manufacture of a stainless surgical instrument
ant materials for both instrumentation and im plants. from raw material to fi nished instrument involves
An understanding of stainless steel and its properties is some 30 different quality controlled processes.
one of the fu ndamentals of fractu re management. The instrument maker is usually presented with a
stai nless steel blank which is roughly the same shape
as the fina l instrument. The blank is machined to
STAINLESS STEEL produce the relevant box joint, screw joint or ratchet.
Hand and eye skills are required to grind and shape the
Stainless steel is a generic term applied to a group of blank into its final form. During fo rging, im purities
special steels containing varying amounts of chro- accumulate on the surface of the blank. These are
mium to improve corrosion resistance. All th ese removed by abrasive wheels anel belts during the
steels will stain and corrode under certain conditions; process of glazing, the first of many stages designed to
the term stainless is, therefore, somewhat misleadi ng. minimi ze corrosion.
Veterinary surgery may involve the use of ma ny The heat treatment process is of para mount impor-
types of sta inless steel. Each will have a different tance in the manufacture of surgical instruments. The
compositi on dictated by the properties which are hardness of the steel is cri tical: if it is too soft, the scissors
requi red. will not keep their edge; if it is too hard, the instrument
Stainless orthopaedic implants must be very re- will crack and break. Instruments that look right but fa il
sistant to corrosion - all other properties are subord i- to perform have often been hardened incorrectly.
nate. Implant stainless steel contains high levels of Fo ll ow ing harde nin g, the in strum e nts are
c11romium and nickel but low levels of carbon and as electropo lished and passivated in special solutions to
such belongs to a gro up of a lloys called austeni tic remove corrosive elements and to encourage the for-
sta in less steels. This type of steel cannot be hardened mation of chromium ox ide. The final process is polish-
by heat treatment but can be hardened to a certain ing, performed either by hand or, increasingly, by
degree by ' workin g ' the metal. Bone plate, for exam- mechanica l tumbling methods. The fi nal polish may be
ple, is rolled during man ufacture, which makes it bright or satin. A bright polished fin ish is most resist-
sti ffer. ant to staining and corrosion. A satin fini sh is produced
Surgical instruments, on the other hand, are re- by microscopically roughening the surface, usually by
quired to have a certain degree of spring and be capable blasting with small glass beads. This increase in sur-
of taki ng and keeping a cutting edge. Surgica l steels face area also increases the risk of stai ning.
therefo re contain re latively high levels of carbon and The manufacture of surgical instnunents remains
may be made hard by heat treatment. These steels very labour intensive, depending on the skills of crafts-
belong to the martensitic group of stainless alloys, men. This is pan iculariy true of low volume production
which are mag netic. Unfortunate ly this composition which does not justify mechanization. The durability of
results inevitably in poor corrosion resistance - hence an instrument depends on strict quality control over all
the requirement for a strict instrument care routine. stages of manufacture together with equal attention to
Stai nless surgical instruments are protected fro m the use and maintenance of the instnllnent.
corrosion by a very thin coating of chromium oxide.
Activities that encourage the production of chromium
oxide (e.g. thorough cleaning of organic deposits, and IMPLANTS AND INSTRUMENTS
dry storage) minimize corrosion and staining. Proce-
dures that damage the protective layer (e.g. poor clean- Most veterina ry orthopaedic instruments and im plants
ing and rinsing, wet storage and certain chemical are selected from the enormous range of human speci-
disinfectants) will encourage staining and rusting . aHties. However, not all veterinary fractures have a


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58 Manual of Small Animal Fracture Repair and Management

comparable human fracture. Increasingly veterinary Ultra high molecular weight polyethylene
orthopaedic surgeons are demanding instruments and UHMWP is primarily used for acetabular components
implants designed specifically for their needs. of total hip replacements but is compatible with all of
Orthopaedic instrumentation may be classified the above.
under the following headings.
WARNING
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Orthopaedic implants To be safe for routine implants, use only


Implant insertion hardware stainless steel 316L type and UHMWP. For
Orthopaedic hand tools total hip replacement any combination of
Orthopaedic power tools hard alloy and UHMWP is acceptable.
Bone manipulation instrumentation
Bone cutting instruments Implant hardware
Tissue retractors . Most implants require dedicated instrumentation.

Orthopaedic implants Intramedullary (1M) pins (hard wires)


The range of available implants is enormous and their IM pins may be inserted by a simple Jacobs chuck.
exact form wi ll not be covered here in detail. The Altematively a power drill may be used. Driving
various s hapes and sizes are illustrated in orthopaedic trochar pins even by hand in a Jacobs chuck can
catalogues available from the major suppliers. produce enough heat to cause necrosis. Using power,
Four materials are currently employed for human heat necrosis followed by implant loosening is a sig-
implants: stainless steel, chrome cobalt molybdenum nificant risk.
a ll oy, titanium and its alloys and high density
polyethylene. All must meet British, US and intema- Arthrodesis wires and K-wit-es (hard wires)
tional standards. Veterinary implants are not restricted These may be inserted us ing asma ll Jacobs chuck if the
in any way but, practically speaking, the available bone is soft. Hard cortical bone is better penetrated by
materials for implants meet the current human specifi- a power drill, preferably with a wire driver attachment
cations. (see section on power tools, below). The exposed
section of wire should be kept short to minimize
Stainless steel wobble and pin bending.
Very high purity austenitic materials are used for the
production of bone plates, compression plates, bone Orthopaedic/Cerclage wire (soft wire)
screws, intramedullary pi.ns etc. The current human Where cerclage wire is cut from a roll, the ends of the
s pecification for stainless steel in the UK is BS7252 wire must be twisted evenl y around each other. To
composition ' D'. Equivalent intemational specifica- achieve this clinically it is important to twist under
tions include ISO 5832-1 , ASTM F 138-92 Grade 2 and tension. Artery forceps or some kind of pliers will
DIN 17443-86. Components meeting these specifica- work but dedicated wire twisters Wllich lock on to the
tions may be mixed. wire are available (Figure 8.1) .
All these specifications are variants of stainless Cerclage wire loop-ended lengths require a match-
steel type 316L, which has no free ferrite stage - hence ing wire tightener (Figure 8.1) to pull the free end
its very high corrosion resistance. through the loop prior to locking and breaking. This
system does not permit further tightening.
Chrome cobalt molybdenum alloy
TI,is alloy is principally employed in the manufacture Rush pins
of total hip replacements. Rush pins are less commonly used in veterinary ortho-
paedics than previously; there has been a shift towards
T itaniulII and titanium alloys the use of arthrodesis wires and K-wires. A rush pin
This group of metals is primarily used in human introducer is available to customize the bending and
orthopaedics in patients known to react to stainless insertion of this implant.
steel. The component that usually causes the problem
is nickel. Pure titallium is MRI-scatmer compatible. Self-tapping screws
Stainless steel implants must be removed prior to MRI Self-tapping (Sherman) screws can be inserted with a
scantling . Both these indications are very uncommon minimum of special equipment:
in veterinary orthopaedics.
Titanium has been used for canine total hip replace- Drills equivalent to the screw core diameter
mettls. Although it has a very high strength to weight (pilot) and outside diameter (clear):
ratio, its wear characteristics are poor.
Titanium and its alloys shou ld not be used with 3.5 mm (9/64 in) pilot = 2.7 mm clear = 3.5 mm
stainless steel components. 2.7 nun (7/64 in) pilot = 2.4 mm c1ear =2 .7 nun

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Instruments and Implants 59

Depth ga uge: it should be noted that self- three fiutes (grooves) to allow removal of
tappin g screws are measured from under the bone debris as the threads are being cut.
head to screw tip, i.e. thread length, whereas
pre-tapped screws are measured as overall Pilot drill equi valent to core diameter
length. The appropriate ga uge must be used (clearance drill has the same diameter as the
or the difference compensated for. screw):
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Screwdriver: self-tapped screws have slotted


heads; 3.5 mm (9/64 in) screws have a 1.5 mm cortical pilot 1.1 mm
cruciate head; 2.7 mm (7/64 in) and 2.0 mm 2.0 mm cortical pilot 1.5 mm
screws have a single slot. Screwdri vers 2.7 lrun cortical pilot 2.0 mm
should be selected accordingly. 3.5 lrun cortical pilot 2.5 mm
3.5 mm cancellous pilot 2.0 mm
4.0 mm cancellous pi lot 2.0 mm
(a)
4.5 lrun cortical pilot 3.2 mm

Screwdrivers. A ll screws ha ve a recessed


hexagonal head and the ra nge of screws is
covered by three different sizes (referring to
(e) the width across the flats of the hexagonal
=~~:= head):

1.5 and 2.0 mm screws require a 1.5 mm


hexagonal screwdriver
(e) 2.7,3.5 and 4.0 mm screws require a
2.5 mm hexagonal screwdriver
if) 4.5 mm screws require a 3.5 mm
hexagonal screwdriver.

Orthopaedic hand tools

Jacobs chuck
(g) This tenn has come to decribe an aluminium handle
~~
~~
'---(h) coupled to a stainless steel three-jawed device for hold-
ing pins. In fact only the stainless drill chuck made by the
Jacobs Manufacturing Company should be described as
a Jacobs chuck (Figure 8.1). Such chucks are fitted to
virtually every orthopaedic drill avai lable in the world
today, as well as most intramedullary pin chucks.
Figure 8.1: Imp/allt hand instrumen ts: (a) Jacobs chllck; (h) The Jacobs (intramedullary) pin chuck is a simple
smaiL pill/rap vice; (e) K-lVire bender; (d) K-wire pUllch; (e) tool widely used to insert intramedullary pins. It can,
wire loop tightcner; (f) hard wire cutter (2.5 111111 maximum); however, be used to hold and insert drills, external
(g) soft wire twister/cutter; (11) soft orthopaedic wire. fixation pins, K-wires and arthrodesis wires. Control is
good but it is difficult to produce the pure axial rotation
Pre-tapped screws (AO type) necessary to obtain a perfectly round hole. It is difficult
Generally, but not exclusively, these are used with to cause heat necrosis using a hand-held chuck. Pin
compression plates requiring a range of sophisticated slippage is a frequent problem in all tools using a
instruments. Much of the specialized equipment is Jacobs chuck. At best this misleads the surgeon as to
designed to place screw holes accurately with a mini- how deep the pin penetration is; at worst the pin can
mum of soft tissue damage. The essential difference cause a serious injury to the surgeon.
between the two types of screw is that the AO type will
not cut their own threads in cortical bone. It is possible Always use the pin guard when dri ving long
in certain circumstances to allow AOtypescrews taeut pins.
their own threads in cancellous bone. To pre-cut the Always lubricate the chuck mechanism. Stiff
threads, a tap is passed down the pilot hole. chucks do not tighten very wel l.
Always replace worn chuc ks and keys.
A tap is a threaded instrument possessing Having fewer teeth, the key wears first.
essentially the same thread form as the screw Regular key renewal will prolong the life of
to be used. At right angles to the threads are the chuck.


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60 M anual of Small A nimal Fracture Repair and Management

Orthopaedic hand drill or shrouded before use. All are fitted with a stainless
Hand drills were widely used in veterinary onhopaed- chuck which can be detached for separate autoclav ing.
ics prior to the more widespread use of power tools. Drill speed is controlled via the trigger and ideally
The big disadva ntage is that two hands are required to should increase s moothl y from zero to around 200 rpm.
operate the drill , leaving the bone to be held by an Most will in fact run at over 500 rpm so caution must
assistant. be exercised.
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Orthopaedic power tools

Power drilling
Power drills remove much of the physica l effon in-
volved in many onhopaedic procedures. In addition
they offer the surgeon more control than hand dri ven
tools in that power drills may be held and contro lled by
a single hand, leaving the other hand free to hold the
bone (or at least a drill guide connected to the bone) .
The major drawbac k of power drilling is that the heat
produced by friction can cause heat necrosis and im-
plant loosening.
Living bone is a difficult medium to drill. Twist
drills are manufac tured with flutes (grooves) spiralling (iii)
along the length of the drill. As the subject material is
drilled, the debris produced accumulates in the flutes
and tra vels up and along the drill , ap pearing at and
being discharged from the drill hole. When drilling
=;: (iv)
(i)

bone, other than very dry bone, the bone debris clogs
the flutes and is not removed fro m the drill tip. A build-
up of debris reduces the cutting efficiency of the tip,
increasing fri cti on, w hich produces more heat, w hich
coagulates any proteins in the bone debris, which then
sets in the flutes - creating a vicious ci rcl e.
The net effect of the drilling properti e.s of stainless (d)
steel and bone is the inevitable produ ction of heat. The
surgeon must take great care to deal with this. Figure 8.2: Orthopaedic power instrumems: (a) recha rgeable
battelY drilL; (b) Symhes reversible drill; (c) 3M milli driver:
(i) handpiece, (ii) saw attachment, (iii) drill auachmem,
Use slow speed drilling, max imum 100 rpm .
(iv) K-wire driver; (d) 3M Minos 100000 rpm air burr
Use onl y s harp drill bits. Drilling 10 holes system handpiece.
will du ll onhopaedic drills. An y contact
between drill tip and other implants will Air- drills
damage the drill tip. Generally speaking these are more ex pensive to buy
Clean bone drills very frequentl y, especiall y and maintain than battery units but do have the adva n-
when drilling deep holes and when using AO tage of being full y autoclavable. Compressed air is
type drill guides, which funher limit debris suppLied by bottle or compressor. Single hose units
clearance. venting at the table s hould use sterile bottled air. Units
Take care when drilling trochar ti ps, which with double return hoses venting remotely are less
are not designed for drilling. Some trochar demanding regarding air supply. The ai r and hose
tips are very poorly designed. Sha n stubby requirements make air drills more awkwa rd to set up
tips are the worst. Overall the length of the tip but they are usuall y lighter than their battery counter-
should be 2-3 times the diameter of the pin. pan s.
Irriga te wi th sterile saline. To cool the drill
tip, it must be removed from the hole! K-wire driver
This device (Figure 8.2) is available as a stand-a lone
Battery drills unit or as an attaclunent for the modular drills. The
Some very ex pensive surgical units will tolerate instrument connects K - w ires or arthrodesis w ires to an
autoclav ing but most units availa ble to the veterinary air motor via a finger-operated clutch. Wires may be
surgeon are based on industrial designs and will be insen ed incrementall y, the wire being fed through the
destroyed if autoclaved. For sterile use, therefore, clutch, ensuring that at no point is a long vulnerable
battery drills (Figure 8.2) must be either gas sterilized length of wire is ex posed.

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Instruments and Implants 61

Power saws of saline cooling will be requi red to avoid heat damage
Dedicated surgical saws are expensive. The mechanism to tissues and coagulation of proteins on the burr.
to convert the rotating motion of dri ve systems into a
to-and-fro saw system is difficu lt to manufacnlre in Dental air drills: Neurological burrs fit the straight
autoclavable materials. Surgical saws cut hard materials nose cone of the slow-speed handpiece (HP fitting
such as bone but leave soft tissues virtually undamaged. burrs) . The slow handpiece runs at a maximum of
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The cutting teeth move only a small distance. Bone, 20 000 rpm with relati vely high torqu e. T he Iligh-
provided that it is held or has sufficient inertia, does not speed handpiece will run at 400 000 rpm but the angle
move and so the teeth will cut it. Soft tissues travel with of the burr attachment severely limits its use. The
the saw blade and the teeth are not drawn across the handpiece can be autoclaved but the airline cannot,
fibres. It should be understood, however, that if soft necessitating a shroud system.
tissues are placed undertension the teeth of the saw will
move across the fibres and will cut. This may be illus- Hobby type drills (electric): These drills have a maxi-
trated by oscillating cast cutters used over prominent mum speed of30 000 rpm todrive burrs either directly
bones or situati ons where the skin becomes tense. from the motor or via a fl exible drive with a separate
Saws may be classified according to the direction of handpiece. The best-known system is the Dremmel,
movement of the saw blade relative to the dri ve shaft: which has a variable speed via a foot control, a flexible
drive shaft, and a separate handpiece which, with some
Oscillating saws: These move in an arc of 5 or 6 modifications, will autoclave satisfactorily.
degrees at ri ght angles to the dri ve s haft. This type of The non-dedicated systems (dental and hobby)
acti on is also to be found in plaster saws. Indeed some give acceptable results but are much less satisfying to
240 V cast cutters have been converted to surgical use use. They are, however, approximately [5 % of the cost
by fitting surgical blades. The results can be satisfac- of dedicated systems.
tory but compromises have to be made with respect to
sterility and safety. The blades are arcs or segments of Bone manipulation instrumentation
arcs and require that bone is either superficial or very A very large number of bo ne clamps are ava ilable to
well elevated (e.g. s kull work or femoral head oste- the human-orthopaedic surgeon. Many are appropriate
otomy) . for veterinary orthopaedics. Very few have been de-
veloped specifically for the veterinary field.
Sagittal saws: These also move 5 or6 degrees in an arc Bone is an unyielding substance. Holding instru-
but in the same plane as the drive shaft. This action is ments are usually adjustable over a range of positions
the most useful in veterinary orthopaedics and is widely and the adjustment may be locked in pos ition by a long
used for osteotomies. The cutting blade can be intro- ratchet or, alternatively, by a threaded thumb screw.
duced deeply into surgical sites without fouling soft Locking clamps are particularly useful in general prac-
tissues with the drive system (e.g. for osteotomy of the ti ce, where assistance is often lacking.
ilium during the triple pelvic osteotomy procedure).
Fragment forceps
Reciprocating saws: These move to and fro along the Fragment forceps (Figure 8.3) or pointed reduction
line of the drive shaft in the manner of a hand-held forceps are single- or double-pointed clamps designed
wood saw . The distance of blade travel is very short. to maintain fragm ent reduction with a minimum of
This type of action is rarely used but an example is the interference with implants and assoc iated instrumen-
ischial Cllt in the triple pelvic procedure. tation. A range of s izes is ava ilab le, covering most
veterinary situations. A common application is the
Burr systems reduction of growth plate separations in the immature
Ideall y, orthopaedic orneurological burr systems should animal, e .g. distal femoral growth plate. Care must be
have high speed and low torque and be easy to sterili ze. exercised us ing fragm ent forceps on immature bone if
To obtain burr speeds in excess of30 000 rpm requires one is to avoid excess trauma or a loss of reduction as
an air-dri ven system. the forceps points bite into the soft bone.
Single-pointed fragment forceps usually apply com-
Dedicated air systems: These systems (e.g. 3M Minos pression at the exact point where screw fixation is
(Figure 8.2) and Halls Surgairtome) run at up to desirable, e.g. lagging bone frag ments. Twin-pointed
[00 000 rpm with a low torque. Using a range of burr forceps are he lpful in these situations. Gynaecological
guards to support the burr shaft it is possible to use burrs vusell um forceps may be used or twin-pointed forceps
upto 70 mm long. Long burrs shou ld not be used without designed for orthopaedics "are ava ilable. The advan-
a burr guard. The risk of shaft shatter in brittle carbide tage of the latter is that they will lock over a range of
blUTS is significant. The speed on both instruments is positions. Good examples of their use include fractures
controlled by a lever on the handpiece. Generally speak- of the latera l condyle and fractures of the central tarsal
ing, air burrs are run at maximum speed. Some system bone in the racing Greyhound .


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62 Manual of Small Animal Fracture Repair and Management

contracture. These forces must be transmitted through


the bone fragment without damaging bone or perios-
teum. Some older designs have a tendency to crush
boneas pressure isapplied (e.g. Fergusson 'Lion' bone
forceps) .
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Bone cutting instruments

Bone cutters
Bone cutters (Figure 8.5) vary according to blade size,
angle of cut and power of cut. The range for humans is
enormous. The following is a selection of cutters found
to be useful in veterinary orthopaedics.

~ - (a)

Figure 8.3: Fragmellt or poillted reductionjorceps: (a) tlVill-


2
point fragment jorceps; (b) plate-holdillg jorceps; (c) small
fragmentjorceps; (d)fragmentforceps; (e) very largejragmelll
forceps. (e)

Bone holding fo rceps


Bone holding forceps (Figure 8.4) are used to grip and
manipulate large bone fragments. Sometimes large
forces are required to overcome the forces of muscle (e)

(fJ

(It)
=====
t=1 (g)

Figure 8.5: BOlle clltting instruments: (a) Liston bone


cutlers; (b) Mcindoe bOlle compollnd cutters; (c) small
al1gled cutters; (d) Gigli saw handles and wire; (e)
osteotome; (j) chisel; (g) gouge; (II) adjustable bone saw.

(e)~_ _ _ :1~~ i Liston cutters: Liston cutters are available in a large


variety of sizes and blade cutting angles. Generall y

~ ~-==)j
they are too heavy in construction for most veterinary
procedures.
(d)

(e)
-'i o-fl
- McIlldoe compoulld culters: McIndoe 7 in (175 mm)
cutters are fine bladed and angled, and ha ve a powerful
compound action (double-jointed). A consequence of
the compound action is that the jaws do not open very
wide.

Small allgled CIllters: These cutters were developed as


Figure 8.4: BOlle holdingforceps: (a) Dillgmalljorceps; (b) general purpose cutters for small animals. Applica-
bone llOldillgforceps; (c) self-cemringforceps; (d) kern bOlle tions include tibial crest transposition, and excision
holdillgforceps; (e) Hey Grovesforceps. arthroplasty in small dogs.

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Instruments and Implants 63

Bone rongeurs scoop out cancellous bone or to scrape cartilage from


Bone rongeurs (Figure 8.6), or bone nibblers, are joint surfaces during arthrodesis procedures. The
available in a range of sizes, angles and weights. A Volkman (Figure 8.7) is the industry standard and is
useful selection includes the following. avai lable as a single- or double-ended instrument; it
will scoop diameters from 4 mm to 10 mOl.

..
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I (a)

(b)
:: 1*' (b) -"=--====::::::1

(tI)
(tI)

(e)
...!!::! . 0
(e)

(g)

Figure 8.6: Bone ml1geurs: (a) small angled rongeurs; Figure 8.7: Curettes, elevators, drill guides alld tissue
(b) duckbilled Daniels (Ongellrs; (e) D Olliels rongeurs; protectors: (a) Volkman Clifeffe; (b) Michele's trephine; (e)
(d) compound action spinal rongellrs; (e) Luer (Ongellrs. periosteal elevator; (d) Freer periosteal elevator; (e) tissue
protector; (j) drill guide; (g) ESF tissue protector.
Liters: This is a heavy, simple action rongeur fo r rough
work (e.g. removal of articular facets). Trephines
Trephines are used to cut windows in cortical bone,
Jall sell: This has a compound action with a smaller either to provide access for a bone scoop or to take a
bite than Luers. core of bone for biopsy. The most widely used type is
the Michele's Trephine (Figure 8.7), usually 8 mm in
Daniels: The Daniels has a very small bite and a simple diameter. Some authors suggest that this instrument
action. may also be used to provide access to the spinal canal
but this is not to be recommended.
Small allgled rongeur: This is designed as a general
purpose small animal rongeur. G igJi saws
The gigli saw (Figure 8.5) is essentially a bone cutting
Osteotomes wire with handles. This device can be threaded around
Osteotomes (Figure 8.5) possess a very fine, very bones which ha ve limited access for conventional
sharp blade between 4 and 25 nun wide. They are used saws (e.g. excision arthroplasty and the ischial cut in
to slice through bone during elective osteotomies such the triple pelvic procedure). To-and-fro movement of
as trochanteric osteotom y and excision arth rop lasty. the wire cuts through the bone. Unfortunately the
' teeth ' on the wire are usually too coarse for medium-
Chisels a nd gouges sized and small patients.
Chisels (Figure 8.5) are very much heavier than
osteotomes in construction and have a bevelled blade. Periosteal elevators
Their use is rare in veterinary orthopaedics. Gouges These elevators (Figure 8.7) are used to reflect muscle
have curved blades of varying radii. from bone. They vary in tip shape, size and degree of
sharpness. A double-ended general purpose instru-
Bone curettes ment is ava ilable for most situations. A finer instru-
Curettes will not cut cortical bone but may be used to ment, the Freer, is useful in spinal procedures.

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64 Manual of Small Animal Fracture Repair and Management

Orthopaedic retractors ment of weights) brings the broad part of the blade into
Retractors (Figure 8.8) are used in orthopaedics to contact with overlying soft tissues, usually muscle
maximize exposure and minimize soft tissue trauma. masses, pushing them away and down. The overall
This in tum leads to faster surgery. Appropriate retrac- effect is to appear to e levate the bone in the exposure.
tion can significantly reduce post-operati ve complica- The degree of retraction will vary with tip length and
tions. blade width.
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Skin and superficial muscle layers may be retracted The most useful Hohmann in veterinary orthopae-
using the general retractors such as Langenbeck's, dics is the 18 mm blade with a short narrow tip. TillS
West's or Travers' . The modified Gelpi hasshortertips variant is almost synonymous with the tenn 'Hohmann'.
than the standard version and may be used as a super- Examples of use include: retraction of tensor fascia
ficial tissue retractor but it is better known as a focal lata to expose the lateral fabella in the over-the-top
deep retractor used to create a window in the soft technique of anterior cruciate ligament repair; eleva-
tissues over a lesion (e.g. OeD in the shoulder and tion of the femoral head and neck for arthroplasty or
elbow). total hip replacement.
Other useful Hohmanns are smaller-scale versions
of the same basic style of the 18 mm with a short
narrow tip, e.g. 12 mm and 8 mm.
The 18 mm Hohmann may also be used to advance

. <S oQ (a)
the tibial plateau relative to the femoral condyles for
the examination of the menisci. The tip is placed
behind the tibia and the blade is levered against the
trochlea. A much better instrument for this important
procedure is the Stifle Distractor (Veterinary Instru-
mentation) which produces much less distortion of the
menisci. These distortions can be confused with
menisceal tears.

(e) Tissue protectors


Twist drills and the various types of threaded external

~
0 fixator pin have a great tendency to attach themselves
to soft tissues, which then become wrapped around the
drill or pin. The consequences may be very severe if the
,0 tissues include nerves or blood vessels. In a large

~ ;: exposure (during plating, for example) it is possible to


clear all soft tissue away from the drill site without
causing extra soft tissue damage. In other procedures
a linUted dissection is desirable to minimize devascu-
larization. In these situations a tissue protector (Figure
~ .21)
= ) if)
8.7) can be very useful.
The tissue protector is in essence a short stainless
Figure 8.8: Retractors: (a) Hohmann; (b) smaiL Gelpi self- steel tube with small teeth at the distal end which can
retainil1g; (e) Gelpi self-retaining; (d) West 's self-retaining; be introduced through the soft tissues and held on to
(e) Travers' self-retaining; (f) Langel/beck 's. the bone. The drill or pin is passed down the tube
without contact with soft tissues. The tissue protector
Hohmann retractors may also be used as a locating device for the drill or
Over a dozen Hohmann variants are to be found in pin, ensuring that bone entry occurs at exactly the
human orthopaedics. Only about four are found in right point. Without such a device, drills (and to a
regular usage in veterinary surgery. The spike part of lesser degree pins) tend to 'skate ' over the bone
the blade is placed at the posterior aspect of the bone surface. This results at best in incorrect positioning of
to be exposed. The tip acts as a fulcrum for the rest of the drill or pin. At worst the drill or pin slides off the
the blade. Downward pressure on the handle (the holes edge of the bone, with consequent damage to patient
in the handle were originally designed for the attach- or surgeon.

