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FELINE

ORTHOPEDICS
Harry W Scott BVSc, CertSAD, CBiol, MIBiol, DSAS(Orth), FRCVS
Royal College of Veterinary Surgeons Specialist in
Small Animal Surgery (Orthopaedics)
Private Orthopaedic Referral Practice
Hampshire, UK

Ronald McLaughlin DVM, DVSc, Diplomate ACVS


Professor and Chief, Small Animal Surgery
Department of Clinical Sciences
College of Veterinary Medicine
Mississippi State University
Mississippi, USA

MANSON PUBLISHING/THE VETERINARY PRESS


Copyright © 2007 Manson Publishing Ltd
ISBN: 978-1-84076-056-9

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Disclaimer
Medical knowledge and best practice are constantly evolving as new research
and experience contribute to our understanding. While the authors have taken
every effort to eliminate inaccuracies, readers are advised to consult the most
current information available on procedures, products, dosages, and formulae.
Drug licensing varies between countries; the information given in this book
mainly reflects UK and USA practice. Neither the Publisher nor the Authors
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Commissioning editor: Jill Northcott


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CONTENTS

PREFACE 6 Postoperative care 38


Posttraumatic osteomyelitis 39
ABBREVIATIONS 7
4 FRACTURE CLASSIFICATION, DECISION
1 INTRODUCTION TO FELINE MAKING, AND BONE HEALING 43
ORTHOPEDIC SURGERY 9 Fracture classification 43
Comparative features 9 Fracture decision making 45
Specific anatomic features and their Fracture healing 47
significance 10
Blood supply to bone 14 5 INSTRUMENTS AND IMPLANTS 50
Bone growth 14 Instruments 50
Implants 51
2 EXAMINATION AND DIAGNOSTIC TOOLS 17
Introduction 17 6 FRACTURE FIXATION METHODS:
Signalment 18 PRINCIPLES AND TECHNIQUES 58
History 18 Preoperative considerations 58
Physical examination 18 Fracture reduction 58
Orthopedic examination 18 Fracture stabilization methods 59
Diagnostic tools 19 Cancellous and corticocancellous bone
grafting 80
3 MANAGEMENT OF THE ORTHOPEDIC Implant removal 82
TRAUMA PATIENT 25 Delayed and nonunion fractures 82
Introduction 25 Articular fractures 84
Physical examination 25
Diagnostic tests 26 7 ARTHROLOGY 87
Resuscitation and stabilization of the trauma Classification of joint disease 87
patient 26 Investigation of joint disease 88
Pre- and postoperative stabilization of Degenerative arthritides 90
fractures and luxations 29 Infective inflammatory arthritides 94
Initial treatment of fractures 33 Immune-mediated inflammatory arthritides 97
Pre- and perioperative analgesia 35 Miscellaneous disorders of joints 101
Pre- and perioperative sedation 38 Ligaments and tendons 104
4

8 FRACTURES AND DISORDERS OF Postoperative care of femoral fractures 215


THE FORELIMB 107 Complications of femoral fractures 215
Part 1: Scapula and shoulder joint 107 Patellar fractures 215
Scapular fractures 107
Dorsal displacement of the scapula 111 Part 4: Stifle disorders 218
Shoulder luxations 111 Patellar luxation 218
Excision arthroplasty 113 Cruciate ligament injuries 222
Shoulder arthrodesis 113 Collateral ligament injury 225
Stifle luxation 228
Part 2: Humerus and elbow joint 115 Stifle arthrodesis 231
Humeral fractures 115
Traumatic elbow luxation 130 Part 5: Tibial and fibular fractures 233
Elbow arthrodesis 134 Proximal tibial fractures 233
Diaphyseal tibial fractures 238
Part 3: Radius and ulna 136 Distal tibial and malleolar fractures 242
Hemimelia 136
Radial head luxation 136 Part 6: Tarsal, metatarsal, and
Fractures 137 phalangeal injuries 244
Fractures of the tarsus 245
Part 4: Carpal, metacarpal, and phalangeal Luxations of the tarsus 247
injuries 145 Shearing injuries of the tarsus 250
Carpal joint injuries 145 Calcanean tendon lacerations 252
Metacarpal and phalangeal injuries 154 Avulsion of the Achilles tendon 254
Onychectomy (declawing) 157 Luxation of the superficial digital
Forelimb amputation 165 flexor tendon 255
Tarsal arthrodesis 255
9 FRACTURES AND DISORDERS OF THE Metatarsal and phalangeal fractures and
HINDLIMB 167 luxations 259
Part 1: Pelvis 167 Hindlimb amputation 259
Pelvic fractures (general) 167
Sacroiliac fractures/dislocation 169 10 FRACTURES AND DISORDERS OF
Ilial fractures 173 THE SKULL AND MANDIBLE 261
Acetabular fractures 176 Mandibular fractures 261
Ischial fractures 180 Maxillofacial fractures 271
Pubic fractures 180 Temporomandibular joint injury 273
Pelvic malunion fractures 180 Fractures of the neurocranium 277

Part 2: Coxofemoral joint 184 11 FRACTURES AND DISORDERS OF


Coxofemoral luxation 184 THE SPINE 279
Hip dysplasia 191 Surgical anatomy 279
Investigation of spinal disease 281
Part 3: Femoral and patellar fractures 192 Treatment of spinal disorders 294
Proximal femoral fractures 192 Common disorders of the spine 296
Diaphyseal femoral fractures 198 Uncommon diseases of the spine 313
Distal femoral fractures 208
5

12 NEUROMUSCULAR DISORDERS 321 Neoplastic disorders of bone 342


Introduction 321 Infections of bone 349
Classification of neuromuscular disorders 322 Congenital defects 349
Causes of neuromuscular disease 322
Neuropathies 322 REFERENCES 351
Myopathies 328
Junctionopathies 332 APPENDIX 390

13 MISCELLANEOUS ORTHOPEDIC INDEX 391


DISORDERS 335
Metabolic bone diseases and disorders of
calcium metabolism 335
6

PREFACE

The most notable change in the companion animal population over the last few decades has been the steady rise
in popularity of the cat. Cats now outnumber dogs as domestic pets in many developed countries; it is estimated
that there are now at least 70 million domestic cats in North America alone. As a consequence the small animal
practitioner is confronted with cats suffering from a variety of orthopedic disorders on a daily basis. Existing
orthopedic texts are heavily biased in favour of the dog with cats receiving little or no mention, yet there are
many minor and a few major differences between the musculoskeletal systems of dogs and cats.
The motivation for writing this book was a desire by the authors to bring together all of the salient facts
concerning feline musculoskeletal disease and present them in an organized and accessible format. As far as
possible the information presented is based on the results of studies involving cats rather than being extrapolated
from other species. When evidence from such studies is lacking or when the evidence is anecdotal, reliance has
been made on the personal experiences and opinions of the authors. It is hoped that this book will play a small
part in the development and continued advancement of feline orthopedics as a discipline in its own right. The
text is intended to be of interest both to students and to practitioners involved in the treatment of feline
musculoskeletal disorders.

