TUGAS MATA KULIAH

ILMU BEDAH KHUSUS VETERINER

“TEKNIK OPERASI FRAKTUR TIBIA FIBULA”

Oleh :

Putu Kreshna Medha 1609511106

I Putu Sandika Arta Guna 1609511110
I Gede Made Andy Pratama 1609511113
Ade Hary Wiweka 1609514084

LABORATORIUM ILMU BEDAH KHUSUS VETERINER

FAKULTAS KEDOKTERAN HEWAN
UNIVERSITAS UDAYANA
DENPASAR
2019
 RINGKASAN

Fraktur adalah kerusakan jaringan tulang yang berakibat tulang yang

menderita tersebut kehilangan kesinambungan, fraktur contohnya disebabkan oleh
suatu trauma, Tibia adalah tulang kering/shankbone adalah satu dari dua tulang
yang lebih besar dan kuat yang ada dibawah lutut pada hewan vertebrata yang
menghubungkan lutut dengan tulang pergelangan kaki, sedangkan Fibula adalah
tulang lutut yang terletak dibagian lateral dari tibia, tulang fibula lebih kecil dari
tulang tibia dan merupakan tulang paling ramping dari antara semua tulang panjang.
Fraktur tibia fibula terjadi pada hewan karena kecelakaan, trauma.

Kata Kunci: Anjing, Fraktur, Tibia Fibula

SUMARRY

A fracture is damage to bone tissue resulting in the suffering bone losing its
continuity, for example the fracture is caused by a trauma. Tibia also known as
shankbone is the larger and stronger of the two bones in the leg bellow the knee in
vertebrates, and it connect the knee with ankle bines while Fibula is leg bone located
in lateral side of tibia, it is the smaller of the two bones and in proportion to its
length, the slenderest of all long bones, The tibia fibula fracture occurs in animals
due to accidents, or trauma

Keyword: Dog, Fraktur, Tibia Fibula

 KATA PENGANTAR

Puji syukur pada kami panjatkan kepada kehadirat Tuhan Yang Maha Esa,
karena berkat rahmat-Nyalah, kami dapat menyelesaikan paper Ilmu Bedah Khusus
Veteriner yang berjudul “Teknik Operasi Fraktur Tibia Fibula” tepat pada
waktunya.

Adapun paper ini kami selesaikan untuk memenuhi tugas yang telah
diberikan kepada kelompok kami tentang Teknik Operasi Fraktur Tibia Fibula.
Dengan adanya tugas mengenai Teknik Operasi Fraktur Tibia Fibula diharapkan
dapat menambah wawasan untuk pembaca juga penulis.

Kami menyadari bahwa paper ini masih jauh dari kesempurnaan. Oleh
karena itu, kritik dan saran sangat dibutuhkan oleh penulis, agar paper ini bisa
menjadi lebih baik lagi.

Denpasar, 18 November 2019

Penulis
 DAFTAR ISI

HALAMAN JUDUL ....................................................................................... i

RINGKASAN ................................................................................................ ii

KATA PENGANTAR .................................................................................. iii

DAFTAR ISI ................................................................................................. iv

BAB I PENDAHULUAN .............................................................................. 1

1.1 Latar Belakang ................................................................................... 1

1.2 Rumusan Masalah .............................................................................. 1
1.3 Tujuan Penulisan ................................................................................ 2
1.4 Manfaat .............................................................................................. 2

BAB II TINJAUAN PUSTAKA.................................................................... 3

2.1 Fraktur Tibia Fibula ........................................................................... 3

2.2 Jenis fraktur ........................................................................................ 3
2.3 Penyebab fraktur ................................................................................ 3

BAB III PRE OPERASI DAN PROSEDUR OPERASI ............................... 4

3.1 Pre Operasi ......................................................................................... 4

3.2 Teknik Operasi ................................................................................... 5
3.3 Prosedur Operasi ................................................................................ 6
3.3.1 fiksasi ........................................................................................ 6
3.3.2 Amputasi ................................................................................... 7

BAB IV PASCA OPERASI ......................................................................... 10

4.1 Perawatan Pasca Operasi.................................................................. 10

BAB V PENUTUP....................................................................................... 11

5.1 Kesimpulan ...................................................................................... 11

5.2 Saran ................................................................................................. 11

DAFTAR PUSTAKA .................................................................................. 12

 BAB I

PENDAHULUAN

1.1 Latar Belakang

Anjing adalah hewan yang sangat dekat keberadaannya dengan manusia,

selain sebagai hewan peliharaan anjing dipelihara untuk membantu meburu,
menggembalakan ternak, hingga menjadi anjing pelacak. Kepribadian yang
mudah akrab pada manusia menjadikan anjing yang dipelihara manusia sering
dilepas liarkan. Pemeliharaan ini memang mudah dilakukan, tapi berakibat
kurangnya tanggung jawab pemilik dan mudahnya anjing terkena penyakit.

Fraktur tibialis sering terjadi terutama pada anjing dan dapat timbul dalam
berbagai bentuk. Karena ada sedikit jaringan lunak yang menutupi
craniomedial, fraktur terbuka sering terjadi. Mayoritas komplikasi fraktur ada
karena pengambilan keputusan yang buruk daripada tidak ada keahlian teknis
dari dokter hewan yang merawat. Pra operasi penilaian fraktur dan perencanaan
perbaikan membantu membatasi tingkat komplikasi fraktur tibialis (Glyde et
al., 2006)

Fraktur atau patah tulang adalah kerusakan jaringan tulang yang berakibat
tulang yang menderita tersebut kehilangan kesinambungan. Patah tulang
disebabkan oleh suatu trauma atau ruda paksa yang berasal dari luar tubuh,
namun adapula yang disebabkan oleh suatu penyakit (Sudisma et al., 2006)

Tibia adalah tulang kering/shankbone adalah satu dari dua tulang yang
lebih besar dan kuat yang ada dibawah lutut pada hewan vertebrata yang
menghubungkan lutut dengan tulang pergelangan kaki, sedangkan Fibula
adalah tulang lutut yang terletak dibagian lateral dari tibia, tulang fibula lebih
kecil dari tulang tibia dan merupakan tulang paling ramping dari antara semua
tulang panjang.

1.2 Rumusan Masalah:

1. Bagaimana pre-operasi dan anestesi operasi dari fraktur tibia-fibula?

2. Bagaimana prosedur operasi fraktur tibia-fibula ?

1
 3. Bagaimana hasil dan pasca fraktur tibia-fibula ?

1.3 Tujuan Penulisan:

1. Untuk mengetahui cara anestesi dan per-operasi dari fraktur tibia-fibula

2. Untuk mengetahui prosedur operasi fraktur tibia-fibula
3. Untuk mengetahui hasil dan pasca dari operasi fraktur tibia-fibula
1.4 Manfaat
Diharapkan mahasiswa dapat mengerti dan mengerti dan mengetahui
dimaksud dengan Fraktur serta bagaimana prosedur dari operasi Fraktur
tibia-fibula

2
 BAB II

TINJAUAN PUSTAKA

2.1 Fraktur Tibia Fibula

Fraktur tibia fibula biasanya dapat terjadi pada hewan peliharaan akibat
kecelakaan karena dilepas liarkan, trauma atau ruda paksa, dan penyakit.
Penanganan pada hewan yang mengalami fraktur harus cepat, dan bila tulang yang
mengalami fraktur tidak dapat difiksasi maka penanganan yang harus dilakukan
adalah amputasi.

2.2 Jenis Fraktur

Secara umum ada dua jenis fraktur yaitu: Fraktur tertutup (Closed fracture)
dimana tidak ada komplikasi luka dan tidak ada pendarahan dan fraktur terbuka
(Open fracture) dimana tulang patah dapat terlihat dan dapat menyebabkan infeksi
(Piermattei et al., 2006)

2.3 Penyebab Fraktur

Penyakit yang ada didalam tulang yang bersifat lokal yaitu seperti: radang
tulang, tumor, dan osteosarcoma, tumor ini biasanya mengenai tulang panjang, lalu
yang bersifat umum adalah penyakit yang menyerang tulang diseluruh tubuh
contohnya : osteogenesis imperpecta, osteoporosis, dll. Untuk penyakit diluar
tulang, umumnya tumor diluar tulang akan mendesak tulang dan bahkan merusak
(Sudisma et al., 2006)

Fraktur karena kecelakaan biasanya terjadi karena hewan peliharaan dilepas

liarkan, sehingga ada kemungkinan hewan tertabrak kendaraan bermotor dijalan,
berkelahi, atau kemungkinan jatuh dan terbentur sesuatu, Fraktur karena Trauma
atau ruda paksa terjadi karena batas lenntur tulang telah terlampaui sehingga akan
terjadi patah tulang. Pada umur tua kemungkinan mudah patah lebih besar
dibandingan umur muda. Fraktur karena penyakit bisa disebabkan oleh penyakit
yang ada didalam tulang, dapat juga disebabkan penyakit yang berada diluar
tulang.