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CHAPTER NINE - - - - - - - - - - - - - - - - - - -

Principles of Fracture Surgery


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Andrew Miller

PRE-OPERATIVE MANAGEMENT Estimation of prognosis/client expectations


Most fractures will heal. Some, however, will not heal
Diagnosis or will heal in an inappropriate manner. In some cases
Diagnosis of fracture is usually relatively straightfo r- healing of the fracture may not be accompanied by the
ward o n clinical or radiographic gro unds. Some frac- return of full limb use or full athleti c ability. It is
tures may be difficult to diagnose, e.g. non-displaced, helpful to be able to predict the chances of fracture
incomplete or stress fractures . In some cases there treatment being successful in each case, wheth er in a
may be multiple injuries in the same o r different sedentary pet or a racing Greyhound. Experience with
locati ons and it is easy to overl ook more subtle a broad range of injuries, good recording of previous
lesions by concentrating on an obvious fracture. results and appreciation of the requirements of the
A complete dia gnosis should include patient signal- patient's owner will assist in this.
ment , location and type of fracture; distal metaphy-
sea l fractures of the radius and ulna in a 12-week-old Predicting complications
Great Dane and a 7-year-old Poodle differ signifi- Some fractures are prone to particular predictable com-
cantl y. plications. Joint stiffness and osteoarthritis are possible
Fractureclassification systems have been discussed following articular fractures. Distal radius and ulna
in Chapter I. fractures in toy breed dogs are predisposed to non-
union. Constipation or obstipation may occur following
Treatment options non-surgical management of some pelvic fractures,
A full diagnosis allows consideration of treatment particularly in cats. Any surgical fracture repair in-
o ptions. Cons ideration must be given to: volvesa certain risk of infection. Unanticipated compli-
cations can bedifficultto explain and it is worth spending
Fracture type and location a few minutes discussing possible complications with
Age, size and function of patient clients prior to undertaking fracture treatment.
Type and quality of bone invo lved
In vo lvement of joint surfaces Estimation of costs
Open or closed fracture The cheapest fracture treatment is the one that works
Single or multiple fractures first time. Estimating the cost of fracture treatment is
Single or multiple limb in vo lvement never easy. It is usuall y helpful to itemi ze anticipated
In volvement of other tissues (e.g. neural tissue, costs prior to obtaining consent for treatment from the
pelvic canal contents) client and to explain w hether the cost includes follow-
Magnitude and direction of forces acting at the up examinations or treatment of complications. The
fracture site treatment that appears cheapest on paper may actually
Experi ence of surgeon work out much more expensive (e.g. cast fixatioll of
Owner's requirements and resources distal radius and uhla fracture ifno ll-unio n results) and
Equipment ava ilable. expected success rate and ris k of complications sho uld
be taken into consideration. Consider also whether
PRACTICAL TIP th ere might be any complicating factors as yet undiag-
It is usually good practice to have several nosed (e.g. pneumothorax, ruptured bladder).
treatment options available. In cases of diffi-
cult fractures or high owner expectations, Patient preparation
consideration should be given to referral of
the patient to a specialist surgical cenb'e at Patient stabilization
the outset. It is beyond the scope of this manual to describe critical
care procedures in detail. Most fracture patients will

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66 Manual of Small Animal Fracture Repa ir and Management

have suffered majortrallma and are very li kely to require Anaesthesia and analgesia
supportive treatment for shock and pain. Other relevant All fracture patients must be provided wi th adequate
features might include respiratory compromise, haem- analgesia throughout all phases of treatment. Useful
orrhage, injury to vital organs and open wounds. drugs may range from non-steroidal anti -inflamma-
tory drugs (NSAIDs) to morphiates. It is beyond the
Patient assessment and minimum database scope of this manual to describe general anaesthesia
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It must never be forgotten that every fracture is anached procedures in detail. The reader is referred to the
to a patient and the whole patient must be assessed prior standard texts.
to fracture treatment. A full physical examination should
be undertaken, as well as selected radiographic and
laboratory examinations. Factors to consider include: WARNINGS
Due to enhanced toxicity, combinations of
Presence of other injuries (bony or soft tissue)
NSAIDs and glucocorticoids should not be
Presence of underlying pathology (e.g. neoplasia,
used.
nutritional bone disease).
NSAIDs should be used with caution in the
Examinations indicated in particular circumstances peri-operative period.
might include:

Rectal temperature and body weight Supportive therapy


PCV and total protein estimation Obvious supporti ve measures include:
ECG
Radiograpllic examination of thorax and abdomen Intravenous fluid therapy (crystalloid, colloid, blood)
(e.g. trauma cases, possibility of neoplasia) Adequate analgesia
Radiographic examination of contralateral limb, Care of traumatic or surgical wounds
pelvis or spine (e.g. in animals with an obvious Prophylactic antibiosis (see later)
unilateral limb fracture that are non-ambulatory) Adequate nutrition (nutritional requirements are
Selected contrast radiographic procedures (e.g. often increased in the face of anorexia)
retrograde urethrography in pelvic fractures, Regular bladder emptying and prevention of
myelography in some spinal fractures). decubitus sores in recumbent patients
Assisted ambulation and physiotherapy.
Examinations may have to be repeated in some cases
and results should always be recorded. Surgeon preparation

Temporary fract ure support Theatre practice


Fractures distal to the elbow or stifle will usually It is good practice to aspire towa rds a completely clean
benefit from temporary external support until defini- operating environment. To this end, the following
tive treatment is possible. A bulky bandage is ideal for measures are recommended:
this but must extend well proximal and distal to the
fracture. Benefits to the patient include reduction in Allow the minimum of air movement - avoid
pain and prevention of further tissue injury, such as constant procession of casual observers, doors
development of a closed fracture into an open wo und. opening, etc.
This is particularly important if the patient is to be Clip hair and clean the patient 's skin in a
transported. In addition, haemorrhage and swelling different room
will be reduced, wllich aids the surgeon. Fractures Empty patient's bladder and rectum prior to
proximal to the elbow and stifle can be difficult to travelling to theatre.
immobilize satisfactorily and may be better left unsup-
ported, as long as adequate provision is made for
analgesia and confinement of the patient. If external Surgical attire
support is desired, a bandage encircling the body may All operating theatre persollnel should wea r some type
be applied. Definitive treatment of fractures using of theatre suit with surgical hood or cap and mask, as
external support alone is discussed in Chapter 7. well as clean theatre shoes. Outdoor clothes and shoes
are not acceptable. The surgeon and assistant(s) should
PRACTICAL TIP wear sterile operating gowns. Surgical attire need not
It is important to make an effort to maintain be expensive but it should be dedicated.
normal joint angulation during bandage Good scrub technique for the surgeon and patient is
application. essential and the surgeon and assistant(s) should wear
surgical gloves.

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Principles of Fracture Surgery 67

PERI-OPERATIVE MANAGEMENT WARNING


Use of prophylactic antibiotics will not
Aseptic technique compensate for poor preparation or surgical
Instruments technique.
Instruments and implants are best autoclave sterili zed,
unless suppli ed sterile. Ethylene oxide isan acceptable Surgical technique
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substitute. It is imponant to check periodically that the


sterilization process is working properly and to handle SUI·gical anatomy and approaches
and store sterili zed materials properly. Familiarity with surgi cal anatomy and approaches is
absolutely essential. It must always be borne in mind
Drapes and draping techniques that anatomy may be severely deranged following trauma
Drapes may be traditional reusable cloth or disposable. and surgical landmarks may have been altered or oblit-
They should be large, easy to handle and, ideally, erated. Majorsurgical approaches and procedures should
impenneable to fluids in order to prevent 'strikethrough' be practised on cadavers wherever possible before being
infection by wicking of bacteria. Draping techniques are attempted forthe fi rst time in the li ve animal. Reference
a matter of personal preference. Free-limb draping is to Piermattei (1993) is strongly recommended.
often required to allow wide access to an injured limb
and it is imponant to be able to drape the distal limb Instrumentation
safely and effecti vely. Secondary draping following the There is no substitute for an adequate range of s urgical
initial skin incision is recommended, to reduce direct instrumentation and implants. In particular, suitab le
contact between surgeon and patient. Small towels or retractors and bone ho lding instruments are required.
drapes may be clipped to the skin edges or adhesive It is often helpful to pack particular sets of instru-
plastic drapes may be applied, though these often loosen ments together. Figures 9.1 to 9.3 sho w examples of
rapidly due to haemorrhage. such kits.

Prophylactic antibiosis Tissue handling


The use of prophylactic antibiotics is justifiable in Bone and so ft ti ssues s hould be handl ed as
fracture surgery. Fractures may be contaminated, tis- atraumatically as poss ible. Surgical approaches that
sues will certainl y be severely traumati zed, operating
time may be prolonged and substantial amounts of
foreign material may be insen ed. All of these factors
increase the risk of bacterial contamination or reduce
the local host defence mechanisms. Infected fractures
require therapeutic use of antibiotics.
Suitable drugs for antibiotic prophylax is should be
effecti ve aga inst anticipated contaminants and present
at the operati ve site in effecti ve concentrations for an
appropriate period. This can be achieved by considera-
tion of the following factors:

Knowledge of th e bacterial flora of the operating


Figure 9.1: Fracture kif illsfr/lmellfs. Upper row (left to right):
environment (e.g. by regular bacterial audit using Hey Groves, Bums, Kern bone holding/oreeps; seleClioll of
strategically placed dishes of bacterial growth Hohmann retractors; Gelpi se/fretaining retractors. Lower row
medium; recordin g results of bacteriological (left 10 right): slIlall bone holding/oreeps (two); farge alld slIlall
exarn.ination of post-operati ve infectio ns) pointed reduction/oreeps; small osteolOme; periosteal elevator.
Administration of selected drug(s) by a suitable
route at a suitable time (e.g. intraveno us ly at the
time of induction of anaesthesia)
Maintenance of antibacterial concentration for an
appropriate period (e.g. by repeated intravenous
injection if duration of surgery exceeds 90
minutes; by systemic administration for 24-72
hours foll owing surgery).

PRACTICAL TIP
The author's current empirical choice of
antibiotic for routine use is c1avulanate- Figure 9.2: Pin and wire kit inSfrUl1Iellts. Upper row: pill
potentiated amoxycillin. benders. Lower row (left to right) : wire ciltler/twisters (two);
small chuck and key; large and small pin cutters.

..
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68 Manual of Small Animal Fracture Repair and Management

ure 9.4). Operati ve time and soft tissue trauma should be


kept to a minimum, so a precise plan of action should be
made and followed. Surgical anatomy should be re-
viewed with consideration of approaches, positioning of
retractors, etc. Radiographs taken in at least two
orthogonal planes should be studied and fracture recon-
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struction rehearsed mentall y or by the use of tracings of


fracture fragments. Particular consideration should be
given to potential locations for lag screws and bone
plates, if plate fixation is planned. Reference to speci-
men bones can be very valuable for planning fragment
reconstruction, reviewing anatomy and ori entation and
pre-bending of implants prior to sterili zation in some
cases (e.g. pelvis). Several options should be considered
and ranked, so that there is at least one back-up plan if
the original strategy must be discarded for whatever
reason. The patient should be completely prepared and
draped and all instrumentation should be assembled
prior to the initial skin incision being made.

Figure 9.3: Range oj drills, guards, depth gallges alld taps M ultiple injuries
for screw insertion
The presence of multiple orthopaedic injuries or involve-
allow separation rather than incision of muscles or ment of more than one limb wi ll influence choice of
tendons should be planned. Osteotomy is preferable to fixation method. In these situations the optimal (i.e.
tenotomy. Sharp dissection and a 'no touch ' surgical strongest) fixation method should always be selected as
technique should be practised whenever possible. Im- the repaired fracture(s) will be loaded to a far greater
portant soft tissue structures (blood vessels, nerves) extent in the early stages of healing than in solitary injuries
should be identified and protected. Penrose drains are and fixation failure is significantly more likely to occur.
ideal for gentle retraction of nerves. In general, it is better to treat multiple injuries during a
single operating session, assuming that the patient's
Haemostasis and irrigation condition and the surgeon's expertise allows for this.
Good haemostasis allows a clear surgical field and
reduces the like lihood of post-operative wound infec- Decision-making in fracture reconstruction
tion due to bacterial strikethrough of blood-soaked Fracture healing requires adequate fracture reduction,
drapes orthe presence of an infected haematoma. Used stability and vascularity and a balance between these
surgical swabs or sponges should be counted and must be achieved. Most fract ures should be recon-
disposed of immediately into a bin or bucket rather structed as accurately as possible (as long as doing so
than being deposited on drapes or instrument trays. does not compromise their vascular supply or the
Tourniquets can be very helpful in minimizing surrounding soft tissue envelope) and then stabilized
intra-operative haemorrhage, especially in the distal as rigidly as possible, using the chosen method. Perfect
li mb, but must be applied with caution (Blass and anatomical recon struction remains mandatory in ar-
Moore 1984) . Electrocautery is very useful and bipolar ticular fractures.
cautery is usually more effective and controllable than Some comminuted diaphyseal fractures cannot be
monopolar. Surgical suction is very helpful for re- anatomically reconstructed due to severity of conuni-
moval of gross haemorrhage or irrigating fluids. mltion or small fragment size. Under these circum-
The surgical field should be irrigated regu larl y stances it may be advantageous to simplify the fracture
using sterile saline or lactated Ringer's solution to by partial reconstruction and then perform osteotomy
refresh exposed tissues and wash away blood and of bone ends to increase cortical contact (Figure 9.5).
bacteria. Dilution of bacterial populations helps to Imperfect or even no reconstruction may be prefer-
decrease the pathogen load at the end of surgery. able to causing excessive further soft tissue damage in
Various antibacterial irrigating solutions are available selected severely conuninuted diaphyseal fractures. In
but their value is unclear. Irrigation fluids should be such cases a minimally invasive strategy (MIS) may be
aspirated promptly and completely from the surgical adopted (see Chapter 10). This involves 'spatial rea-
site and drapes should be kept dry. lignment' (Aron et at., 1995); that is, re-establishing
normal bone length with less than five degrees of
Fracture planning rotational or angular malalignmentofthe proximal and
The importance of preparing a surgical strategy before distal ends (or joints) and at least 50 % axial overlap.
commencing surgery cannot be over-emphasized (Fig- Spatial realignment may be achieved closed - for

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Principles of Fracture Surgery 69

I Fracture type I

IDiaphyseal or Articular?
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Number of fractures
Additional musculoskeletal
IOpen* or Closed? I injuries

1 Size of 1
patient Bone type I
I Simple or Conuninllted? I
I I
!
IReconstrllctable I I Non-reconstructable I I Cortical II Cancellous I Age, health,
soft tissue
I viability
t t
IButtress 1 Simplify and 1
reconstruct

CONSIDERATION OF
FORCES ACTING AT I EXPECTED RATE I
FRACTURE SITE(S) OFHEALING I

1 No tre~tment 1 1 OPTIMAL , I 1 Specific 1


reqUired TREATMENT contraindications

Extraneous factors
(e.g. finances, temperament,
equipment & expertise
.
available)
IACTUAL TREATMENT PLAN(S) I
Figure 9.4: Fracture treatment planfling. * See Chapter 10 jor management of open wounds alld fractu res.

(a) (b) (e)


(

(
'<!) "

I\ L (

i ![;8
Excise
(

O~~~t~~y·T-- ----r· (

Figure 9.5: Simplification 0/ a cOlllminuted diaphyseal/mcture. (a) Comminuted diaphyseaL/raclure. (b) Partial reconstruction
a/major fragments llsing lag screws to produce inrerjragmel1tary compression. SmallJragments are excised and osteotomy of
major fragmellls is performed to mGzimize bone to bone COlltaCt. (e) A neutralization plate is applied. The bone is inevitably
shortened to some extent. This is rarely problematical in the femur or humerus.


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70 Manual of Small Animal Fracture Repair and Management


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Figure 9.6: (a-c) SevereLy comminuted tibial diaphyseal fracture treated by spatial realigllment a lld buttressillg by all external
skeletal jixator. III the distal limb, spatial realignment may be achieved by suspending the limb vertically. A cancellolls bone
graft may be inserted ijrrearmem;s opel/. (eI) Buttressing the samefraclllre llsing a plate and screws with cancellolls bone graft.

example, by traction on the bone (Johnson el aI. , 1996) Compression may be dynamic, i.e. dependent upon
- or open, in which case an ' open but don 't touch' forces created by loading, or sIatic, i.e. independent of
(OBDT) approac h is adopted towards fracture frag - loading, and may be created in a number of ways:
ments. The intention is to minimize interference with
Cerclage wires (static compression)
fracture fragments and their envelope of organizing
Tension-band wires (dy namic compression)
haematoma and soft tissue in the hope of reducing the
Lagged bone screws (static compression)
likelihood of fragment sequestration.
Tension-band plates (dynamic compression)
Following spatial realignment, the fractured region
Dynamic compression plates (static compression
must be buttressed rigidly to allow for weightbearing on
unless used as tension band).
the limb wllile the fracture heals and this can be achieved
using an extemal skeletal fixator (+/- intramedullary (See Operati ve Techniques 9.2, 9.3, 9.5 and 9.6.)
pin +/- 'tie-in ' configuration), a buttress plate (+/- Static compression is often temporary due to the
inttamedullary pin) or an interlockin g nail (Figure 9.6). viscoelastic nature of bone and bone remodelling.
It is important to realize that the minimally in vasive Following fracture reconstruction, forces acting at
strategy does not represent an abandollment of AO/ the fracture site may be neutrali zed using some device
ASIF principles (see section below). Rather, tins plnlo- - usuall y a bone plate or external ske leta l fixator that
sophy is deri ved from increased understanding of the spans the fracture completely and transmits loading
relevance of interfragmentary strain on bone cells and forces between proximal and distal intact fragm ents.
fracture healing and depends upon ri gid fi xation. The There should be some degree of load sharing by bone
combination of many large interfragmentary gaps and and implant at the fracture site (see Operative Tech-
rigid fiXation minimizes interfragmentary movement nique 9.6).
and tllereforestrain, optimizing the local environment for Fractures that cannot be reconstructed and there-
the production of new bone. It is believed that, in some fore catmot share in load bearing may be buttressed
cases, fracture healing can be by inttamembranous ossi- using bone plates or external fixators. In this situation
fication, i.e. the direct production and mineralization of the implant is responsible for all load bearing (see
osteoid without intervening cartilaginous tissue. Thjs Operative Teclltliques 9.4 and 9.6).
rapid healing can be coupled with earl y limb use, so that The interlocking nail is also applicable to neutrali -
fracture disease is prevented. Clearly, rigid support by zation or buttressing.
buttressingdevicesrequi res thattlleyareextremelysttong, Compression is he lpful in fracture stabili zation and
and a clear understanding by the surgeon ofbiomechanical hea ling, but it is not always feasibleordesirable. When
concepts sllch as area moment of inertia, polarmoment of formu lating a treatment plan, it is important to identify
inertia and interfragmentary strain is required. whether interfragmentary compression is possible or
desirab le, or indeed whether the fracture can be recon-
Compression, neutralization or buttressing? structed fu ll y, partially or not at all.
Interfragmentary compression minimizes fracture gap Fracture fixation options are sununarized in Table
and increases interfragmentary friction and stability. 9.1.

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Principles of Fracture Surgery 71

Fracture type Ideal fixation * C ompromise fixation

Simple transverse diaphyseal Compression plating External coaptation


External fi xator
Intramedu llary pin plus externa l
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fi xator
Interlockin g nai I
Non-compression plate

Oblique or spiral diaphyseal Interfrag mentary compression Interfragmentary compression by


by lag screw(s) plus cerclage wires and intramedullary
neutralization plating pmnmg
Interfragmentary compression by
cerclage wires or lag screws and
externa l fixator
Interl ocking nail
Intramedu llary pin

Comminuted diaphyseal! Interfrag mentary compression Partial reconstruction using inter-


by lag screws plus fragmentary lag screws followed by
neutrali zation plating transverse osteotomy (simplification)
and neutralization plating
Partial reconstruction using
interfragmentary lag screws or
cerclage wires followed by
buttressing using plate or ESF.
Minimal or no reconstruction
followed by buttressing using
plate, pin and plate, interlocking
nai l, pin and external skeletal
fixator, or external fixator alone
(See Chapter 10)

Articular fracture Anatomical reconstruction K-wire fixation if fragm ents


and ri gid internal fi xation small
with interfragmentary Fragment excision if very small
compression using lag screws
Arthrodesis if severe derangement
± plates
of articular surface
Non-surg ical management (e.g.
selected acetabular fractures)

Open fracture Externa l fi xator Amputation if severe dera ngement


Plate and screws in selected of limb
fractures

Avulsion fracture Tension-band technique Lag screw fixa tion

Pathological fracture No fixation Depends upon pathology, necessity


Address underl ying of fixation and type/location of
pathology fracture .
Tab le 9.1: Fractllre fixatiol1 options.
• Ideal fixal ;oo method is dC lcnnincd by the perceived ba lance betwee n qu ali ty offmclUrc reduct ion, degree of ri gidi ty offi~;u;on 3ml J I110UlI l of soft ti ss lle damage causcd in achiev ing t he~,-, for any
given rr~Clu re and pa tient age or typc. Other factors. includin g surgeon 's experie nce. personal prefere nces and inSlrtlmenlalioll avai lab le. must also be taken imo account. These recommendat ions
are ba~d upon Ihe author 's preferen ces
t Seve rel y commin uted fmclurcs can prcscll1 a rea l chall enge to the surgeon and serious considerat ion must be givcllto Ihe va lue of rcconsl ruction versus the risk of fu rther iulrogenic trallllW . Under
lhese circu llIswnces the ideal fixat ion met hod depends II [XJn Ihe morphology of the fraCiure and alrnOSI any of Ihe methods listed may be regarded as appropriu le allemat ivcs.

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72 Manual of Small Animal Fracture Repair and Management

Fracture reduction and stabilization osteoblasts and induce formation of new bone
Methods of reducing fracture fragments include (BMP; bone morphogenetic proteins). BMP is
toggling, leverage and traction/counter-traction in sim- now produced synthetically (Kirker-Head, 1995)
ple fractures and the use of various fragment forceps in Filling of interfragm entary defects and/or
comminuted or small-fragment fractures. Pre-opera- provision of structural support.
tive traction (e.g. by suspending the limb) may be
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useful in stretching or fati guing muscles, thereby fa- Bone grafting is indicated in any situation where it is
cilitating reduction. anticipated that healing could be delayed:
Fragments may be stabili zed temporarily using
fragment or bone holding forceps. Temporary Kirschner Comminuted fractures
wires (K-wires) may be driven across the fracture site Presence of bony defects
or cerclage wires passed around it before definitive Delayed or non-union fractures
fi xation is applied. Alternatively, fragments may be Elderly patients
reconstructed using lag screws or cerclage wires to Arthrodesis.
restore bone anatomy prior to the application of neu-
tralizing or buttressing devices. WARNING
Bone graft, usually being dead tissue, should
PRACTICAL TIP be used with caution in the face of infection.
Many fractures require specific mani- Cortical bone graft is contmindicated in this
pulations to effect reduction. These can often circumstance.
only be learned by experience or from more
experienced colleagues, but wherever possi- Bone for grafting can be obtained from a number of
ble they have been descrihed in appropriate sites :
sections of this manual.
Cancellous bone: proximal humeral or tibial
Fragment management metaphysis, wing of ilium
Bone fragments must be handled with care. Soft tissue Corti co-cancellous bone: wing of ilium, rib, ulna
attachments should be maintained if possible . Any Cortical bone: ulna (autogenous), most long
fragment devoid of a substantial soft tissue attachment bones (allograft).
is dead bone and its potential value in reconstruction
must be weighed against the risk of infection and The most commonly used site is the proximal humeral
sequestration. Free fragments that can be stabilized metaphysis, as a large volume of cancellous bone can
securely by interfragmentary compression and that be obtained with least donor site morbidity (pen wick et
contribute to reconstruction and overall stability may aI., 1991). Use of long bones carries the risk of iatro-
be retained. Others should be discarded. Alternatively, genic fracture. As an alternative, cortico-cancellous
fragments may be left undisturbed and the fracture bone sludge can be obtained from the wing ofthe ilium
buttressed. The intention is that the fragments will then using a power reamer (Culvenor and Parker, 1996;
be incorporated in the healing process. Stallings et aI., 1997).
Solid cortical or corti co-cancellous bone grafts
Bone grafting: types, indications and application must be rigidly stabilized. Soft cancellous or cortico-
Three types of bone graft are used in fracture surgery; cancellous grafts are simply packed around fracture
cancellous, cortico-cancellous and cortical. Bone sites and maintained in position by surrounding soft
grafts in small animal s urgery are usually avascular, tissues.
although vasculari zed bone grafting is possibl e
(Szentimrey and Fowler, 1994; Szentimrey et aI. , Drains
1995). Bone autograft (derived from the same indi- Drains are used only rarely following fracture surgery,
vidual) or allograft (derived from a different indi- probably due to concern over the risk of ascending
vidual of the same species) can be used. Zenograft infection. Closed suction drainage can be useful for
(bone obtained from a diffe rent species) is not used in 12- 24 hours post-operatively ifmajorfluid accumula-
small animal surgery. Autogenous cancellous bone tion is anticipated.
graft is by far the most useful. Bone grafts speed
fracture healing in several ways: Post-operative external support
Bandaging can be useful for a few days following
Osteoconduction: provision of a scaffold for surgery to liIT1it post-operative swelling and thereby
neovasculari zation and new bone formation reduce patient discomfort, protect the surgical wound
(Elkins and Jones, 1988) and optimize tissue perfusion. In certain circumstances,
Osteoinduction: provision of factors that recruit external support may be necessary to supplement in-
local pluripotential cells to differentiate into ternal fixation devices.

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Principles of Fracture Surgery 73

Principles of use of pins and wires of the smaller fragment


The advantages and disadvantages of different types of One end should have a sledge-runner tip
pin are shown in Tables 9.2 to 9.4, and indications and The other end should be hooked
contra indications are given ill Tables 9.5 to 9.7. The whole pin is sLightly curved.

Kirschner wires The use of Rush pins is iIIustraled in Chapter 18.


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K-wires are solid steel pins of 0.9-2 mm diameler.


They may ha ve trocar or bayonet tips. Arthrodesis Interlocking nails
wires are the most usefu l, ha ving a trocar tip at each An interlocking nai l (ILN) is a solid steel rod 6 or 8 mm
end. in diameter, with a number of holes in itthrough which
bone screws can be inserted to fix the rod within the
Steinman pins bone and eliminate rotati onal and axial movement
These pins are solid steel rods, circular in cross- (See Chapter 3). The screws are inserted using either a
seclion. They are available in sizes from 1.6 to 8 mm specially designed jig or fluoroscopy. The 8 mm ILN
in diameler and 300 lrun in length and generall y have appears to provide superi or resistance to bending and
trocar tips at each end. One end may be threaded, which torsion than comparable plate or external fi xator re-
may reduce pin migration. pairs (Dueland et al., 1996). Interlockin g nails are used
increasingly in humans and their use is becoming
Rush pins accepted in veterina ry surgery (Muir et aI., 1993) .
Rush pins are a form of dynamic intramedullary cross-
pilming, most often used for the fixation of dista l Kuntscher nails
femoral condylar fractures (Lawson, 1959; Campbell, These are hollow trefoil (c1overlea!) or V-shaped nails,
1976). They are best manufactured as required, using usually with a taper at one end and a slot used for
appropriately sized K-wires or small Steinman pins removing the nail at the other. They are available in
according to the following guidelines. greater widths than Steimnan pins, but are of little use
in small animal orthopaedics.
Pins should not exceed one-third of the width of
the medullary canal Eliminating rotational instability
Pins should be approximately 3 times the length Rotation in long bone fractures is a major problem with

Advantages Disadvantages
Resist bending forces well due to location at neutral Resist rotation, distraction and shearin g very poorl y
axis of bone Rarely provide adequate stability alone
Quick and easy to insert and remove May allow wicking of bacteria along medullary
Little special equipment or training required canal
Fracture healing relatively easy to assess
Table 9.2: Advallfages and disadvaflfages of illframeduliary pillS.

Advantages Disadvantages
Resist bending forces well due to location at neutral Insertion technique requires practice
ax is of bone Limited usefulness other than distal femur
Resist rotation well due to spring-loaded effect
Fracture healing relatively easy to assess

Table 9.3: Advamages alld disadvantages of Rush pins.

Advantages Disadvantages
Resist bending fo rces well due to location at neutral Difficult to insert and remove
axis of bone Special equipment and training required
Resist rotation, distraction and shearing well due to
interlocking function
Fracture healing relatively easy to assess
Table 9.4: Advantages alld disadvantages of illferlockillg nails.

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74 Man ua l of Small Animal Fracture Repair and Management

I
Indications Contraindications
Completely reducible, intrins icall y stable simple Irreducible fractures with s ignificant rota ti on,
transverse' or short obuque interlocking di aphyseal distraction or shearing
fractures in animals with good healing potential Open or infected fractures
Completely reducible long oblique o r spiral frac- Metaphyseal or articular fra ctures
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tures with cercl age wires


Any fracture where th e pin cannot be inserted
Irreducible severely conuninuted fractures if used safel y (e.g. radius)
in conjuncti on with ESF or plate and screws as part
Avulsion fractures
of a minimall y invasive strategy
Cats
• Many transverse fractures arc poor c3ndidalcs for intramedullary pinning due lO lack of rcsisl anc.: 10 TOIalion

Table 9.5: I lldicatiolls alld colltrailldicatiollsjor intramedullary pillS.

Indications Contra indications


Distal fe moral condylar fractures Open or infected fractures
Selected other metaphyseal fractures Avulsion fractures
Comminuted fractures
Table 9.6: Indications alld cOl1traindicatiollS for Rush pillS.