Harry W Scott
Ronald McLaughlin
7

ABBREVIATIONS

ACD acid citrate dextrose IM intramuscularly


ANA antinuclear antibody IVDD intervertebral disc disease
AO Arbeitsgemeinschaft für IV intravenously
Osteosynthesefragen KE Kirschner–Ehmer
ASIF Association for the Study of Internal L + number lumbar vertebra or spinal cord
Fixation segment
AWG American wire gauge LC-DCP limited contact dynamic compression
C + number cervical vertebra or spinal cord plate
segment MCE multiple cartilaginous exostoses
Cd + number caudal vertebra or spinal cord segment MPSS methylprednisolone sodium
CK creatine kinase succinate
COP cyclophosphamide, vincristine MRI magnetic resonance imaging
(oncovin), and prednisolone MTU muscle tendon unit
CPD citrate phosphate dextrose NSAID nonsteroidal anti-inflammatory
CrCL cranial cruciate ligament drug
CSF cerebrospinal fluid OCD osteochondritis dissecans
CT computed tomography OSA osteosarcoma
DCP dynamic compression plate PCV packed cell volume
DJD degenerative joint disease PMMA polymethylmethacrylate
EDTA ethylenediamine tetra-acetic acid PMS polyarthritis/meningitis syndrome
ELISA enzyme-linked immunosorbent assay PPP periosteal proliferative polyarthritis
EMG electromyogram or PTH parathyroid hormone
electromyography rpm revolutions per minute
FCE fibrocartilaginous embolism RSH renal secondary hyperparathyroidism
FeLV feline leukemia virus S + number sacral vertebra or spinal cord
FeSFV feline syncytia-forming virus segment
FeSV feline sarcoma virus SC subcutaneously
FIP feline infectious peritonitis SLE systemic lupus erythematosus
FIV feline immunodeficiency virus SWG (Imperial) standard wire gauge
HBOC hemoglobin-based oxygen carrying T + number thoracic vertebra or spinal cord
solution segment
Ig immunoglobulin TMJ temporomandibular joint
ILN interlocking nail VCP veterinary cuttable plate
8

Dedication
Dedicated to the many veterinary clinicians who use their knowledge,
skills, and talents to enrich the lives of our feline friends.
9

CHAPTER 1
INTRODUCTION TO
FELINE ORTHOPEDIC
SURGERY
Musculoskeletal disease is less common in the cat than conservative treatment may be appropriate, treatment
in the dog, with the exception of abscesses and should always be tailored to the individual case. The
cellulitis caused by cat bites1,2. An increasing goal of the feline orthopedic surgeon should be to
population of cats, living longer than ever before, and return the patient to optimum function as quickly as
more enlightened clients seeking improved veterinary possible using the simplest means available.
care, however, have led to feline orthopedics becoming
an important discipline in its own right. Optimal COMPARATIVE FEATURES
diagnosis and treatment of feline orthopedic disorders In comparison with the dog, developmental
requires a species-specific approach that is expressed in orthopedic disease is rarely encountered. Many of the
the familiar aphorism ‘cats are not small dogs’. conditions that are commonly seen in immature dogs,
It is often stated that cats make good orthopedic such as elbow dysplasia or aseptic necrosis of the
patients because of their small size, undemanding femoral head, have not been reported in the cat. A
lifestyle, and their ability to redistribute weight number of developmental disorders, such as hip
and protect an injured limb. There is a common dysplasia and patellar luxation, are recognized,
misconception that feline fracture repair is simple to although their clinical significance in the cat may
perform and healing is not prone to complications. It differ from that in the dog.
has been said that two cat bone fragments will unite if Traumatic injury is a common occurrence and
placed together in the same room. This casual attitude musculoskeletal trauma accounts for a large
is not borne out by clinical and experimental studies, proportion of the disorders seen in the cat.
which show that the cat is subject to the same range of Orthopedic disorders of the feline hindlimb are
complications of fracture repair as the dog3–8. The much more prevalent than those of the forelimb with
notion that feline orthopedics is straightforward is a 73% of all fractures involving the hindlimb or
testimony to the cat’s ability to compensate for pelvis and sacrum in one survey of over 100 cats9.
impaired function. Knowledge of the comparative surgical anatomy
The obvious drawback of small size is the difficulty and physiology of the feline musculoskeletal system
that this creates for the surgeon in terms of visualization is clearly of importance for the feline orthopedic
and manipulation of small bones and bone fragments. surgeon. When performing an orthopedic
The small bones of the distal extremities, in particular, examination, the clinician should be cognizant of
are not easy to visualize accurately on radiographs aspects that are unique to the cat. There are many
and are difficult to manipulate and repair surgically. minor and a few major differences between
A bad workman may blame his tools but even the most the musculoskeletal system of the cat and the
dexterous of surgeons will be frustrated without the dog. Feline musculoskeletal anatomy predominantly
correct instruments and implants. Fortunately the reflects the size, mobility, and diet of the cat. For
armamentarium of the modern feline orthopedic example, the cat’s retractile claw mechanism is
surgeon comprises a range of equipment designed for ideally suited for catching and holding small prey,
small bone fracture repair that is ideally suited for cats. and the feline locomotor system is adapted for agility
Historically, there has been a trend towards conservative and for great bursts of speed over short distances. In
treatment of many feline orthopedic injuries, the canine comparison with the dog, the feline musculoskeletal
equivalent of which would be treated surgically. While system tends to be more flexible, skeletal muscles are
10

more strap-like, and intervening connective tissues elbow, is of importance when making a surgical
are looser. Cats are relatively small and lightly built approach to these joints. In addition to specific
and have a higher body surface area to weight ratio anatomic differences between the dog and the cat,
than dogs. The corollary of this is that the cat’s the relative sizes and dimensions of bones and
skeleton is of a lightweight design. Long bones have muscles may differ. For example, the feline ulna
a large medullary cavity and thin cortices and flat and fibula are more substantial than their canine
bones, such as the scapula and pelvis, are only a few counterparts, the lumbar vertebrae, in particular,
millimeters thick. Additionally, the long bones are are longer and more slender, and the scapula is
relatively straight and tubular in comparison with broader and shorter.
those of the dog. Differences in skeletal morphology
between breeds are relatively minor10 and it is, SPECIFIC ANATOMIC FEATURES
therefore, potentially easier to standardize surgical AND THEIR SIGNIFICANCE
techniques, instruments, and implants for the cat SHOULDER/BRACHIUM
than for the dog. • The acromion has both hamate and suprahamate
Other notable features are the greater range of processes. The hamate process projects from
motion in the spine and the shoulder in comparison the distal aspect of the acromion (1). The
with the dog and the different distribution of weight suprahamate process (metacromion) is a flat
bearing between the fore- and hindlimbs when walking. protuberance extending caudally from the distal
A recent study of cats using pressure platform analysis spine of the scapula 10–20 mm proximal to the
showed that, as in the dog, limb load forces when acromion. The surgeon should be aware of this
walking are greater in the forelimbs than in the structure when elevating the infraspinatus
hindlimbs. However, in comparison with the dog, muscle from the spine of the scapula during
the distribution of load at a walk is different, with the surgical approaches to the distal portion of the
hindlimbs of the cat sharing more of the load11. The bone13.
differences in range of motion of the major joints of • There is a beak-like bony projection called the
the appendicular skeleton have been well coracoid process extending craniomedially from
documented12 (Table 1). the rim of the glenoid. The coracoid process is
Familiarity with normal feline osteology is sufficiently large to be at risk of fracture.
essential for the correct interpretation of • A small ossicle representing the clavicle is
radiographs. It is often helpful to radiograph the consistently present. It is seen radiographically
contralateral normal limb and to have feline bones as a slender curved bone, approximately 20 mm
or a skeleton and a set of normal feline radiographs long, just cranial to the shoulder joint, and can
for comparison. An awareness of the differences easily be misdiagnosed as a fracture of the
between the dog and the cat in the arrangement of scapula. It is a vestigial structure with no bony
muscles and nerves, especially around the hip and connections and has no clinical significance.