3
 BAB III
PRE OPERASI DAN PROSEDUR OPERASI
3.1 Pre Operasi
Sebelum pembedahan dilakukan persiapan operasi yang matang agar
operasi pada hewan tersebut berjalan dengan sukses dan lancar tanpa adanya hal-
hal yang menggangu jalannya operasi dan menghambat kesembuhan hewan
tersebut. Persiapan yang perlu dilakukan meliputi persiapan alat, bahan dan obat,
persiapan ruang operasi, persiapan pasien dan persiapan operator.

a. Persiapan alat, bahan dan obat

Alat dan bahan harus di sterilisasi dengan autoclave ataupun alkohol 70%.

b. Persiapan Ruang Operasi

Ruang operasi dibersihkan, meja operasi disterilkan dengan desinfektan

serta didalam ruang operasi tersedia lampu penerangan.

c. Persiapan Hewan/Pasien

Sebelum pembedahan dilakukan pemeriksaan fisik yang meliputi :

signalement, berat badan, umur, pulsus, frekuensi nafas, suhu tubuh, sistem
digestivus, respirasi, sirkulasi, syaraf, reproduksi, perubahan anggota gerak dan
perubahan kulit yang telah dicatat semua pada ambulator yang telah terlampir.
Pemeriksaan radiografi dilakukan untuk meneguhkan diagnosa fraktur yang terjadi
(Ozoy dan Altunatmaz, 2003)

Gambar: Radiografi Fraktur Tibia Fibula

4
d. Persiapan Operator dan Asisten Operator

Seorang operator dan asisten harus memahami prosedur operasi, dapat

memprediksi hal-hal yang akan terjadi selama operasi berlangsung, dapat
memperkirakan hasil operasi, operator harus dalam keadaan sehat dan bersih,
operator harus memakai peralatan operasi dan seorang operator harus terampil
dalam melakukan operasi dan menjahit luka operasi (Sudisma et al., 2006)

e. Anestesi

Sebelum di anaestesi pasien diberikan premedikasi Atropin sulfat, 10-15

kemudian diberikan anestesi umum berupa kombinasi ketamine-xylazine sesui
dosis yang telah dihitung.

3. 2 Teknik Operasi
Teknik operasi fraktur tibia-fibula adalah operasi memperbaiki keadaan
tibia-fibula yang mengalami fraktur baik dilihat dari garis patahan, jumlah dan arah
garis patahan, posisi fragmen, dan hubungan antara fragmen dan/atau dengan dunia
luar yang ditangani sesuai prosedur.
Fraktur tibia-fibula dapat terjadi karena anjing yang mengalami trauma
karena pukulan benda keras atau tertabrak kendaraan serta karena keadaan
patologis misalnya penyakit metabolisme.
• Pemakaian traksi untuk mencapai alignment dengan memberi beban
seminimal mungkin pad daerah distal.
• Manipulasi dengan Closed reduction and external fixation (reduksi
tertutup + fiksasi eksternal), digunakan gips sebagai fiksasi eksternal,
dilakukan jika kondisi umum pasien tidak memungkinkan untuk
melakukan pembedahan.
• Indikasi fiksasi eksternal adalah fraktur yang disertai dengan kerusakan
berat dari jaringan lunak, fraktru dengan cidera saraf atau pembuluh
darah, fraktur comminuted yang berat dan tidak stabil, serta fraktur
dengan infeksi.
• Prosedur operasi dengan open reduction and internal fixation (ORIF)
(reduksi terbuka + fiksasi internal) yang berarti dilakukan pembedahan

5
 dan pemasangan alat fiksasi internal untuk mempertahankan posisi
tulang, misalnya dengan munggunakan , plat, kawat, dan wire.
• Alat ini bisa dipasang di sisi maupun di dalam tulang yang mengalami
fraktur dan dikerjakan dengan prosedur aseptis untuk menghindari
infeksi internal.
• Indikasi fiksasi internal adalah fraktur yang tidak dapat sembuh atau
bahaya vaskular nekrosis tinggi, fraktur yang tidak bisa direposisi
tertutup, dan fraktur yang dapat direposisi tetapi sulit dipertahankan.
• Jika keadaan luka sangat parah dan tidak beraturan maka dilakukan
debridement terlebih dahulu untuk memperbaiki keadaan jaringan
lunak di sekitar fraktur.

3.3 Prosedur Operasi

3.3.1 Fiksasi
Hewan dibaringkan dalam posisi lateral dengan sisi kanan berada di bawah
(mediolateral). Sayatan dibuat secara paralel pada sisi craniomedial tibia
dimulai dari crista tibiae memanjang ke distal sepanjang tulang. Daerah medial
tibia sangat tipis dan tidak dibungkus oleh otot-otot, sehingga hanya fascia dan
jaringan ikat yang tampak dan kemudian disayat. AV.Saphena medialis dan
N.Saphenus menyilang disepertiga medial distal dari os tibia, pembuluh darah
ini harus dikuakkan dengan hati-hati kemudian terlihat beberapa patahan dari
tulang tibia dan jika dipalpasi maka akan terdengar bunyi krepitasi. Patahan
tulang kemudian direduksi, diretraksi serta direposisikan ke bentuk semula.
Sebuah lag sekrup dipasangkan menyilang sebagai penahan agar pecahan tulang
posisinya stabil serta sebuah kawat diikatkan pada pecahan tulang dibagian
distal sebagai penahan agar tulang tidak bergeser pada saat pemasangan pelat.
Kemudian Pelat DCP diukur sesuai dengan panjang tulang tibia dan
sebelum dipasangkan pelat dibentuk/dibengkokkan terlebih dahulu dengan
menggunakan alat pembengkok (bending iron) sesuai dengan lekukan pada
tulang tibia, pelat dilekatkan di atas permukaan medial tulang, selanjutnya
dilakukan pengeboran tulang untuk pemasangan sekrup dengan menggunakan
bor listrik dan pemandu bor (drill guide) dipasang untuk mencegah terjadinya

6
kontak langsung mata bor dengan pelat, sebanyak 8 lubang dibor satu demi satu
secara bergantian sesuai dengan metode kompresi pemasangan pelat (Piermattei
1983). Pada saat pemasangan sekrup, ukuran dan panjang sekrup terlebih
dahulu disesuaikan dengan kedalaman lubang menggunakan pengukur
kedalaman (depth gauge), setelah sesuai sekrup dipasangkan dan dikencangkan
satu persatu dengan menggunakan obeng (screw driver). Fascia dan jaringan
ikat dijahitkan setelah pemasangan pelat dan kulit ditutup dengan jahitan
terusan menggunakan benang cat gut 2/0 dari sisi dalam sayatan.

Gambar: Prosedur operasi fiksasi

3.3.2 Amputasi
Hewan dibaringkan diatas meja operasi dengan posisi rebah dorsal. Lokasi
yang akan dilakukan amputasi dicukur dan diberikan povidone iodine.
Penyayatan dilakukan pada daerah tarsal atau ±5cm dibawah lokasi fraktur.
Kulit di preparer sampai pada persendian antara os.tibia fibula dengan ossa
tarsal lalu lakukan ligasi pada pembuluh darah untuk menghindari adanya
perdarahan. Karena bagian tulang yang mengalami fraktur telah mengalami
callus hingga menutupi persendian, maka gergaji digunakan untuk
mengamputasi.

7
 Gambar: Insisi kulit pada lokasi fraktur

Setelah tulang dipisahkan, kulit diukur dan potong untuk menutup

bagian yang telah diamputasi. Penjahitan kulit dilakukan dengan pola
subkutikuler dengan menggunakan benang vicryl 2.0. Luka jahitan ditetesi
dengan povidone iodine atau betadine dan dioleskan salep oksitetraasiklin
dan ditutup dengan menggunakan perban.