Indications Contra indications


Diaphyseal fractures of the long bones Open or infected fractures
Irreducible severely comminuted fractures Metaphyseal or articular fractures
Avulsion fractures
Any fractures w here the pin cannot be in serted
safe ly (e.g. radius)
Table 9. 7: Indications alld comrailldicGriolls/or illler/ocking flails.

intramedull ary pins as, in general, they are very poor at disad va ntages relating to potential fo r sarcoma induc-
resisting it. Rotati on within the developing callus is a ti on and relative mismatch between ri gidity of bone
major obstacle to healing and a common cause of and implant. Rods fo rm ed fro m self-re inforced
delayed o r non-uni on. Rotational instability can be polyga lactide or polylactide have been d escribed for
minimized by the follo wing meas ures: use in cancellous bone and, mo re recently, in the
diaphysis (Axelson et al., 1988; Riiihii et a1. , 1993a,b) .
· Select transverse or short oblique interlockin g Suggested benefits include a gradu al tran sfer of stress
fractures with good intrinsic rotational stability fro m implant to bone durin g th e healin g phase and
(NB: rotational stability is often poor in such avoidance of a second surgery for implan t removal.
fractures) These implants are inserted into slig htly smaller
· Select fractures with potential for rapid healin g, pre-drilled bone tunnels using specially designed ap-
e.g. s imple fractures in young healthy dogs or plicators. They are diffic ult to remove 0 nee inserted
cats and are radiolucent, although this latter a ttribute may
Use cerclage wires in appropriate long oblique or facilitate assessment of the fracture line. Biodegrad-
s piral fractures able implants have, to date, gained little popularity in
· Use external fi xator as auxiliary fixati on th e UK other than for the reattachment of intra-articu-
· Use plate and screws as auxiliary fi xation lar osteochondra l fragments to the canine tibial tarsal
· Use interlocking nail bo ne, presum ably due to relati vely hi gh costs of
· Use extem al support judiciously. implants and applicators and limited ra nge of sizes
ava ilable.
Use of multiple intramedull ary pins (stack pilming) is
of little value, as pins tend to loosen and migrate. Orthopaedic wire
I
Orthopaedic wire should always be monofi lament steel
Biodegradable rods and should be obtained from the same so urce as pins.
Metallic implants may have th eoreti cal and practi cal Useful diameters range from 0.8 to 1.2 ml n. Wire nar-

Iii

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Principles of Fracture Surgery 75

rower than 0.8 nun or thicker than 1.2 mm cannot be


tightened adequately. Wire may be tightened using
combined cutter/twisters, parallel pliers, or various spe- Distractive force A
cial wire twisters or tighteners. AO/ASIF wires have
looped ends to permit tensioning using a special device.
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Indications and principles of cerclage wire


Full cerclage wires encircle the bone completely. Hemi-
cerclage wires pass through a tunnel in th e bone at
some point, which may provide more secure fixation
but can be challenging to apply. Cerclage wires may be
used to supplement intramedullary pins by applying
interfragmentary compression in long oblique or spiral Distractive force B
fractures, or completely reducible mildly comminuted
Figure 9.7: Tension-band effect: the sum 0/ tlVO forces (A, B)
fractures, but are inappropriate for sole fixation oflong
exerted at different angles will result ill a compressive/orce
bone fraen"es. There is no detrimental effect upon the (e). The example sholVs tensioll -band wiring in the
bone (Wilson, 1987). {rearmem o/tibial tuberosity avulsiol1.
Principles for use of cerclage wire are as foll~ws:
, where a relatively small fragment of bone is detached
Fracture should be fully reconstructable by tensile forces generated by soft tissues to which it is
Length of fracture should be at least 2 times attached (e.g. tibial tuberosity separation, distal tibia l
diameter of bone malleolar fracture, osteotomy of the greater trochanter
At least two cerclage wires should be used ofthe femur). The wire is used in conjunction with one
Wires should be not less than 1 cm apart or two small pins, whose function is to aid in fragment
A ll wires must be tight. stability by resisting the comparatively small angular
or rotational forces.
Tension-band wire
A tension-band is an inelastic device positioned in a Principles of use of external skeletal
location whereby it is placed under tension. The ten- fixation
sion-band, which may be a wire or a plate, converts
tensile force to compression (Figure 9.7). This is Definitions
termed dynamic compression. Tension band wires are External skeletal fixators (external fixators, fixators,
generally indicated for treatment of avu lsion fractures, ESFs) consist of a series of percutaneous transosseous

Size Transfixing pin' Con necting bar


Small 2 mm (1/16-3/32") 3 mm (1/8")
Medium 3 mm (3/32- 1/8") 4 mm (3/16")
Large 4 mm (5/32-3/ 16") 8 mm (5/ 16")
Extra Large 5 mm (3/ 16-1/4") 10 mm (7/ 16")
• Core lIialTlcler or pin

Table 9.8: Externaijixator sizes.

Advantages Disadvantages
Minimal instrumentation required Soft tissue problems possible
Certain components recyc lable! App lication technique requ ires practice
Minima l disruption of local soft tissues Prematu re pin looseni ng common
Minimal fo reign body at fracture site Perception as panacea has led to abuse
Open wound management easy Difficult to apply to proximal limb
Easy to combine with other implants
Rigidity and alignment easily adjustable
Gradual linear and angu lar traction possible,
allowing progressive correction of deformities -
Assessment of fracture healing easy
Easy to remove
t Clamps anll (possibl y) bars may be reusell. PillS may nOi.

Table 9.9: Advantages and disadvantages 0/ externaL skeletal jixation.

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76 Manual of Small Animal Fracture Repair and Management

Indications Contraindications
Diaphyseal fractures Sole fixation method in pro xima l limb
Highly comminuted fractures Situations where anatomical fixati on is required
Open or infected fractures
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Mandibular fractures
Auxi liary fixation
Corrective osteotomy
Transarti cular immobilization
Table 9.10: Indications and cOllfrailldicariofls for external skeletalfixatioll.

transfixing pins th at penetrate both corti ces of the bone


to which they are applied but mayor may not penetrate
soft tissues on both s ides of the limb, connected by
some type of external bares). The pins may be smooth
in outline, or may be centrall y or terminally threaded.
COImecting bars may be steel rods to which th e
transfixing pins are connected by clamps or may be
acry lic resin (e.g. polymethy lmethacrylate bone ce-
ment, denta l acrylic, etc. ). Clamps may be s ing le, to
cOlmect pins to bars, or doub le, for connecting a
number of bars to one another in the assembly of more
complex configurations.
Fixators are extremely versatile devices and are
very well to lerated, but it is prudent to counsel owners
regarding their appearance, or to show photographs of
previous cases.
External fixators are available in a range of sizes
(Table 9.8). The advantages and disadvantages of
external skeletal fi xa tion are shown in Table 9.9, and
the indications and contraindications for its use are in
Table 9.10.

APEFsystem
The acrylic pin external fixator (APEF) system uses
corrugated tubing that is attached to traditional trans-
fi xing pins before being filled with pre-packaged
po lymethylmethacrylate. This system is used in an
identical maImer to traditional systems, but it has th e
Figure 9.8: (a) APEF system comprising traditional
ad vantage that all pins may be inserted prior to app li- transfixing pillS and plastic lIlbillg containing acrylic cement.
cation ofthe connecting bar. Hence, greater versatility (b) Temporary/racture stabilization /Ising removable
in mu ltiplanar pin insertion and more in ventive con- clamps and steel bars. Plastic tubing is pushed over pin ends
fi guration design are possible (Figure 9.8). Acrylic jollowingjracllIre reduction alld bOllom-plugged. Acrylic is
mixed ill self-colllained packets and poured i1ll0 tubing while
appears to be strong enough to satisfy its role as a
still in the liquid phase. Tlte steel damps and bars are
connecting bar (Willer et al., 1991) and APEF systems removed ollce the acrylic is set.
appear to perform we ll in sma ll animals (Okrasins ki el Cour1 ~'Sy of J .P. Lapish
al., 1991 ).
tions on the basic extern al fixatorcould be constntcted,
Configurations but a good philosophy is to apply the simplest configu-
To allow fracture healing, the fi xator must fulfil the rati on that will provide sufficient strength for the job in
biomechanical demands of the particular fracture over hand. W ith current hardware, unilateral systems are
th e required period of time. Fram e configuration and satisfactory for most s ituations and have a lower com-
properties are, therefore, important considerations. plication rate than more complex systems. External
One advantage of fixators is the abi li ty to va ry the fixator configurations are described as uniplanar or
characteristics of the frame, changing the number, size biplanar and unilateral or bilateral (Carmichael, 1991).
and orientation of its components to suit the needs of In addition, ring fixator systems exist (e.g. !lizarov).
any particular fracture. An infinite number of varia- Useful confi gurations are illustrated in Figure 9.9.

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Principles of Fracture Surgery 77

(a) (b) (e)


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(tI) (e) if)

Figure 9.9: External skeletalfixator configurations. (a) Unilateral uniplanar Type ],


halfframe. (b) Unilateral uniplallar extemal skeletalfixator and intramedullary pill
tie-ill. (e) Unilateral biplanar; quadrangular, delta frame. (d) Bilateral unip/anar
(modified) Type 2. (e) Bilateral hiplanar Type 3. (f) !lizarav ring.

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78 Manual of Small Animal Fracture Repair and Management

Altering rigidity of the external skeletal fixator mal stress concentration during loading, especially on
The followin g measures will increase the stiffness of a the cis cortex when unilateral systems are used (cis
unilateral frame. refers to the near cortex; trans is the distant cortex) .
Excessive strain causes bone resorption and replace-
Apply frame in a mechanically advantageous ment with fibrous, synovial-like and cartilaginous
position ti ssue around the pin, with consequent pin loosening.
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Increase the number of transfixing pins (up to Loose pins do not contribute any stability to the fixa-
four per main fragment) tion , but do cause periosteal and soft tissue pain,
Increase the diameter of transfixing pins (up to leading to poor limb use and predisposing to pin tract
20-30% of bone diameter) infection.
Increase the spread of transfixing pins The holding power of pins depends largely on their
Increase the rigidity of the connecting bar (Polio design, the insertion method and the nature and quan-
et al., 1993) tity of the involved bone (Clary and Roe, 1995). Pin-
Increase the number of connecting bars bone purchase is less critical in situations of rapid
Decrease the distance between clamp and skin or healing or good load shari ng between bone and fixator.
contour the cOImecting bar to the limb (Bouvy et The use of threaded pins increases holding power.
al., 1993) Threads may be cut into the pin (negative profile, e.g.
Use a biplanar configuration Ellis pin), or may be rolled on during manufacture
Use intramedullary pin ' tie-in ' configuration (positive profile, e.g. IMEX pin) (See Operative Tech-
(Aron et aI., 1991). nique 9.4). Negative profile pins have the disadvan-
tage that a stress riser exists at the thread/non-thread
The opposite measures can clearly be used to decrease junction. This region must be protected by being
frame stiffness. located within the medullary canal, or else there is a
risk of the pin breaking (Palmer and Aron, 1990).
I1izarov and ring fixators Hence, Ellis pins have a fairly short tltreaded section .
The ring fixators, of which the I1izarov system is one Positive profile pins do not have this weakness, but do
example, offer a different philosophy. These devices ha ve the disadvantage that they cannot be inserted
usea number of very small pins (in effect K-wires) that through fixation clamps. Whatever pin type is se-
are inserted through the limb in whichever plane is lected, it should not exceed 20-30% of the diameterof
most appropriate and connected to an encircling or the bone in question.
hemicircumferential connecting bar. Crucially, these Recommended methods of pin insertion include
pins are tensioned before tightening, making them slow-speed drilling and insertion into slightl y smaller
disproportionately strong in much the same way as the pre-drilled holes, especially for positive profile pins
spokes of a bicycle (Thommasini and Betts, 1991). (Clary and Roe, 1996). High-speed drilling leads to
Ring fixator systems offer tremendous versatility in thermal necrosis of bone and poor fixation; manual
constructing frames to deal with almost any situation. insertion is prone to lead to mechanical damage to the
Complicated fractures, filling bone defects (Lesser bone due to hand wobble (Egger et al., 1986).
1994), correction of angular deformities and limb
lengthening procedures using distraction osteogenesis Post-operative management
(Elkins et al., 1993) can be undertaken. Their main Despite the presence of percutaneous pins, infection is
disadvantages relate to the greater difficulty in appli- rare and antibiotic therapy is not necessary other than
cation and their cumbersome nature as compared with in the peri-operative period. Pin tracts require no
bar fixator systems. specific treatment and are best left to heal by second
intention. The patient should be restricted to the house
External fixator boot and to controlled activity, as fixators can get tangled in
On occasion, in the distal limb, it is necessary to apply trees, bushes, etc. and could be avulsed prematurely.
an external skeletal fixator to the metacarpals or meta- Follow-up radiographs should be taken at regular
tarsals. This is often a transarticular external skeletal intervals. The progression of fracture healing is easy to
fi xator. The arched structure of the bones and their assess as there is minimal hardware at the fracture site
relatively small size may make pin selection and place- to obscure this on radiographs.
ment challenging. A 'boot' of cast material may be
applied to the distal limb and pins incorporated into it Staging down
rather than being driven into the metatarsa ls or As healing progresses and callus formation increases,
metacarpals (Gallacher et aI., 1990, 1992). it is advantageous to decrease the strength ofthe fixator
as the strength of the bone increases. This can be done
Pin design and insertion technique by reversing the measures taken to increase the strength
The pin-bone interface is the weakest link in any of the fixator outlined above. This is usually appropri-
external fixator configuration and the point of maxi- ate around 6 weeks after surgery (Egger et aI., 1993).

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Principles of Fracture Surgery 79

If done too soon, there will be insufficiently strong Types of screw


callus and healing will be retarded due to instability. Screws can be divided broadly into:
Fixators are generally removed piecemeal, firstl y
Cortical and cancellous
by removal of additional connecting bars (if present),
Self-tapping and non self-tapping (ASIF-type).
then by remova l of centrally located transfixing pins.
This can be done without general anaesthesia if Cortical screws have a relatively fine thread pitch and
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desired, although thi s is us ually necessary for are designed for use in thin but hard cortical bone,
radiograph.ic evaluation in any case. There will often although they may also be used in cancellous bone.
be haemorrhage from empty pin tracts, but th.is rarely Cancellous screws have a much coarser pitch and are
requires s pec ific treatm ent other than a light designed for use in cancellous bone only; they have a
bandage. sma ller core diameter and therefore a lower AMI than
Dynamic extemal fi xators exist that allow strictly corresponding cortical screws. They may be full y
controlled axia l micromovement, which increases cal- threaded or partially threaded. Partia lly threaded screws
lus formation and maturation, accelerating clinical can be difficult or impossible to remove following
union (Lanyon and Rubin, 1984). Note that this healing, as bone fills the space left around the non-
micromovement is very strictly controlled, being purely threaded portion.
axia l in nature, and this situation is fundamentally Self-tapping screws ha ve a cutting tip and a 'trian-
different from one of unstable fixation or staging gu lar' thread. These cut th eir own thread in bone,
down. These devices are currently prohibitively ex- inevitably damaging it to some extent. If the screw
pensive for the veterinary market. must be removed during surgery, the tluead will often
strip, necessitating the insertion of a larger screw. The
Principles of use of plates and screws screw head is of the traditional s lotted type. Non-self-
Bone plates act as intemal splints, stabilizing fracture tapping screws have a rounded tip and a ' buttress'
fragments whi le healing occurs. Plates are contoured thread (Figure 9.11) and req uire the use ofa tap to cut
to fit the bone and fixed to it by screws. They depend a tluead in the bone prior to their insertion. The tap
upon friction between plate and bone for their grip. damages the bone much less, so screws can be re-
Plates are generally good at resisting distraction and movedand replaced ifrequired. The tap should always
rotation, but are weaker than intramedullary devices be used, even in soft bone. The screw head has a
with respect to angulation. hexagona l recess to receive the screwdriver and allows
significantly better purchase and less chance of dam-
Types of plate age to the head as compared with the slotted type. The
Bone plates have undergone considerable evolution underside of the head is semi-circular, allowing greater
since their development and some examples are illus- versa ti lity in directing the screw through the plate hole.
trated in Figure 9.10. Screws may be used wi th flat steel washers to
prevent the screw head from sinking into soft bone.
WARNING Screw sizes and appropriate drill sizes are Listed in
The Sherman and Burns style plates and Table 9.11.
sem i-tubular plate are not recommended.
PRACTICAL TIP
Various special plates also exist for use in particular The DCP is the most versatile plate for
situations (e.g. curved plates for acetabular fractures, routine use.
T -plates for metaphyseal fractures) and custom-made The most useful screws are non-self-tapping
plates can be manufactured if required for specific (ASIF-type) cortical screws.
awkward situations.

Screw size Thread hole Gliding hole Tap


1.5 mrn cortical 1.1 mrn 1.5 mm 1.5 mm
2.0 mrn cortical 1.5 mm 2.0mm 2.0mm
2.7 mm cortical 2.0 mrn 2.7mm 2.7 mrn
3.5 mm cortical 2.5 mrn 3.5 mm 3.5 mm
3.5 mm cancellous 2.0 mrn 3.5mm 3.5mm
4.0 mm cancellous 2.0 mrn 4.0mm .. 4.0mm
4.5 mm cortical 3.2mm 4.5mm 4.5 mrn
6.5 mrn cancellous 3.2 mrn 6's"mm 6.5 mrn
Tab le 9.11: Appropriate drill alld lap sizes for various screws.

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80 Manual of Small Animal Fracture Repair and Management

Figure 9. 10: (a) Sherman, Bums style plates: Round holes; (e) Reconstruction plate: DCP-style plate that is notched
plate "arrows considerably between holes, resulting in between screw holes to allow for more versatile
sigllijicollt weakening. three-dimensional bellding. at the cost of some strength.
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Usefllifor pelviC (Dyce alld Houlton, 1993) or distal femoral


condylar fracture repair (Lewis et aI. , /993) where very
complex plate contouring may be required

E5
(b) Semi-tubular plate: Weak plate, designedfor millimal loadillg.
Screw holes may be oval, allowing eccentric screw placement
alld a degree ofaxial compression.
(j) Vete rinary cuftable plate: Semi-tubular, round hole plate.
Purchased as very /ollg plate, from which the required length
is cut. High screw density is useful when bOlle stock is limited
e.g. buttressing severely comm inute,l 10llg bOlle fractures.
May be stacked aile all lOp of another in order to increase
(e) Venables plate: Stronger plate. Screw holes round and strength (McLaughlin et aI., /992). Useful ill smaller bOlles
(Gentry el aI., 1993).
offen illslI/ficiellt /lumber. Modem variant is thicker and
stronger lhall traditional design.

©
(d) Dynamic compression plaIe (D C? ) A OjASI F type: Strollg (g) Limited contact dynamic compression plate (LC- DCP):
plate, specially engineered self-compressing screw holes use Plare with specially-designed undercuts that reduce
'rollillg ball' principle to allow axial compressiolillsing impairment of osseous blood flow by limiting contact area
special 'load' drill guide to position screw hole eccemrically between plate and hOlle and elimillate stress cOllcell1rarion at
ill plate hole. Enormous range of sizes available. The best screw holes. Screw holes are bevelled to allow axial
plate for routille lise. compression in either direction.

~ ~
(It) The DCP screw hole. When the
semi-circular screw head contacts the
'Load' drill guide 'Neutral' drill guide
'shoulder' ill the specially-designed
plate hole the screw slides towards the
(i)

-------11Q~t
fracture site.
(i) The DC? drill guide has'neutral'
alld 'load'fimctions; the 'load' guide
normally has all arrow that should
poillt towards thejracture site. Axial
compression is produced by positioning
the screw eccentrically within the screw
hole i.e. distant from thejracture site.
UJ Tightening the screws results in
compression o/the /ractllre as the
screws slide towards one another.

(h)

axial ,.! minimal axial


Ui . . ... compression compression

.;:
.,
,.
-::
':,. .,
~1)1
--....;~--, .
-------1til~-

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Principles of Fracture Surgery 81

(a) (b) Interfragmentary compression may be dynamic


(i.e. it is produced by axial loading or muscle forces) or
static (i.e. it does not depend on the above forces).

lntelfragmentary compression using lag screws: In-


sertion of a lagged screw across a fracture gap will
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result in interfragmentary compression (see Operative


Figure 9.11: Screws. (a) NOIl~seil·tappi l1g AD-type screw.
Technique 9.5).
(b) set/tapping screw, Lag screw fixation may be the sale method of
fixation (e.g. lateral distal humeral condylar fracture)
or may be used to reconstruct comminuted fracture
AO/ASIF principles and instrumentation fragments. In the latter situation, lag screws may be
The formation of the Arbeitsgemeinschaft fiir used through the plate, or separate from it. Note that lag
Osteosynthesefragen I Association for the Study of screws generate static compression.
Internal Fixation group (AO/ASIF) in Switzerland in
the 1950s was in reaction to an unacceptable incidence WARNING
of fracture disease associated with contemporary frac- Only lag screws should cross fracture lines,
ture fixation methods. The group defined a number of unless this causes fracture collapse.
aims and principles for a rapid return to full function
following fracture treatment (Prieur and Sumner-Smith, Axial compression using plates: Plate fixation with
1984): axial compression is a good way of repairing simple
transverse or short oblique fractures but is not appro-
Anatomical reduction of fracture fragments, priate for comminuted fractures. Plates can generate
especially with respect to articular surfaces axial compression in several ways and more than one
Preservation of blood supply to bone fragments of these may act in any given situation:
and soft tissues by delicate atraumatic surgery
Stable internal fixation, satisfying the Application of the plate to the tension surface of
biomechanical requirements the bone will allow the tension-band effect to
Early active pain-free movement and full weight apply and will result in axial compression of the
bearing of the traumatized limb, avoiding bone under the plate. This is dynamic
fracture disease. compression (Figure 9.12)
Load
The AO/ASIF group also designed novel implants and
instrumentation to achieve these goals, the prime
amongst which is the dynamic compression plate.
It can be seen that, currently, two of the AO/ASIF Load
principles (i.e. anatomical reduction and internal fixa-
tion) are not invariably the surgeon's aim. Other prin-
ciples (i.e. rigid fracture fixation, atraumatic technique
and early mobilization) are still paramount. For a full
description of AO/ASIF philosophy and techniques,
refer to the excellent manual of Brinker et al. (1984). Compression Tension

WARNING
The development of AO principles still Compression Compression
represents one of the most important
advances in the history of orthopaedic
surgery and the surgeon would be ill advised
to ignore them.

Interfragmentary compression
Compression between fracture fragments reduces the
fracture gap and, by increasing interfragmentary fric- Figure 9.12: Tension-band effect using plate. Most bones
tion, increases ' stability. Both these factors help to (e.g. femur) are loaded eccentri~'ally alld have tension and
optimize conditions for healing in the presence of rigid compressiol1 sur/aces. Fractures will there/ore also tend to
have tension and compression surfaces. Application 0/ an
stability. Note that the size of the fracture gapes) can inelastic device (plate) to the tension surface will convert
have a crucial bearing on interfragmentary strain if tensile/orces generated by loading to compression at that
there is interfragmentary movement (see Chapter 3). surface. This l1eed not be a DCP-style plate.

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I
I

82 Manual of Small Animal Fracture Repair and Management

. Use of a tensioning device at the end of the plate span fractures that are not reduced and bear fu lly
can produce static axial compression the forces generated by weight bearing. It is
. Use of a DCP can allow generation of static axial obvious that the plate is extreme Iy vulnerable in
compression by eccentric screw positioning in this situation. Implant strength a nd healing rate
the oval plate hole using a special drill guide (see should be ma ximized.
Operati ve Technique 9.6).
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Application of plate and screws


Neutralization and buttressing The basic guidelines for plate and screw app lication
Axial compression in conuninuted fractures is not are as follows:
desirable. Fracture fragments may be reconstructed
using lag screws, so that interfrag mentary com pres- · Use as long a plate as possible a nd contour it
sian is present. Axial compression subsequent to this accurately to the bone
would disrupt interfragmentary compression. Instead,
plates are used to protect the repaired fracture from
· Engage at least six cortices prox imal and distal to
the fracture
load ing when weightbearing occurs. · Fi ll all screw holes
· All screws must be tight and should engage both
Neutralization plates span the reduced fracture cortices
and transmit loading forces past the fracture (see · Only lag screws may cross fract ure lines (in
Operative Technique 9.6). Variable amounts of some situations lagging a screw across a fra cture
load-sharing between fracture and implant occur. line may cause fragment collaps e; in this
Very accurate plate contouring is essential so situation a position screw may be inserted, thread
that unwanted forces are not created within the cut in both cortices - i.e. no lag effect)
repaired fracture as the screws are tightened.
Buttress plates (see Operative Technique 9.6)
· Avoid cortical defects, especiall yon the
compression surface
· Learn to plan fixation carefully and work
quickly.
PRACTICAL TIP
Compression, neutralization and buttress
Clearly, it is not always possible to fulfil all these
are descriptions of plate application and
guidelines. Some fractures (for exa mple, metaphyseal
function rather than design. The DCP is
or articular fractures) do not allow fo r six cortices to be
most commonly used in all these roles,
engaged on either side. These guide Iines should, how-
although custom-made plates are very useful
ever, form a useful checklist to ap ply to most plate
in buttressing roles.
fixations.

Advantages Disadvantages
Anatomical fracture reconstruction possible Specialist equipment and training required
Healing with little or no external callus formation Wide ex posure of bone required
possible Large foreign body inserted at fract ure site
Most forces acting at the fracture resisted well Substantial investment in materials
Rigid fixation allows early pain-free mobility and
prevents fracture disease

Ta ble 9.12: Advantages and disadvantages aJplate and screw fixation

Indications Contraindications
Fractures involving sizeable fragments that can be Inadequate screw purchase in bone possible (e.g.
reconstructed very young patient, osteopenia)
Fractures where anatomical reconstruction and mini- Selected comminuted fractures in w hich alterna-
mal callus formation are required (e.g. articular tive buttressing methods apply.
fractures)
Any fracture requiring compression
(e.g. non-union)
Buttressing non-reconstructable fractures
Arthrodesis
Table 9.13: indications and cOlltraindications oj plate and screw fixation

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Principles of Fracture Surgery 83

The advantages and disadvantages of plate and


sc rew fi xati on are listed in Table 9. 12, and the indica-
tions and contra indications in Table 9.13.

Combining fixation system: maximizing


rigidity of fixation
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C hemical and physical compatibility


As a rul e, different implant systems should not be
mi xed, du e to possible small differences in chemical
composition that cou ld cause galvanic effects or
variances in dimension that could lead to mis matches,
e.g. between tap and screw sizes (Baumgart, 199 1).
Practi call y spea king, all reputable instruments and
implants should be of identical chemistry and con-
structi on and incompatibility should be unlikely (see
C hapter 8).
Combining different fixation methods can be enor-
mous ly helpful in situations where max imum strength
o r ri gidity of fi xation is required, e .g . for buttressi ng
non-reconstructable severely comm inuted fractures. Figure 9.13: Radiograph of healing comminuted humeral
This approach is generally combined w ith a minimally fracture treated by cerclage wiring alld pinplale blillressing
6 weeks earlier. There is moderate bridging callus formation
in vasive 'open but don't touch' (OBOT) philosophy
(the so-called bia-buttress). The pill had migrated proximally
(see Chapter 10) and allows considerable in venti ve- and was removed. The free and broken screw are remnants
ness. of a failed surgical repair.

Pin-ESF systems va lescence/rehabilitation. Modern fracture fixation


Combining an intramedullary device with an external methods allow rigid immobili zation of th e frac ture
fixat or prod uces a very strong fixation , but significant without immobilization of the limb, and controlled
complications can be assoc iated with th e use of such a limb use should be allowed along with provis ion of
combined device in the proximal limb (Fola nd el aI. , analgesia, in order to minimi ze fracture disease. Vig-
199 1). The intramedullary pin may be a llowed to orous or uncontrolled activity should be avoided until
protrude through the s kin and be clamped to th e con- fracture healing has occurred. Short bouts of leash
nectin g bar of the external fixator. This is a ' ti e-in ' exercise (for exa mple, 10-15 minutes two to three
configuration (see Figure 9. 14). The fl aring of the bone times a day) are genera ll y appropriate for the first 3-4
towards the metaphys is usually allows sufficient room weeks, after which time this may be increased, pending
fo r insertion of transfixing pins. th e res ults of follow-up rad iography.