TABLE 1 RANGE OF MOTION OF THE MAJOR JOINTS OF THE APPENDICULAR SKELETON.


Joint Range of motion Range of motion
cat (degrees) dog (degrees)
Shoulder Flexion–extension 170–190 125–145
Adduction–abduction 100–120 80–100
Elbow Flexion–extension 130–155 140–150
Carpus Flexion–extension 160–180 175–190
Hip Flexion–extension 150–170 150–170
Adduction–abduction 80–100 100–120
Stifle Flexion–extension 150–170 130–150
Tarsus Flexion–extension 140–170 155–185
Introduction to feline orthopedic surgery
11
1

Hamate
Metacromion process

Metacromion

Supraglenoid Hamate
tubercle Supraglenoid
process
Coracoid tubercle
process
Coracoid
process
Clavicle
A B

1 A Lateral view of the scapulohumeral joint showing the coracoid process, suprahamate process of the acromion
(metacromion), hamate process of the acromion, supraglenoid tubercle, and clavicle.
B Ventral view of the scapula.

• The humerus is penetrated by an oval does not provide sufficient fixation, in


supracondylar (epicondylar) foramen just approximately 50% of cats it may be possible to
proximal to the medial epicondyle (2). Elevation drive a much smaller pin (<1.6mm) into the medial
and retraction of soft tissues during the surgical aspect of the condyle and still avoid the foramen14.
approach to this area is complicated by the
passage of the median nerve and the brachial
artery through this foramen. Great care should be
taken not to damage these neurovascular 2 2 Craniocaudal
structures when retracting the soft tissues about radiograph of the
the elbow13. elbow joint
• Similarly, when there is a humeral supracondylar showing the
fracture there may be impingement of bone supracondylar
fragments on the median nerve and brachial foramen on the
artery. In this situation the medial wall of the medial aspect of the
foramen can be removed using rongeurs to distal humerus
allow the nerve to course in the adjacent soft (arrow).
tissues5.
• Intramedullary pin insertion for humeral fracture
repair is complicated by the presence of the
supracondylar foramen. Pins placed distally in the
humerus can enter the foramen, damaging the
median nerve and brachial artery and penetrating
the elbow joint. Intramedullary pins should
generally be positioned 7–9mm proximal to the
medial epicondyle5. If this short intramedullary pin
12

• The ulnar nerve lies under the short part of the predisposing cause of fracture in some breeds of
medial head of the triceps brachii muscle (3). dog, has not been reported in the cat.
This muscle runs caudal to the medial aspect of • A sesamoid bone in the tendon of origin of the
the humeral condyle where it inserts on the supinator muscle is a normal anatomic variant
medial side of the olecranon process. Care should present in approximately 40% of cats. This may
be taken to avoid injury to the nerve when the be visible on mediolateral radiographs of the
muscle is elevated to expose a fracture line13. elbow joint where it articulates with the
craniolateral aspect of the radial head. It should
ELBOW/ANTEBRACHIUM not be confused with an osteophyte or chip
• In contrast to the dog the olecranon fossa is not fracture15.
perforated by a supratrochlear foramen. The distal • The anatomy of the feline antebrachium allows
humeral epiphysis is less prone to fracture because considerable pronation and supination (45–55°)
of the absence of this foramen. Consequently, and it is, therefore, important to attempt to
humeral intracondylar Y and T fractures, and preserve motion between the radius and ulna
lateral and medial condylar fractures are rare in when undertaking orthopedic procedures in this
the cat. area. There is greater mobility between the two
• The straighter conformation of the distal bones in comparison with the dog. This means
humerus and the humeral condyle, and the that treatment of fractures of the antebrachium
relatively wide and thick epicondylar crests, in by fixation of the radius or ulna alone is less likely
comparison with the dog, may also help protect to result in adequate stability of the adjacent
this region of the skeleton from fracture. bone5. It may be necessary to repair both
Furthermore, incomplete ossification of the fractured bones, especially if one or both are
humeral condyle, which is a common comminuted.

3 3 Medial aspect of the elbow joint


Brachial artery showing the passage of the median nerve
and brachial artery through the
Median nerve
supracondylar foramen in a caudocranial
direction. Note the position of the ulnar
Supracondylar nerve deep to the short part of the medial
foramen head of the triceps brachii muscle.

Ulnar nerve

Triceps brachii
muscle, short
part of medial
head
Introduction to feline orthopedic surgery
13