Gambar: Penjahitan kulit

8
Gambar: Hasil post-operasi

9
 BAB IV
PASCA OPERASI

4.1 Perawatan Pasca Operasi

Balutan perban Robert Jones diterapkan setelah operasi selama 7 sampai 10
hari. Elizabeth collar digunakan untuk mencegah gigitan atau gangguan pada
perban dan melindungi jahitan bedah. Pemberian antibiotik spektrum luas seperti
Amoxicillin-Clavulanic acid (Amoxiclav®) 20 mg/kg berat badan peroral selama
7-10 hari sebelum dan sesudah pembedahan dilakukan sebagai pencegah
kemungkinan terjadinya kontaminasi bakteria yang dapat menyebabkan
osteomyelitis. Sedangkan Tramadol 0,3 mg/kg berat badan intramuskular diberikan
selama tiga hari sebagai obat untuk menghilangkan rasa sakit pasca operasi.

10
 BAB V
PENUTUP
5.1 Kesimpulan
Fraktur tibia fibula biasanya dapat terjadi pada hewan peliharaan akibat
kecelakaan karena dilepas liarkan, trauma atau ruda paksa, dan penyakit. Secara
umum ada dua jenis fraktur yaitu: Fraktur tertutup (Closed fracture) dimana tidak
ada komplikasi luka dan tidak ada pendarahan dan fraktur terbuka (Open fracture)
dimana tulang patah dapat terlihat dan dapat menyebabkan infeksi. Untuk penangan
jika bisa dilakukan fiksasi ataupun amputasi sesuai drajat keparahan fraktur.

5.2 Saran

Untuk pemeliharaan hewan kesayangan sebaiknya lebih diperhatikan agar

kemungkinan terjadinya fraktur lebih kecil. Jika telah terjadi fraktur dan hewan
dioperasi pemilik sebaiknya melatih kembali hewan untuk berjalan secara perlahan
untuk mempercepat kesembuhan hewan.

11
 DAFTAR PUSTAKA

Glyde Mark, and Richard Arnett. 2006. Tibial Fracture in the dog and cat.Irish
Veterinary Journal vol 59 no 5

Ozoy S, Altunatmaz K.2003. Treatment of extremity fractures in dogs using

external fixators with closed reduction and limited open approach. Turkey:
Istanbul. Surgery Department, Faculty of Veterinary Medicine, Istanbul
University.

Piermattei DL, Flo GL. 1997. Fracture of the tibia and fibula. In: Brinker, Piermattei
and Flo’s Handbook of Small Animal Orthopaedics and Fracture Repair.
3rd edn. Saunder, Philadelphia, Pennsylvania, p 581.

Sudisma,I.G.N.,I.G.A.G.Putra Pemayun, A.A.G.Jaya Warditha, I.W.Gorda.

(2006). Ilmu Bedah Veteriner dan Teknik Operasi. Fakultas Kedokteran
Hewan Universitas Udayana. Denpasar.

Yunianto, Husnul Hamdi. 2014. Penanganan Multifle Fraktura Tibialis Diafisis

Dekstra Dengan Pemasangan Pelat DCP (Dynamic Compression Plate).
Prosiding Konferensi Ilmiah Veteriner Nasional (KIVNAS) ke-13
Palemban

12
Vet. Med. – Czech, 48, 2003 (5): 133–140 Original Paper

Treatment of extremity fractures in dogs using external

fixators with closed reduction and limited open
approach
S. ����1, K. A���������1
1
Surgery Department, Faculty of Veterinary Medicine, Istanbul University, Istanbul, Turkey

ABSTRACT: Humerus, tibia and antebrachium fractures determined in 30 dogs of different breed, age, weight and
gender were treated using Type I and II external fixators. Meynard and handcuff clamps were used in the external
fixators. Limited open approach was applied in 6 of the cases and closed reduction techniques in 24. In cases where
closed reduction and stabilisation was done, the patients were seen to use their leg within 3–10 days post-operatively
and that walking was reasonably good a�er 20 days. In cases to which a limited open approach had been applied,
use of leg was achieved in a period close to the closed method.

Keywords: dog; fracture; external skeletal fixation; closed reduction; limited open approach

The primary aim of fracture treatment is to achieve
the fastest possible healing and enable the patient
to function normally by allowing early walking
(Aron, 1998; Shahar, 2000). For this, the aim is to
produce anatomical unity between the joints above
and below the fractured bone and functioning of
the extremity (Piermatei and Flo, 1997). In the
treatment of radius and tibia fractures in dogs,
external fixation methods are primarily suggested
(Johnson et al., 1989; Font et al., 1997; Palmer, 1999).
External fixators are used either primarily or as a
support for internal fixation and are frequently
applied using a closed method (Foland and Egger,
1991; McLaughlin and Roush, 1999).
External fixators are used extensively in both
human and veterinary orthopaedics as a treatment
option in severely comminuted and open fractures,
infected non-union cases, arthrodesis, for bone-
lengthening and also correcting growth disorders
(Harari, 1992; Aron et al., 1995; Altunatmaz and
Yucel, 1999).
External fixators can be applied either with an
open approach or closed reduction. In the fracture
treatment with an open approach, manipulations
necessary during the operation will cause
secondary trauma in the injured region and the
blood circulation of the bone will be damaged,
causing a delay in the healing period (Dudley et
al., 1997; Lauer et al., 2000).
In severely comminuted and dislocated
diaphyseal fractures, reconstruction is known to
be very difficult. However, during surgery, priority
should be given to establishing anatomical structure
and protecting vascularisation of the bone rather
than to its reconstruction. This kind of an approach
is the basis of biological osteosynthesis (Aron et al.,
1995; Johnson et al., 1998; Palmer, 1999).
External fixation has advantages such as causing
minimal damage to the injured region, maintaining
bone length, minimising the atrophy forming
in the bone and so� tissues, allowing complete
weight-bearing on the healing bone and keeping
so� tissue trauma at the fracture line at the lowest
(Johnson and Decamp, 1992; Egger, 1998; Lewis et
al., 2001).
Healing in fractures treated using external
fixation occurs mainly via endostal callus rather
than a periostal one (Harari et al., 1996). Some cases
however, heal primarily. Researchers (Johnson et
al., 1989; Harari et al., 1996; Egger, 1998) report
that healing takes place in 3–12 weeks with this
application. As well as healing, delayed healing and
non-union cases have also been reported (Aron et
al., 1986; Carnmicheal, 1991; Harari, 1992; Rudd and