Pin-plate systems Physiotherapy


Combining an intramedullary pin with a plate is even Physiotherapy is diffic ult to use to any great extent in
more rigid (Hulse et aI., 1994). To faci litate sc rew dogs and cats for reaso ns of practi cality and expense.
inserti on, th e pin should be 50-70% ofthe diameter of In most cases, however, owners can be instructed in a
the medullary cavity (Figure 9.13). Monocortical screws few simple flexion -extension exercises if appropriate.
may be used with success. Controlled or even assisted ambul ation is useful and
swi mming can be particularly beneficial once skin
wounds have sealed, allowing full limb mobilization
POST-OPERATIVE MANAGEMENT and maintaining muscle bulk without excessive load-
ing of repaired fractures. Many equine rehabilitation
Client education units are happy to allow dog owners to use their
facilities and a few swimming pools specifically for
Rest "equirements dogs now exist. Experienced supervision is required
Requirements for post-operati ve care of fracture sur- for swimming in order to eliminate vio lent uncon-
gery patients must be explained clearl y to their ow ners trolled movement in the early stages of healing.
and doc um ented on case notes. Written directions
PRACTICAL TIP
sho uld be provided for owners wherever possible. The
Frequent short bouts of exercise or
traditional view that cage rest should be advocated
physiotherapy are superior to infrequent
following fracture surgery is out-dated and in most
long bouts.
cases detrimental to fracture healing and patient con-

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84 Manual of Small Animal Fracture Repair and Management

Following up protection ' ), though this may be less important than


previously believed (Glennon er aI., 1994; Muir er aI.,
Critical appraisal of fracture repair 1995). Implants will also occasionally loosen, espe-
Constant self-appraisal is essential to maintain and cially pins, and may cause discomfort if they are loose
improve standards. Radiographs of fracture repairs or other problems if they migrate. If there has been
should always be taken at the end of surgery and at infection of the fracture site, this may becomeassociated
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intervals until fracture healing has been documented. with the implant ('cryptic infection') and lead to recur-
The result of surgery should be assessed and compared rent lameness or, possibly, predispose to fracture-asso-
with the original fracture plan. The fracture plan itself ciated sarcoma, although a definite link between metallic
should also be reviewed and appraised once its result implants and cancer in dogs has not been shown (Li er
is known. al., 1993). Persistence of bacteria at a significant propor-
tion of metallic implants has been documented (Smith er
Record keeping aI., 1989). Implants in some sites, e.g. pelvis and hu-
Detailed records should be kept and reviewed regu- merus, are rarely removed. It must be remembered that
larly in order to assess the results of fracture treatment open screw holes left after implant removal will concen-
and to compare these with the experiences of other trate stress and predispose to fracture, so restricted
surgeons and published results. If results of fracture exercise or even external support should be advised
repairs appear unusually poor, possible reasons forth is especially after plate removal. The perceived benefits
should be sought and treatment protocols amended and possible risks of implant removal must always be
accordingly. If results appear unusually good, reasons weighed up against one another.
for this should be identified and published in order to
disseminate the increased knowledge and improve REFERENCES
quality of care generally.
Aron DN, Foutz TL, Keller WG and Brown J (199 1) Experimental and
clinical experience with an IM pin exte rnal skeletal fixalo r tie-in
Assessment of fracture healing (see Chapter 5) configuration. Veterinary alld Comparative Orthopaedics alld
Fracture healing should be assessed physically and Tralllllafology 4, 86-94.
Aron DN, Johnson AL and Palmer RH (1995) Biologic strategies and
radiographically at regular intervals, usually monthly a balanced concept for repair of highly comminuted long bone
or bimonthly. Functional union will usually occur fractures. CompendiulII ojCofllilluillg EducQtiolljor the Practising
prior to radiographic union. Healing is easier to assess Veterinarian 17, 35.
Axelson P, Rtiihti JE, Mcro M, Vainionpaa S, TonnaHi P and Rokkanen
with some fixation systems than others. Fractures P (1988) The use of a biodegradablc implant in fracture fixation: a
treated by plate and screw application can be particu- rcview of the literature and a re port of two clinical cases. Journal
ofSmal! Animal Practice 29, 249- 255.
larly difficult to assess as the fracture line may be Baumgart F (1991) The 'mixing' of implant systems. Veterinary and
difficult or impossible to visualize immediately fol- Comparative Orthopaedics and Traumatology 4, 38-45.
lowing repair and therefore assessment of healing, Blass CE and Moore RW (1984) The tourniquet in surgery: a review.
Veterinary Surgery 13(2), 111 - 114.
which may occur with little or no visible ca llus forma- Blass CE, Piennattei DL, Withrow SJ and Scott RJ (1986) Static and
tion, may be challenging. Conversely, fractures treated dynamic cerclage wire analysis. Veterinary Surgery 15(2),18 1-
184.
using external skeletal fixation will usually be fairly Bouvy BM, Markel MD, Chelikani S, Egger EL, Piermattei DL and
visible and there will usually be appreciable amounts Vanderby R (1993) Ex vivo biomechanics of Kirschner-Ehmer
of callus formation, which facilitate assessment. external skeletal fixation applied to canine tibiae. Veterinary Sur-
gery 22(3) , 194-207.
Brinke r WD, Hahn RB and Prieur WD (1984) Manual of llllernal
Recognizing and dealing with complications Fixation i/l SlIIal/ Animals. Springer- Verlag, Berlin.
Campbell JR (1976) The technique of fixation of fractures of the distal
It is important to realize and accept that not all fracture femur using Rush pins. Journal ofSmal/ Animal Pracrice 17, 323-
fixations will be without complications. Problems 329.
noted on post-operative radiographs (e.g. inappropri- Cannichael S (1991) The external fixator in small animal orthopaedics.
Journal of Smal/ Animal Practice 32, 486- 493.
ate implant placement) should not be tolerated, but Clary EM and Roe SC (1995) Enhancing extcrnal s kelctal fixation pin
should be remedied by immediate revision surgery. pcrfonnance: consideration of the pin-bonc intcrface. Veterinary
and Comparative Orthopaedics and Traumatology 8(1), 1-8 .
Evidence of infection or of delayed or non-union Clary EM and Roe SC ( 1996) 1/1 vitro biomechanica l and histo logical
should be treated aggressively. Complications will assessment of pilot hole diameter for pos itive-profile external
skeletal fixation pins in canine tibiae. Velerinary Surgery 25, 453-
always occur, but their frequency can be minimized by 462.
attention to good planning and surgical technique. Cu lvenor JA and Parker RJ (1996) Collection of corticocancellous bone
Anticipating complications wi ll allow their early de- g raft from the ilium of the dog using an acetabular reamer. JOllrnal
of Small Animal Practice 37, 513-515.
tection and treatment. Ducland RT, Berglund L, Vanderby R and Chao EYS (1996) Structural
properties of interlocking nails, canine femora and fe mur-inter-
locking nail constructs. Veterinary Surgery 25, 386-396.
Implant removal Dyce J and Houlton JEF (1993) Use of reconstruction plates for repair
Surgical implants may be removed following complete of acctabular fractures in 16 dogs. Journal of Smal/ Animal Prac-
fracture healing if required. This can be beneficial in tice 34, 547-553.
Egger EL, Histand MB, Blass CE and Powcrs BE (1986) Effect of
tenus of removing any shielding effect from the bone, fixation pin insertion on the bone-pin interface. Veterinary Surgery
which could result in disuse atrophy ofthe bone ('stress 15(3),246-252.

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Principles of Fracture Surgery 85

EggerEL, Histand MS, Norrdin RW, Konde U and Schwllrz PD (1993) Traumatology 5, 22-25.
Cllnine osteolOlllY heali ng when stabili zed wit h decreasingly rigid Muir P, Parker R, Goldsmid SE and Johnson KA (1993) Int erlocking
fixat ion compared to constantly rigid fixati on. Veterinary and intrnmedullary nail stabilisation of a diaphyseal ti bial fracture.
Comparative Orthopaedics and Traumatology 6, 182- 187. Journal of Small Animal Practice 34, 26-30.
Elkins AD and Jones LP ( 1988) The effects of Plaster of Paris and Muir P, Markel MD, Bogdans ke JJ and Johnson KA ( 1995) Dual-
autogenous cancellous bone on the healing of cortical defects in the energy Xray absorptionometry and force-plate analysis of gait in
femurs of dogs. Veterinary Surgery 17(2), 71-76. dogs with healed relllom after leg-lengthening plate fi xation. Vet-
Elkins AD, Morandi M and Zembo M (1993) Distmction ostcogenesis erinary Surgery 24, 15-24.
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in the dog using the Ilizarov external ring fixato r. Journal of tile Okrasins ki EB, Pardo AD and Gmehler RA (1991) Biomechanical
American Animal Hospital Association 29, 419-426. evaluation of acry lic external skclctnl fixatio n in dogs and cats.
Foland MA, Schwarz PD and Salman MD (199 1) The adjuncti ve use of Journal oftlte American Veterinary Medical Association 199(1 1),
half-pin (type I) external skeletal fixators in combin:llion with 1590.
intramedullary pins for fe moral fra ctu re fi xation. Velerinaryand Pa lmer RH and Aron DN ( 1990) Elli s pin com pli cations in seven dogs.
Comparative Ortho{Jaedics and Traumatology 4,77-85. Veterinary Surgery 19(6),440-445 .
Gallacher LA, Rudy RL and Smeak DD (1990) The external fixa tor Pardo, AD ( 1994) Relationshi p of ti bial intramedullnry pins to canine
boot: appliclltion, techniques and indications. J ournal oflhe Ameri- stifle joint structures: a comparison of nonnograde and retrograde
can Animal Hospital Associalioll 26, 403- 409. insertion. Journal ofthe American Animal Hospital Associarion 30,
Ga llacher LA, Smeak DD, Johnson AL, Boone RJ and Rudy RL (1992) 369-374.
The external l1 xator boot for s upport of surgica l repnirs of injuries Penwick RC, Mosier DA and C lark DM (1991 ) Healing of canine
involvi ng the crus and tarsus in dogs and cats: 21 cases. J ournal of autogenous cancellous bone graft donor si tes. Veterinary Surgery
the American AI/imal Hospital Association 28, 143- 148. 20(4),229-234.
Gentry SJ , Taylor RA and Dee JF (1993) TIlC use of veterinary cuttable Piermattei DL (1993)AnAtlasofSurgical Approaches 10 the Bonesand
plates: 21 cases . Journal oftheAlllerican Animal Hospital Associa- Joill/s of the Dog and Cat, 3rd edn . WB Saunders Co.
tion 29, 455 - 458. PolIo FE, Hyman WA and Hulse DA (1993) The role of the cxtcma l bar
Glennon JC, Flanders JA , Beck KA, Trotter EJ and Erb HN ( 1994) The in a 6-pin type 1 extemal s kcletal fixation device. Veterinary and
effect of long-term bone plate applicat ion for fi xation of radial Compararive Orthopaedics alld Traumarology 6, 75- 79.
fractures in dogs. Veterinary Su rgery 23, 40-47. PricurWDand Sumner-Sm ith G ( 1984) In: Manual oflmernal Fixation
Hulse D, Nori M, Hylmm B nnd Slater M (1994) Clinica l, in vitro and in Small Animals, cd WO Bri nker, RB Holm and WD Prieur, pp 6-
mathematical analysis of pl ate/rod buttressing for biologica l frac- 7. Springer-Verlag, Berlin.
turestabilisation. Veterinary Surgery 23 , 404 (ACVS abstmct 40). Riiiha JE, Axelson P, Rokknnen P and Tonnatii P ( 1993a) Intramedul-
Johnson AL, Seitz SE, Sm ith CW, Johnson JM and Schacffer DJ ( 1996) lary nailing of di aphyseal fractures with self-reinforced polylactide
Closed reduction and type-II external fi xati on of comminuted implants. Journal of Small AI/illlal Practice 34, 337-344.
fractures of the rndius and tibia in dogs: 23 cases (1990-1994) Riiihii JE, Axelson P, Skutnabb K, Rokkanen P and TonniiHi P (1993b)
Journal of the American Veterinary Medical Associatioll 209, 8, Fi xation of cancellous bone and physeal fractures with biodegrad-
1445- 1448. abl e rods of self-reinforced polylactic acid. Journal of SlI1all
Kirker-Head, C.A. (1995) Recombinant bone morphogcnctic proteins: Animal Practice 34, 13 1- 138.
novel substances for enhancing bone hell ling. Veteril/ary Surgery RoeSC, Johnson ALand Harari J ( 1985) Placement of multiple fu ll pins
24,408-4 19. for external fixa tion. Technique and results in fourdogs. Veterinary
Lanyon LE lind Rubin CT ( 1984) Static versus dynam ic loads as an Surgery 14(3), 247-252.
influence on bone remooelling. Journal of Biomechanics 17,897- Smith MM , Vasseur PB and Saunders HM (1989) Bacterial growth
905. associated with metallic implants in dogs. Jou rnal ofthe American
Lawson DD (1959) TIle techniquc of Rush pinn ing in frncture repair. Animal Hospital Association 195, 765- 767.
Modem Veterinary Practice 40, 32-36. Stallings JT, Parker RB, Lewis DD, Wronski TI1J and Shiroma J (1997)
Lesser AS ( 1994) Scgmenta l bone transport for the treatment of bone A comparison of autogenous cortico-cancellous bone graft ob-
deficits. Journal of the American Animal Hospiral Associatiol/30, tained from the wing of the ilium with an acetabular reamer to
322 - 330. autogenous canccllous bone graft obtained from the proximal
Lewis DD, van Ee RT, Oakcs MG and Elkins AD ( 1993) Use of humerus in dogs. Veterinary and Comparative Orthopaedics and
reconstruction plates for stabilisation of fmctures and osteotomies Trallmatology 10, 79-87.
involving the s upracondylar region of the femur. Journa l of the Szentimrey D and Fow ler D (1 994) The anatomic basis of a free
American Animal Hospital Association 29, 17 1- 178 vascularised bone graft based on the canine distal ulna . Veterinary
Li XQ. Hom DL, BlackJ and Stevenson S (1993) Relationship betwccn Surgery 23, 529-533.
metallic implmns and cancer: a case-control study in a canine Szentimrey D, Fowler D, Johns ton G and Wilkinson A (1995) Trans-
popul ation. Veterinary and Comparative Orthopaedics and Trau - plantation ofth ecanine d istai ulna asa free vascu larised bone graft.
matology 6, 70-74. Veterinary Surgery 24, 215 - 225.
Marti JM and Mill er A ( 1994a) Delimitation of safe corridors for the Thommasini MD and Betts CW ( 1991) Usc of the ' Il izarov' extenUl I
insertion of extemal fi xator pins in the dog. I: Hindlimb. Joufllal fixator in a dog. Veterinary and Comparative Orthopaedics alld
of Small Animal Practice 35(1), 16-23. Traumatology 4 , 70- 76.
Marti JM and Miller A ( 1994b) Delimitation of safe corridors for the Willer RL, Egger EL and Histand MB ( 199 1) Comparison of stainl ess
insertion of extema l fixator pins in the dog. 2: Forelimb. Journal of steel vcrsus ncrylic for the conncct ing bar of extemal skeletal
Small Animal Practice 35(2), 78-85. fi xators. Journal ofthe American Animal Hospital Associarion 27,
Mclaughli n RM Jr, Cockshutt JR and Kuzma AB (1992) Stacked 541-548.
veterinary cuttable plates for treatment of comminuted diaphyseal Wilson JW (1987) Effect of cerclage wires on periosteal bone in
frnctures in cats. Velerillary and Comparative Orthopaedics and growing dogs. Veterinary Surgery 16(4), 299-302.

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86 Manual of Small Animal Fracture Repair and Management

OPERATIVE TECHNIQUE 9.1


Insertion of intramedullary pin
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Jacobs Jacobs
chuck chuck
& pin & pin

(aJ (bJ

II

Fig ure 9.14:


Pin insertion:
(a) normograde;
(b) retrograde.

Pins may be inserted normograde or retrograde.

Tray extras
Gelpi relrac tors; bone holding forceps; pointed reduction forceps; Jacob's chuck or motori zed pin dri ver;
small and large pin cutters; appropriate pin (s)

Surgical approach
Appropriate for bone involved

Selection of pill size


Pin diameter slightl y less than diameter of medullary cavity at its narrowest point (isthmus).

Length of pin best determined from pre-operati ve radiograph of same bone in contralateral limb: tip should
impact in (distal) metaphysis; free end should protrude approximately 5- 10 mm (prox imally) to allow
removal.

Pin may be cut to appropriate length pre-operati vely (best option), or notched pre-operati vely and broken in
situ, or cut fo llowing insertion (very robust pin cutters may be required; hacksaw is inappropriate)

Redu ction and fixatioll


The fracture is exposed if required and the fragment ends are examined for fi ssuring. Any fiss ures present
should be protected using cerclage wi res. The fracture should be reduced and temporaril y stabilized using
suitable bone holding forceps.

Normog1'at[e pin inse,.tion


The pin is dri ven into the medullary canal at some point distant from the fracture and adva nced along the
medullary canal, tra versing the fracture site and impacting in the metaphysis of the opposing fragment.

The pin is then cut (unless pre-cut) leaving 5- 10 mm protruding to allow for removal.
It is sometimes possible to perfonn normograde insertion closed.

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Principles of Fracture Surgery 87

OPERATIVE TECHNIQUE 9.1 (CONTINUED)


Insertion of intramedullary pin
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Retrograde pin insertion


The pin is inserted into the medullary canal at the fracture site and driven along the medullary canal until it
ex its the bone at some appropriate distant site.

The chuck is reversed and the pin is then draw n out of the exit site until only the tip is visible at the fracture.

The fracture is reduced and the pin is dri ven across the fracture site and im pacted in the metaphys is of the
opposing frag ment.

Open pin insertion is always required and double-pointed pins are advantageous.

Most long bones are suitable fo r either normograde or retrograde pinning.

Landmarks for normograde pinning:


Humerus
Craniolateral metaphys is proximally
Femur
Intertrochanteric fossa, immediately medial to greater trochanter
Tibia
Craniomedial aspect, immediately caudomedial to insertion of straight patellar liga ment.

PRACTICAL TIP
T he tibia should be pinned normograde (Pardo 1994).

WARNING
The radius s hould never be pinned.

PRACTICAL TIP
Remember to allow for radiographic magnification (10-15 %). Small changes in pin diameter
produce large changes in AMI and pin strength.

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88 Manual of Small Animal Fracture Repair and Management

OPERATIVE TECHNIQUE 9.2


Application of cerclage wire
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Tray extras
Gelpi retractors; bone holding forceps; pointed reduction forceps; parallel pliers and wire cutters or combined
cutter/twisters; assorted wire (0.8, 1.0 and 1.2 mm diameter) ; wire passer.

Reduction and stabilization


The fracture is reduced and stabilized using bone holding forceps or temporary K-wire.

Application of cerclage wire


For full cerclage wire (Figure 9.15a), the wire is passed around the bone, avoiding soft tissue entrapment (a
wire passer may be helpful), or through bone tunnel for hemicerclage (Figure 9.15b)

The ends are twisted tight (tension must be placed on the wire as it is tightened to ensure that even and secure
twisting occurs) and cut short (two or three twists should remain). The free end may be twisted and bent flat
if desired.

As an alternative, ASIF type wire loop or ' dynamic' double loop cerclage may be used (Blass et aI., 1986).

(a)

Figure 9.15: Cerclage.


(a) Futt cerclage. (b)
(b) Hemicerclage wire.

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Principles of Fracture Surgery 89

OPERATIVE TECHNIQUE 9.3


Application of tension band wire
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Tray extras
Pointed reduction forceps; Jacob 's chuck or motorized pin driver; small pin cutters; assorted small pins; pin
bender; parallel pliers and wire cutters or combined cutter/twisters; assorted wire (0.8, 1.0 and 1.2 mm diameter).

Reduction and stabilization


The frachlfe or osteotomy is reduced using one or two K-wires or arthrodesis wires.

A transosseous tunnel is drilled distant from the fracture site in the main fragment (distance ~ approximately
2.S x length of smaller frag ment).

A piece of wire is passed through the bone tunnel and the ends are crossed over.

A second length of wire is passed around the ends of the pins (ensure that loca l softtissues, e.g. tendons, are
not entrapped) or through a bone tunnel adjacent to the pins.

The ends of the pins are bent over and the wires are twisted tight evenly (tension must be placed on wire as
tightened to ensure that even and secure twisting occurs).

The wires are cut short and the ends are bent down.

Figure 9.16: Tension band wire.

PRACTICAL TIP
Use small pins and heavy tension-band wire. Ensure the wire tension-band is of adequate length.

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90 Manual of Small Anjmal Fracture Repair and Management

OPERATIVE TECHNIQUE 9.4


Application of external skeletal fixator
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Tray extras
Appropriate retractors and bone-holding forceps for open reduction; Jacob's chuck or motori zed pin dri ver;
small and large pin cutters; appropriate drills, transfixing pins, clamps and connectin g bars; spanner or socket
for ti ghtening clamps.

Reduction and stabilization


The fracture is reduced. Reduction may be open or closed and may involve the use of cerclage wires, lag
screws or intramedullary pins.

Application ofwlilateralltlliplanar (Type /) extemalfixator (Figure 9.17)

Figure 9.17: Application oj


Type I external Jixator.

The appropriate size of system is selected. Transfixing pins should not exceed one-third of the diameter of
the narrowest part of the bone involved.

Stab incisions are made through the skin on the appropriate aspect of the limb as far distant from the fracture
proximal and distal as possible, without interfering with adjacent joints or vital soft tissue structures (Marti and
Miller, 1994a, b). The incisions should be large enough (0.5 to I cm) to prevent any tension in the skin after pin
insertion, as this will result in skin necrosis. Stab incisions should ideally be distant from any surgical incision.

Proximal and distal pins are inserted either directly, using a low speed drill, or into slightl y smaller pre-drilled
holes if the bone is hard. These pins should be inserted at converging angles of around 60° - 70° to the bone
axis and should be threaded (Figure 9. 18) (positive profile is best). All pins must penetrate both cortices of
the bone.
Ellis pin (negative profile)

<ftJ1tJJJt/J_ _ _ __
~;;Jifflffl"ositive profile pin
~L- _ _ _ _ _------'

Central thread positive profile pin (for bilateral fixators)

<~-----,7JJJJJJJJJ11-7-
Figure 9.18: Types oj
!lXotor pill.

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Principles of Fracture Surgery 91

OPERATIVE TECHNIQUE 9.4 (CONTINUED)


Application of external skeletal fixator
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The connecting bar, with all the required clamps attached, is connected to these transfi xing pins and their
clamps are tightened, leaving a gap of around 1 em between skin and clamp to a llow for swelling. Clamps
may be positioned with the nut ' inside' or ' outside' the bar according to personal preference. ' Outside' is
probably better as the length of pin from bone to clamp is less and therefore the fixation is stronger.

A second connecting bartnay be attached in the same way, external to the first, if increased strength of fixation
is required.

Fracture reduction is checked and the remaining pins are inserted as above, using their loose clamps as guides.
This is essential to ensure proper alignment of all the pins. It is not possible to insert all the pins and tben apply
the bar. In general, sets of pins within major fragments should converge. Positive profile pins cannot be inserted
through the clamps, so smooth or negative profil e pins should be used. All pins must penetrate both cortices.

The remaining clamps are tightened and fracture alignment checked again.

Application of unilateral biplanar external Jixator


Proceed as above.

A second fixator is applied using the same principles within an arc of 90° to the first (e.g. primary fixator
applied along medial aspect of the radius with the second applied cranially).

The two fi xators are connected using small connecting bars and double clamps.

When both devices lie within a 90° arc the system is regarded as unilateral. If the arc is greater than 90°, it
is bilateral.

Application of a bilateraluniplanar (Type II) external Jixator


Proximal and distal pins should be inserted perpendicular to the bone axis. These should penetrate the soft
tissues on both sides of the limb and should be connected to a cOlmecting bar on either side of the limb. These
pins should have a centrally located positive profile thread.

Additional pins are placed as before. It is difficult to maintain alignment of the transfi xing pins through the
limb and to engage the clamps on the far side properl y. It is helpful to attach a second connecting bar on the
operator side and to use this as a drill guide in order to improve planar alignment of the pins (Roe et al., 1985).
The supplementary cOlmecting bar on the operator side is subsequentl y removed. Alternati vely, further pins
may be unilateral (modified Type II).

Application of bilateral biplanar (Type III) external Jixator


Use principles described above.

Radiographs in at least two planes should be taken to assess fracture alignment prior to the pins being cut short.
Sharp pin ends should be covered by cohesive tape (adhesive tape is very difficult to remove later) and the
fi xator may be protected by a small bandage. It is sometimes helpful to apply a padded bandage around the
limb for 2-3 days to reduce post-operati ve swelling.

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92 Manual of Small Animal Fracture Repair and Management

OPERATIVE TECHNIQUE 9.5


Application of lag screw
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Tray extras
Appropriate retractors and bone-holding instruments; appropriate drills, guides and taps; appropriate screw
sizes.

Reduction and stabilization


The fracture is reduced and stabilized temporaril y using pointed reduction forceps. A hole the same diameter
as the screw threads is drilled in the cis cortex (gliding hole) and an insert guide is passed through this. A drill
the same diameter as the screw core is inserted through the guide to ensure central placement and a hole is
drilled in the trans cortex (thread hole) . The hole in the cis cortex may be countersunk if required, although
this can be risky in the very thin cortices of canine and feline bone.

The necessary length of screw is measured using a depth gauge. The trans cortex onl y is tapped and the screw
is inserted. Approximately 2 mm is added to the measured length. (The length of the screw is measure from
the head to the tip, which tapers and does not grip the bone well . Adding 2 mm ensures adequate thread contact
in the trans-cortex.)

Tightening the screw generates ax ial compression along its length and compresses the trans cortex towards
the screw head, where it engages the cis cortex or the plate. For maximum function, the lag screw should be
inserted midway between the perpendicularto the fracture line and the perpendicular to the longitudinal axis
of the bone. A lag effect can be created using a partially threaded cancellous screw, although it may be difficult
to ens ure that the threaded portion of the screw is of an appropriate length.

Lag
screw

Figure 9.19: Insertion o/lag screw.

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Principles of Fracture Surgery 93

OPERATIVE TECHNIQUE 9.6


Application of plate and screws
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Tray extras
Appropriate retractors and bone-holding instruments; appropriate drills and taps; appropriate sizes of plate
and screws.

Redllctiolllllld stabilization of a. simple transverse lliaphysealfractllre llsing a compression ]Jlate


(Figure 9.20)
The fracture and most or all of the involved bone should be exposed. The bone ends must be examined for
occult fissurin g. (If fissuring is present, axial compression should be avoided. Secure the bone ends using
cerclage wire to prevent further fissurin g and proceed with neutrali zation plate fi xation.)

The fracture is reduced, us ually by toggling or traction, and reduction is maintained using bone holding
forceps or temporary K-wire(s).

The plate is contoured to fit the bone. A small gap may be left between plate and bone over the fracture (pre-
stressing) to produce compression of the trailS cortex (Figure 9.21). An appropriate ly sized thread hole is
dri lied close to one fracture end (Figure 9 .20a), the hole is measured through the plate and the thread is tapped.
The plate is applied to the bone and a screw is inserted but only tightened until the underside of the screw head
contacts the 'shoulder' of the screw hole (Figure 9.20b).

The plate is slid proximally or distally so that the screw contacts the side of the screw hole distant from the
fractu re site and clamped or held in that position. Using the ' load' drill guide, the screw hole on the opposite
side of the fracture is drilled, ensurin g that both ends of the plate contact bone (Figure 9.20c) . This hole is
meas ured and tapped as before. The screw is inserted and both screws are fully tightened in turn, compressing
the fracture (Figure 9.20d).

Further screws are inserted on either side, using the 'neutral ' dri ll guide (Figure 9.20e), progressively moving
away from the fracn"e. All screws are checked for ti ghtness prior to clos ure.

I
d*
I
(a)

j -I I II I-r
fu*La :z= I
I rs;;::J IS;;!
(b)

~ II I I I I T r
I

I rs;;;a IS;;!
(e)

La
axial compression

(d)
I rs::::J IS;;!

m ~I Figure 9.21: Application of a pre-stressed plate. (a) Exact


colltollrillg of a plate to a surface call result ill a lIarrolV gap
ill fhe/ar cortex after screw fixation (b) The plate call be

~
pre-stressed to create a curve in the part thaI wili fie above
the fracture. The far cortex is 110W compressed whell the
IS;;! screws are tightened.
.
IIS:J
(e)

Figure 9.20: Application of a compressioll plate. r:;

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94 Manual of Small Animal Fracture Repair and Management

OPERATIVE TECHNIQUE 9.6 (CONTINUED)


Application of plate and screws
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Reduction and stabilization of a comminuted diaphyseal fracture using lag screws and a neutralization
plate (Figure 9.22)
The fracture is approached as above and stepwise fragment reconstruction is commenced from either main
fragment. Fragments are stabilized temporarily using pointed fragment forceps or K-wires. Any fragments
that cannot be securely fixed must be discarded.

Interfragmentary compression is achieved using lag screws and the fracture is rebuilt until only two main
fragments remain. These are reduced with care, and lag screw fixation may again be used. Consideration must
be given to the location of lag screw heads in relation to the position of the plate. Lag screws may be inserted
through the plate if required. The plate is contoured to the bone without pre-stressing.

Plate screws are inserted using the ' neutral ' drill
guide and the steps detailed above. The order of
screw insertion is not critical; it may be advanta-
geous to insert the terminal plate screws first to
ensure that the ends of the plate are located over
bone. All screws are tightened prior to closure. The
repair, especially the compression surface, is exam-
ined for cortical defects and these are packed with
cancellous bone if present.
Figure 9.22: Application of a
Pointed
neutralization plate using Lag fragment
screws. forceps Neutralization plate

Reduction and stabilization of a severely comminuted diaphyseal fracrure using a buttress plate
(Figure 9.23)
Little or no attempt is made to reconstruct the fracture, although large fragments may be reconstructed using
lag screws or cerclage wires if wished.

A pre-contoured plate is applied to the major proxi-


mal and distal fragments to regain normal bone
length and alignment. The ' load' guide should be
used with the arrow pointing away from the fracture
to ensure that there is no axial compression.

Figure 9.23:
Application of a fi~
buttress plate. fI?

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CHAPTERTEN---------------------------------------

Complex, Open and Pathological


Fractures
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Chris May

COMPLEX FRACTURES In these circumstances, a shift to a minimally invasive


strategy (MIS) is adva ntageous. Such strategies have
This first section considers the management of se- also been called ' biologic' in American literature, but
verely comminuted diaphyseal fractures (see defini- this terminology is avoided here because the author
tion of complex fractures in Chapter 1). Comminution regards all fracture healing as biological.
occurs because of a high energy impact and is usually
associated with considerable damage to local soft A minimally invasive strategy for repairing
tissues and other body systems. Careful and complete complex fractures
evaluation of the whole patient is essential. The principles of this strategy are:
One major challenge with these fractures arises
from the need to provide rigid fixation and early return Use closed alignment, or minimal exposure
to function for an inherentl y unstable fracture site. aligrunent of the two major fracture fragments to
There may also be devitalized bone fragments and achieve spatial reconstruction (see below)
extensive soft tissue damage. In some situations, ana- Aim for maximum preservation of blood supply
tomical reconstruction with plate and screws will be to the bone fragments
appropriate (Chapter 9). In other cases, attempts at Provide sufficient stability to allow for the
anatomical reconstruction may be considered unfeasible lack of load shari ng by the non-reconstructed
or even undesirable because: bone.

Reconstruction may be impossible due to small Spatial reconstruction has been defined by Aron et al.
fragment sizes (1995) as:
Reconstructive surgery would be prolonged and/
or would result in excessive tissue dissection. Reconstruction of normal bone length
This would damage local blood supply to the Adjustment of the two main bone fragments to
fracture site, compromising fracture healing and within 5° of normal torsion or angulation
predisposing to infection. At least 50% overlap, in the mediolateral and

(a) (b) (e) (d) (e) (f)


Figure 10.1: Techniques, compatible with a minimally invasive strategy, for stabilizing complex fractures: (a) externalfixator;
(b) external jixator + intramedullary alignment pin; (c) exrernaljixator + 'tied-in ' imramedullary alignment pill; (d) bridging
plate; (e) plate alld 'rod' (imramedllllary pill) technique; (j) interlocking nail.