HIP/THIGH TARSUS
• Unlike in the dog, the ligament of the head of • The medial and lateral collateral ligaments of the
the femur, or round ligament, is purported to talocrural joint are each comprised of two short
provide a significant proportion of the blood ligaments; there is no long component as seen
supply to the femoral capital epiphysis16. This in dogs. This is of relevance when performing
may explain why aseptic necrosis of the femoral prosthetic collateral ligament replacement for
head (Legg–Calvé–Perthes disease), commonly the treatment of talocrural luxation or
seen in small breed dogs, has not been reported subluxation.
in the cat. The blood supply via the round
ligament will also help protect the epiphysis from SPINE
vascular compromise after capital physeal • The nuchal ligament, which in the dog extends
separation. Although these fractures should be from the spinous process of the axis to the tip of
treated promptly, the prognosis in cats is the first thoracic spinous process, is absent in the
generally good, even in cases in which repair is cat. The surgeon should be aware of this when
delayed. making a dorsal approach to the cervical spine.
• The arrangement of the muscles around the hip The lack of ligamentous support accounts for the
differs from that of the dog. The tensor fascia propensity for neck ventroflexion with
lata and the vastus lateralis muscles are broader neuromuscular disorders in the cat.
in cats. The craniolateral approach to the feline • The spine of the cat is more supple than that of
hip is most commonly used. When making this the dog. Part of this increased flexibility can be
approach a longer incision is necessary through accounted for by the fact that the intervertebral
the insertion of the tensor fascia lata muscle discs contribute a larger proportion to the total
than in the dog. Similarly the vastus lateralis length of the vertebral column (20% in the cat
muscle requires more subperiosteal elevation and 15–17% in the dog). The intervertebral
to gain adequate exposure of the femoral discs of the cat are prone to degeneration in the
neck17. same way as in nonchondrodystrophoid breeds
• The sartorius muscle is undivided in the cat, of dog. Affected cats are frequently
unlike in the dog where it has cranial and caudal asymptomatic; the reasons for this have not yet
bellies. This muscle may be encountered when been determined.
making a lateral approach to the femoral shaft. • The spinal cord is longer relative to the
• The sacrotuberous ligament, which in the dog vertebral canal in the cat than in the dog. In
extends between the caudolateral angle of the the past there has been some uncertainty about
sacrum and the lateral part of the tuber ischium, the exact termination of the spinal cord. Various
is absent in the cat. levels from the caudal border of the seventh
• A kinematic study has shown that the principal lumbar vertebra (L7) to the caudal border of
load-bearing areas of the feline acetabulum are the sacrum have been given by different
the central and caudal thirds rather than authors. There may be some slight individual
the cranial third. This is of relevance to the and breed variation but it is likely that the
treatment of acetabular fractures. The frequent cranial limit is accurate for adults and the more
recommendation that simple caudal acetabular caudal one for young kittens22,23. In
fractures should be treated conservatively may comparison with the dog, there is reasonably
need to be reconsidered in the cat18. close correlation between spinal cord segments
and vertebrae, and a focal lesion will therefore
STIFLE/CRUS tend to affect a smaller number of cord
• There is variable mineralization of the medial segments in the cat.
fabella and the popliteal sesamoid bone19,20.
Unmineralized sesamoid bones will not be
visualized on radiographs.
• In contrast to that in the dog, the cranial cruciate
ligament is larger than the caudal cruciate
ligament21. This may be one of the factors
contributing to the relative infrequency of cranial
cruciate ligament rupture in the cat.
14

BLOOD SUPPLY TO BONE developing periosteal callus, bone fragments, and


Arterial blood supply to a typical long bone is cortex. Revascularization and bone healing are
provided by an afferent vascular system, comprised delayed by severe trauma to the bone and soft
primarily of the nutrient artery and the proximal tissues, overzealous soft tissue dissection and
and distal metaphyseal arteries 24–27(4). Small improper tissue handling during surgery, poor
periosteal arterioles also provide blood to the outer reduction of bone fragments, and inadequate
cortical layer in the region of fascial attachments and stabilization of the fracture.
muscle insertions. The intermediate vascular system
of compact bone comprises Haversian canals, BONE GROWTH
Volkmann canals, and minute canaliculi creating a The bones of the appendicular skeleton grow in
vascular lattice to provide nutrients to the length by endochondral ossification, and in width by
osteocytes. Venous drainage occurs via the efferent intramembranous ossification. Endochondral
vascular system from the periosteal surface of the ossification is characterized by osteoblastic conversion
bone. This centrifugal blood flow from the of a cartilaginous model to bone. Longitudinal bone
medullary cavity to the periosteal surface is growth occurs at the physes, which remain open until
disrupted to varying degrees when fractures occur. bone growth has ceased. Functional physeal closure
The afferent blood vessels then hypertrophy and occurs when there is anatomic continuity of osseous
increase in number to reestablish the medullary tissue between the epiphysis and the diaphysis.
blood supply quickly. Additionally, a new and Closure of the physis and cessation of bone growth
temporary extraosseous blood supply develops from occurs before fusion can be documented radio-
the surrounding soft tissues to vascularize the graphically.

Fascial
Medullary attachment
Periosteal arterioles
arteries

Periosteal
Nutrient arterioles
artery
Anastomosis
Periosteal
arteries
Nutrient
artery

Metaphyseal Medullary Extraosseous


artery artery arteries

A B C

4 A Arterial blood supply to normal mature bone.


B Schematic diagram showing the arterial blood supply of a section of the diaphysis of normal mature bone.
C Arterial blood supply to fractured bone showing the development of an extraosseous blood supply.
Introduction to feline orthopedic surgery
15

GROWTH PLATES times and there is no precise sequence of physeal closure.


In contrast to those in the dog, the growth plates of However physes can be classified on the basis of closure
kittens are simple and flat. Physeal closure times were times into first, middle, and last groups (5, Table 2)28.
documented in entire cats based on the radiographic The physes that close last are most prone to
examination of 37 kittens and anatomic dissection of delayed closure and cartilage remnants persist beyond
eight kittens28. There are individual differences in closure 2 years of age in some cases.

First

Middle

Last

5 Cat skeleton showing closure times of the growth plates of clinical significance. Physeal closure times classified as first,
middle, and last.

TABLE 2 PHYSEAL CLOSURE TIMES IN THE CAT.


First (4–8 months) Middle (8–14 months) Last (14–24 months)
Scapular tuberosity Proximal ulna Vertebrae
Distal humerus Metacarpals Proximal humerus
Proximal radius Proximal femur Distal radius
Accessory carpal bone Distal tibia Distal ulna
Phalanges I & II Distal fibula Distal femur
Fibular tarsal bone Proximal tibia
Metatarsals Proximal fibula
16

Growth plate disturbances angular limb deformity is uncommon in the cat,


Traumatic injury may cause disturbance in the largely because of the smaller stature and reduced
growth of the physis leading to a reduction or overall growth potential. An important additional
cessation of growth and bone shortening. factor is the linear shape of the distal ulnar physis of
Disturbances of physeal growth may also be the cat in contrast to the conical ulnar physis of the
associated with angular limb deformity if there is dog. The shape of the canine physis increases
asynchronous growth in paired bones, such as the its surface area, facilitating rapid growth, but also
radius and ulna (6), or if the disturbance in a single predisposes the germinal cells to compression injury.
physis is asymmetrical. In comparison with the dog, In young cats the physes represent significant
structural weak links in the skeleton and Salter–Harris
fractures are a common occurrence in this age group.

6 The effect of neutering on growth plates


A number of studies have reported on the effect
of neutering on physeal closure times in cats29–31. The
relationship between castration at about the time of
puberty (28 weeks of age) and the timing of physeal
closure was studied in male cats29. The time of closure
has also been compared in neutered and entire male
and female cats30. In both of these studies, physeal
closure was found to be delayed in castrated male cats
with some individuals having open physes beyond
4 years of age. One study looked at the effect of
neutering male and female cats at 7 weeks and
7 months of age on the proximal (first group) and
distal (last group) radial physes and eventual radial
length31. This study found that castration had no
effect on the timing of proximal radial physeal closure.
Castrated cats, however, had delayed closure of the
distal radial growth plate irrespective of the age at
castration. In female cats closure of the proximal radial
physis was delayed in cats neutered at 7 weeks of age
A B but not at 7 months of age, whereas closure of the
6 Craniocaudal radiographs of the antebrachium showing distal radial physis was delayed in both groups of
angular limb deformity. (Radiographs courtesy of Malcolm ovariohysterectomized cats. Final radial length was
McKee.) found to be significantly increased in both groups of
A Carpal varus associated with a disturbance in the growth neutered male and female cats compared with entire
of the distal radial physis. cats. Neutering of immature cats of both sexes may
B Postoperative view following corrective ostectomy and predispose to Salter–Harris fractures and the last
application of a type 2 acrylic external fixator. group of physes will be most at risk of injury.
17