133
Original Paper
Whitehair, 1992). In fractures to which they applied
external fixation, Johnson et al. (1989) observed that,
bone healing or duration of union occurred at the
same time or earlier compared to those treated with
internal fixation.
In external fixation applications, complications
such as pin loosening, pin-base infection, pin
breaking, non-union or delayed union are frequently
encountered (Johnson et al., 1989; Anderson et al.,
1993; Lewis et al., 2001).
MATERIAL AND METHOD
The material for this study comprised of 30 dogs
of different breed, age, gender and body weight,
brought to the Istanbul University Veterinary
Faculty Surgery Department with a complaint of
lameness or inability to use the leg (Table 1).
In the clinical examination, cause of the fracture,
location of the fractured bone, whether the fracture
was open or closed and other injuries were deter-
mined. A 2-way (AP, ML) radiograph was taken of
the area and the reduction technique (limited open
or closed) to be applied was decided.
Patients were sedated and the operation site was
shaved and disinfected. Following this the animals
were put under general anaesthesia. A Type I exter-
nal fixator (unilateral-uniplanar) was used in cases
with a humerus fracture and a Type II external fixa-
tor (bilateral-biplanar) was used in cases with tibia-
fibula and radius-ulna fractures. Straight Steinmann
pins were used for fixation in all cases (Table 2).
Two different types of clamp (Meynard and
handcuff clamps) were used to a�ach the pins to
the fixator. Due to the small diameter of the bar,
the handcuff clamp was only used in dogs weigh-
ing under 10 kg.
The fixation procedure was carried out using
the limited open method in 6 fractures and via
closed approach in 24. In 1 case where an external
fixator was applied to the radius using the closed
method, an intramedullary pin was placed in the
ulna using an open approach. In 2 cases which had
open fractures in the distal diaphysis of the tibia-
fibula, the fixator was applied in transarticularly. In
1 case, which had been given an internal fixation
but in which complications had developed due to
osteomyelitis, an external fixator was applied us-
ing a closed approach. In one severely dislocated
case (No. 9), distraction was used to bring the
bone fragments closer together using the closed
134
Vet. Med. – Czech, 48, 2003 (5): 133–140
method. In one other case with an open fracture
in the distal diaphysis of the tibia-fibula, the fixator
was removed and plate osteosynthesis was carried
out due to non-union.
In the cases to which an external fixator was ap-
plied using the limited open approach, the incision
was kept minimal. The incision was closed a�er
the bone fragments were aligned and fixation was
complete.
In open and infected fractures, an external fixator
was applied a�er debridement and thorough irriga-
tion of the area using sterile saline solution.
Postoperative antibiotics were given to all cases.
The fixator was dressed using a large amount of
co�on-wool and the area was covered.
Immediately a�er fixation, the fractured bone was
radiographed and re-positioning was checked for
alignment. Distances between the bone fragments
were also recorded.
The condition of the callus was evaluated with
radiographs taken regularly during the postopera-
tive period. The fixator was removed in cases which
showed sufficient callus formation.
RESULTS
Treatment with external fixation and results a�er
the treatment were evaluated in a total of 30 dogs
in which, a�er clinical and radiological examina-
tion, radius-ulna fractures were determined in 6,
tibia-fibula fractures in 14 and humerus fractures
in 3 (Tables 1 and 2).
Fourteen of the dogs, which had been diagnosed
with a fracture and had been treated were adults
and 9 had not yet completed their growth. The
bodyweight of the cases ranged between 4–48 kg.
In the 6 cases with radius-ulna fractures, the frac-
ture was in the mid-diaphysis in 3 cases and in the
distal diaphysis in the remaining 3.
Of the tibia-fibula fractures 2 were located in the
proximal diaphysis, 2 in the mid-diaphysis, 9 in
the distal diaphysis and 1 in the distal epiphysis.
All of the humerus fractures were located in the
mid-diaphysis.
Of the fractures that were treated with external
fixation, 3 were open fractures (tibia-fibula frac-
tures). One of these cases (Case No. 11) was an old
fracture and necrosis was present in a 3 cm-long
part of the bone.
Type I external fixation was applied to cases with
humerus fractures (Figure 1) and Type II external
Vet. Med. – Czech, 48, 2003 (5): 133–140 Original Paper

Table 1. Findings of cases managed with external skeletal fixators

Case Weight Bone and type Fracture

Breed Age Gender Reduction technique
No. (kg) of fracture type

1 SiberianHusky 3 mo F 10 radius-ulna distal 1/3 close closed

2 Crossbred 3 mo M 13 humerus midsha� close limited open appr.
3 Crossbred 3 yrs M 15 tibia-fibula distal 1/3 close closed
4 Crossbred 2.5 mo F 9 tibia-fibula distal 1/3 open limited open appr.
5 Crossbred 2.5 mo F 7 humerus midsha� close limited open appr.
6 Cocker Spaniel 8 mo M 10 radius-ulna Midsha� close closed
7 Boxer 6 yrs M 26 tibia-fibula distal 1/3 close closed
8 Anatolian Shepherd 2 yrs F 36 radius-ulna midsha� close closed (i.m. pin to ulna)
9 German Shepherd 3 yrs M 27 radius-ulna midsha� close closed
10 Siberian Husky 6 mo M 18 tibia-fibula midsha� close closed
11 Crossbred 4 yrs M 22 tibia-fibula distal 1/3 open closed
12 Anatolian Shepherd 5 yrs F 32 tibia-fibula distal 1/3 close closed
13 Anatolian Shepherd 7 mo F 17 tibia-fibula distal 1/3 close closed
14 Crossbred 3.5 mo M 4 humerus midsha� close limited open appr.
15 Se�er 1 yrs F 15 tibia-fibula distal 1/3 close closed
16 Crossbred 3 yrs F 14 tibia-fibula distal 1/3 close closed
17 Doberman Pinscher 3 yrs M 23 radius-ulna distal 1/3 close closed
18 Napolitan Mastif 9 mo M 48 tibia-fibula proksimal 1/3 close closed
19 Boxer 8 yrs M 25 tibia-fibula midsha� close closed
20 Yorshire Terrier 11 yrs M 8 tibia-fibula distal 1/3 close closed
21 German Shepherd 2 yrs F 23 tibia-fibula distal 1/3 close limited open appr.
22 Crossbred 2 yrs M 15 radius-ulna distal 1/3 close closed
23 Crossbred 3 mo M 8 tibia-fibula proksimal 1/3 close closed
24 Doberman P. 9 mo M 27 tibia-fibula midsha� close closed
25 Colie 2 yrs F 19 radius-ulna distal 1/3 close closed
26 German Shepherd 8 mo M 24 tibia-fibula proksimal 1/3 close closed
27 German Shepherd 2 yrs M 28 tibia-fibula proksimal 1/3 close closed
28 German Shepherd 9 mo M 24 tibia-fibula proksimal 1/3 close closed
29 PitBull terrier 2 yrs M 25 tibia-fibula midsha� close closed
30 Crossbred 10 yrs M 15 tibia-fibula distal 1/3 close closed

fixation was used in those with radius-ulna and
tibia-fibula fractures (Figure 2).
A�er the fracture was stabilised using a fixator,
measurements showed the distance between the
bone fragments to differ between 0.5–1.5 mm.
In postoperative radiographic check-ups (obser-
vation of sufficient mineralised callus formation)
the fractures were observed to heal in between
16–40 days. Although there was no contact with
external surroundings, the healing period in
3 humerus mid-diaphyseal fractures treated using
a limited open approach was seen to be approxi-
mately the same as those treated using the closed
method.

135
Original Paper Vet. Med. – Czech, 48, 2003 (5): 133–140

Table 2. Results of cases managed with external fixator

Type of Distance Time of sufficient Time of fixator

Case Fracture Postoperative
external between the bone callus presence removel
No. type complications
fixator fragments (mm) (days) (days)
1 close Type II 1 21 21
2 close Type I 2 23 23
3 close Type II 15 40 40 pin loosening
4 open Type II 2 20 20
5 close Type I 1 16 21
6 close Type II 1 27 34
7 close Type II 0.5 21 36
8 close Type II 6 18 24 pin track discharge
9 close Type II 9 25 52 pin track discharge
10 close Type II 11 23 29
11 open Type II 5 – 33 non-union
12 close Type II 1 21 60 tarsal valgus
13 close Type II 1 27 27
14 close Type I 0.5 15 20
15 close Type II 3 21 31 tarsal valgus
16 close Type II 6 28 45
17 close Type II 2 26 39 pin loosening
18 close Type II 11 23 23
19 close Type II 14 40 40 pin track discharge
20 close Type II 3 36 42
21 open Type II 1 26 178 ankylosis
22 close Type II 2 22 22
23 close Type II 0.5 24 24
24 close Type II 9 28 40
25 close Type II 10 38 38
26 close Type II 4 35 35
27 close Type II 7 43 43
28 close Type II 4 35 40
29 close Type II 5 25 35
30 close Type II 6 35 44

All the cases that were treated (except case No. 11)
were seen to make slight ground contact with the
leg 3–10 days a�er external fixation and to function
close to normal within 20 days with full weight-
bearing on the fractured leg.
The fixator was removed in cases which had
sufficient mineralised callus formation and which
could bear weight on the leg. While this period
was approximately between 20–30 days, it was also
delayed due to the late appearance of the patient
owners (178 days).
In the radiographs taken 24 days later of case
No. 8, in which a fixator was applied to the radius
using the closed method and an intramedullary pin