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96 Manual of Small Animal Fracture Repair and Management


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Figu re 10.2: (a) 'Hanging limb' preparation prior to closed reductioll of a radius and ulna fracture ill a dog. (b) Application of
an externaljixator to the limb shown in (a).

craniocaudal planes, of the two main bone (Marti and Mi ller, 1994a,b) and it is more difficult to
fragments. achieve a rigid construct because of the proximity of
the torso.
For adhering to these principles, the author's prefer- Closed alignment is often not possible with these
ence is the use of external skeletal fixation (ESF). bones and the hanging limb position does not complete
Alternative methods incl ude bridging plates with or spatial reconstruction. The alternative is to make a
without an intramedullary pin and interlocking 1Il - minimal surgica l approach between muscle bellies to
tramedullary nai ls (Figure 10.1) (see Chapter 9). accomplish alignment of the two main frag ments and
positioning of the fixation device whilst leaving the
Minimally invasive strategy for fractures ofthe intervening minor frag ments undisturbed (min.imal
antebrachium and crus exposure alignment) .
Spatial reconstruction can be achieved by suspending
the patient in the hanging limb position routinely used M inimal exposure alignment
to overcome fragment overriding. Reduction is con-
firmed by closed palpation, or by a minimal exposure Only expose the main prox imal and distal
of the fracture site, and the fixator is placed with the fragments - do not handle individual
animal maintained in the suspended position (Figure intervening cortical fragments as this may
10.2). In most cases a modified type II fixator is deprive them of blood supply
indicated (Chapter9). However, more rigid configura- Only remove those fragments that are totall y
tions may sometimes be required initially because of devoid of soft tissue attachments
the lack of load sharing by the bone. As fracture Achieve spatial alignment of the two main
healing progresses, the ESF is usually removed by fracture segments by minimal manipulation
staged disassembly, typically beginning 4 to 6 weeks In some cases, alignment can be achieved
after the initial repair. th rough fascia or muscle, thus avoiding
complete exposure of the fracture site and
Minimally invasive strategy for fractures of the further damage to soft tissues and blood
femur and humerus supply.
Both the femur and the humerus can be repaired by a If ESF is used fo r stabilization, there should
mi nimally in vasive approach. However, these are be mi nimal pin penetration of surrounding
more cha llenging than distal limb fractures, because muscle masses.
there are no safe corridors for ESF pin placement

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Complex, Open and Pathological Fractures 97

Although placement of autogenous cancellous bone


grafts is simple and recommended in most commi-
nuted fracture repairs (Chapter 9), the author does not
routi nely graft when using a MIS, particularly if it
involves disturbing fracture frag ments.
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Cortical autografts and allografts


In fractures with severe bone loss, replace ment of large
sections of diaphysis may prove necessary. This may
be achieved with an autograft (rib or distal ulna) or with
a cortical allograft from banked bone. In either case,
fi xa tion is by rigid bone plating with strict adherence
to the principles of fi xation and of asepsis.
Figure 10. 3: Schematic view of a complex femoral fracture For further discussions of bone grafting and bone
to illustrate placement of all intramedllJJary alignment pill banking see Weigel (1993) and Parker (1993).
and extemaljixator: (a) minimal exposu re of the main
jragmenrs to facilitate pill positioning (see text for details);
(b) t/se of bOlle !lOldillg forceps to 'slide' the fragmellfs alollg
the pill, thus restoring limb length; (c) application afthe OPEN FRACTURES
extemaljixator (see text jar details).
In open fractures, the amount of energy absorbed by
In both the humerus and the femur, reduction Illay be the limb at the time of fracture has important prognos-
faci litated by the use of a narrow intramedullary tic implications . High energy impacts cause greater
ali gnment pin (Figure 10.3). Typicall y, a 3-4 mm soft tissue devitalization and may have a higher risk of
pin is used for a 30 kg dog and a 1- 1.5 mm K-wire infection. Wound size may not be a major considera-
for a cat. Larger pins are unnecessary and may hinder tion in prognosis, as severe soft tissue crushing can
fi xa tor pin placement. Theoretically, normograde occur even with small puncture wo unds. The classifi-
pl ace ment ofthe alignment pin is less likely to disturb cation of open fractures is discussed in Chapter 1.
the local blood suppl y. However, the author finds
accurate pin positioning to be eas ier via retrograde
placement. Provided the ends of the two major frag-
ments are ex posed through a small incision in the
overl ying fascial plane (MIS !) and the intervening
fragments are not disturbed, retrograde placement of
the alignlllent pin does not appear to affect fracture
hea ling adversely in practice.
The alignment pin maintains axial alignment and
helps to minimize the number of fracture manipula-
tions necessary before application ofESF, thus helping
to preserve blood supply. The pin is generall y left in
place as it increases the rigidity of the construct.lt may
also be ' tied in ' to the fixator (Figure 10.1), and is then
removed as part of the staged disassembl y during
fracture hea ling.
When ESF is used, a rigid construct is created to
cope with the non-load sharing and the excessive
muscle tensions in the proximal limb. This may be by
an enhanced bi-planarconfiguration (Aron el ai., 1995)
but the author has success with double bar type I
fi xation us ing threaded pins and ensuring a minimum
of six (preferably eighl) corlices gripped by the
fixator pins in each segment (Figure 10.4). An alter-
nati ve to traditional ESF devices is the use of
polymethylmethacrylate to form the connecting bars,
with either pins or bone screws for transfixati on (Dew
el al. , 1992; Ross and Matthiesen, 1993). This allows
more creative formation of the connecting bars, which Figure 10.4: Post-operative radiograph showing the use all
can help in constructing a rigid device despite the all illframedullary aligllll/em pin alld external jixator for
confines o f limited transfixation pin positioning. managillg a complex jemoral jracfllre in a dog.

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98 Ma nual of Small Animal Fracture Repair and Management

The goals in the treatment of open fractures are: Do provide limb splint support for the fracture
sites (e.g. Robert Jones bandage, gutter spLint or
To stabilize the fracture and allow wo und Zimmer splint). The dressings should stay in
management place until the animal reaches an operating suite.
To prevent contamination progressing to If they must be removed (e.g. for evaluation of
infection the soft tissue envelope, or fo r radiography), they
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To achieve bone union and restore limb function should be replaced as soon as possible.
as soon as possible. Do obtain appropriate radiographs as soon as
possible.
Open fracture management can be considered in four
phases: The rational use of antibiotics
Antibiotic use in open fracture management is a com-
First aid care plex and controversial topic more thoroughly covered
The rational use of antibiotics in other publications (Patza kis et al., 1974; Worlock et
Wound management al., 1988; Patzakis and Wilkins, 1989; Robinson et al.,
Fracture stabilization. 1989; Gustilo etal., 1990).
Antibiotic therapy should be instituted as soon as
First aid care possible in all open fractures. An intravenous bacteri-
Primary consideration must always be given to the cidal antibi otic is preferred, such as clavulanate
basics of acute care for trauma patients. potentiated amoxycillin or a cephalosporin. Tissue
samples (Figure 10.5) are submitted for aerobic and
WARNING anaerobic culture and antibiotic sensitivity testing.
Approximately 30 % of patients with open Antibiotics are discontinued after 5 days unless there
fractures have significant injuries to other are positi ve findings on culture or if the patient 's
body systems. condition indicates frank infection. Sensitivity testing
may dictate a change in the antibiotic being used and
Open frac tures have a high association with compro- antibiotic therapy should continue ror at least 3 weeks
mised neurovascular fun ction. Th is should be full y if culture is positive.
assessed as early as possible, as it will ha ve a major An exception to these general guidelines is in very
bearing on fracture management. Severe compromise severe type III open fractures, in which there may be
of the soft tissue envelope may be an indication for merit in a continuous antibiotic course.
early amputation.
Immediate fi rst aid considerations for the open Wound management
fracn.re site include the following. The principles of wound management in open fractures
are no di fferent from those for other open wounds. Good
Do not obtain samples for bacterial cultures at wound management hinges on haemostasis, copious
this stage. Recent studies suggest that such irrigation, debridement of devitalized tissues, drainage
cul tures are not helpful in plann ing fracture and wound closure or reconstruction (Figure 10.5).
therapy (Moore el al., 1989) .
Do nol probe or manipulate the fracture site. Fracture stahilization
Do cover open wounds with sterile, soaked Fracture sta biliZQtion occllrssimultQl leollsly with 11lan-
compression dressings. The dressings may be agell/ em of the open IVound . Indeed, stability at the
soaked in any of the following: fracture site contri butes significantl y to combating
Sterile normal saline loca l infection because:
Chlorhexidine diacetate solution (0.05 %)
Povidone-iodine solution (0.5- 1%). Restoration of limb length minimi zes dead space.
Stabilization of the fracture secondarily stabili zes
The dilution and composition of these solutions is the neighbouring soft tissues and facilitates
critical and the author prefers to use only sterile saline. revascularization. Oxygenation via a health y
The use of compression dressings helps to control blood suppl y is the single most important factor
haemorrhage from the site. in re-establishing tissue resistance to infection.
Stabilization of tissues assists white blood cell
infiltration of the contaminated tissues by
WARNING
providing a constant chemotactic gradient, not
The hospital environment is the major
found in unstable tissues.
source of contaminating organisms that
Early stability provides for muscle and joint
produce subsequent infection in open
mobility, which helps to encourage both venous
wounds.
and lymphatic drainage and reduce oedema.

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Complex, Open and Pathological Fractures 99

FIRST AID FOR THE FRACTURE SITE


I. PREVENT FURTHER CONTAMINATION
Cover wi lh steri le dressings (or even clean towels in an emergency).
2. ACHIEVE HAEMOSTASIS
Pressure
Direct clamping/ligation of aneries (tolerated by conscio us patient).
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3. PROVIDE TEMPORARY SUPPORT FOR THE FRACTURE

DEBRIDEMENT AND IRRIGA TlON


I . INITIAL STEPS WITHOUT ANAESTHESIA
Genlly debride and obtain samples for bacterial culture.
Lavage with copious amounts of sterile sali ne deli vered via a shower
head. For cost-efficacy in very contaminated wounds, tap water
lavage will suffice.
2. AFTER PATIENT STABILIZATION
Anaesthetize.
Debride (asepti c precautions, waterproof drapes).
Pulsati le lavage at 8 psi (this e ffect can be approximated with a Sterile saline, a giving set, 3-way
home-made lavage gun) lap, 30 ml syringe and 18 g needl e
Lavage with copious amounts (up to 10 lit res). Soluble anti biotics are handed asepticall y and
may be added to the last 1 to 2 Iitres. connected as shown. The saline
is handed to a non-sc rubbed
assistant who can plug in extra
IF IN DOUBT: LEAVE THE WOUND OPEN
bags as needed.
WOUND CLOSURE
I. PRIMARY WOUND CLOSURE
May be possible in type I and some type II open fracture wounds.
Close over drains. Consider suction drains if Illuch dead space.
2. OPEN WOUND MANAGEMENT
Essential in most type II and type 111 open fra cture wounds.

OPEN WOUND MANAGEMENT

Ini tially use dressings to encourage Re-eva luate after 24-48


furth er debridement hours and consider
(e.g. hydrocolloids, hydrogels, AS NEEDED repeat ing surgical
hydrocellular dressings, wet-packs) debridement

Dressing for epithelialization (warm , humid


environm ent, non-adherent dressing). .....E---------- +
Once granulation tissue is
establi shed (5 - 10 days) consider:
Consider: · Delayed primary closure
. Continue with hydrocolloid or hydrocellular · Skin grafting procedure
• Change to semi-permeable film dressing · Dressing for epithelialization

Figure 10.5: Wound management ill open!ractures.

In most cases, rigid fixation will be required and this is open fractures is associated with good results and a
most readily achieved by either lag screws and bone reasonably low complication rate. In humans, compli-
plates or by external skeletal fixation (ESF). cation rates as low as 8.2 % for acute osteomyelitis,
0.5 % for chronic osteomyelitis and a 2.2 % incidence
WARNING of salvage by amputation have been reported follow-
Whichever technique is chosen, the surgeon ing fIXation by bone plating or intramedullary nailing
must pay meticulous attention to the with reamed or locking nails (Clancey and Hansen,
principles of fracture fixation as the risks of 1978; Chapman and Mahoney, 1979; Rittman el al.,
infection and/or non-union are high if the 1979). Most complications were associated with type
stabilization is anything less than optimal. III open fractures. "
Steinmann pins, commonly used for intramedul-
Internal fixation lary nailing in veterinary surgery, cannot be routinely
The role of internal fixation in open fractures is contro- recommended for the more severe types of contami-
versial, but appropriate use of the technique in fresh, nated fracture as they often fail to provide appropriate

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100 Manual of Small Animal Fracture Repair and Management

stability and may contribute to the intramedullary substitution with a variety of artificial prostheses an-
spread of infection. In most veterinary cases, rigid chored around screws placed into the residual bone.
internal stabilization of open fractures will comprise Ho we ver, in many cases, the extremity can be stabi-
lag screw and bone plate fixation. Specific indications lized by ESF throughout the period of wound manage-
for primary internal fixation of open fractures include: ment and without addition of prosthetic implants.
Subsequent fibrosis is often sllfficiellllO stabilize the
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Fractures in multiple injury patients when earl y injured joints.


mobili zati on is essential and ESF is impractical
Articular fractures Bone grafting
Open fractures of the long bones of elderl y
animals in which ESF may be inadvisable. The high risk of non-union associated
with open fractures makes grafting of
Plate application should ideally be through the open autogenous, cancellous bone desirable in
wound or by extension of the open wound after debri- almost all cases.
dement (Chapman, 1993). This may not al ways be
practical but it does minimizes the additional soft
tissue trauma inherent in a second, elective incision. WARNING
Whenever possible, soft tissue cover should be pro- Large cortical allografts or autografts are
vided for the plate. In gaining access tllrough the open contraindicated in the face of infection.
w6und and endeavouring to place the plate under
healthy soft tissue cover, it may prove necessary to Particular indications for using autogenous cancello us
apply the plate in a non-traditional location. bone grafts in open fractures include:

External skeletal fixation Comminution


ESF is the author's first choice for most open fractures, Bone loss
unless a specific indication exists for internal fixation. Internal fixation by plates and screws.
It is undoubtedl y the method of choice for stabilizing
open fractures below the stifle in the pelvic limb or Grafting may be performed early, when adequate soft
below the elbow in the thoracic limb. Correctly ap- tissue cover exists, or at the time of delayed primary
plied, ESFprov ides suitable stability and has a number closure of the wound if initial soft tissue cover is
of advantages over internal fixation for the manage- inadequate to retain and revascularize the graft. In type
ment of open fractures : III injuries it may be appropriate to delay grafting for
several weeks to allow for adequate soft tissue recov-
The device is relati vely easy to appl y and may even ery first.
be adjusted during the fracture hea ling process
There are no metal implants at the fracture site Amputation
and ready access is usuall y gained for open In some injuries, early amputation may be the treat-
wound management. ment of choice. Indications include:

Disadvantages of ESF, specific to open fractures, Reduction of morbidity. Early amputation can
include: provide a rapid return to acceptable function,
and, for many dogs and cats, a return to pre-
The pins may interfere with plastic injury life style. This may be judged preferable
reconstruction procedures to a prolonged clinica l course and the associated
There is a risk of pin loosening and pin tract risk of complications inherent in managing
infection adding to contamination problems complex open fractures.
The physical bulk of the more complex devices Severe type III injuries. The severe vascular
may be awkward and interfere with attempts at compromise in such injuries makes amputation
early limb mobility, particularly in patients with the only viable procedure in many cases.
multiple limb injuries. Removal of large amounts of poorly vascularized
tissues may e ven be essential to preserve li fe.
Shearing injuries Financial cons iderations. The combined
Shearing injuries of the distal extremities are particu- requirements of open wound management and
larl y amenable to transarticular ESF. The injuries are complex fracture management are potentially
often complex and comprise 'degloving ' ofsofttissues expensive in labour and materials. In open
and abrasion of bones, ligaments and other articular fractures it is a matter of financia l realism that
structures, usuall y over the tarsus or carpus (Chapter earl y amputation may be the only option for
20) . Historically, these ha ve been repaired by ligament many owners.

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Complex, Open and Pathological Fractures 101

PATHOLOGICAL FRACTURES Neoplasia


Consider amputation or a limb salvage procedure.
A pathological fracture is fracture of a bone without
excessive trauma as a consequence of pre-existing Osteomyelitis
bone disease reducing the ultimate strength of the Appropriate treatment of the inciting infection is com-
bone. bined with rigid fixation (Chapter 25).
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Local disease that may result in pathological frac-


ture (Figure 10.6): Bone cysts
Treat with reduction, rigid fixation and packing of
Neoplasia deficits with autogenous bone grafts. Consider
Osteomyelitis corticocancellous grafts if large stmctural defects exist.
Bone cysts
Local bone atrophy (e.g. disuse) . Alimentary hyperparathyroidism
Often these cases present with folding fractures and the
Generalized diseases that may result in pathological bone is already too soft to withstand fixation. The best
fracture (Figure 10.7) are: strategy is usually to provide analgesia and cage rest.
The nutritional disease is corrected immediately but
Hyperparathyroidism (alimentary, renal or definitive treatment of bone deformities is delayed.
primary) Several weeks later, once bone density has improved,
Hyperadrenocorticism corrective osteotomies can be pJalUled as needed.
Rickets (now rare in pets in the UK)
Generalized neoplasia (e.g. myeloma). Stress riser effect
When load sharing between a fracture fixation device
The prognosis and treatment of pathological fractures and the bone is spread along the longest length of bone
are ultimately governed by the primary disease process possible, the risk of a stress riser effect is minimized.
and also by the site of the pathological fracture. Patho-
logical fractures of the vertebral column giving rise
to significant neurological injury frequently have a
poor prognosis.

Figure 10.6 ParllOlogicaijractlire secondary to a primary Figure 10.7 Pathologicalf:a.ctu~e secondary to nutritional \, .... i
bone TllmOllr. secondary hyperparathyroidIsm ill a puppy. ..! \ ' /)
_, 'J
c ... ,
...-.

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102 Manual of Small Animal Fracture Repair and Management

Thus, when internal fi xation is used on boneof reduced Marti JM a nd Miller A ( 1994a) Deli mitation of safe corridors for the
insertion of exte m al fixator pins in thcdog 1: Hindlimb. J ournal of
strength, the longest possible bone plate should always Small Animal Practice 35. 16-23
be applied. Similarl y, if ESF is used, pin placement Marti JM and Mille r A (1994b) Delim itation of safe corridors for the
corridors for the insertion of extenta l fixa tor pins in the dog 2:
should be distributed along the greatest possible length Forelimb. Journal of Smal/ Animal Practice 35, 78- 85
of bone. Moore TJ, Mauney C and Barron J (1989) T he use of quanti-
tative bacterial counts in open fract ures. CliniC(11 Orthopaedics
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248,823
Pa rker RB (1993) &tablishment of a bone bank. In : Disease Mecha-
REFERENCES AND FURTHER nisms in Smal/ Animal Surgery, cd. MJ Bojrab. Lea and Fcbiger,
Philade lphia
READING Patza kis MJ and Wilkins J ( 1989) Factors inil uenci ng infec tion rate in
o pen fracture wounds. Clinical Orthopaedics 243, 36
Aron ON, Palmer RH and Johnson AL (1995) Biologic strategies and Patzakis MJ, Harvey JP and Ivle r D (1974) The role of allli hi otics in the
a balanced concept fo r repair of high ly comminuted long bone management of open fractures. Journal of BOlle and Joil1l Surgery
fra cturcs. CompendiulII ojCollfilllling Education .7, 35-49 56-A, 532
BrinkcrWO, Holm RB and Prieur WD (cds) (1984) Mallilol of/l11ernal Rittman WW, Schibli M, Malter P and Al1g6wer M ( 1979) Opcn
Fixalioll ill Small Animals. Springcr-Verlag, Berli n fractures: long tenn results in 200 consecutive cases. Clinical
Chapman MW ( 1993) Open frac tures. In: Operative Orthopaedics, 2nd Orthopaedics 138, 132
cdn, cd . MW Chapman. JB Lippincott Co., Philadelphia Robinson D, On E, Hadas N et al. ( 1989) Microbiologic flora contami-
Chapman MW and Mahoney M (1979) The role of inte rnal fi xation ill nating open fractures: its signifi cance in the choice of prim ary
Ihe management of open fractu res. Clinical Orthopaedics 138, 120 ami biotic agcnts and thc likelihood of deep wound infection.
C I:l1lccy GJ and Hansen ST J r (1978) Open fraclUres of the ti bia: II Journal ofOrlhopaedics alld Traumatology 3, 283
review of 102 cases. JOl/mal oJ BOlle alld Joim Surgery 60-A, 118 Ross JT and Matthiesen DT (1993) TIle lISC of multi ple pin and
Dew TL, Kem DA and Johns ton SA ( 1992) Treatment of compl icated methylmcthacrylate extenta l s kcleta l fixation for the treatment of
femora l fractu res with external skeletal fixa tion utili zing bone orthopaedic inj uries in the dog a nd cat. Veterinary and Compara-
screws and polyme thylmethacrylatc. Veterinary and Comparative tive Orthopaedics and Trallmarology 6, I (5- 121
Orthopaedics alld Traumatology 5, 170-175 Weigel JP (1993) Bone grafting. In : Disease Mechanisms in Small
Gustilo RB, Merkow RL a nd Templeman D (1990) The management of Animal Surgery, cd. MJ Bojrab. Lea and Fcbiger, Philadelphia
open fractures. Journal of Bone and Joilll Surgery 72-A, 299 Worlock P, Slack R, Harvey L and Mawhinney R ( 1988)Theprevcntion
Hara ri J (eel .) (1992) Externa l skeletal fi xation. Veterinary Clinics of of infectio n in open fractures. An cxperi mcnta l study of the effect
North America 22:1 of a ntibiotic thera py .Journal ofBone and Joilll Surgery 70-A , 134 1

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CHAPTER ELEVEN

Fractures in Skeletally
Immature Animals
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Stuart Carmichael

INTRODUCTION out of a total of 283 fractures were in dogs of under one


year. This represents almost 50 % ofthetotal.In cats, 121
When a fracture occurs in an immature animal, both out of 244 fractures were presented in animals less than
bone hea ling and fracture management will be mark- one year old, representing 49 % of all fractures seen.
edl y influenced by the growing process taking place in Many of these fractures are found affecting the meta-
the skeleton. This presents an additional set of consid- physeal growth plate, as a direct result of the structural
erations and challenges for the orthopaedist. The ac- weakness in this area. In Marretta and Schrader's study,
tive anabolic state of the skeleton produces rapid 135 of the 452 (30%) fractures reported in juveniles in
fracture healing and, as a result, non-union fractures the study were described as epiphyseal.
are extremely rare in immature animals. Malunion or
the production of excessive amounts of callus around
the fracture site are more realistic problems. Growth SPECIAL CONSIDERATIONS WHEN
may be altered as a result of abnormal activity at the MANAGING FRACTURES IN YOUNG
growth plates leadin g to shortening or progressive ANIMALS
deformity of the affected long bone. If implants are
used to stabili ze the fracture they may impair the Growth
growth process or be engulfed by newly form ed bone The successful management of fractures in immature
during healing, making removal of these implants a animals depends on a good working knowledge of the
complicated procedure. growth process. It is outside the remit of this chapter to
Therefore, when facing a fracture problem in an consider all aspects of growth, which are well docu-
immature animal, the orthopaedist not only needs a mented elsewhere (Brighton, 1978; Ham and Cormack,
good working knowledge of the best way to stabilize 1979; Herron, 1981) but it is worth reviewing some
the bone but also has to understand the growth process important points which may influence decision-mak-
fully and how it will influence the outcome offracture ing processes when dealing with these fractures.
repair. The dynamic state of growth during this period The growing process is taking place at all parts of
is also important since a three-month-old patient with the skeleton but is concentrated at certain points:
a fracture will present a very different set of problems
to one in a patient of seven months of age. The metaphyseal growth plates
Structural weakness present at the metaphyseal The periosteum
growth plate, particularly in the newly formed bone, Subchondral area in the epiphysis.
predisposes to failure at this site.
The range of fractures seen in young animals is As bone is produced in these specific areas, the shape
therefore very different from those in the adult and of the skeleton is defined and the long bones achieve
demands an entirely different approach to management. their adult proportions. When a fracture occurs, bone
development must be altered. The objective of man-
agement is to restore the situation to normal as quickly
INCIDENCE OF FRACTURES IN as possible.
YOUNG ANIMALS
The metaphyseal growth plate ('growth plate' or
A very high proportion of all fractures in dogs and cats 'physis') .
are found in animals less than one year of age. In a four- The most important area of growth is the metaphyseal
year retrospective study of long bone fractures in dogs, growth plate. Bone is formed very rapidly in this
452 of 844 (54 %) were present in animals less than one location by the process of endochondral ossification
year old (Marretta and Schrader, 1983). In a similar (Figure 11.1). Any disturbance to this area by fracture
study in dogs and cats by Phillips (1979), 123 fractures or by fixation methods will have a profound effect on

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104 Man ual of Small Animal Fracture Repair and Management

Bone Average closure


Germinal e~eP 0~(!)0 time (months)
if!:! 0~

Proliferating : ~~
$
ei4$ Dog Cat
$ a;'
Scapula
~ 09
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I~ ~oI
Tuber scapulae 6 4
Palisading
Hemipelvis
Multiple junction (Acetab) 3.6
Tuber ischii (secondary) 10
Zone Hypertrophy Femur
of growth _ _ _..J
Femoral head 10.5 8
@5 "
Calcification
@ Cl Greater trochanter 10.5 7.5

e0@~
Zone of Distal 11 15
cartilage
transformation Degeneration @ Fibula
Proximal 10 13
12

-i
Distal 9.5
oste0geneSiS '
Zone of H umerus
ossification
Vascular Proximal 12.5 21
entry Lateral/medial condyle 6 3
Lateral epicondyle 7 3
Metaphysis ~ ,
Remodelling i1J Metacarpals/tarsals
I~~ Distal epiphys is II- V 7 9
Figure 11.1: Metaphyseal growth plate showing tlte dijferem Phalanges
regions of cartilage differentiation alld bone /ormatioll. Proximal II-V 6 4.5
Radius
bone growth and development. The growth plate is Proximal 8.5 7
mechanica ll y weaker than the adjacent bone or articu- Distal 10.5 16.5
lar structures, and so a high incidence of growth plate
Tibia
fractures are seen in inunature animals compared with
Proximal 11 15
a corresponding low number of liga mentous or soft
tissue disruptions of the adjacent joints. The weakness Tibial crest 8 15
of this area is due to the presence of cartilaginous Distal 10.5 10.5
matrix and newly formed bone (Figure 11.1). Medial malleolus 4.5
A fracture occurring in a long bone inevitably leads Ulna
to some disturbance of growth. Fortunately th ere seem Proximal 10 10
to be good compensatory mec hanisms which act to Distal 8.5 18
preserve limb length . General stimulation of growth of Carpus
th e affected long bone in the period after fracture has Carpal bones 3.5
been described in children (Rey nolds, 1981). In addi-
Accessory 4.5 4
tion, compensatory increase in length of adjacent long
Tarsus
bones has been observed experimentally (Wagner et
al., 1987) and in healed fracture cases (Alcantara and Tarsal bones 5
Stead, 1975; Denny, 1989). These processes will allow Fibular tarsal 3 9
some compensation for initial disruption in growth and Skull: Individual bones are joined at birth
act to preserve total limb length provided the growth by cartilaginous or fibrous sutures.
plates remain functional. These stay physiologicall y open until
When planning fracture repair, it is important to 11 - 14 months of age, after which
consider the time at which a particular growth plate they may become fused by calcifica-
loses function naturall y and closes. T he average time tion
of closure of commonly involved growth plates in the
dog and cat is detailed in Table 11.1. Vertebrae: The primary centres have fused to
form a complete neural arch at birth.
Periosteum and subchondral areas The epiphyseal plates stay open for
New bone can be produced in both of these areas to varying periods up to 11 months
augment fracture healing and remodelling. The perios- Table 11.1: Average time a/radiographic growlII plate
teum is of particular interest in yo ung animals as it is closure: dog alld cat.

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Fractures in Skeletally Immature Ani mals 105

very thick and easily stripped from the bone . As a res ult
of its mec hanical strength it is able to hold fragments
in the vicinity of the fracture, allowing reincorporation
during the rapid healing process. This may allow
anatomical healing in the absence of surgical reassembly
of fract ure fragments in comminuted fractures and is
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one of th e major factors supporting a more conserva-


tive approach to fracture surgery in immature dogs.
Needless to say, th e periosteum must be preserved and
handled with care during surgery .