CHAPTER 2
EXAMINATION AND
DIAGNOSTIC TOOLS

INTRODUCTION diagnoses are then investigated with the aim of


Lameness is the predominant clinical sign in cats achieving a specific diagnosis.
with orthopedic disorders, but because of the cat’s Causes of feline lameness have been reviewed
independent lifestyle this is less readily observed in recently1. The more common musculoskeletal causes
comparison with the dog. Investigation of lameness in of lameness are listed in Table 3. Lameness or limb
the cat has much in common with the dog but there weakness may also be caused by a variety of
are important differences. Many of the conditions conditions unrelated to the limb bones and joints.
encountered are similar but their significance may These include conditions of the spine and peripheral
differ and there are also causes of lameness that are nerves, such as vertebral fracture and brachial plexus
rarely or never seen in dogs. The goal of the avulsion. These conditions should be suspected if
examination should be to formulate and prioritize evidence of neurologic dysfunction is detected on
a list of differential diagnoses; these differential examination.

TABLE 3 DIFFERENTIAL DIAGNOSIS OF LAMENESS.


Diagnosis Skeletally immature <2 years Skeletally mature >2 years
Cat bites ++ +
Fractures ++ (often physeal) +
Traumatic luxations + ++ (hip>hock>stifle>
elbow>carpus>shoulder)
Avulsion injuries (tibial tuberosity, etc.) ++ –
Septic arthritis ++ +
Calicivirus arthritis ++ –
Periosteal proliferative polyarthritis ++ ++
Other immune-mediated polyarthritides + ++
Neoplasia (bone, periarticular soft tissue) + ++
Osteoarthritis – ++ (elbow & shoulder
most common)
Hip dysplasia ++ +
Patellar luxation ++ +
Cranial cruciate ligament rupture – ++

– to ++ indicates an increasing relative frequency of occurrence


18

SIGNALMENT Another difficulty is determining whether conditions


The age, sex, breed, and weight of the cat may give that are identified during subsequent investigations
an indication of the type of conditions most likely to are incidental when there has been no history of
be encountered. For example, male (entire and clinical signs, for example, an osteoarthritic joint
neutered) cats less than 2 years of age are more identified radiographically. Additional problems are
likely to suffer from fractures and luxations as a commonly encountered with cats that have suffered
result of traumatic incidents 2,3. Degenerative unobserved traumatic incidents. Cats are frequently
conditions such as osteoarthritis or cruciate disease presented, having been missing for several days, with
are relatively less common and are typically seen in an apparent orthopedic disorder and no history to
older cats. Joint and bone neoplasia is also more guide the clinician as to the cause. It should be
common in the older cat, although lymphoma is an noted that some nontraumatic conditions, such as
important exception. There are a few nontraumatic ischemic neuromyopathy, might mimic unobserved
conditions that have a sex predisposition, such as traumatic injuries, such as pelvic fracture or spinal
periosteal proliferative polyarthritis, but gender is fracture/luxation.
generally not a major factor. Cat bites and traumatic
conditions are more common in young cats, PHYSICAL EXAMINATION
probably because of their territorial aggression and A general physical examination should precede the
lack of experience of natural and man-made hazards. specific orthopedic component of the examination.
Breed predispositions are less important in the cat The examination may detect evidence of concurrent
than the dog. This may be because pedigree cats are or intercurrent disease. This may provide clues to the
seen less frequently than their canine counterparts. orthopedic disorder; for example, cats with certain
The morphology of pedigree cats also differs very types of immune-mediated polyarthritis may have
little from nonpedigree cats so, in contrast to dogs, disease of other body systems. Intercurrent disease
conformation rarely plays a significant role in may influence the prognosis and have a bearing on
musculoskeletal disorders. With the exception of the administration of anesthetics and intravenous
certain inherited and congenital disorders, there are fluids; a degree of renal insufficiency is not
few conditions that are regularly seen more uncommon in geriatric cats, for example. Cats with
frequently in specific breeds. Body weight may unobserved trauma that have been missing are
predispose cats to clinical signs of musculoskeletal generally cachectic and the immediate concern is
disease in general and osteoarthritis in particular. fluid and caloric resuscitation. Cats with traumatic
One study found that overweight cats were orthopedic injuries frequently have concurrent
2.8 times more likely and obese cats were 5.4 times injuries involving other body systems. The
more likely to suffer from lameness visible to investigation and treatment of the trauma patient are
owners4. discussed more fully in Chapter 3.

HISTORY ORTHOPEDIC EXAMINATION


History taking is the component of the investigation The specific orthopedic examination is performed in
that is most likely to be neglected in practice a standard fashion regardless of species. The main
because it is perceived as time-consuming. However, difficulties are the lack of patient compliance for gait
the history often provides relevant information analysis and potential difficulties with the restraint of
concerning the cause of musculoskeletal disease and a fractious and painful cat. Observation of the gait
should always precede physical examination of the should be made by allowing the patient to walk
patient. The astute feline clinician should be wary of a unrestrained around an examination room. This can
number of pitfalls. Cats are small and light and have sometimes only be achieved by allowing the cat to
an independent lifestyle, so they are very good at settle first in a quiet environment or by observation
disguising mild to moderate musculoskeletal through a window from outside the room. It is
impairment. It is not unusual for the duration sometimes helpful to ask the owner to video the cat at
of clinical signs to be underestimated by the home. The cat’s posture and stance should also be
client because early signs have been overlooked. noted at this stage of the examination.
An apparently acute condition may, therefore, An initial evaluation is generally performed
already be chronic at the time of first presentation. with the cat in a standing position and using
Examination and diagnostic tools
19