136
Vet. Med. – Czech, 48, 2003 (5): 133–140
a c
was placed in the ulna using an open approach,
while there was sufficient healing in the radius, the
union in the ulna was seen to be insufficient.
Various complications were seen in the cases
included in our study which were; pin loosening
in 2, pin-base infection in 3, valgus deformation
in 2, non-union in 1 and ankylosis in 1 case. Pin
loosening and pin-base infection was usually seen
in pins placed in the proximal fragment. In a case
which had an open and infected fracture, the in-
fection was seen to disappear a�er application of
a fixator. However, as non-union was present, the
fixator was removed and treatment was carried out
with plate osteosynthesis.
DISCUSSION
When treating fractures in immature animals, it
is very important to protect the growth plates and
provide early return to function (Altunatmaz and
Yucel, 1999; Lewis et al., 2001). Ten cases, to which
we applied external fixation, had not yet completed
Original Paper
Figure 1. Radiographic view of midsha� humeral fracture
belonging to a crossbreed dog, to which limited open
approach was applied. a – radiographic view before
surgery, b – immediately a�er surgery, c – radiography
20 days a�er surgery and healing via endostal callus,
before removal of fixator
their development. During fixation utmost care was
taken not to damage the growth plates and in the
postoperative follow-ups no complications were
encountered relating to obstruction of growth in
these cases.
Type II external fixators can be applied to tibia-
fibula or radius-ulna fracture cases of all ages and
bodyweight (Aron et al., 1995; Aron, 1998; Kraus et
al., 1998; Lewis et al., 2001). Likewise in this study,
location of the fracture did not cause any problems
with respect to application of the fixator. The fact
that 6 radius-ulna and 11 tibia-fibula fracture cases,
to which a fixator was applied using the closed
method, and 3 humerus fracture cases fixed using
an open approach healed in a short period without
complication, once again proved the significance
of biological fixation (Toombs, 1992; Johnson et al.,
1998; Palmer, 1999).
The fact that the patients were able to walk by
touching the fractured leg on the ground within
3–10 days a�er application of the fixator and that
they could use their leg to a great extent within 20
days, are important developments with respect to
137
Original Paper Vet. Med. – Czech, 48, 2003 (5): 133–140

Figure 2. Radiography of mid-

sha� tibia-fibula fracture
belonging to a Siberian husky,
using external fixator with
closed reduction. a – before
surgery, b – immediately a�er
surgery, c – appearance 22 days
a�er surgery showing prob-
lem-free healing

138
Vet. Med. – Czech, 48, 2003 (5): 133–140
avoiding possible complications, such as bone and
muscle atrophy, by allowing early return to function
of the extremity. Also easy application of the fixator,
its low cost and re-useability are other significant
advantages (Carnmicheal, 1991; Aron et al., 1995).
It was not a problem during the healing process
that the bone fragments could not be aligned as
well as with internal fixation. This result is clear
proof that, when anatomical alignment is achieved
healing can take place in a short time without the
need for perfect positioning of the fragments.
External fixators can be removed a�er a postop-
erative period of approximately 3–5 weeks, when
the callus tissue has reached the point where it pre-
vents rotation of the bone fragments. However, in
intramedullary fixation the pins are removed only
a�er bone healing is completed. In a case to which
external fixation had been applied to the radius
and an intramedullary pin to the ulna, although
sufficient callus formation was observed in the ra-
diographs taken 24 days a�er fixation, union was
not yet complete in the ulna. This is a clear example
of early healing in closed treatment with external
fixation.
While it had been reported (Johnson et al., 1989;
Harari et al., 1996) that fractures treated with ex-
ternal fixators heal with endostal callus rather than
periostal callus, in the fractures that were fixed us-
ing closed and limited open approaches, healing
was observed to take place with the formation of
a large callus (both periostal and endostal callus
formation) (Figures 1 and 2).
In one clinical study (Aron et al., 1986), it was
reported that fixation done using smooth pins only
provided a trouble-free fixation for 2.2 months, that
this period was 4.3 months for fixation done using
smooth and threaded pins together and 4.8 months
for fixation with threaded pins alone. However, in
this study where only smooth pins were used, the
pins were seen not to provide stability for more than
40 days and that pin loosening occurred especially
in areas with a thick muscle layer.
Using the drill at high speed during the insertion
of pins produces heat related necrosis in the bone
and this in turn causes pin loosening and failure
in fixation. To avoid this, the process of pin insert-
ing should be done at low speed. A manual drill
may be preferred but the oscillation produced is
another cause of pin loosening (Anderson et al.,
1996; McLaughlin and Roush, 1999). In 2 cases
which showed pin loosening and 3 cases in which
pin-base infection had developed, the fact that
Original Paper
these complications occurred in the pins placed
in the proximal fragments suggests that this may
be a result of the area being covered with a thick
muscle layer.
In one of the cases with an open fracture, although
infection was treated, non-union was present, of
which the reason was excessive loss of bone.
Treating infection is one of the fields of use of ex-
ternal fixation (Harari, 1992; Lewis et al., 2001).
In this study, in which 2 different types of clamps
and external fixators were used with a closed or
limited open approach, very short healing period,
sufficient stability, early return to function in the
extremity, easy application and low cost conclude
that external fixation with closed or limited open
application should be preferred in appropriate
cases.
REFERENCES
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the antebrachium in the dog and clinical studies on
these conditions. Turk. J. Vet. Surg., 5, 118–126.
Anderson M.A., Mann F.A., Wagner-Mann C., Hahn A.W.,
Jiang B.L., Tomlinson J.L. (1993): A Comparison of
nonthreaded. Enhanced threaded and Ellis Fixation
pins used in type I External skeletal Fixators in dogs
Vet. Surg., 22, 482–489.
Anderson M.A., Mann F.A., Kinden D.A., WagnerMann
C.C. (1996): Evaluation of cortical bone damage and
axial holding power of nonthreaded and enhanced
threaded pins placed with and without drilling of a
pilot hole in femurs from canine cadavers. J. Am. Vet.
Med. Assoc., 208, 883–887.
Aron D.N. (1998): Practical techniques for fractures. In:
Bojrab M.J. (ed.): Current Techniques in Small Animal
Surgery. 4th ed. Philadelphia. 934–941.
Aron D.N., Toombs J.P., Hollingworth S.C (1986): Primary
treatment of severe fractures by external skeletal fixa-
tion: Threated pins compared with smooth pins. J. Am.
Anim. Hosp. Assoc., 22, 659–670.
Aron D.N., Palmer R.H., Johnson A.L. (1995): Biologic
strategies and balanced concept for repair of highly
comminuted long bone fractures. Compend. Cont.
Educ. Pract. Vet., 17, 35–50.
Carnmichael S. (1991): The external fixator in small ani-
mal orthopaedics. J. Small Anim. Pract., 32, 486–493.
Dudley M., Johnson A.L., Olmstead M., Smith C.W.,
Schaeffer D.J., Abbuehl U. (1997): Open reduction and
bone plate stabilization, compared with closed reduction
and external fixation, for treatment of comminuted
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Original Paper
tibial fractures: 47 cases (1980–1995) in dogs. J. Am. Vet.
Med. Assoc., 211, 1008–1012.
Egger E.L. (1998): External skeletal fixation. In: Bojrab
M.J. (ed.): Current Techniques in Small Animal Surgery.
4th ed. Philadelphia. 941–950.
Foland M.A., Egger E.L. (1991): Application of Type III
external fixators: a review of 23 clinical fractures in 20
dogs and two cats. J. Am. Anim. Hosp. Assoc., 27,
193–202.
Font J., Franch J., Cairo J. (1997): A review of 116 clinical
cases treated with external fixators. Vet. Comp. Orthop.
Traumatol., 10, 173–182.
Harari J. (1992): The use of external skeletal fixation in
small animal surgery. Isr. J. Vet. Med., 47, 43–49.
Harari J., Bebchuk T., Segun B., Lincoln J. (1996): Closed
repair of tibial and radial fractures with external skel-
etal fixator. Compend. Cont. Educ. Pract. Vet., 18,
651–657.
Johnson A.L., DeCamp C.E. (1992): External skeletal
fixation – Linear fixations. Vet. Clin. North Am. Small
Anim. Pract., 29, 1135–1143.
Johnson A.L., Kneller S.K., Weigel R.M. (1989): Radial
and tibial fracture repair with external skeletal fixation,
effects of fracture type, reduction and complications
on healing. Vet. Surg., 18, 367–372.
Johnson A.L., Eurel J.A.C., Losonsky J.M., Egger E.L.
(1998): Biomechanics and biology of fracture healing
with external skeletal fixation. Compend. Cont. Educ.
Pract. Vet., 20, 487–500.
Kraus K.H., Wo�on H.M., Boudrieau R.J., Schwarz L.,
Diamond D., Minihan A. (1998): Type-II external
Corresponding Author
Dr. Kemal Altunatmaz, Surgery Department, Faculty of Veterinary Medicine, Istanbul University, 34851-Avcilar,
Istanbul, Turkey
Tel. +90 212 591 69 84, fax +90 212 591 69 76, e-mail: altunatmaz@hotmail.com
140
Vet. Med. – Czech, 48, 2003 (5): 133–140
fixation, using new clamps and positive-profile
threaded pins, for treatment of fractures of the radius
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method evaluation: Articulations and diagonals in an
8-pin type 1B external skeletal fixator. Vet. Surg., 29,
28–37.
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(2001): Recent advances in external skeletal fixation. J.
Small Anim. Pract., 42, 103–112.
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nal skeletal fixation. Vet. Med., 53–62.
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North Am. Small Anim. Pract., 29, 1171–1185.
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Animal Orthopaedics and Fracture Repair. Saunders
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and ulna. Vet. Clin. North Am. Small Anim. Pract., 22,
135–148.
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Pract., 22, 181–194.
Received: 02–09–30
Accepted a�er corrections: 03–05–05
Prosiding Konferensi Ilmiah Veteriner Nasional (KIVNAS) ke-13
Palembang, 23-26 November 2014