Bone strength and structure


Juvenile bone is markedly different in composition
from th at fo und in th e adult, resulting in softer more
pliable bones. The bone structure itself is more porous,
with an increased number of Haversian canals. Imma-
ture bone is much more resistant to fracture than adult
bone because of these properties (Sharrard, 1993). Figure 11.3: Pathologicalfracrure o/thefemur in a dog
Nevertheless fractures in immature animals are com- sufferingfroll1 Ill/tritional secondary hyperparathyroidism,
mon and constitute a considerabl e proportion of all The bone gives the appearance offolding, hence the term
fractures seen in small animal patients (see above) . 'foldil1g fracture',

Incomplete fractures Poor holding potential fo r implants


A higher percentage of incom plete or greenstick frac- The soft nature and thin cortices of immature bone
tures are seen in yo ung animals, as a result of their more have significance forth e placement of implants such as
pliable, less rigid s keleton. In incomplete fractures part bone screws, wltich achieve the best grip in hard
of the cortex fails while the remainder remains intact material like mature cortical bone. The same sec urity
and can act as a support for the damaged bone (Figure cannot be obtained in immature bone and this must be
11.2). considered in the selection of implants, especially
when the use of bone plates is considered. Conversely,
Poor mineralization of bone the large medullary canal present in juveniles, with its
The demands of the growing skeleton for calcium can high proportion of trabecular or cancellous bone, is
result in weakness as a result of poor minera lization if significant when intramedullary devices are consid-
dietary defici ency is present. Secondary nutritional ered.
hyperparathyroidism is th e common underlying cause
and multiple fo lding fractures of poorly mineralized Other considerations
bone may result (Figure 11.3).
Prompt diagnosis
Rapid identification of the fracture and prompt deci-
sion making with regard to frachlre management are
vital to ensure a successful outcome in young animals,
as th e healing process can be extremely fast. Since
most growth stops at about nine to ten months of age,
this identifies the time scale during which these condi-
tions apply.

Radiographic interpretation
Early diagnosis depends o n a thorough clinical exami-
nation and pertinent radiographic in vestigations. Ra-
diographic interpretation poses problems itself in
immature animals as a result of incomplete calcifica-
tion of th e young bones and the presence of open
physes, both of which can produce a confusing picture
and disguise fractures. •.
Figure 11.2: A greenstick/racture of rlie IOlVer tibia ill a
young cat. The fracture can be seen as a spiral line Fracture manipula tion
traversing the distal third of the bone. The cortex is still part The rapid healing process in immature animals is an
il1taCI and the fracture remaills ulldisplaced. obvious biological advantage but can cause problems

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106 Manual of Small Animal Fracture Repair and Management

if fracture management is dela yed for any reason. GROWTH PLATE FRACTURES
Callus already formed may have to be broken down to
reset the fracture. This can produce difficulty in achiev- When trying to identify or assess fractures in this
ing proper fracture reduction, especially when closed location, it is important to understand the different
fracture reduction is employed, and can result in longer loads being applied through the area. Epiphyses can be
operating times and additional soft tissue traumatiza- broadly divided, by function, into pressure and traction
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tion if surgical reduction is selected. In many cases epiphyses. The forces app lied through the growth plate
imperfect reduction may be preferred to additional often dictate the type of fracture produced and the
traumatic manjpulation and a reliance may be placed management regime necessary to resolve the problem.
on the compensatory mechanisms present in youn g All injuries of the epiphyseal region must be inves-
bone to produce a functiona l result in the absence of ti ga ted carefull y so that fra ctures are not overlooked.
complete anatomical reduction. Fractures ha ve to be dealt with rapidly and often
require surgical intervention to preserve full y the fun c-
Post-fracture patient management tion of the adjacent joint. In volvement of the articular
Additional problems are posed by the activity of the s urface and/or impairment of growth by damage to the
patient during the healing period. Puppies and kittens growth plate are important complications of fractures
are by nature very active and extremely diffic ult to rest. in this area and significantly affect prognosis. The
Any fi xation method must take account of tIlis problem Salter-Harris classification of growth plate injuries
and allow the owners a reasonable chance of adhering (Figure 11.4) is often used to describe and attempt to
to management instructions. At the same time the low comment on prognosis of individual fractures. In real-
body weight of youn g puppies and kittens reduces the ity, all fractures involving the growth plates must be
load on the bones and so the mechanical challenge on regarded as having an adverse effect on long bone
the healing fracture. This improves the overall success growth and a prognosis must be given accordingly. In
of fixation. the same way, if surgica l fixation is attempted due

Normal Type I Type II

Metaphysis

Epiphysis

Type III Type IV Type V

Figure 11.4: The Salter-Harris classification of growth plate fractures.

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Fractures in Skeletally Immature Animals 107

consideration must be given to the effect on continued


Factors Type
growth from the surgical intervention and from any
implants employed. IIlI IIIIlV
Positive
Growth plate fractures adjacent to Potential for rapid healing + +
pressure epiphyses
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When faced with these fractures at pressure epiphyses, Negative


it is convenient to review Salter types I and II sepa- Small fracture fragments + +
rately from Salter types III and IV. Proximity of joint + +
Soft cancellous bone + +
Fractures involving the growth plate without Possibility of further +
involvement orthe articular surface (Salter I and II) damage during fracture
Fractures falling into this classification form the larg- manipulation
est group of physeal fractures occurring in cats and Involvement of the articular - +
dogs. In the series described by Marretta and Schrader surface
(1983),65.5% of the fractures were identified as either
Table 11.2: General considerations in managemel1f of
Type I or II. Fractures can be found at various sites fractures involving the growth plate without (Salter types I
(Figure 11.5) but the most common locations involve and II) and with (Saiter types III alld IV) involvement a/the
the distal and proximal femoral epiphyses, respec- articular surface in skeletalLy immature animals.
tively. Fractures in both of these sites present different
problems for management (Chapter 18) . The majority Type IV fractures predominated (24%). The involve-
of distal femoral fractures are classified as Salter type ment of the articular surface alters the priorities in
II while most proximal femoral fractures are classified dealing with these fractures. It is imperative that the
as Salter type I. General considerations for dealing fracture is reduced accurately to allow the articular
with this type of fracture are outlined in Table 11.2. surface to heal well and avoid the possibility of debili-
Recommendations are as follows: tating joint disease later in life. Compression fixation
has been demonstrated to lead to improved articular
Secure the epiphysis with the least invasive surface healing and so fractures are often stabi lized
method possible using lag screw fixation. Early mobilization is also
Preserve soft tissues around physis encouraged, to protect the function of the joint. Gen-
Use parallel, small K-wires if possible eral considerations are detailed in Table 11.2. Recom-
Place the implants to avoid impairing joint mendations are as follows:
function
Aim for early limb use. Accurate anatomical reduction of the articular
surface is a priority
Fractures involving the growth plate with Stabilize the articular fracture with compression
involvement of the articular surface (Salter III fixation if possible
and IV) Place the implants to avoid impairingjoint function
The most common site of occurrence is the distal Preserve soft tissue structures
humerus, though other sites have been reported. In the Plan early limb use.
series described by Marretta and Schrader(1983),25.5 %
of the fractures were identified as either type III or IV. The application of all of these recommendations will
obviously depend on the site involved, the age and size
of the patient and the details of the fracture. Impaired
growth is a much more important consideration in
animals under 6 months of age. Similarly, problems
with small fragments and soft bone are more likely in
very young anjmals. However, the important princi-
ples outlined for each fracture type must be applied for
any chance of good success in any patient.

General guidelines for management of


growth plate fractures

Early recognition and treatment is important


Surgical intervention is usually indicated
Figure 11.5: The location ill the skeleton a/Salter-Harris Handle fracture fragments carefully to avoid
type I and If fractures. further damage

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108 Manual of Small Animal Fracture Repair and Management

Take special care in manipulating epiphyseal


fracture surface to avoid damaging germinal
layer
Implant selected should occupy < 20 % of the
physeal diameter
Avoid fi xing cortical bone on both sides of the
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growth plate, which would prevent longitudinal


expansion
Complete and accurate reduction of articular
fra ctures is necessary
Aim for early removal of implants once fracture
has healed.

Implants used in the management of


growth plate fractures
It is worth considering the relative merits of different
implant systems commonly used to stabili ze physeal Figure 11. 7: Cralliocaudal alld {a feral post-operative
fractu res. The systems include: radiographs of a cat with Rush pins llsed 10 stabilize a distal
femoral fracture.

Parallel pins Rush pins (Figure 11.7) achieve better seating in


Rush pins the epiphyseal fragment and should allow longitudinal
Crossed pins ex pansion,as their bodies lie within the intramedullary
Biodegradable pins canal. However, studies have shown that impaired
Bone screws. growth is common even after this type of fi xa tion.
Crossed pins are popular for dealing with physeal
It is common to use small diameter smooth pins (K- fractures but they can be difficult to position in the
wires) to stabilize the Salter I and II fractures (Figure epiphyseal fragment to allow good purchase. They can
11.6). To give rotational stabi lity, two or three wires also bridge the growth plate and theoretically impair
are usually used. Carefu l positioning allows them to be longitudinal development while in position, especially
placed so that they do not interfere with joint function if placed almost perpendicular to the long axis of the
during the healing process. The manner in which they bone.
are positioned determines the effect they will have on Biodegradable pins are commonly used in a paral-
continued physeal function. The optimal position seems lel fashion and have the advantage of not requiring a
to be parallel pins running perpendi cular to the growth second surgical procedure for removal. Reported suc-
plate. Tills method is simple, minimally invasive and cess has been good.
ideal for very young animals. Migration of pins may Fractures involving the articular surface (Salter III
occur but tills is not a major problem as earl y removal and IV) are best stabilized using a lag screw. The use
is planned. of bone screw fi xation or the use of any threaded
Figure 11.6: Proximal femoral im plants to span the fracture is not common ly indi-
physealfracture (Sct/fer- Ha rris type cated to stabili ze physea l fractures, because of the
I) in a cat. ThejraclUre was stabilized possible effect they may ha ve on growth plates (New-
using three K-wires. A concomitant ton and Nunamaker, 1985). The possible exceptions
fracture of the g reater trochanter was
repaired wirll (IVO K-wires.
are fractures in animals reaching the end of their
growing period.

Managing growth plate fractures adjacent


to traction epiphyses
Av ulsion fractures are common and are a direct result
of the force app lied from the attached muscle mass
resisting movement of the adjacent joint: the epiphysis
is literally pulled free from the area of endochondral
ossification, resulting in an avulsion fracture. Any site
where a major muscle mass attaches to a traction
epiphysis is a potential site for fracture (Figure 11.8),
but these injuries most commonly involve the tibial
tuberos ity (Chapter 19) or the greater trochanter of the
femur (Chapter 18). Such fractures pose a serious
teclmical challenge because of the small size of the

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Fractures in Skeletally Immature Animals 109

months of age nearing the end of growth and they often


involve the bones of the upper limb.
Fractures resulting from bone weakness due to pre-
existing bone disease must always be considered in the
juvenile fracture patient as a result of possiblecongeni-
tal or hereditary disorders or, more commonl y, nutri-
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tional imbalances affecting the bo nes (Figure 11.3).


These so-called pathological fractures us ually occur
with a history of minimal trauma and there may be
evidence of multiple s ite in volvement.

General considerations
In general management, strategies sho uld be simple
Figure J 1. 8: Location in the skeletoll of commoll sites of and in volve stabilization systems that can be removed
avulsioll!racfltres at tractioll epipyses. early and easi ly. Rapid biologica l healing means that
many of these fracttlfes can be managed us ing external
bone and the large forces generated by the attached coaptation. However, each indi vidual case must be
muscle. Surgical intervention is necessary to reappose considered carefull y before a choice of fi xation is
the fracture s urfaces and allow healing to take place. made, taking into account both positi ve and negati ve
Stabilization of the fracture is achieved using combi- factors.
nations of pins and wires.
In most cases the safest way to deal wit h this Positive factors
fracture separation is to apply a tension-band wire.
This will produce secure fracture stabili zation with Rapid healing
minimal compromise to the surrounding soft ti ssues. Production of large callus
Using small pins to secure the fragment reduces the Low mechanical loading compared with adult
possibility of iatrogenic fracture while allowing two Thick periosteum can act to support fragments of
fixation points for rotationary stability. Very fine pins bone.
can be used as they are protected by the tension wire.
The wire must be of sufficient diameter to develop Negative factors
tension when tightened to res ist the distractive pull of
the muscle in volved. Soft bones with relatively thin corti ces
In very young dogs a compressive force across the Poor purchase fo r implants
growth plate will cause the plate to fuse, with possible Variable length and shape of diaphysis
undesirable effects. The most conunon example of this Impairment of continued growth
is seen in young Greyhounds with avuls ion injuries of Implants engulfed by new bone, making removal
the insertion of the straight patellar ligament. The tibia difficult
may continue to grow, leaving the tibial tuberos ity Exuberant callus with soft tissue entrapment.
fused be low the plate and so in an anatomically incor-
rect position (Chapter 19). For this reason two pins Specific recommendations for fracture
inserted either parallel or in a convergent or divergent management
fashion without a tension wire may be preferred, avoid-
ing direct compression across the growth plate in very Incomplete (greenstick) fractures
young animals. An alternative approach is to remove These are often found on the tension surface of the
the tension wire earlier in the healing period, leaving bone, whi le the compression s ide bends or folds in-
the pins in position, but this necessitates an additional stead of breaking. Diagnosis can be difficult in the
surgical procedure. absence of recogni zable defonnity. The patient may
present with an acute lameness, with foca l pain over
the siteofthe incomplete fracture. Definitive diagnosis
DIAPHYSEAL FRACTURES depends on positi ve identi fi cati on of the cortiea I brea k,
using radiography. Primary management, once the
Fractures affecting the diaphysis of immature patients diagnosis has been established, is aimed at preventing
are usuall y low energy type and are typically incom- the fracture line propagating furth er and producing a
plete or simple fractures. This is due directly to the complete fracture, and at preventing angulation at the
pliable nature of inunature bones. High energy frac- fracture site as the bone heals.
tures (typically comminuted fractures) are not as fre- A dressing,castor external fixato rin the lower limb
quently found as in adults. When they dooccurthey are will protect the bone and provide support whi le the
usually found in young, large or giant breed dogs 6-9 fracture heals. In the upper limb the bone is less

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110 Manual of Small Animal Fracture Repa ir and Management

accessible and an external fixator may be the surest All of these methods rely on a good biological
method of prov iding the necessary support. The frac- response and short fracture healing time so that de-
ture will heal very quickl y and earl y removal of the pendence on the implant is onl y required fo r short
support in 3-4 weeks should be planned. peri ods of time.

Simple fractures F ractures as a result of pre-existing bone disease


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Sim ple fractures tend to occur in the mid-diaphyseal Secondary nutritional parathyroidism arising from di-
area. They will heal quickly if rea pposed and stabi- etary imbalance is the most common cause of bone
lized. The simplest methods of stabili zation should be disease in juveniles, resulting in poor s keletal miner-
considered because of the biological advantage these ali zation and weak bones. There may be pathological
fractures have. For fractures of the lower Lim b a tu bular folding fractures (Figure 11.3), which can be difficult
cast may allow good, uncomplicated healing, provided to diagnose since the bones may be di fficul t to visual-
the normal conditions fo r selecting a cast as the method ize on radiographs because of poor calcification. The
of stabilization are satisfied (Chapter 7). Otherwise radiographs need to be inspected carefull y as multiple
surgica l fi xation w ith an external fi xator w ill allow fractures may be present. Diagnosis is made fro m the
stabili zation. For the upper limb, intramedullary pins history, radiographic evidence of poor mineralization
and external fixators used alone or in combination w ill and the characteristic appearance of the fractures.
allow healing to occur. Fracture healing should be Ma nagement is primaril y aimed at preventing further
checked at regular intervals and the s upport removed frac tures and ensurin g pain relief for the patient. It is
as soon as it is redundant. often a mistake to use external or internal fixation
devices, due to the poor mechanical state of the bone.
Commi nuted fra ctures The devices may produce additional fractures and
When comminution is present different mechanical and complicate the situation even more. The patient is cage
biological circumstances exist, producing a more com- rested to try to prevent furth er fra ctures occurring
plicated picture. The simplest way to approach these while the dietary problem is reversed.
situations is to make full use of the biological potential
of the comminuted fragments to heal together: provide General guidelines for dealing with
rigid splinting across the fracture site. In the lower limb diaphyseal fractures in skeletally immature
t11is can be best achieved by applying an external fixator, animals
which is ideally designed to maintain Limb length and
position without involving the area of the frac ture. It will Eliminate bone disease as a cause of fracture
also pennit early Limb use, which is an important factor Use minimall y invasive technique if s urgery is
since these fractures may take longer to stabilize than required
sim ple fractures. The use of external coaptation meth- Complete anatomical construction of fracture is
ods is far from ideal in many of these cases. Cast fixation unnecessary
will not easily preserve limb length; in circumstances Casts may be considered, due to rapid healing
where prolonged healing time is antici pated, immobili- requiring short support peri od
zation of joints and muscles (especially when exuberant Check stability weekl y and remove implant or
callus is being produced) may lead to fracture disease cast as soon as practical.
(Chapter 23).
In the upper limb, the bone is once again less Implants used in diaphyseal fracture
accessible, due to the surrounding muscle mass, and management
this produces a dilemma when considering the best No single fi xation teclmique will overcome all the
option to givea good result. Often external fi xa torscan problems that can be encoun tered in the juvenile frac-
be used, despite the fact that their use is less idea l as a ture patient. The surgeon should understand the ben-
result of the increased muscle mass. If they are placed efits and disadvantages of using each type of implant
carefully they will produce good stability with mini- in order to make a correct selection in any g iven
mum invasion of the fracture site. Combining these situation.
with intramedullary pins can give better alignment of
the main fragments and enhance the stability by ' tying Bone plates
in ' the fi xator (Langley-Hobbs et aI. , 1996). Ofte n the most predictable and dependable implant in
Bone plates have been used to provide a biologica l orthopaedic surgery in adults, bone plates produce
bridge across the fracture with good success (D rape, both mechanical and biological difficulties in juve-
personal communication). In these cases no attempt is niles. The soft cortical bone does not provide good
made to reconstruct the fracture. The plate is attac hed screw purchase for stability and the strong rigid bone
proximally and distall y. Plates with low mechanical plates and screws are mismatched with the more flex-
strength, such as cuttable plates, have been used in ible diaphyseal bone in young animals. Biological
small dogs and cats. problems may be produced by the extensive surgical

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Fractures in Skeletally Immature Animals 111

exposure and dissection required to place the plate, and Be simple to apply and remove
the large contact area with bone. Growth may be Allow growth to continue unimpaired
compromised if it is necessary to fix the plate in the Allow assessment of clinical union on different
proximity of the growth plate. Early removal of a bone occasions
plate necessitates a second major surgical procedure. Allow radiographic assessment of healing
Be well tolerated and produce no problems that
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Intramedullary pin or nail might complicate hea ling.


The medullary canal of growing bone is relatively
larger in diameter than an adult bone and contains more
cancellous bone. Intramedullary pins are useful, pro- REFERENCES AND FURTHER
ducing good mechanical and biological environments READING
in suitable fractures. Early removal can be achieved
easily with a minor surgical procedure. Alcantara PJ and Stead AC (1975) Fractures of the distal femur in the
dog and cat. Journal of Small Animal Practice 16,649-659
Berg RJ, Egger EL, Konde U and McCurmin DM (1984) Evaluation of
External fixators prognostic factors for growth following distal epiphyseal injuries
in 17 dogs. Veterinary Surgery 13, 172- 180
The external fixator is disadvantaged by poor purchase Brighton C (1978) Stmcture and function of the growth plate. Clinical
of pins in cortical bone in much the same way as bone Orthopaedics 136, 22-32
plates. However, the short duration of dependence on Denny HR ( 1989) Femoral overgrowth (0 compensate for tibial short-
ening in the dog. Veterinary and Comparative Orthopaedics alld
the implant, the flexibility possible in designing and Traulllatology 1, 47.
applying frames and the relative ease of removal Ham A Wand Cormack DH (1979) 377, Histophysiology of Cartilage.
Bone and Joims. jp Lippincott, Philadelphia, PA
makes the fixator a versatile and useful method of Herron AJ (1981) Review of bone stmcture, function, metabolism and
stabilizing fractures in young animals. growth. In : Pathophysiology ill SlIIal/ Anill/al Surgery, PP. 791-
801. Lea and Febiger, Philadelphia, PA.
Langley-Hobbs S, Camlichael S and McCartney W (1996) Use of
external skeletal fixators in the repair of femoral fra ctures in cats.
REMOVAL OF FIXATION SYSTEMS Journal of Small Animal Practice 37, 95- 101.
Lawson DD (1958) The use of Rush pins in the management of fractures
in the dog and the cat. Veterinary Record 70, 97-172
This should be planned in every fracture. This is more Marretta SM and Schrader SC (1983) Physeal injuri es in the dog. A
review of 135 cases. Journal of American Veterinary Medicin e
important in young animals since problems may occur Associarion 182,707-710.
as a direct result of the implant's presence as the animal Milton JL, Home RD and Goldstein OM (1980) Cross-pinning : a simple
ages. The longer the implant remains in position, the technique for treatment of certain metaphyseal and physeal frac-
tures of the long bones. Journal of the American Animal Hospital
more likely it is to produce a problem. Implants should Association 16, 891 -905
be removed when their presence is no longer essential Newton CO and Nunamaker OM (1985) Paediatric fractures . In: Text-
book of Small Animal Orthopaedics, cds CD Newton and DM
to the stability and function ofthe bone. This can be at Nunamaker, pp 461-466. Lippincott, Philadelphia, PA
the time of clinical union of the fracture but the point Phillips lR ( 1979) Asurveyofbone fractures in the dog and cat. Journal
of radiographic union is more often selected as a safer of Small Animal Practice 20, 661 - 674
Reynolds DA (198 1) Growth changes in fractured long bones. A study
option. In very young dogs removal ofthe implant may of 126 children. Journal of Balle alld Joint Surgery, 638, 83-88
ensure continued longitudinal growth. SalterRB and Harris WR (1963) Injuries involving the epiphysea l plate.
Journal of Balle and Joint Surgery, 45A, 587
The ideal method of fracture repair in immature Sharrard WJW ( 1993) Fractures and joint injuries. In: Pediatric Ortho-
animals would incorporate the following points: paedics and Fractures, 3rd edn, ed. WJW Sharrard, p. 1365.
Blackwell Scientific Publ ications, Oxford
Wagner SO, Desch JP, Ferguson HR and Nassar RF (1987) Effect of
Allow rapid healing by callus formation distal femoral growth plate fusion on fcmoral-tibiallength. Veleri-
Allow weight bearing and limb use throughout nary Surgery 16, 435-439
healing


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PART THREE - - - - - - - - - - - - - - -

Management of Specific Fractures


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CHAPTER TWELVE - - - - - - - - - - - - - - - - - -

The Skull and Mandible


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Harry W Scott

INTRODUCTION either joint is suspected. Special projections and the


use of intraora l non-screen film may be required to
Trauma to the head ma y result in fractu res of the visua lize indi vidual structures, details of which may be
calvarium, the maxillofacial region, the mandible, the found in standard texts.
dentition or any combination of these. Such injuries
frequently produce severe disfi gurement and pain, and
are among the most distressing for patient and client PRINCIPLES OF JAW FRACTURE
alike. Many of these fractures pose special problems REPAIR
because they are open and invo lve concurrent trauma
to soft tissue structures such as the oral mucosa, nasal The basic principles of fracture repair are the same as
passages and tongue. Treatment must not onl y address those for fractures elsewhere, with the addition of
fracture fixati on but also the soft tissues, the dentition factors that are unique to the jaw because of the
and the maintenance of nutrition. Emergency treat- presence of the teeth . Most of the dorsal two-tllirds of
ment may be required in severely traumati zed patients the mandible is occupied by tooth roots; the ventra l
to maintain a patent airway and prevent further injury third includes the mandibular canal, which contains
to soft tissue structures. Early reduction and stabilization the mandibular al veolar artery and vein and the man-
are necessary when the fracnlre fragments obstruct the dibular alveolar nerve. The mandibular canal has one
airway, impinge on the brain or eye, or prevent eating caudomedia l opening, the mandibular foramen, and
and drinking. two or three mental foramina on the rostrolateral
The location and nature of jaw fractures can fre- aspect, the largest of which (the middle mental foramen)
quently be visuali zed on physical examination; never- is located ventral to the septum between the first two
theless, radiologica l examination should always be premolars. The mandibular alveolar artery and its
performed to assist in the identification of concomitant branches provide the sole blood supply to the alveolar
fractures, temporomandibular joint (TMJ) luxation bone, periodontal ligament and the teeth (Roush et al.,
and dental trauma. Evaluation of radiographs of this 1989). Disruption of the blood suppl y to the rostral
region is complicated by the great range of normal fragment after osteotomy of the mandible is followed
variation in skull shape and size between breeds of by the development of a transient extraosseous bl ood
dog. Breed differences are less pronounced in the cat suppl y via the soft tissue attacllments until the normal
but the small size and the superimposition of structures vascular pattern is re-established (Roush and Wilson,
complicates radiographic interpretation. With correct 1989). Thus the integrity of the rostral soft tissues is
positioning distortion is e liminated and the bilateral important for revascularization of bone and hence the
symmetry of the sknll can be used to advantage to prognosis for fracture union.
facilitate assessment of unilateral abnormalities. Inter- Considerations when undertaking fractu re repair
pretation of radiographs obtained to assess fracture are the avoidance of iatrogenic trauma to the teeth and
healing in the max illofacial region and the calvarium is associated neurovascular structures, removal of di s-
difficult because the thin cortical bone hea ls with less eased teeth within the fracture line, and - most impor-
callus formation than that of long bone fractures. An tant of all - restoration of correct dental occlusion.
external callus can be demonstrated radiologically Implants should never be placed into or within the pulp
during the healing of mandibular fractures but because or dentine of the root, including unerupted teeth in
the mandible is not a weight-bearing bone this is less youn g animals, and the mandibular canal and its fo-
extensive than that seen during the healing of most ramina should be avoided. Small malalignments that
long bone fra ctures (Morgan and Leighton, 1995). are well tolerated in diaphyseal fractures of the appen-
Routine radiography includes the lateral and dorso- dicular skeleton are usually unacceptable in the man-
ventral or ventrodorsal views and lateral oblique pro- dible. Caudal malalignment of only 2-3 mm may
jections of both TMJs when fracture or luxation of prevent closure of the mouth by up to 10 mm (Weigel, ,

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116 Manual of Small Animal Fracture Repair and Management

defects at the fracture site, partic ularly in the presence


of metal implants, should be avoided since they are
associated with an increased incidence of osteomyeli-
tis, delayed union and non-union (Ross and Goldstein,
1986). A large defect that cannot be c losed by simple
tissue apposition can be closed using a mucosal-
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submucosal advancement flap based on the lip margin .