minimal restraint. Careful and methodical palpation confirm a tentative diagnosis or to differentiate
of the muscles and joints of the limbs should be between the different conditions in a short list of
performed first, usually starting proximally and differential diagnoses. In many cases the diagnosis
working distally. It is helpful to compare left and may be obvious and is achieved without the need for
right limbs for overall symmetry, evidence of pain or further work up; for example, cat bites and cellulitis.
tenderness, muscle atrophy, and joint thickening or In other cases, where the condition is mild or where
swelling. Muscle atrophy is most easily detected there are financial constraints, it may be preferable to
where there are large muscle masses adjacent start a therapeutic trial and reassess in the light of the
to bony prominences, such as the blade of the response to treatment.
scapula and the greater trochanter. Joint thickening
and swelling cannot usually be appreciated in the RADIOGRAPHY
hip and shoulder because of overlying muscle Radiography is the most commonly used ancillary
masses. Synovial effusion is easier to detect with diagnostic tool in the investigation of orthopedic
the joint bearing weight but, in general, palpable disease. The use of radiography as an aid in the
joint effusion is less common in comparison with investigation of joint disease is discussed in
the dog. Chapter 7. Radiographs should be interpreted in the
A more focused orthopedic evaluation is light of the clinical findings and should not be
generally performed with the cat gently restrained in used as a substitute for a correctly performed clinical
lateral recumbency by an assistant. It is preferable to examination. Radiography is often used to confirm a
commence the examination with the healthy limbs, suspected clinical diagnosis and occasionally to
in order to accustom the cat to being handled and to differentiate between two or more diseases with
minimize the chances of the patient becoming similar clinical signs. Radiography is used in traumatic
fractious. Careful palpation and manipulation of the injuries to assess the location and extent of fractures
joints of all of the limbs is begun distally starting and to assist with the planning of surgical repair.
with the phalanges and working proximally. The For diaphyseal fractures, especially if there is
range of joint motion is assessed by putting the comminution, radiographs of the contralateral bone
joints through a full range of flexion/extension are obtained to assist further with fracture planning
and abduction/adduction, as appropriate, while and bone repair. Radiographs of the thorax and
observing the cat for any evidence of discomfort. abdomen are warranted for cats that have suffered
Joint stability is assessed at this time in lateral to severe trauma, irrespective of whether there are
medial and cranial to caudal planes. Any evidence of clinical signs of a respiratory or abdominal disorder.
joint effusion, periarticular thickening, and crepitus Feline radiography is best performed with the patient
is noted. Specific manipulations such as the cranial heavily sedated or under a general anesthetic to
draw sign and tibial compression tests are identical to eliminate movement and allow optimum positioning.
those performed in the dog and are applicable to the Changes are often subtle and the bones are small, so
cat. Others, such as the Ortolani sign, are less high quality radiographs are essential. Fine detail
frequently performed. These maneuvers are best screens should be used and human mammography
performed under sedation or general anesthesia and film/screen combinations are preferred for the distal
are discussed more fully with the relevant disorders. extremities. Radiographs should be correctly
Long bones and the overlying soft tissue structures collimated to minimize scatter and should be
are also palpated along their length for irregularity or obtained in two orthogonal planes (i.e. at right angles
discomfort. A maneuver that provokes an apparent to each other). Radiographic interpretation is
pain response should be repeatable to ensure its best made with the aid of a bright light and
significance. A comprehensive examination should magnifying glass, in addition to a conventional
be performed on all four limbs before focusing viewer. Radiographic interpretation should be
attention on the affected limb. thorough and complete so that each structure is
assessed according to its roentgen signs (i.e. changes
DIAGNOSTIC TOOLS in number, position, size, shape, margin, opacity,
Following the orthopedic examination a decision internal architecture, and function). The pattern of
is made about treatment or further investigation. changes for individual conditions is discussed in the
Further investigations should be performed to relevant chapters.
20

SYNOVIOCENTESIS AND JOINT FLUID ANALYSIS clipped and prepared at the site of the puncture (7) but
Synoviocentesis and analysis of synovial fluid is an it is not necessary to use surgical drapes or gloves. A
underutilized procedure in feline medicine. Analysis 3ml syringe and a 25 gauge hypodermic needle of
is particularly useful for differentiating between sufficient length to penetrate the soft tissues (usually up
degenerative and inflammatory causes of arthritis and in to 25 mm) is used to aspirate fluid from the joint. The
determining whether an inflammatory arthritis is volume of fluid obtained from normal joints is typically
infective or immune mediated. General anesthesia or less than 0.25ml for the shoulder, elbow, stifle and hip
heavy sedation is required for synoviocentesis in the cat. joints and less than 0.1ml from the carpal and tarsal
It is usually convenient to perform radiography first and joints5. Difficulty may be encountered introducing the
then immediately tap affected joints in the light of the needle into the hip joint and multiple attempts are
radiographic interpretation. A small area should be sometimes necessary.

A B C

D E F

7 Six sites for synoviocentesis.


A Carpus. The antebrachiocarpal joint is located with thumbnail pressure with the joint flexed. The needle is introduced
slightly to one side of the median plane.
B Elbow. The joint is held in flexion and the needle is introduced from the caudolateral aspect between the lateral humeral
epicondyle and the olecranon.
C Shoulder. Gentle traction is placed on the limb to open up the joint space. The needle is introduced into the
scapulohumeral joint from the craniolateral aspect just distal to the acromion process.
D Hock. The joint is held in flexion and the needle is introduced into the tarsocrural joint from the caudolateral aspect
between the lateral malleolus and the lateral trochlear ridge of the talus.
E Stifle. The joint is held partially flexed and the needle is introduced just medial or lateral to the mid-portion of the
straight patellar ligament and directed proximally.
F Hip. The femur is held partially abducted and rotated outwards. The needle is introduced into the coxofemoral joint
just caudal to the greater trochanter and directed cranially at an angle of approximately 45°.
Examination and diagnostic tools
21

Synovial fluid from cats with inflammatory arthritis joints, is abnormal and indicates joint effusion.
may clot on standing (a positive fibrinogen clot test). Turbidity indicates increased white or red cell counts
Clotting is prevented by placing samples that are to be and a yellow discoloration, or xanthochromia, is
submitted for cytologic examination in blood tubes almost always due to the presence of heme
containing ethylenediamine tetra-acetic acid (EDTA) pigments derived from previous hemorrhage. Red
as an anticoagulant. Cells in synovial fluid degenerate discoloration may indicate recent hemorrhage but is
rapidly and cytologic examination should preferably more likely due to contamination during sampling,
be performed within 4 hours. For submission to an which can be seen as a swirl of blood entering
external laboratory, cooling to 4°C (39°F) provides the syringe during the procedure. A subjective
preservation for up to 24 hours. Samples for bacterial assessment of viscosity is made by performing the
culture should not be placed in EDTA because it string test, whereby synovial fluid is allowed to drip
inhibits bacterial growth. Since the volume of synovial slowly from the syringe (onto a slide) or a drop is placed
fluid samples obtained from cats is small, proper between the finger and thumb, which are then slowly
sample handling and correct choice of tests are critical drawn apart. Normal fluid will produce a string that is at
(Table 4). least 20–40 mm in length. Viscosity is a measure of the
The features of synovial fluid that are most hyaluronic acid content and is reduced in inflammatory
frequently evaluated are: arthropathies. The viscosity will also be reduced owing
• Physical characteristics (volume, color, turbidity, to a dilution effect if there is a substantial joint effusion,
and viscosity). irrespective of the etiology.
• Cytologic examination (total nucleated cell count
and differential cell count). Cytologic examination
• Mucin clot test. If sample size is limited, cytologic examination should
• Bacterial culture. take priority. A hemocytometer is used because fluid
volume is generally insufficient for Coulter counter
Physical characteristics evaluation. Cytology provides estimates of the total
The physical characteristics of the fluid are noted at the nucleated and differential cell counts, thus allowing
time of collection. Normal synovial fluid should be of the important distinction to be made between
low volume, should appear clear and colorless or straw- inflammatory and noninflammatory disease. Normal
colored, and should have a high viscosity. Aspiration of feline synovial fluid is less cellular than canine synovial
more than 0.25 ml of fluid, even from the larger fluid5,6. If necessary, examination can be performed

TABLE 4 SYNOVIAL FLUID ANALYSIS.