P-07

PENANGANAN MULTIPLE FRAKTURA TIBIALIS DIAFISIS DEXTRA DENGAN

PEMASANGAN PELAT DCP (DYNAMIC COMPRESSION PLATE)

Yunianto1,2*, Husnul Hamdi2

¹Praktisi Dokter Hewan di Cibinong – Bogor; ²Dokter Hewan Rumah Sakit Hewan Jakarta
*Korespondensi: yoen2006@gmail.com

Kata Kunci: Dynamic Compression Plate, fraktura tibialis diafisis dextra, sekrup cortical.

SIGNALEMEN DAN ANAMNESE

Seekor anjing jenis Labrador Retriever betina bernama Magic berumur 6 (enam) tahun
berbulu hitam dengan berat badan 34 kg dan suhu badan 38.5°C datang ke Rumah Sakit
Hewan Jakarta pada tanggal 7 Mei 2014 dengan anamnese anjing setelah ditabrak mobil
mengalami kesakitan dan kepincangan serta kaki kanan belakang selalu diangkat.

RADIOLOGI
Pengambilan foto rontgen dilakukan untuk meneguhkan diagnosa dan mengetahui
bentuk/macam cedera tulang. Hasil foto rontgen yang diambil dari 2 posisi yang berbeda yakni
medial-lateral dan anterior-posterior atau cranio-caudal menggambarkan hewan mengalami
multiple fraktura tibialis diafisis dextra. Tampak bentuk patahan terpecah menjadi 2 – 3 bagian.
dan gambaran pasca operasi pemasangan pelat dapat dilihat pada Gambar 1.

Gambar 1. Foto rontgnen multiple fraktura tibialis diafisis dextra

PROTOKOL PEMBIUSAN
Hewan dipuasakan 8 – 12 jam sebelum operasi, pemberian premedikasi dengan atropin
sulfat dosis 0,04 mg /kg subkutaneus. Cairan laktat ringer diberikan secara intravena sebagai
infus dengan kecepatan aliran 10 ml/kg/jam selama operasi. Anestesi diinduksi dengan
kombinasi Ketamine hidroklorida dan diazepam masing-masing pada tingkat dosis 5 mg/kg dan
0,05 mg/kg berat badan secara intravena. Setelah intubasi, anestesi dipertahankan pada nilai
2,0-2,5 persen isoflurane dengan aliran standar 100 persen oksigen. Desinfeksi daerah yang
akan dioperasi dengan alkohol dan povidone iodine.

TEHNIK PEMBEDAHAN
Hewan dibaringkan dalam posisi lateral dengan sisi kanan berada di bawah (mediolateral).
Sayatan dibuat secara paralel pada sisi craniomedial tibia dimulai dari crista tibiae memanjang
ke distal sepanjang tulang. Daerah medial tibia sangat tipis dan tidak dibungkus oleh otot-otot,
sehingga hanya fascia dan jaringan ikat yang tampak dan kemudian disayat. AV.Saphena
medialis dan N.Saphenus menyilang disepertiga medial distal dari os tibia (Gambar 2, panah
biru), pembuluh darah ini harus dikuakkan dengan hati-hati kemudian terlihat beberapa patahan
dari tulang tibia dan jika dipalpasi maka akan terdengar bunyi krepitasi. Patahan tulang
kemudian direduksi, diretraksi serta direposisikan ke bentuk semula. Sebuah lag sekrup
348
 Prosiding Konferensi Ilmiah Veteriner Nasional (KIVNAS) ke-13
Palembang, 23-26 November 2014

dipasangkan menyilang sebagai penahan agar pecahan tulang posisinya stabil serta sebuah
kawat diikatkan pada pecahan tulang dibagian distal sebagai penahan agar tulang tidak
bergeser pada saat pemasangan pelat (Gambar 2, tanda panah kuning).
Kemudian Pelat DCP diukur sesuai dengan panjang tulang tibia dan sebelum dipasangkan
pelat dibentuk/dibengkokkan terlebih dahulu dengan menggunakan alat pembengkok (bending
iron) sesuai dengan lekukan pada tulang tibia, pelat dilekatkan di atas permukaan medial
tulang, selanjutnya dilakukan pengeboran tulang untuk pemasangan sekrup dengan
menggunakan bor listrik dan pemandu bor (drill guide) dipasang untuk mencegah terjadinya
kontak langsung mata bor dengan pelat, sebanyak 8 lubang dibor satu demi satu secara
bergantian sesuai dengan metode kompresi pemasangan pelat (Piermattei 1983). Pada saat
pemasangan sekrup, ukuran dan panjang sekrup terlebih dahulu disesuaikan dengan
kedalaman lubang menggunakan pengukur kedalaman (depth gauge), setelah sesuai sekrup
dipasangkan dan dikencangkan satu persatu dengan menggunakan obeng (screw driver).
Fascia dan jaringan ikat dijahitkan setelah pemasangan pelat dan kulit ditutup dengan jahitan
terusan menggunakan benang cat gut 2/0 dari sisi dalam sayatan.

Gambar 2. Teknik pembedahan

PERAWATAN PASCA OPERASI

Balutan perban Robert Jones diterapkan setelah operasi selama 7 sampai 10 hari. Elizabeth
collar digunakan untuk mencegah gigitan atau gangguan pada perban dan melindungi jahitan
bedah. Pemberian antibiotik spektrum luas seperti Amoxicillin-Clavulanic acid (Amoxiclav®) 20
mg/kg berat badan peroral selama 7-10 hari sebelum dan sesudah pembedahan dilakukan
sebagai pencegah kemungkinan terjadinya kontaminasi bakteria yang dapat menyebabkan
osteomyelitis. Sedangkan Tramadol 0,3 mg/kg berat badan intramuskular diberikan selama tiga
hari sebagai obat untuk menghilangkan rasa sakit pasca operasi.

PEMBAHASAN
Fraktur tibia relatif umum terjadi di anjing dan kucing, bentuk fraktur tibial diafisis merupakan
kasus yang paling sering ditemui. Lebih dari 55% fraktur tibialis diafisis terjadi pada hewan
berumur kurang dari satu tahun (Johnson,1993), hal ini mencerminkan prevalensi peningkatan
insiden traumatis pada hewan muda. Berbagai pola fraktur diafisis dalam banyak kasus dapat
terkait dengan usia hewan, fraktura non-comminuted dan greenstick atau tidak lengkap lebih
sering terlihat pada hewan muda sedangkan fraktur kominuta terlihat terutama pada hewan
dewasa. Perbedaan frekuensi patah tulang kominuta pada dewasa dibandingkan remaja
mungkin berhubungan dengan peningkatan kerapuhan tulang dewasa dan penurunan
kapasitas tulang tersebut untuk menyerap energi yang ditimbulkan. Perbaikan fraktur tibialis
diafisis dengan pelat menguntungkan pada sejumlah situasi klinis (Johnson, 1993). Fiksasi
pelat pada fraktur tibialis umumnya diperuntukkan bagi kasus patah tulang yang tidak terkait
dengan adanya luka pada jaringan lunak yang terkontaminasi atau terinfeksi. Pelat dapat
berfungsi sebagai penekan, penetralisasi atau penopang pada tulang, tergantung pada bentuk
patahan tulangnya. Pada fraktur transversal sederhana atau fraktur oblik yang pendek, pelat
digunakan sebagai kompresi tulang untuk menjaga stabilitas aksial dan rotasi tulang serta
mendorong kembali fungsi tulang ke aktivitas awal. Dalam fraktur bentuk spiral, oblik dan
comminuted, untuk membuat kompresi antar fragmen tulang yang terbaik adalah dengan
menggunakan sekrup lag yang ditanamkan melalui pelat (Piermattei, 1983; DeYoung,1993).
Setelah rekonstruksi fraktur, pelat dipasangkan sebagai penetralisasi untuk meningkatkan

349
Prosiding Konferensi Ilmiah Veteriner Nasional (KIVNAS) ke-13
Palembang, 23-26 November 2014

stabilitas fraktur. Dalam beberapa kasus fraktur, fiksasi pelat pada fraktur tibialis sering lebih
tepat daripada bentuk-bentuk fiksasi internal lainnya.