Ifnecessary; alveolar bone can be removed beyond the
mucosal margins to gain free tissue and facilitate flap
advancement and suturing. Sma ll fragments of bone
devoid ofsofttissue attachment should be discarded to
prevent the development of sequestra; larger frag-
ments should be retained even if they are avasc ular,
provided they contribute to fracture stability .
• Fracn"es frequentl y occur through dental alveoli
Fig llre J2. J: Schematic view of the canine skull showing
normal delllal occlusion. either because of prior weakening caused by periodon-
tal disease or beca use the alveolus serves as a stress
1985). To achieve normal occlusion the mandibular riser. Some authorities have advocated the extraction
canine tooth should be positioned in the middle of the of teeth on the fracture line based on the rationale that
space between the ma xillary lateral incisor and canine the presence of a tooth in the fracture line increases the
tooth (Figure 12.1), and the cusp of the mandibular incidence of osteomyelitis and non-union (Rossman et
fourth premolar should be positioned between the al., 1985; Manfra Maretta and Tholen, 1990). Several
maxillary third and fourth premolars (Ross, 1978). studies in humans have shown that immediate extrac-
Malocclusion may result in complications such as tion of the tooth does not prevent these complications
impaired mastication , abnormal tooth wear, accumu- (Neal el aI., 1978; Kahnberg and Ride ll, 1979) and loss
lation of plaque and tartar, periodontal disease, and of teeth and associated alveolar bone increases the
degenerative disease of the TMJ (Chambers, 198 1). difficulty of achieving anatomical reduction. A recent
A number of methods of fracture repair ha ve study of mandibular fractures in the dog showed that
distinct adva ntages and are more readily adapted for there was an increased frequency of complications
use in the repair of jaw fractures in dogs. The surgical following remo val of teeth (Umphlet and Johnson,
options in cats are limited by the small size of the 1990). Extraction of teeth should only be performed if
fracture fragm ents, the irregular shape of the bones there is severe periodontal disease, or if the tooth roots
and the sparsity of the cortical bone. Almost a ll are fractured or loose and cannot be stabilized (Shields
fract ures of the mandible are open, due to the tight Henney et al., 1992). If the dental fracture is coronal
attachment of the gingiva to the underl ying bone. The and the pulp cavity has not been invaded, the fragment
use of broad spectrum antibiotics has been associated should be removed and the tooth restored by enamel
with a reduced incidence of compl ications in open bonding. Fractured teeth with apical fragments can
mandibular fractures in humans (Zallen and Curry, often be salvaged but usually require root canal therapy.
1975) and dogs (Umphlet and Johnson, 1990). Avulsed teeth may be re-implanted, provided the al-
Cephalcx in or potentiated amoxycillin are good em- veolar socket is intact, but wi ll require root canal
pirical choices based on the type of micro-organisms therapy once stable. Disruption of the blood supply to
composing the microbial flora of the mouth. Anima ls the teeth along the fracture line may cause inflamma-
with concurrent severe periodontal disease may ben- tion o f the pulpal tissues lead ing to pe riapical
efit from antibiotics directed at the type of micro- abscessation; such teeth should be monitored closely
organi sms assoc iated with thi s disease, such as during the post-operati ve period and complications
clindamycin, or metronidazole either alone or in treated either by extraction or root canal therapy, as
combination with spiramycin. approp riate (Smith and Kern, 1995).
The viability of the soft tissues should be assessed
durin g fracture repair. Judicious debridement of de-
vitali zed soft tissue should be performed followed by ANAESTHESIA
primary closure of the resulting mucosal defect where
possible. Primary repair of the gingiva is often limited General anaesthesia is required for nearl y a ll patients
by the lac k of available purchase to secure the suture to allow a full physical and radiographic evaluation
adjacent to the alveolar bone and the delicate nature of of the injury. The animal should be anaestheti zed as
the tissues. Absorbable suture materials are preferred, soon as it is safe to do so following assessment and
such as small-diameter polyglactin (Vicryl; Ethicon) appropriate treatment of other injuries. Injectable
in a simple interrupted pattern. Soft tissue defects over agents may be used to allow examination of the oral
intact bone will rapidly granulate and re-epithelialize; cavity, the application of a mu zzle, or for short

..,

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The Skull and Mandible 117

procedures such as the wiring of a mandibular sym- with the neck extended (Egger, 1993). Using a finger
physeal fracture; for longer procedures inhalation inserted into the oropharynx, medial to latera l pres-
agents should be administered through a cuffed en- sure is exerted in the piriform fossa, just caudal to the
dotracheal tube that wi ll prevent the inhalation of epihyoid bone. A skin incision is made ap proxi-
blood and debris. A conventionally placed tube im- matel y 1.5 times the diameter of the endotracheal
pedes oral manipulations and prevents closure of the tube and continued through the platysma muscle and
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mouth to check for correct reduction by alignment of sphincter colli muscle into the pharynx. Artery for-
the teeth; consequently pharyngostomy intubation ceps inserted fro m the exterior are used first to grasp
should be used when undertaking repair of bilateral, the cuff inflation tube and then the endotracheal tube
comminuted or multiple fractures of the maxilla or itself, with the adapter removed, and pull it through
mandible (Hartsfield el al., 1977). After anaesthetic the pharyngotomy incision. Following fracture repair
induction, intubation is performed in the usual way the pharyngotomy wound is left unsutured and al-
and the animal is positioned in lateral recumbency lowed to heal by second intention. For patients with
concomitant upper airway obstruction, following rou-
(a) Force of tine endotrachea l intubation, a tracheotomy should
masticatory m. be performed fortracheostomy tube placement (Smith
Bending force and Kern, 1995).
on fracture

BIOMECHANICS OF JAW FRACTURES


The dominant muscle pull on the mandible is from the
temporalis, masseter and the medial and lateral ptery-
goid muscles, whose combined effect is to close the
jaw. In the dog these muscles are very strong and are
capable of generating massive occlusal forces. The
(b) Force of only muscle whose action is to open the jaw is the
masticatory m. relatively weak digastricus muscle which attaches to
Bending force
on fracture the ventral aspect of the mandibular body. The primary
force acting on the mandible during mastication is
bending which induces maximum tensile stress at the
oral or alveolar side of the mandible. Shear, rotational
and compress ive forces are of much less significance,
particularly when fractures are unilateral due to the
splinting effect of the hemimandible. The forces acting
on the maxilla are similar but of smaller magnitude. To
take advantage of the tension-band principle, all im-
plants should be placed on the alveolar border unless
(e) Force of this is likely to jeopardi ze the tooth roots and the
masticatory m. neurovascu lar structures in the mandibular canal.
Bending force Forsimple mandibular fractures the direction of the
on fracture
fracture line will influence the inherent stability of the
fracture and should be considered when choosing the
method of fixation (Figure 12.2).

TECHNIQUES USED IN MANAGING


HEAD FRACTURES
Long-term mouth closure
Figure 12.2: Biomechanics of mandibular fractures. (a) A
fracture perpendicular to the long axis a/the body a/the
A ll of these techniques rely on interdigitation of the
mal1dible wilL tend to open at the dorsal end a/the/racture teeth of the upper and lower dental arcades to achieve
fine. (b) For oblique fractures, stability will depend all the fracture reduction through occlusal aligrunent. A 5-10
angle alld direction oflhe obliquity. A/racture line that fllns mm gap should be left beiween the upper and lower
from dorsocaudal to vellIrorostral isJavourable because
incisors to allow for the animal to lap a semi-liquid
muscle/orees compress the fracture line and it will be
il1herently stable. (c) A fracture Line (Ilat is oriellfated/rom
diet. If proper occlusion can only be maintained by
dorsorostral to ventrocalldal is unfavourable because similar closing the jaws then no gap is lefland the ani mal is fed
forces lead to distraction a/the rostral/ragmen!. by gastrostomy or pharyngostomy, or by introducing

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US Manual of Small Animal Fracture Repair and Management

liquid food into the cheek pouch. The major disadvan- Less stability than a properly perform ed open
tage of all of these methods is that they interfere with reduction
normal masticatory fun ction. Reliance is made on th e owner for daily
maintenan ce of the muzzle
External coaptation Dermatitis may develop under the muzzle
External coaptation may be indicated in the following Immobilization ma y lead to soft tissue contraction.
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circumstances: Some patients may not tolerate application of a


muzzle
Stable fractures of th e mandible and maxilla with Delay in return to normal eating and drinking
minimal displacement Ris k of heat stroke due to interference with panting
Fractures in young animals, provided occlusion Risk of inhalation pneumonia if the animal vomits
is good Less suitable for cats and contraindicated in
Unilateral or bilateral fi ssure or greenstick brachycephalic breeds because of interference
fractures with breathing. It is essential to check that an
Fractures of the ramus of the mandible including animal can breathe through its nose before
th e condyloid process, provided displacement is application of a muzzle.
not too severe
Fractures secondary to periodontal disease where Intraoral techniques
th ere is insufficient bone stock to accept Depending on the location of th e fracture, dental
implants occlusion is maintain ed by th e place m e nt of
As a temporary means of stabilization before interarcade wires either around the inciso r teeth
definitive repair (Merkley and Brinker, 1976), through drill holes in
As an adjunct to other methods of th e alveolar ridge just caudal to th e canine teeth, or
stabilization between the tooth roots of the maxillary fourth premo-
lar and the mandibular first molar (i.e. th e carnassial
External support using a mu zzle fashioned from adhe- teeth) bilaterall y (Lantz, 1981). The endotracheal
sive tape (Withrow, 1981) (Figure 12.3) or a commer- tube is removed following recovery from general
cially available nylon muzzle (Mikki; MDe products) anaesthes ia and th e wires are tightened to secure the
is a practical, cheap and non-in vasive method of man- jaw in the desired pos ition . The technique may be
aging selected jaw fractures. Muzzle coaptation is used for conuninuted fractures in which accurate
probably the commonest definitive stabilization tech- bone fragm ent reconstruction is not possible, espe-
nique for mandibular fractures in dogs (Umphlet and cially where th e contralateral hemimandible is intact,
Johnson, 1990). Despite its common usage, there are and for combined fractures of the mandible and
numerous disadvantages, some of which are similar to maxilla ifthey cannot be stabili zed separately (Brinker
those for external coaptation of limb fractures: etal., 1990). A variation on this technique, applicable

Non-sticky
side

Figure 12.3: Tlte appLication of a tape fIlUU}e. Th ree pieces of adhesive tape are used/or the basic muzzLe. (aJ Theftrst piece
ellcircles the muzzle (sticky side out). (b) A' second strip of tape is then placed around the back of the head with each end running
alongside the muzzle (sticky side out). The ends should be of sujjiciellliength to fold back behind the ears again after a third piece
of tape has been applied. (c) A third strip of tape is placed arollnd the muzzle (sticky side down) to bind ill the second piece. Th e
ends of the second piece are now folded back on themselves alld anchored behind the head. (d) A fourth strip acting as a chin strap
may be added.

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The Skull and Mandible 119

only to cats and small dogs, is the placement of Angle th e drill holes towards the fracture s ite to
screws in the mandible and maxilla caudal to the facilitate th e subsequent passage and tightening
canine teeth; elastic bands are then placed over the of the wire
screw heads which protrude into the buccal space to When drilling through the mandibular canal, use
achieve alignment (Nibley, 1981) . If th e screws are a Kirschner wire (K-wire) rather than a drill bit
placed unilaterally th ey should be positioned strate- to reduce the risk of damaging the neurovasc ular
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gically to oppose any malalignment of th e jaw. The structures


client should be instructed how to remove the e lastic Use the tension-band principle, i.e. place the first
bands in an emergency. wire close to th e alveolar border and ti ghten this
A technique that has been described more recently is wire first
the use of dental composite for the fixation of mandi- In all but the most stable fractures use two wires,
bular fractures and luxations in dogs and cats (Bennett et preferabl y at an angle to one another. Place one
ai., 1994; Goeggerle et aI. , 1996). The upper and lower wire perpendicular to th e fracture line and the
canine teeth are bonded together to provide the same other parallel to th e long axis of th e mandibular
functional effect as a muzzle. This method of mouth body (Figure 12.4). A triangular configuration,
closure is said to provide a better prognosis for restoration with one hole in the rostral fragment and two
of occlusion compared with muzzling and eliminates holes in the caudal segment, is very effective for
the risk of iatrogenic damage to the teeth and periodontal oblique fractures (Figure 12.5)
structures that exists with interarcade wiring. When using a s ingle wire, place th e wire
Advantages of intraora l methods over the use of perpendicular to the fracture line to minjmi ze
muzzle fixation are as follows: iatrogenic shear forces
Use wire ofthe correct size. Wire that is too thin
No risk of dermatitis will either break or cut through the bone; wire
No risk of patient interference that is too thick will not be fl exible enough to
More applica ble to th e cat. allow manipulation and tightening. Use 18 -22
gauge wire, accord ing to the s ize of the patient
Disadvantages are as follows: Avoid excessive soft tissue dissection and
entrapment of soft tiss ue beneath the wire
Potential damage to teeth and periodontal tissues Tighten wires securely from caudal to rostral;
by the implants symphyseal fractures should be wired last.
Tube feeding is necessary if the incisors are
wired, or if the jaw is completely closed Interfragm entary wiring is not suitable for repair of
The appliance cannot be removed quickly in an fractures with conuninution that cannot be recon-
emergency. structed.

WARNING
Because of these drawbacks the use of alternative
techniques is recommended whenever possible.

Interfragmentary and cerclage wire fixation


The most frequent application of wiring tec hniques is
cerclage or circumferential wiring for the repair of
fractures of the symphysis, and interfragmentary wir-
ing, wh ich involves the placement of wire directly
across a fracture line. Interfragmentary wiring is a Figure 12.4: Implallt placement ill the repair of a mandibular
versatile and economical technique when properly body fracture using interfragmellfQlY wiring.
perform ed and should be considered as the standard
method of internal fixation of jaw fractures (Rudy and
Boudrieau, 1992). However, it is an invasive proce-
dure that requires a thorough knowledge of tooth root
anatomy and is unforgiving of technical errors. The
following are guidelines for correct placement of
interfragrn entary wires:

Avoid tooth roots when drilling holes


Drill all holes and place all wires before tightening
Drill holes 5-10 nun from the fracture line and Figure 12.5: llllerjragmentary wiring of an oblique
avoid weakened bone and soft alveolar bone mandibular body fracture.

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120 Manual of Small Animal Fracture Repair and Management

Term Definition
Interdental wiring Fixation technique used in management of mandibular and maxillary fractures.
Fragment alignment and stability are achieved by the placement of one or more wire
loops that span the fractured region and are anchored around intact teeth on either side
of the fracture.
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Interdental splint Uses the same principle as interdental wiring except that the wire is augmented with
a dental acrylic splint which also spans the fractured region. In some circumstances
the wire is omitted and the dental acrylic splint is bonded directly to tooth enamel.
Intraoral splint Dental acrylic appliance placed against the hard palate and either wired or bonded to
the teeth of the maxilla in order to maintain aligrunent and support of fracture
fragments.
Interarcade wiring Intraoral placement of wire between the mandible and maxilla to produce partial oral
closure. Fracture fragment alignment is maintained as a result of interdigitation of
teeth of the upper and lower dental arches.
Table 12.1: Wiring and splints llsed for fractures of the jaw.

Interdental wiring and splints viable alternative to bone plating and external skeletal
Interdental wiring is commonly used for the manage- fixation for the repair of mandibular fractures (Kern et
ment of human jaw fractures and has been adapted for ai., 1995). The technique is quick, economical, simple
use in dogs, either as the sale method of repair for to perform and avoids the risk of iatrogenic damage to
maxillary fractures and simple transverse mandibular the tooth roots and neurovascular structures of the
body fractures, or as an adjunct to other techniques for mandibular canal.
the repair of more complex jaw fractures. Unfortu-
nately, the dental anatomy of the dog and cat does not Intraoral splints
lend itself to this technique because of the large inter- The most effective type of intraoral splint is fabricated
dental spaces and the lack of a supragingival 'neck' to from aery Lic and is wired or bonded directly to the
the teeth. Fractures often involve at least one of the coronal surfaces of the teeth. The surfaces of the teeth
roots of the adjacent teeth; therefore the wire should for attachment of the splint are acid-etched and a thin
normally incorporate a minimum of two teeth on either layer of lubricating jelly is applied to protect the soft
side of the fracture line. The technique is only applica- tissues. Polymerization is an exothermic reaction and
ble to animals with an intact and healthy dentition. A there is a risk of thermal necrosis of oral tissue. This
number of configurations of wire have been described can be avoided by applying the acrylic powder in
(Weigel, 1985) but a simple loop or figure-of-eight multiple thin layers in an alternating pattern with liquid
pattern works well. If interdental wire is to be used monomer to build up the splint, or more simply by the
alone, the wire is passed through holes created in the use of cold-cure acrylics. The wire may be interdental
gingiva at the neck of the tooth using a small K wire. or may be placed around the maxilla or through holes
Slipping of the wire can be prevented by creating a drilled in the maxilla. Disadvantages with this tech-
small notch in the teeth at the gingival margin, using a nique include interference with the management of
small round burr. Over-tightening of the wire must be soft tissue injuries and development of stomatitis and
avoided because this causes opening of the ventral side gingivitis secondary to entrapment of food between
of the fracture line. the appliance and the gingiva. Care must be exercised
An alternative method of interdental fixation is the to prevent entry of acrylic into the fracture site during
use of acrylic or dental composite to construct an construction of the splint, since thls increases the risk
interdental splint that is bonded directly to the enamel of delayed healing.
of the teeth after etching with phosphoric acid gel.
Mandibular splints are created on the buccal and lin- External skeletal fixation
gual surfaces of the first to third premolar teeth, and The standard Kirschner-Ehmer splint with connect-
only the lingual surface of the fourth premolar and ing bars and clamps can be used for the fixation of
molars, to allow for the scissor bite of the carnassial mandibular and maxillary fractures. Such splints are
teeth. The acrylic may be reinforced with interdental heavy and cumbersome, and difficult to apply, but
wiring or with a preformed metal splint. The combina- these problems can be overcome by the use of dental
tion of acrylic with metal reinforcement has been acrylic for pin stabilization (Tomlinson and
shown to be significantly stronger and stiffer than Constantinescu, 1991; Davidson and Bauer, 1992).
either metal or acrylic alone (Kern et aI., 1993). A The general principles are similar but the use of
recent study of this form of fixation showed that it is a acrylic permits the placement of numerous pins of

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The Skull and Mandible 121

differing sizes and at variable angles, and the splint grade, startin g with the shorter segment. Fractures
can be curved around the j aw rostrally to incorporate in the segment of the mandible between the second
bilateral pins. Standard intramedullary pins, threaded premolar and the first mo lar are the most amenable
pins or K-wires, can be used as transfixation pins and to pin fixation but alternative methods of fi xation
may be inserted either as half-pins or full pins. At are recommended because of the aforementioned
least two and preferably three pins of the correct disadvantages.
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diameter should be used in each main fragment to


provide rigid fixation. Threaded pins are recom- Bone plating
mended because they can be placed perpendicular to Although bone plating provides an opportunity for
the long axis of the bone, they grip more securely, and rigid fixation, rapid return to pain-free norm al fun c-
they prolong the stability of the pin- bone interface tion and primary bone healing, the technique has
(Aron et al., 1986; Bennett et al., 1987). Threaded numerous disadva ntages when used for the repair of
pins with an outer thread diameter greater than the jaw fractures. Application invo lves considerab le
shaft diameter may be used but are more expensive disruption of soft tissues and fracture frag ment vas-
and probably confer little advantage when used for cularsupply, which may compromise healing (Roush
jaw fractures. Pin brea kage is much less of a problem et al., 1989). Furthermore, damage to the tooth roots
following repair of jaw fractures than with fractures or neurovascular stru ctures during screw pla cement
of the weight-bearing bones ofthe appendicular skel- is almost inevitable and ma y res ult in endodontic
eton, because the forces on the jaw are smaller and disease. Precise contouring of the plate is required if
can be more easily controlled by appropriate post- malocclusion is to be avoided when the screws are
operative care. The pins may be bent over to lie tightened. Application of the plate on the tension
parallel to the skin to increase the strength of the pin- side of the bone near the al veolar border provides
acrylic interface. The acrylic can either be injected the best fixation but is not recommended, because of
into flexible tubing or a penrose drain, using a cath- the likelihood of interference with the tooth roots
eter syringe, or be allowed to become doughy before and the ri sk of complications due to gingival erosion
being moulded over the bent fixation pins by hand. A over the implants (Verstraete and Lighthelm , 1987) .
20 mm diameter acrylic rod is stiffer and stronger Some of these problems can be overcome by usin g
than a medium Kirschner- Ehmer connecting bar ASIF-style plates that enable the surgeon to angle
(Willer et al., 1991) and is strong enough for the the screws away fro m the tooth roots; reconstruction
largest of dogs. Advantages of the technique are: that plates ha ve the added advantage of allowing more
it is easy to apply to a wide variety of fracture precise three-dimensional contouring. Toavoidsome
configurations; it is minimally in vasive; the fracture of these complications, the screws may be inserted
fragments and associated soft tissue and blood supply in monocortical fas hion so that they only engage the
are not disturbed; and there are no implants at the cortex in contact with the plate. In two recent experi-
fracture site to potentiate infection. Indications in- mental studies six-hole ASIF plates were applied in
clude fractures where there is comminution and those compression mode with the screws penetratingCthe
where there is gross soft tissue damage. Furthermore, cortex on only the ventrobuccal aspect of the man-
stable fixation can be achieved in fractures where dible (Roush and Wilson, 1989; Kern et al. , 1995).
there are deficits due to loss of bone or teeth. Stable fixation was achieved as indicated by pri -
mary bone healing and most of the recognized com-
Intramedullary pinning plicati ons were avoided. Conventional bone plating
This technique has been advocated for the repair of is most useful for large or giant breed dogs with
mandibular fractures (Brinker et al., 1990) but has unstable unilateral or bilateral mandibular body
little to commend it. The pin inevitably causes
disruption of the neurovascular structures in the
mandibular canal and damages the tooth root apices
and associated soft tissues (Weigel, 1985 ; Roush
and Wilson, 1989). Umphlet and Johnson (1990)
reported that intramedullary pinning of mandibular
fractures was associated with more complications
than other methods of fixation. The mandibular
canal is relatively straight from the root of the
canine to the first molar but it then curves upwards
until it opens on the medial aspect ofthe ramus as the
mandibular foramen. A large pin tends to cause
malocclusion as the bone accommodates to the shape
of the pin, whereas a smaller pin provides insuffi- Figure 12.6: Plating a/a mandibular body fracture (see text
cient stability. The pin is usually inserted retro- for details).

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122 Manua l of Small Animal Fracture Repair and Management

Vertical ramus
12%

Symphysis
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15%
Incisor Condyle Symphysis
5% Cani ne 5% 73% Body Condyle
Premolar Molar
9% 31 % 18% 16% 7%

Figure 12.7: 11,e distribution o!lI/olldibularjraclllres ill the Figure 12.8: Th e distributioll a/Illolldibular fractures ill the
dog. cat.
fractures (Ha rvey and Emily, 1993). The plate is 23 % of all fractures in cats and 1.5 % and 2.5 % in dogs
placed o n the ventral third of the latera l surface of (Hill, 1977; Phillips, 1979). In two recent retrospective
the mandible and may be combined with interdenta l studies of mandibular fractures, in cats (U mphlet and
fi xa ti o n or the use of a mu zzle for 3-4 weeks pos t- Johnson, 1988) and in dogs (Umphlet and Johnson,
operati vely (Fig ure 12.6). 1990), the commonest method of treatment for cats
Recently the use of miniplates and screws designed was cerclage wiring of symphyseal fractures, whereas
specifically for the treatment of humans wit h maxillo- for dogs the commonest technique was the useofa tape
facial trauma has been described for the repair of man- muzzle for fractures caudal to the second premolar
dibular and maxillofacial fractures in dogs and cats teeth. The distribution of mandibular fractures in these
(Boudrieau and Kudisch, 1996). The ability to perfonn studies is shown in Figures 12.7 and 12.8 . The pre-
precise three-dimensional contouring of the miniplates, dominance of symph yseal fractures in the cat was
combined with their small size, makes them applicable largely responsible for the high incidence of mandi-
for fractures where conventional plates would be uns uit- bular fractures in this species. Road traffic accidents
able or difficult to apply. The authors concluded that were the most frequent cause, fo llowed by fights, fall s
max illofac ial miniplatesare particularly indicated in the and iatrogenic effects as a result of dental extractions.
management of selected comminuted fractures or frac-
tures in which ga ps are present, thus precluding the use Decision making in mandibular fracture repair
of interfragmentary wire. Currently ava ilab le mini plate The choice of technique will be based o n the s ize, age
systems are ex pensive and their use is therefore likely to and use ofthe animal, the locati on and stabi lity of the
be confined to referral institutions with a particular fracture, concurrent injuries and economic considera-
interest in these types of injury. tions. It will also be influenced by the personal prefer-
ences and expertise of the surgeon and the equipment
Partial mandibulectomy/maxillectomy available. The number and diversity of techniques that
These techniques are widely used for the management have been described for mandibular fracture repair are
of ora l neoplasia and are well tolerated in dogs and matched only by the vari ety and unpredictability of
cats. Hemimandibular instability and TMJ degenera- fracture configurations. Before embarking on treat-
tion are inevitable sequels of mandibulectomy (U mph let ment it is important to formulate a fracture plan tai-
et at. , 1988). Mandibulectomy has been recommended lored to the individual patient. A lack of avai lable
for the management of fractures where primary repair expertise or equipment for optimum repair should
is likely to fail because of the presence of extens ive prompt consideration of referral. Table 12.2 gives a
trauma or infection, or in cases where primary repair summary of the commonly used techniques and their
has already failed and resulted in an inability to eat or suitability for fracture repair based on the anatomical
drin k (Lantz and Salisbury, 1987). The technique location and stability of the fracture.
s ho uld be regarded as a salvage procedure and, with
rare exceptions, should not be used for primary repai r Fractures of the mandibular symphys is
unless there are financia l constraints that preclude the The symphysis of the mandible is a fibrocartilaginous
use of other methods. joint or synchondrosis uniting the right and left man-
dibular bodies. The joint is flexible and pemlits a
moderate amount of independent movement of the two
APPLICATION OF FIXATION hemimandibles. Thesimplest method of repair is the use
TECHNIQUES TO SPECIFIC ofacircumferential wire (Figure 12.9). The wire(18-20
FRACTURES ga uge for dogs, 20-22 ga uge for cats) is placed using a
large-bore needle wllich is inserted through the skin of
Fractures of the mandible the ventral nlidline chin along the lateral aspect of the
Fractures of the mandible are the third most common mandible to exit the gingiva jusi caudal to the canine
fracture in the cat, accounting for between II % and tooth. The wire is then threaded through the needle,

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The Skull and Mandible 123

Fracturc location FractUl'c type Procedures


Sy mphysis Simple separation C ircumferential wiring
Comminut ed fractures Tape muzzle
Dental composite and w ire
Part ial mandibu lectomy
Dental compos ite bonding of canines/int erarcade wiring
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Rostral body Stabl e Tape muzzle


Inlerfragmentary wire
Interdental acryli c s plint
Unstab le Externa l lixator
Interfragmentary wire +/- interden tal wire
Int erdental acrylic splint
Partial mandibulectomy
Dental composite bonding of canines/interarcade wiring
Caudal body Stable Tape muzzle
lnterfragmentary wi ring +/- interdenta l wiring
lmerdenta l ac rylic splint
Unstable Plate
Exte"nal fixator
In lerfragmentary w iring +/- interdenta l wiring
lnterdenta l acrylic splint
Dental composite bonding of canines/i nterarcade wiring
Ramus Stable Tape muzz le
Unstable Tape muzzle
Plate
Interf"agme ntary w iring +/- K-wire
Dental composite bonding of canines/ interarcade wiring
Coronoid process Stable Tape muzzle
Unstable Tape muzzle
Dent al composite bondi ng of canines/interarcade wiring
Condyloid process Stable Tape muzzle
Unstable Tape muzzle
Interfragmentary wiring +/- K-wire
Mandibular condy lectomy

Table J2.2: Decision making in the management of mandibular fractures. Bold type indicates the author's preferred methods.

which is withdrawn and the procedure is repeated on the that wi ll provide adequate stability with the least
contralateral side using the same hole in the skin. The potential for complications should be chosen. Muzzle
wire is tightened by twisting the ends together until fixation can be used for fractures where there is innate
stability is achieved. After 6 weeks the wire is removed stability, especially in young ani ma ls where healing is
under a general anaesthetic. Clinical union usually expected to be rapid, provided the canine teeth are able
occurs within tllis period, although in some animals to occlude normally when the mouth is gently closed.
stability may occur in the absence of bone healing, The stability ofthe fracture will depend on the location
owing to the formation of a fibrous union. and direction of the fracture line, as previously stated.
For comminuted or oblique symphyseal fractures Healing times for mandibular fractures may be longer
the addition of a figure-of-eight wire or a wire brace than the previously reported period of 3-5 weeks
(Kitto, 1972) around the base of the caIline teeth may (Brinker et aI. , 1990). Umphlet and Jolmsotl (1990)
be necessary to avoid collapse of the teeth medially. found that clitlical union for canine mandibular frac-
Alternatively, an intraoral acrylic splint can be used to tures in the premolar region occurred in an average
achieve normal occlusion, either incorporating the time of 9 weeks (range 4 - 16 weeks). Overa ll it was
wire or bonded to the canine teeth (Harvey and Emily, found tha t the more caudally placed the fracture, the
1993) (Figure 12.9). longer was the time required for hea ling.
The ventral surgical approach is preferred for ac-
Fractures of the body of the mandible cess to most mandibular fractures (Piermattei, 1993)
The body of the mandible is the tooth-bearing portion (Operative Technique l rl).
of the bone. The premolar region is the commonest site Bilateral fractures immediately caudal to the ca-
of jaw fractures in the dog (Umph let and Jolmson, nine teeth or in the rostral premolar region can be
1990). If the fracture is inherently stable almost all managed using either external skeletal fi xation (Figure
repair techniques are applicable and the simplest method 12.10) or tension-band wiring of the dorsal surface.

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124 Manual of Small Animal Fracture Repair and Management

Fortension-band wiring a ventral approach is used first


to reduce the fracture and place the interfragmentary
wires; intraoral tension -band wires are then placed
through holes drilled in the alveolar bone of the two
fragments. The drill holes must be placed carefully to
avoid the root of the mandibular canine tooth, which
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occupies a large portion of the rostral fragment. The


rostral hole is drilled between the canine teeth and the
lateral incisors, and the caudal hole between the second
and third premolars. To provide secure fixation, the
holes are placed well below the dorsal margin of the
alveolar bone.
External skeletal fi xation has two distinct advan-
J tages over tension-band wiring. Firstly, the implants
are not placed immediately adjacent to the fracture
Figure 12.9: Circumferential wiring a/a mandibular site in an area where there may be little bone stock;
sYlllphysealfracture in a cat. (a) A small, midline skin and secondly, stability can be achieved where there is
incision is made on the velltral aspect 0/ the ja w below {he loss of bone fragm ents or even of an entire canine
canine (eeth. A large bore hypodermic needle (see text) is
tooth. For comminuted fractures where the canine
inserted through the skill incision to emerge intraorally
between the mandibular lIIucosa alld the skill, just calldal to teeth are intact and stable, the canine teeth can be
a lower canine tooth. Olle end a/the wire is passed through bonded together, as previously described, to maintain
the centre of the needle to emerge ventrally. The fleedle is normal occlusion during the hea ling process. Where
withdrawl1 leaving the wire ill positioll alld the procedure is there are multiple small fragments of bone and bro-
repeated all the other side. (b) The wire ends are then twisted
ken teeth, an alternative approach for comminuted
to stabilize the reduced/racture. The twisted ends call then
be bent over or left protruding. fractures is a partial mandibulectomy.

(a)

Figure 12.10: External skeletal fixation 0/ mandibular fractures. (a) Schematic view 0/ a bilateral comminuted mandibular body
fractu re repaired with pins and a dental acrylic cOllnecting bar (see text for details of application). (b) Bilateral open fractures of
the rostral mandibular body ill a dog /oilowing a road traffic acefdem. (c) The same dog 24 flOurs after repair of the fractures
using an acrylic fixGlO r.