Normal joint Osteoarthritis Immune-mediated Bacterial
arthritis infective
arthritis
Volume (ml) 0–0.25 0–0.50 0–2.0 0.25–1.0
Color Clear/pale yellow Yellow Yellow-white White
+/– blood tinged +/– blood tinged
Clarity Transparent Transparent Transparent or opaque Opaque
Viscosity Very high High Low/very low Very low
Mucin clot Good Good–fair Fair–poor Poor
Spontaneous clot None Sometimes Often Often
White cells (cells/μl) <1000 1000–5000 5000–9000 5000–100000
Neutrophils <5% <10% 10–95% >95%
Mononuclear cells >95% >90% 5–90% <5%
Protein (g/l [g/dl]) 20.0–25.0 [2.0–2.5] 20.0–30.0 [2.0–3.0] 25.0–50.0 [2.5–5.0] >40.0 [>4.0]
22

on a stained smear prepared from a single drop of PRESSURE PLATFORM GAIT ANALYSIS
synovial fluid. A smear is made on a glass microscope Pressure platform gait analysis offers an objective
slide at the time of collection, air-dried, and then noninvasive method for evaluating limb function
stained with a Romanovsky’s stain, such as Wright’s, in cats. The technique has been described
before examination. Many commercial laboratories experimentally in normal cats8. Pressure platform gait
request submission of a freshly prepared unstained analysis has been used to evaluate long-term limb
air-dried smear in addition to a sample of fluid function after onychectomy9 and also for assessment
in EDTA. and comparison of the efficacy of analgesic drugs
after onychectomy10.
Mucin clot test
Although viscosity provides a guide to the amount of FLUOROSCOPY
hyaluronic acid in synovial fluid, the mucin clot Although not generally available, fluoroscopy has
test gives a much more accurate semi-quantitative been used to aid in the intraoperative placement of
assessment of the quality and the concentration of implants, such as pins and screws, and to assess
hyaluronic acid and is not influenced by the dilution fracture alignment. Other uses include contrast
effect of an effusion. A few drops of synovial fluid are studies (myelography, arthrography) and location of
added to about 10ml of 2% glacial acetic acid in a glass radiopaque foreign bodies.
test tube and allowed to stand. Synovial fluid that has
been collected in a plain tube or in heparin should be SCINTIGRAPHY
used, since the test is inhibited by the presence of Scintigraphy involves the injection of a radioisotope
EDTA. Acid precipitation of a normal concentration (technetium methylene diphosphonate), which emits
of well polymerized hyaluronic acid produces a tight gamma radiation. The agent is injected intravenously
clot with a clear surrounding solution. The presence and an image is created using a gamma camera showing
of increasingly severe inflammatory pathology is areas of increased bone turnover. Scintigraphy is
inferred from the production of a soft clot, a friable rarely performed in cats because of concerns about
clot, or flocculent material in a cloudy surrounding radiation safety, expense, and lack of availability. The
solution. technique is a very sensitive indicator of bone lesions
but is nonspecific.
Bacterial culture
This is used to isolate the causative organism and SONOGRAPHY
guide antibiotic therapy in suspected cases of septic Sonography has limited application for the investigation
arthritis and should include both aerobic and of orthopedic disease because of the inability of
anaerobic culture. Isolation of bacteria from ultrasound to penetrate osseous tissues. Sonography has
synovial fluid is inconsistent and a negative culture been used for the investigation of Achilles tendon
does not rule out septic arthritis. The likelihood of injuries in cats11, and in the investigation of joint
a positive culture can be significantly increased disease, which is discussed in Chapter 7. Sonographic
either by submission of a sample of synovial assessment of secondary fracture healing of the long
membrane or by inoculation of the synovial fluid bones has been described12 and a preliminary report
into sterile blood culture medium before submission described the use of ultrasound-guided needle biopsy
to the laboratory7. Liquid blood culture medium for the diagnosis of bone lesions13. Use of this
reduces the in vitro phagocytosis of bacteria by technique is likely to be restricted to specialized centers
leukocytes and has a dilution effect on bacterial because of the small size of the structures under
inhibitors. investigation and difficulties in the interpretation of the
images obtained.
Other tests
Numerous other tests have been used to analyze ADVANCED IMAGING TECHNIQUES
synovial fluid in humans but their value has not been The use of magnetic resonance imaging (MRI) and
demonstrated in cats. Common additional tests include computed tomography (CT) has been restricted in the
measurement of glucose, which is decreased in past by their expense and lack of availability. They are
inflammatory disease, and protein, which is elevated in being used increasingly in the investigation of spinal
inflammatory disease. Both of these tests require and joint disorders in dogs but there are few reports
concurrent submission of serum so that the two levels of their use in cats. The small size of cats means that
can be compared. imaging of feline structures requires the use of
Examination and diagnostic tools
23

equipment that is capable of obtaining very high oxide sterilization, whereas the reusable needle can
definition images. Magnetic resonance imaging is be autoclaved. An accurate histopathologic diagnosis
most useful for lesions involving the spinal cord and can be obtained in approximately 90% of cases if an
nerve roots and for soft tissue structures of joints, experienced histopathologist examines the sample. The
whereas CT is most useful for osseous lesions. technique has been described in detail14. Briefly, the
site is clipped and prepared and a small incision is made
BONE BIOPSY in the skin over the center of the lesion. The biopsy
Bone biopsy is indicated in the definitive diagnosis of tract may be contaminated with tumor cells and should
proliferative and lytic bone lesions. Different types of be positioned so that it can be included in the excised
bone tumors and osteomyelitis caused by bacteria or tissue if definitive surgical treatment is to be performed
fungi may have a similar radiographic appearance subsequently. The needle is advanced through the soft
and can only be differentiated on the basis of tissues, with the stylet in place, until bone cortex is
histopathologic examination. Biopsy is performed less contacted. The stylet is removed and the needle is
frequently in the cat than the dog because of the advanced until it contacts the transcortex. The needle
relative infrequency of osteosarcoma. The Jamshidi- is removed and the specimen is pushed out using a
type bone marrow biopsy needle is suitable for probe, which is inserted into the opening at the tip of
obtaining bone biopsies from cats (8). Use of the the needle. The process is repeated through the same
needle only requires one small incision and the size of incision, so that at least two samples are obtained, one
the sample obtained is small, thus minimizing the risk from the center and the other in the transition zone.
of iatrogenic fracture. Jamshidi needles are available in Diagnostic accuracy can be increased if the bone is
single-use or reusable versions. The single-use needle radiographed postoperatively to confirm correct
can be reused a number of times but requires ethylene selection of the biopsy site.