DAFTAR PUSTAKA
DeYoung DJ, Probst CW. 1993. Methods of Internal Fracture Fixation In: Textbook of Small
Animal Surgery. 2nd edn. Slatter, D. (Edt.), W. B. Saunders, Philadelphia. p 1611-1631.
Piermattei DL, Flo GL. 1997. Fracture of the tibia and fibula. In: Brinker, Piermattei and Flo’s
Handbook of Small Animal Orthopaedics and Fracture Repair. 3rd edn. Saunder,
Philadelphia, Pennsylvania, p 581.
Johnson AL, Boone EG. 1993. Fractures in the tibia and fibula In: Textbook of Small Animal
Surgery. 2nd edn. Slatter, D. (Edt.), W. B. Saunders, Philadelphia. p 1866-1876.

350
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/267417278

Tibial fractures in the dog and cat: Options for management

Article  in  Irish Veterinary Journal · May 2006

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 Volume 59 (5) : May, 2006 continuing education
Irish Veterinary Journal

continuing education
Tibial fractures in the dog and cat:
options for management
Mark Glyde and Dr Richard Arnett
School of Agriculture, Food Science and Veterinary Medicine,
University College Dublin, Belfield, Dublin 4, Ireland

Introduction
Tibial fractures are common and may present in a variety of forms.
Because there is little soft tissue covering over the craniomedial
aspect of the tibia, open fractures are common. Tibial fractures have
the highest rate of non-union after those of the radius (25% and 60%
of all non-unions, respectively). The majority of fracture complications
come as a result of poor decision-making by, rather than poor
technical expertise of, the attending veterinary surgeon. Pre-operative
assessment of the fracture and planning the repair helps to limit
complication rates of tibial fractures.

Figure 1: Cross-section of the right proximal tibia. Figure 2: Cranial aspect of the Figure 3: Lateral aspect of the
left tibia. A; tibial crest, B; Gurdey’s left tibia. A; tibial crest, B; Gurdey’s
tubercle, F; medial tibial condyle, tubercle, C; muscular groove (of
The location and anatomy of the tibia provides several advantages to G; lateral tibial condyle, H; medial the long digital extensor tendon),
malleolus. G; lateral tibial condyle.
the surgeon:
• as it is superficial, it is easy to approach medially, with only one
neurovascular bundle present. Also, minimal muscle elevation is muscle attachment on the proximal lateral aspect (Figure 1) and a
necessary; low cortical:cancellous bone ratio which leads to relatively rapid bone
• it is a relatively ‘familiar’ surgical site; healing.
• the proximal tibia is a relatively ‘powerful biological’ site, with good Fractures of the tibia also create several potential difficulties for the
surgeon:
• as the tibia is superficial, open fractures are common;
Author for Correspondence:
Mark Glyde • the tibia is an irregular shape (Figures 1, 2 and 3). In the proximal
School of Agriculture, Food Science and Veterinary Medicine third it is triangular in cross-section. It is much wider proximally than
University College Dublin distally and tapers to an isthmus in the distal diaphysis. The tibia also
Belfield, Dublin 4 has a sigmoid shape in both a craniocaudal and mediolateral plane and
Ireland o
has approximately 10-15 of torsion (twist) along its length. The distal
Telephone: +353 (0)1 716 6058
half of the bone is torsed medially relative to the proximal half;
Fax: +353 (0)1 716 6061
• unlike the femur, the tibia has articular surfaces proximal and distal

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Figure 5a: Site for

Figure 4: Cross-section of the distal third of the right tibia. intramedullary pin
insertion. Medial view
to the line of the shaft, making intramedullary pin placement difficult; of the proximal right
tibia. A; tibial crest, F;
• the insertion of the patella tendon on the tibial crest can produce medial tibial condyle
high tensile and bending loads on repairs to fractures of the proximal
tibia;
• the limited muscle attachments to the distal tibia and the high
cortical:cancellous bone ratio of the distal third of the tibia (Figure Figure 5b: Site for
intramedullary pin
4) result in a relatively slow rate of bone healing compared to the
insertion. Dorsal view
proximal tibia. Blood supply to a healing fracture comes initially from of the tibial plateau of
the surrounding muscle attachments through the periosteal blood the right tibia. A; tibial
vessels, the so-called extraosseous blood supply of healing bone; crest, B; Gurdey’s
tubercle, C; muscular
• concurrent fissure fractures are common in tibial fractures,
groove (of the long
particularly of the distal third. digital extensor
All of the fracture repair modalities (bone plates, external skeletal tendon), D; Fibular
fixators, interlocking nails, intramedullary pins, external coaptation) head, E; intercondylar
eminences, F; medial
may be used on the tibia. It is essential to consider the strengths
tibial condyle, G;
and weaknesses of each fracture repair method when making an lateral tibial condyle.
assessment of any fracture and planning which method of repair to
use.
Tibial pins should not be too large (they are usually 50 to 60% of the
Intramedullary pins medullary diameter at its narrowest point); they need to curve slightly
Intramedullary (IM) pins are only suitable for relatively simple tibial as they pass down the shaft of the tibia. Once seated, the pin must be
fractures. Normograde pin placement is the only suitable method cut short enough so that it will not touch the femoral condyles at full
in the tibia. Tibial fractures should never have an IM pin placed by a extension of the stifle joint. The reduced pin size means a consequent
retrograde method because the pin will pass into the articular part reduction in stability. Therefore, IM pins should only be used for tibial
of the stifle joint. In these instances the pin commonly damages the fractures where significant compressive and rotational forces are not
cruciate ligaments, menisci and articular cartilage resulting in pain, present.
lameness and, ultimately, degenerative joint disease.
For normograde IM pin placement, make a 1-2cm skin incision over Cerclage wire
the medial tibial condyle at the junction of the cranial and middle It is technically very difficult to place an effective cerclage wire around
thirds (Figures 5a and 5b). The pin should be driven distally entering the tibia. Unlike the case of femoral fractures, cerclage wire does not
the medial ridge of the tibial plateau at that location. The fracture is provide reliable additional support to IM pin repair, due to the shape
held in reduction while the pin is driven into the distal fragment. Judge of the tibia. Fractures of the distal third are an exception where, for
the correct depth of insertion by measuring with a second pin of a short length, the tibial diameter is uniform (Figures 2 and 3). This
identical length. It is essential to remember that the medial malleolus location has little soft tissue covering thus loop cerclage, rather than
extends distally past the location of the talocrural joint (Figures twist cerclage, wires must be used to prevent the wire protruding
2 and 6). As the IM pin is being driven distally, it is important to through the skin.
remember this, it will help to prevent the pin from penetrating the The shape of the tibia results in a compromise of three principles of
talocrural joint. The base of the medial malleolus, rather than the tip, cerclage wire application:
is the distal extent of maximum pin insertion. Flex and extend the 1. The wire must be tight and directly against the bone with no
hock joint to ensure that the pin has not been driven too far distally entrapped soft tissue. However, the proximal half of the tibia is
and penetrated the joint. triangular in cross section (Figure 1) which prevents application