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The Skull and Mandible 125

Interfragmentary wiring, combined with interden- applied for 2-4 weeks and th e animal is fed a semi-
tal wiring if necessary, is adequate for most other liquid diet. Clinical union takes an average of 11 weeks
unstable fractures. (range 10- 13 weeks) (Umphlet & Johnson, 1990). In
Where fractures are bilateral or th ere is comminu- some cases a fibrous union may develop because of
tion, gross soft tissue trauma, or loss of bone stock, motion at the fracture site but good mandibular func-
external s keletal fi xation is a more appropriate method tion may still result (Chambers, 1981). Open reduction
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of repair. If the fracture is bilateral it is best to place the and internal fixation may be indicated for severely
fixation pins as half-pins. An alternative technique for displaced condylar fra ctures, us ing interfragmentary
bilateral or comminuted fractures is bone plating, wire, small intramedullary pins or K-wires.
especially for caudal body fractures, where it is easier Mandibular'condylectomy and meniscectomy are
to avoid the mandibular canal and the tooth roots. well tolerated in normal dogs (Tomlinson and Presnell,
However, plating is not a good choice for cats or for 1983) and this is the preferred method of managing
young dogs with growing teeth. painful non-union fractures, DJD, and ankylosis attrib-
utable to periarticular fibros is (Lantz et ai., 1982;
Fractures of the ramus of the mandible Lantz, 1991). The surgical approach to the TMJ is
The (vertical) ramus is th e caudal non-tooth-bearing described in Operative Technique 12.3.
verti cal part of the bone. It has three processes: the
coronoid process, the condyloid or articular process
and th e angular process. The mandibular notch is Fractures of the maxillofacial region
located between the coronoid and the condyloid proc- Fractures of this regio n account for approximately 1-
esses; the angle of the mandible is its caudoventral 2 % of all fractures in the dog and cat (Leonard, 1971 ;
portion. Beca use of its protected location, fractures of Phillips, 1979). In addition to the maxilla, the other
the ramus are less common than fractures of the body bones rostral to the orbital region are frequently in-
of the mandible. The ramus differs from the rest of the volved. These are the incisive, nasal and palatine bones
mandible in that the bone is thinner and weaker and, which constitute the hard palate, the upper dental
because of its shape, it is more diffi cult to hold in arcades and the muzzle. Fractures of the face near the
alignment using internal fixation. However, the bone orbit may invol ve th e frontal, zygomatic, temporal and
is surrounded by broad muscular insertions over its ethmoid bones. There is often epistaxis due to concur-
entire surface, th e coronoid process in particular being rent trauma to the nasal turbinates but haemorrhage
well protected by the overlying zygomatic arch and tends to be self-limiting and these injuries are not of
masseter muscle. Fractures in this region are usually primary concern, provided reduction of the fractured
closed, stable and minimally displaced. If significant bones is achieved. The extent of the fracture may be
malocclus ion is present, concomitant TMJ luxation or determined by physical and radiographic examination.
fracture/luxation should be suspected. As with fractures of the mandible, restoration of nor-
Muzzle fixation is the preferred technique for most mal dental occlusion and masticatory function is para-
fractures of the ramus. The options for grossly dis- mount.
placed or unstable fractures, especially in larger dogs, The majority of fractures are stable and minimally
include Kirschner wires, interfragmentary wires or displaced and can be treated using external coaptation.
mini-plates (Sumner-Smith and Dingwall, 1973). Den- Because the muscular forces on the maxilla are much
tal malocclusion as a complication of fracture repair is less than those on the mandible, less rigid fixation is
less common in this region oJ th e mandible (Umphlet required and a fibrous union may produce a satisfac-
and Johnson, 1990). For surgical approach, see Opera- tory functional result, provided dental occlusion has
tive Technique 12.2. not been compromised. Fractures that communicate
with the nasal cavity or the s inuses are likely to be
Fractures of the condyloid process contaminated and the patient should be treated with
Condylar fractures are uncommon and when they do antibiotics, as in any other open fracture. Frontal bone
occur are often associated with fractures of the rostral fractures may develop subcutaneous emphysema if
mandibular body or mandibular symphysis. The con- fractme fragments penetrate the frontal sinus. These
dylar fracture is easily overlooked even when radio- rarely require surgical intervention unl ess they im-
graphic examination is performed. As with other pinge on th e eye, in which case small fragments should
articular fractures, rigid internal fixation and an early be removed and larger fragments should be stabilized.
return to function have been recommended. However, Conservative treatment may require aspiration of the
most fractures are minimally displaced and internal emphysema, if extensive, followed by application of a
fixation is difficult because of the small size of the compressive dressing to pre vent recurrence. Fractures
fragments and the inaccessibility of the joint. In most of the zygomatic arch are relatively common and may
cases good resuits can be obtained with conservative require surgery if they interfere with mastication or
management, and post-operati ve periarticular fibrosis compress ocular structures. An occasional complica-
is avoided (Salisbury and Cantwell, 1989). A muzzle is tion of healing of fractures of the zygomatic arch or the

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126 Manual of Small Animal Fracture Repair and Management

ramus of the mandible is the production of excessive used to manipulate the bone fragments to achieve dental
bony callus that interferes with normal jaw movement occlusion before they are embedded in acrylic.
(Belrnett and Campbell, 1976; Van Ee and Pechman,
1987). The condition is treated by resection of a
portion of the zygomatic arch and fibrous tissue adhe- POST-OPERATIVE MANAGEMENT OF
sions as necessary. The surgical approach is made JAW FRACTURES
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through the skin and platysma muscle directl y over the


bone. Post-operative care for all animals with jaw fractures
Most of the standard internal fixation techniques includes the feeding of a liquid diet for the first 4-7
are applicable for comminuted or displaced fractures days after surgery, followed by avoidance of hard
in this region, particularly interfragmentary and inter- foods until the fracture has healed. Animals that are
dental wi ring. Draping of the maxilla is si milar to that anorexic may require tube feeding . Nasopharyngeal
of the mandible. The surgical approach should be made tube placement can be performed in the conscious
directl y over the site of the fracture, although for patient and is particularly useful for cats, where inser-
multiple fractures (especially along the nose) a dorsal tion is very easy. In cases where long-term nutritional
midline approach with retraction of soft tissues later- support is anticipated (more than 7 days) a gastrostomy
ally may be best to avoid neurovascular structures. tube should be placed at the time of fracture repair. A
Care should be taken to avoid the infraorbital artery technique of blind percutaneous placement of the tube
and nerve exiting through the large infraorbital foramen has been described (Fulton and Dermis, 1992). In
of ihe maxilla which lies dorsal to the septum between animals with oral wounds or where an intraoral appli-
the third and fourth maxillary premolars. The osseous ance has been used for fracture repair, the mouth
lacrimal cana l should be avoided when drilling holes should be rinsed dail y with wann water or an antiseptic
for orthopaedic wire in the small lacrimal bone in the mouthwash. Intraoral appl iances may cause trauma to
rostral margin of the orbit. soft tissues and will inevitably cause a degree of
Intraoral approaches are used for fractures of the stomatitis and gingivitis secondary to food entrapment
hard palate or along the dental arcade. Longitudina l between the appliance and the gingiva. This problem
fractures of the hard palate or nasa l bones are not generally resolves spontaneously within 7 days of
uncommon in the cat and may be seen as one compo- removal of the appliance.
nent of the specific triad of injuries (thoracic injury,
facial trauma and extremity fractures), first termed the
' high-rise syndrome' by Robinson (1976), that occurs PROBLEMS ENCOUNTERED IN
when an animal jumps or falls from a height and lands REPAIRING JAW FRACTURES
on its forelimbs and chin. Traumatic clefts of the hard
palate can be repaired using wire fixation perpendicu- There are two situations where an increase in the
lar to the fracture line, anchored between the teeth on frequency of complications of fracture repair can be
either side of the buccal cavity - usually the fourth predicted:
premolars in the cat, and additionally the canine teeth
in the dog. Where more support is required the wire is Fractures where there is severe comminution or
anchored overtheends of a small pin or K-wire passed bone loss
just dorsal to the hard palate. The mucoperiosteum Fractures where there is advanced periodontal
along the fracture line may sometimes require suturing disease.
to prevent the development of an oronasal fi stula.
Extemal skeletal fixation is particularly suited to The critical size of a bone defect that will not heal is
bilateral or severely comminuted maxillary fracture probably about 20- 40 mm (Schmitz and Hollinger,
repair since the presence of multiple small fragments 1986). External skeletal fixators and bone plates are
makes these fractures difficult to stabilize by any other the best teclmiques for bridging deficits. A cancellous
means (Stambaugh and Nunamaker, 1982). The only bone graft should be used for all fractures where a
requirement is that there must be sufficient bone stock problem is anticipated if an open approach is per-
caudal to the fracture line to allow placement of the formed. Substantial defects may be managed as partial
fixation pins. A type 2 fixator is most commonly mandibulectomies requiring no further treatment
employed and the pins are driven as either half-pins or (Lantz and Salisbury, 1987); alternatively, plate fixa-
full pins, depending on the configuration ofthe fracture. tion and cortical bone grafting may be performed
If the fracture is bilateral they are driven as full pins (Boudrieau et aI., 1994).
across the nasal cav ity, taking care to avoid the tooth Approximately 85 % of all dogs and cats older than
roots and the infraorbital foramen. Fixation pins are 6 years have periodontal disease (Tholen and Hoyt,
always inserted parallel to the hard palate, with the teeth 1983). If an animal has clinically significant periodontal
held in the correct alignment, using at least two pins for disease a complete dental prophylaxis should be per-
each major fragment. Once inserted, the pins may be fonned, with dental extractions as appropriate, at the

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The Skull and Mandible 127

same time as fracture fixation. Pathological fracture FRACTURES OF THE CAL V ARIUM
ma y occur in anima ls with severe periodontal disease
as a res ult of minimal trauma through an alveolus Fractures of the calvarium are uncorrunon and tlus may
already weakened by osteolys is. These animals are be due in part to the fact that most animals are either
also at risk of iatrogenic fracture as a res ult of at- killed outright or die soon after injury as a result of
tempted extra ction of teeth where th ere has been severe brain trauma (Hill, 1977; Phillips, 1979). These
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extensive bone loss but the teeth are still securely fractures are in va riably associated with injury to the
maintained in the ir sockets . Management of iatro- underlying neurological structures. Brain trauma can
genic fractures is frequently complicated by the bone be classified as concussion, contusion and lacerati on,
loss and th e presence of poor quality osteoporotic in increasing order of severity. All three types of injury
bone, with limited osteogenic potential, and infected may occur in assoc iation with fractures of the s kull but
bone secondary to the periodontal disease. Typically laceration is th e commonest (Dewey et al., 1992).
these patients are geriatric small-breed dogs with in - All an imals with head trauma constitute a medical
complete dentition caused by previous extractions or emergency and in a small proportion of cases rapid
shedding of teeth. Internal fixati on is generally not a surgical intervention may also be indicated. Details of
good option because of th e poor bone quality. Judi- medical therapy for head injury are not within the
cious extraction of diseased teeth is indicated where scope of this book. The level of consciousness and
there is periapi ca l abscess formation , though this ma y brainstem refl exes are important in the initial assess-
result in further weakening of the bone. Options fo r ment and in the monitoring of animals with head
fracture management are limited to long-term mouth trauma. Transient loss of consciousness followed by a
closure techniques or mandibulectomy, the choice of rapid recovery may occur when the brain is concussed
technique depending on the type of fracture. A func- and this is associated with a good prognosis.
tional resu lt is to be expected for fractures that are Most skull fractures can be managed conserva-
unilateral and stable even in cases where the bone fail s ti vely (Newton, 1985; Egger, 1993). The benefits of
to heal and a fibrous union develops. For unstable surgical intervention must be weighed against the
fractures, especially when bilateral, it may be prefer- complications of administering a general anaesthetic
able to perform a primary mandibulectomy rather than to a neurologically compromised patient. In the ab-
risk a prolonged and potentially unsuccessful attempt sence of neurological deteri oration, surgery may be
at fracture repair. delayed for 24-48 hours if time is needed for patient
stabili zation. Surgical intervention may be indicated in
the following circumstances (Dewey et al., 1993):
POST -OPERATIVE COMPLICATIONS
OF JAW FRACTURE REPAIR Open fractures
Fractures where there is depression of the
Complications of jaw fracture repair and their associ- fragments more than the width of the calvarium
ated management are essentially the same as those in the fracture area "
described for fractures of the appendicular skeleton Retrieval of contaminated bone fragm ents or
but with the addition of problems relating to the denti- foreign material
tion. These include osteomyelitis, delayed union, non- Persistent leakage of cerebrospinal fluid
union, malunion and malocclusion, bone sequestration, For decompression where th ere is a deteriorating
facial deformity, oronasal fistula and dental abnormal- neurological status despite medical therapy .
ity. Complications were reported in 34% ofmandibu-
larfractures in 105 dogs (Urn ph let and Johnson, 1990) Fractures of the base of the skull are rarely treated
and 24.5 % of mandibular fractures in 62 cats (Umphlet because of the severity of th e injury and their inacces-
and Johnson, 1988) - figures which are higher than sibility for surgical intervention.
those for long bone fractures. The most frequent com- The surgical approach to the calvarium is made
plication in dogs and cats was dental malocclusion, with the patient positioned in ventral recumbency with
which, besides adversely affecting function, increases the head supported and stabilized. A midline s kin
the risk of delayed union and non-union by increasing incision is made extending from the external occipital
th e forces of leverage against th e fixation device. protuberance to the level ofthe eyes (Piermattei, 1993)
Treatment for this complication is determined by the (Figure 12.11). Alternatively a lateral curved incision
severity of th e associated clinical s igns. Options in- may be made, depending o n the location of the frac-
clude immediate removal of the fixatio n device fol- ture. The superficial tempora l fascia is incised and the
lowed by correct reduction and fixation, and extraction temporalis muscle elevaied subperiosteally and re-
or orthodontic movement of the maloccluded teeth tracted laterall y to expose the area of the fracture.
(Manfra Maretta et al., 1990). Malocclusion second- Multiple ho les are drilled in the calvarium around the
ary to segmental defects may be corrected by bone periphery of the fracture, enabling the insertion of
grafting and plate fixation (Boudri ea u et aI., 1994). small instruments to elevate the fragments (Oliver,

-
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128 Manual of Small Animal Fracture Repair and Management

Burr/d rill holes ~~==;:~~~::::::~;;:::~o~o-- Drill hole Bone Meninges


VetBooks.ir

Figure 12.1 J: Exposure alld reductio" o/fractures o/the calvarium.

1975). Unstable fragments can be removed even if Kahnberg KE and Ridell A (1979) Prognosisoft ccth involved in the line
of mandibular fractures. lnternaliollal Journal a/Oral Surgery 8,
large since the temporal is muscle provides adequate 163.
protection of the brain parenchyma. Kern DA,S mith MM, Grant JWand Rockhil l AD (1993) Eva luat ion of
bending strength of fi ve interdcntal fi xation nppamtuses appl icd to
canine mandibles. American JOl/rnal 0/ Velerinary Research 54,
1177.
Kern DA, Smith MM , Stevcnson S. et al. (1995) Evaluation of thrce
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Journal 0/ the Americall Veterillary Medical Association 206,
Aron ON, Toom bs j p and Ho llingswonh SC ( 1986) Primary treatment 1883.
of severe fract ures by external skeletal fi xation: threltdcd pins Kitto HW (1972) A tcchniqucof mandibul ar fi xation in cat symphyseal
compared with smooth pins. Journal oj rile Americall Anilllal fractures. Th e Veterinary Record 91 , 59 1.
Hospital Associatioll 22, 659. Lantz GC (J 98 1) Interarcade wiring a5:1 method of fixat ion for selected
Bennett D and Cutnpbell JR ( 1976) Mechanical interfe rence with lower mandibular fractures. Journal 0/ the A mericall Animal Hospital
jaw movement as a compli cati on of skull fractu res. lOl/mal of Association, 17,599.
Small AI/ima/ Practice 17, 747. Lantz GC (1991) Surgical correct ion of unusualtcmporomandi bular
BcnncuJ W, Kapatkin AS and Manfra Ma retta S ( 1994) Dental compos- j oint conditions. COII/pendium Oil Comilluillg Education for the
ite for the fixat io n of mandibular fractures and luxatio ns ill 11 cats Practising Velerinarian 13, 1570.
and 6 dogs. Veterillary Surgery 23, 190. Lantz GC and Salisbury SK ( 1987) Partia l mandibulcctomy for treat-
Bennett RA, Egger EL, Histand M and Ellis AB (1 987) Comparison of ment of mandibular frac tures in dogs: cight cases (1981- 1984).
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Boudrie:m RJ and Kudisch M ( 1996) Miniplate fi xation of mandibu lar mandibular condylectomy: experimcnta l and cl inical results. Jour-
and maxillary fmctu rcs in 15 dogs and 3 cats. Veterinary Surgery nal o/the American Allilllal Hospiral Association 18, 883.
25.277. Leonard EP (197 1) In: Orlhopaedic Surgery o/Ille Dog alld Cal. WB
Boudrie:1U RJ , Tidwell AS, Ullman SL and Gores BR ( 1994) Correction Saunders, Philadelphia.
of mandibu lar nonunion and malocclusion by plate fixation and Manfra Maretta S and Tholen MA (1990) Extraction techniques and
autogenous cortical bone gmfts in two dogs. Journal o/the Ameri- management of associated complications. In: 511101/ Animal Oral
call Veterinary Medical Association 204, 744 . Medicine and Surgery (cds. MJ Bojmb and MA Tholcn). Lea &
Brinker WO, Piennattei DL and Flo GL (1990) Fractures lind disloca- Febiger, Philadclphi a.
tions of the upper and lower jaw. In : Handbook 0/ Small Animal Manfra Marella S, Schrader SC and Matthicscn DT ( 1990) Problems
Orthopaedics and Fracfllre Treatment, 2nd edn. WB Silunders, associated with the managemcnt and treatment of jaw fractures.
Philadelphi a. Problems ill Veterinary Medicine 2, 220.
Chlllllbcrs JN ( 198 1) Pri nci ples of lllanagelllent of mandibular fractures Mcrklcy DF and Brinker WO ( 1976) Facial reconstructi on foJ[owing
in thc dog and cat. Journal 0/ Veterinary Orthopaedics 2, 26. massive bilateral max illary fra ctu re in the dog. Journa l 0/ the
Davidson JR and Bauer MS (1992) Fractures of thc mandible and Americall Allimal Hospital Associ(l[ion 12, 83 1.
maxil la . Veterillary Clillics 0/ North A merica Smal/ Animal Prac- Morga n IP and Leighton RL ( 1995) Axial skclctal trauma. In: Radiol-
tice 22 , 109. ogy o/Small Animal Fracture Managcment. WB Saundcrs, Phila-
Dewey CW, Budsbcrg SC and Oliver JE (1992) Pri nciples of head delphia.
trauma management in dogs and cats - Part I . CompendiulII on Nea l DC, Wagner WF and Albert B ( 1978) Morbidity associated with
Comilll/ing Educmion/or the Practising Ve terinarian 14, 199. teeth in the line of mandibular frac tu res. JOl/rnal of Oral Surgery
Dewey CW, Budsbcrg SC and Oli ver JE ( 1993) Princi ples of head 36, 859.
trauma management in dogs and cats - Part 2. CompendiulII on Ncwton CD (1985) Fractures of the skull . In: Textbook o/Small Animal
Comilluillg Education/or the Praclisillg Veterinarian IS, 177. Orthopaedics. JB Lippincott, Philadelphia.
Egger EL ( 1993) Skull and mandibular fractures. In: Textbook a/Small Nibley W (198 1) Treatment of caudal mandibular fractures: a prelimi-
Animal Surgery, 2nd edn (ed. D Slatter). WB Saunders, Philadel- nary repon . Journal of rile American Animal Hospital Association
phia. 17, 555.
Fulton RB and Dcnnis JS (1992) Blind percutancous placement of a Oliver JE ( 1975) Craniotomy, cmn iectomy, and skull fmctures. In :
gastrostomy tube fo r nutri tional support in dogs and cats. Journal Currem Techniques;1I SIIIal/ Animal Surgery (cd . MJ Boj rab). Lea
a/the Americall Veterillary Medical Association 201 , 697.
& Febiger, Phi ladelphia.
Goeggcrle UA, Inskccp GA and Toombs JP ( 1996) Managing mandibu-
Philli ps IR ( 1979) A survey ofbonc fractures in the dog and cat. J Ol/rnal
lar fractures in dogs. Compelldium 011 Continuing Education/or the
0/511101/ Animal Practice, 20, 66 1.
Practising Veterinarian 18, 5 11. Pi ennattci DL ( 1993) The head. In: An Arias o/Surgical Approaches fO
Hartsfield SM, Gcndrcau CL, Smith CW et 01., (1977) Endotrachea l the BOlles and J oints a/the Dog and Cat, 3rd edn. WB Saundcrs,
intubation by pharyngotomy. Journal 0/ the American Allimal Phi ladelphia.
Hospital Associatioll 13,7 1. Robinson GW (1976) The high rise trauma syndrome in cats. Fe/ille
Harvey CE and Em ily PP (1993) Oral surgery. In : Small Animal Practice 6, 40.
Delllislry. Mosby, St Louis, MO. Ross OL (l978) Evaluation of oral abnormalities. In : Proceedil1gs
Hill FWG ( 1977) A su rvey of bone fractures in the caL J Ollrnal o/SlIIall American Animal Hospital Association, 45111 Anllual Meelillg, Salt
Allimal Practice 18, 457.

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The Skull and Mandible 129

wke City, UT, 79. lis hing, Edwardsvi1lc, Kansas.


Ross DL and Goldstein GS (1986) Oral surgery basic techniq ues. Tom linson JL and Constantinescu GM ( 199 1) Acrylic extemal s keletal
Veterinary Clinics oj North America Small Animal Praclice 16. fi xation of fractures. Compendium 011 COII/illllillg Educ(lliolljor the
967. Practising Veterillarian 13,235.
Rossman LE, Garber DA and Harvey CE (1985) Disorders of teeth. In: Tomlinson J and Presnell KR ( 1983) Mandibular condylectorny effects
Veterinary Dentislry(cd. C.E. Harvey) . WB Saunders, Philadelphia. in nonnal dogs. Vererinary Surgery 12, 148.
Roush JK and Wilson JW (1989) Healing of mandibular body osteoto- Umphlet RC and Johnson AL ( 1988) Mandibular fractures in the cat. A
mies ufter plate and intramedullary pin fi xation. Velerinary SlIr- retrospective s tudy. Velerillllry Surgery 17,333.
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gery J8, 190. Umphlet RC and Johnson AL ( 1990) Mandibular fra ctures in
Roush JK , Howard PE and Wilson JW ( 1989) Nonna l blood supply to the dog. A retros pect ive study of 157 cilses. Velerinary Surgery
the canine mandi ble and mand ibula r teeth . American Journal oj 19,272.
Vete rinary Research SO, 904. Um phl ct RC. Johnson AL. Eurell JC and Losons ky J ( 1988) Thc effect
Rudy RL and Boudrieau RJ (1992) Maxillofacia l and mandibu lar of partial rostra l hemimandibulectomy on mandibular mobil ity and
fra ctures. Seminars in Veterinary Medicine and Surgery (Small temporomandi bul ar j oint morphology in the dog. Veterinary Sur·
Anilllal) 7, 3. gery 17, 186.
Salis bury SK and Cantwell HD (1989) Conservati vc management of van Ee RTand Pechman RD ( 1987) False ilnkylosisofth c tcmporoman-
fracture s of the mandibular condyloid proccss in three ca ts and dibu lar j oint in a cat. JOllrnal oJlhe Americall Veterinary Medical
one dog. Journal aJlhe American Veterinary Medical Association Associalioll 191, 979.
194,85. Verstraete FJM and Lighthelm AJ ( 1987) Dental trauma caused by
Schmitz JP und Hollinger JO (1986) The critical size defect as an screws used in internal fi xat ion of mandibular osteotomies in the
ex perimental modcl for craniomandibulofacial nonunions. Clini· canine. Journal oj Veterinary Dellfisrry 4, 5.
cal Orll/Opaedics, 205, 299. Weigel JP (1985) Trauma to oral structures. In: Velerillary Delltis1ry
Shields Henney LH . Galburt RB and Boudrieau RJ (1992) Treatment of (cd. CE Harvey). WB Saundcrs, Phillldelphia.
dental injuries foll owing craniofuciul trauma . Semillars in Veleri· WillerRL, EggerEL and HistandMB ( 199 1). A comparison of stai nless
nary Medicine and Surgery (Smal/ Allimal) 7, 2 1. steel versus acrylic for the connecting bar of external skeletal
Smith MM and Kern DA ( 1995) Skull trauma and mandibular fractures. fi xators. Journal oJtlle Ameriwn Animal Hospiral Associalioll 27,
Velerillary Clinics aJNorth America Small Animal Praclice 25, 11 27. 541.
Stamb.lugh JE and Nunamaker DM (1982) External skelctal fi xation of Withrow SJ ( 198 1) Taping of the mandible in treat ment of mandibular
comminuted maxillary fra ctures in dogs. Velerillary Surgery 11,72 . fmctures. Jolirnalojrhe AmeriClIlIAllimal Hospiwl Associarioll 17,
SUTllller·Smith G und Dingwall JS (1973) The plating of mandibu lar 27 .
frac tures in giant dogs. The Veterillary Record 92. 39. Zal len RDand Curry JT( 1975) A studyofantibiOlic usage in compound
Tholen MA and Hoyt RF ( 1983) Oral pathology. In : eOIlCePIS ill mandibular fractures. Journal ojOml Surgery 33, 43 1.
Vererinary Delllisrry (ed. MA Tholen). Veterinary Medicine Pub-

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130 Manual of Small Animal Fracture Repair and Management

OPERATIVE TECHNIQUE 12.1


Surgical exposure of the mandibular body
VetBooks.ir

Positioning
The animal is placed in dorsal recumbency and routine aseptic preparation of the surgical field is performed.
In those cases where access to the oral cavity is req uired the mouth is repeatedly irriga ted with dilute povidone
iodine solution and the tongue is reflected back on itself into the pharynx so that it does not interfere with
assessment of dental occlusion. An intraoral drape faste ned to the s kin at the level of the oral conunissures
is used to cover the anaestheti c apparatus in those animals intubated conventionally. The drape may be
reflected rostrally to allow observation of the oral cavity following pharyngostomy endotracheal tube
placement. In either case the anaesthetic machine is placed to the side ofthe patient to allow unimpeded access
to the surgical field.

Assistant
Optional.

Tray Extras
Pointed reduction forceps; Gelpi and HolunarUl retractors; selected implants and hardware for insertion.

Surgical Approach
Exposure ofthe mandible is achieved by incising
the thin sheet-like platysma muscle, which is
then retracted laterally with the fascia and skin
(Figure 12.12). Exposure of the medial aspect of Facial
vesse ls
the bone can be increased by separating the
mylohyoideus muscle from the medial edge of Ventral buccal
the mandible and retracting it medially. Although branch of
Mandibular facial nerve
subperiosteal elevation of the digastricus muscle body -f-l'l-l'F'I-
from the ventral aspect of the mandible may be Masseter m.
middle and
performed for access to caudal body fractures, it Platysmam. deep
is preferable to preserve the attachment by retrac- portions
elevated
tion of the muscle to either side as necessary. It is from
important to avoid the facial vein and accompa- Digastricus m. -r-H.4---l:-' masseteric
nying nerve trunks laterally. fossa

Myelo- Masseter m.
hyoideus m. superficial
portion

Figure 12.12: Ventral exposure of a mandibular body


fracture (see text/or deta ils).

Woulld Closure
The intermuscular septum between the digastricus and masseter muscles is sutured using absorbable material
of the surgeon's choice. The rest of the closure is routine.

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The Skull and Mandible 131

OPERATIVE TECHNIQUE 12.2


Surgical exposure ofthe mandibular ramus
VetBooks.ir

Positioning
Lateral recumbency with the head supported. Intubation as described in main text.

Assistant
Optional.

Tray Extras
Pointed reduction forceps; Gelpi and Hohmannn retractors; selected implants and hardware for insertion.

Surgical Approach
The surgical approach to the angle of the mandible is
hampered by the heavy musculature, the parotid gland
and the neurovascular structures in this region (Figure Platysma m.
12. 13). After incising the platysma muscle, the dorsa l
and ventral buccal branches of the facial nerve, and the Parotid ducl
parotid gland and its duct shou ld be identified
(Piermattei, 1993). Exposure of the fracture is achieved Ib~~~~==~r -"W----;tt1. Parotid gland
by incising across the superficial layers of the masseter
muscle parallel with the caudal border of the mandible. /.f-,J./--;77'l r ventral buccal
branch of
facial nerve
The middle and deep layers of the muscle are elevated
subperiosteally from their insertion on the masseteric
fossa and retracted dorsally, allowing exposure of the
ramus to the level of the TMJ.

Platysma m.

Figure 12.13: Surgical approach to the mandibular ramus


(see text for details).

Wound Closure
The aponeurosis covering the superficial layer of the masseter muscle is sutured. The rest of the closure is
routin e.

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132 Manual of Small Animal Fracture Repair and Management

OPERATIVE TECHNIQUE 12.3


Surgical exposure of the temporomandibular joint
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Positioning
Lateral recumbency with the head supported. Intubation as described in text.

Assistant
Optional.

Tray Extras
Pointed reduction forceps; Gelpi and Hohmanrum retractors.

Surgical Approach
The skin incision is made along the ventral
border of the zygomatic arch and crosses the
TMJ caudally (piennattei, 1993) (Figure 12.14).
The platysma muscle and fascia are incised and
retracted with the skin; the attachment of the
origin of the masseter muscle on the zygomatic Zygomatic
arch Platysma
arch is incised and subperiosteal elevation of m.
the muscle is performed. The palpebral nerve
and the transverse facial vessels and dorsal