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of the wire directly against the bone. When the wire is tightened
it contacts only the three points of the triangle. In addition, the
numerous muscle origins (popliteus, medial and lateral heads of
the deep digital flexor, caudal tibial) from the caudal aspect of the
proximal half of the tibia makes effective muscle elevation for passage
of cerclage wire difficult. The location of the popliteal/cranial tibial
artery and the tibial nerve further complicates tissue elevation in this
region;
2. If using twist cerclage rather than loop cerclage, to prevent loss
of tension after placement, it is important that the knots are not
cut less than three twists (cutting less than three twists can lose up
to 20% tension) and that the twists are not bent over (bending the
twists over to lie flat against the bone can result in up to 70% loss of
tension). Lack of soft tissue on the craniomedial aspect of the tibia
means that placement of twist cerclage via the standard craniomedial
approach requires bending of the twists to lie flat and consequently
knot tension is usually not maintained. Use of loop cerclage rather
than twist cerclage will overcome this problem and is strongly
recommended; Figure 6: Radiograph of an 11-hole,
3. Avoid, if possible, placement of cerclage wire on a conical diaphysis 3.5mm broad dynamic compression bone
(e.g., the proximal half and distal one-fifth of the tibia, Figures 2 plate applied as a buttress plate to the
and 3). Placement of the wire proximal to a transverse K wire or medial aspect of the right tibia, to repair a
minimally comminuted fracture.
placement as a hemicerclage wire is needed to prevent slippage
though probably does not maintain effective tension.
In the authors’ opinion, cerclage wire has limited indications as Tips on application of bone plates to the tibia
an adjunct to the repair of tibial fractures for both biological
and biomechanical reasons. Lag screws will provide superior l Make a skin incision on the cranial aspect of the crus for the
interfragmentary compression with usually less soft tissue damage. medial approach to the tibia. This approach will simplify closure
Cerclage wire may be of use in distal tibial fractures where longitudinal and prevent the skin being closed directly over the plate.
fissures are present. In fractures of this nature the placement of Wound breakdown over the distal tibia is a problem if this is
cerclage wire to prevent further fractures during reduction and not done.
manipulation of the fractured tibia is often useful.
l Intraoperative contouring of the bone plate, prior to
External coaptation application to the bone, is necessary due to the sigmoid shape
The use of external coaptation is only suitable in relatively simple tibial of the tibia in a mediolateral and craniocaudal plane.
fractures. Full casts are reasonably good at preventing bending and o The use of aluminium bending templates
rotational forces of low magnitude, which occur in simple transverse greatly simplifies contouring and they are a
fractures in small or medium sized animals. useful (and inexpensive) investment;
External coaptation is unsuitable for use in fractures where bending
o When viewed from a medial aspect, the plate
and rotational forces of high magnitude (such as in large breed or
is applied to the line of ‘best fit’ and typically
very active dogs) are expected. External coaptation is also unsuitable
requires placement along the caudal edge of
in comminuted fractures or in long oblique fractures as it cannot
the proximal third;
prevent collapse and overriding of the fracture fragments.
o Bending of the plate can be done with either
Bone Plates a bending press, bending pliers or bending
Bone plates are very useful for the repair of tibial fractures (Figure irons;
6). They can be used for grade 1 open fractures although for more
o Slight twisting of the plate is usually
severe open fractures such as grade 2 or 3 fractures, external fixators
necessary if the plate is applied to the full
are preferable. Bone plates are applied to the medial aspect of the o
length of the tibia, to account for the 10-15
tibia. The use of the plate-rod technique is possible for the tibia
of tibial torsion. Whether twisting of the
although this procedure is technically more difficult than when applied
plate is necessary will be apparent from using
to the femur (the narrowest part of the tibia is in the distal half and
a plate template and needs to be done with
the limited widening in the distal tibial metaphysis makes distal screw
bending irons.
placement more difficult).

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Figure 7: Graphic showing a type II ESF and a modified type II ESF.
Remember when applying bone plates to the distal tibia that the
talocrural joint lies proximal to the medial malleolus by 0.5 to1cm. The
distal tibial widens or flares at about a 20o angle to the long (saggital)
axis of the tibia. If the most distal screw is placed perpendicular to the
bone surface, rather than perpendicular to the long axis of the tibia,
penetration of the talocrural joint may result.
External Fixators
External fixators (ESF) are the gold standard in the repair and
management of open tibial fractures. The tibia is the easiest bone to
which to apply an ESF. It is recommended that surgeons developing
their ESF technique should work first on the tibia before repairing
fractures of the radius and other long bones using this method.
All types of ESF can be applied to the tibia. The most useful ESF for
the repair of tibial fractures are the type II and modified type II ESF
(Figure 7).
Interlocking Nails
Interlocking nails (ILN) are effective for managing a variety of tibial
fractures including comminuted and open fractures. They are the most
commonly used method of treatment for tibial fractures in humans
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continuing education
because they can be inserted by a closed technique with the use of
fluoroscopy. As this imaging modality is not commonly available in
veterinary practice, ILN are generally placed via an open or limited-
open approach.
Unlike an IM pin, the interlocking nail can neutralise bending, rotational
and compressive forces. Compared to a bone plate, the ILN has
a similar bending strength although is slightly weaker in resisting
torsional loads.
The largest nail that will fit, based on preoperative measurements of
the medullary canal made from radiographs of the fractured leg, is
used. Usually 8mm diameter ILN are suitable for large dogs, 6mm ILN
for medium dogs and 4.7mm ILN for small dogs and cats.
ILN are larger, and therefore more rigid, than IM pins. For this reason,
starting the pin medially and making allowance for it to bend as it
passes distally is not possible. The ILN is inserted more centrally on
the tibial plateau than an IM pin and for this reason must be recessed
or countersunk to avoid subsequent damage to the stifle joint. Central
placement of the ILN and recession and countersinking is made
possible with the customised insertion device of an ILN. This is not
possible with IM pin placement.
 continuing education Volume 59 (5) : May, 2006
Irish Veterinary Journal

Tips on ESF application to the tibia

l Preplan the type of ESF you will be applying. Using an l Use cancellous thread positive profile pins in the proximal
acetate sheet trace over the radiograph of the fracture and tibia.
use this tracing to draw a template of the proposed ESF. This
preplanning ensures that you will have enough equipment to l Make a cranial skin incision if placing a type II ESF, to avoid
apply the planned ESF and also simplifies application of the having pins near the skin wound.
ESF.
l Use an ‘open-but-do-not-touch’ approach for comminuted
l The type of construct that you will need should be fractures where the bone column is not being surgically
determined on the basis of thorough fracture assessment. reconstructed.
Remember that:
o Four pins per fracture fragment will l Place a bone graft in comminuted fractures. Consider a
provide the maximal stiffness; delayed bone graft in grade II and III open fractures.
o Pins should be spread evenly over the length
l Hanging the leg from a roof bolt or support stand,
of the fracture fragment (fracture
provided this can be done in a sterile manner, simplifies
configuration permitting) and the central
application of an ESF. Remember that the natural torsion of
pins (closest to the fracture line) should be
the tibia means that the fracture will not be anatomically
1-2cm from the fracture to provide maximal
aligned while the leg is hung. It will be necessary to
stiffness;
temporarily release the tension on the leg (raise the table or
o Use threaded pins, preferably positive profile lower the support) to correctly align the fracture.
pins. They have a resistance to pull out four
times greater than smooth pins,decrease
the incidence of premature loosening of the
pins and double the ‘life’ of an ESF. The
most common complication with ESF, and
the main reason for their failure, is
loosening of the pins and consequent loss of
stability before the fracture has fully healed.
Using positive profile threaded pins will
decrease the chances of this occuring;
o A traditional K-E (Kirschner-Ehmer) type I
ESF is weak with mediolateral bending and
in torsion. Consequently, type I ESF are
only suitable for very simple fractures.
More complex fractures require a type II
ESF or a newer generation stronger ESF,
such as the ImexTM SK, which uses carbon
fibre or titanium connecting bars;
o A modified type II ESF is much simpler
to apply than a full type II although it is less
rigid. Application of a full type II requires
some type of aiming device or the
temporary use of a double connecting bar
during drilling and placement of the pins.

l Avoid placing pins into the proximal lateral third of

the tibia. This area is associated with a high incidence of
loosening of the pins because of the bulk of the cranial tibial
muscle and the soft tissue tension which develops from stifle
joint movement. Placing half pins on the medial aspect of
the proximal tibia and placing the full pin further distally is
advisable.

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