i ii iii 8

A B

8 Jamshidi-type bone marrow biopsy needle.


A (i) Cannula and screw-on cap. The cannula has a tapered point to retain the specimen in
the needle. (ii) Pointed stylet for use when the needle is advanced through the soft tissues.
(iii) Probe used to expel the specimen from the base of the needle.
B After the stylet has been removed, the needle is advanced through the bone using a
twisting motion until the opposite cortex is reached. The needle is then withdrawn and
the specimen expelled. The procedure is repeated using the same skin incision, with the
cannula directed towards the periphery of the lesion.
24

MUSCLE AND NERVE BIOPSY virus (FIV) tests may also be performed routinely
Definitive diagnosis of many neuromuscular disorders or if they are specifically indicated. Other tests
requires histopathologic examination of muscle and performed on the basis of the clinical signs and other
nerve tissue. The procedures for muscle and nerve findings include coronavirus, antinuclear antibody,
biopsy and the processing of specimens have recently rheumatoid factor, creatine kinase, toxoplasma
been reviewed15. Samples should be sent to serology, and measurement of acetylcholine
laboratories specializing in the evaluation of nerve receptor antibody and molecular techniques16. The
and muscle biopsies (1–3). The laboratory should be significance of these tests and the indications for
consulted beforehand for advice about the correct them are discussed in the relevant chapters. Sampling
selection and processing of samples. and examination of cerebrospinal fluid are discussed
in Chapter 11.
ADDITIONAL LABORATORY TESTS
The extent of routine preoperative blood testing is (1) Dr GD Shelton, Comparative Neuromuscular
controversial but a biochemistry panel, hematology, Laboratory, Basic Science Building, Room 1107,
electrolytes, and urinalysis are recommended for any University of California, San Diego, La Jolla, CA
cat >5 years old undergoing a lengthy orthopedic 92093-0612, USA. Tel: (858) 534 1537.
procedure (>60–90 minutes). Blood testing is (2) Dr KG Braund, Peripheral Nerve Laboratory,
particularly indicated for geriatric cats, and for cats 1476 Lakeview Ridge, Dadeville, AL 36853,
that have a preexisting medical condition or evidence USA. Tel: (256) 825 2624, Fax: (603) 676 2383.
of intercurrent disease on clinical examination. Young (3) Dr C Hahn, Neuromuscular Disease Laboratory,
cats (<5 years old) presented for elective orthopedic Royal (Dick) School of Veterinary Studies, The
procedures require only a packed cell volume (PCV), University of Edinburgh, Easter Bush, Midlothian,
total protein, and urine specific gravity. Feline EH25, UK. Tel: (131) 650 6236, Fax: (131) 650
leukemia virus (FeLV) and feline immunodeficiency 6588, Email: vetneurolab@ed.ac.uk.
25

CHAPTER 3
MANAGEMENT OF
THE ORTHOPEDIC
TRAUMA PATIENT
INTRODUCTION involving the skull and spine and open fractures,
A logical approach to the assessment and management there are few instances where orthopedic injuries
of the traumatized cat will help maximize survival and constitute an emergency. Since many concurrent
increase the success rate of subsequent surgery. injuries produce minimal clinical signs on first
The major cause of feline orthopedic injury is presentation, they can easily be overlooked in favor of
vehicular trauma; other etiologies include falls from the more obvious orthopedic injuries. Diagnosis and
heights, animal fights, and gunshots wounds. Multiple treatment of thoracic injury is especially important
orthopedic injuries are not uncommon and there are prior to anesthetic administration. In one study, 40%
frequently injuries to multiple body systems (Table 5). of cats showed no clinical signs suggestive of thoracic
Thoracic injuries, in particular, are often seen in cats injury despite having abnormalities detected
with fractures and represent a common cause of death radiographically2.
following trauma1. In one study of 93 cats with
traumatic fractures, 38.7% had radiographic evidence PHYSICAL EXAMINATION
of thoracic trauma, the most common injuries being Examination of the orthopedic trauma patient can be
lung contusion and pneumothorax2. Traumatic rib divided into three phases. As with all trauma victims,
fractures in cats, although usually of little clinical triage of all of the injuries is very important. At the
significance in their own right, should alert the time of first presentation evaluation of the respiratory
clinician to the likely presence of other more severe and cardiovascular systems should receive priority, in
intrathoracic and orthopedic injuries3. order to identify potentially life-threatening injuries.
It is essential that the patient is adequately Orthopedic injuries are not immediately life-
stabilized and properly evaluated for concurrent threatening, whereas mortality due to thoracic trauma
injury before performing orthopedic surgical or peritoneal hemorrhage in traumatized cats is not
intervention. With the exceptions of fractures uncommon.

TABLE 5 COMMON THORACIC AND ABDOMINAL INJURIES SEEN IN CATS WITH TRAUMATIC FRACTURES.
Thoracic injuries Abdominal injuries
Diaphragmatic rupture Abdominal rupture
Pulmonary contusion Bladder rupture or avulsion
Pneumothorax Ureteral avulsion
Pneumomediastinum Perforation/tear of colon or rectum
Hemothorax Hepatic laceration
Pericardial tamponade Gall bladder rupture
Posttraumatic arrhythmia Splenic laceration
Rib fractures Kidney laceration or avulsion
Thoracic wall injuries Penetrating abdominal wounds
26

An initial rapid evaluation of the trauma patient is examination using a facemask or flow-by. Struggling
performed by checking respiratory rate and character, and excessive manipulation at this stage may be life-
mucous membrane color, capillary refill time, and threatening and should be avoided. Following this
pulse rate and quality. Careful observation of the cat’s cursory examination, cats with dyspnea should be
breathing pattern can provide an indication of the placed in an oxygen tent or cage while being
location of the problem without immediate resort to stabilized. Longer-term administration of oxygen is
stressful diagnostic procedures4. The lungs and best performed via a nasal cannula or a hood. A mild
heart should be auscultated, checking for evidence sedative, such as butorphanol at a dosage of
of pulmonary or pleural pathology and cardiac 0.2–0.4 mg/kg, may be required when these methods
murmurs or arrhythmias, respectively. During the are employed.
initial examination, attention should also be paid
to the cat’s level of consciousness and ability to FLUID THERAPY
ambulate. The integrity of the urinary bladder can be Fluid therapy in cats has recently been reviewed5,6.
checked by gentle abdominal palpation, although this Cats that have suffered major trauma will have
does not rule out trauma to the ureters or urethra. hypovolemic shock, as evidenced by pallor of the
Following stabilization of the patient and treatment mucous membranes, delayed or absent capillary refill,
of life threatening injuries, a more thorough physical hypothermia, weak or nonpalpable peripheral pulses,
and orthopedic examination can be performed. and mental depression. The tachycardia typically
This should encompass all body systems and include displayed by dogs is not a typical feature in the cat and
a cursory neurologic examination. In those patients the heart rate is most often normal or slow. In
suspected of having injury to the nervous system, addition, cats that have suffered unobserved trauma
a complete neurologic examination is then performed. and been missing for several days will be cachectic
The third and final phase of the examination and dehydrated. The priority in all cases is to
involves ongoing assessment including re-evaluation restore hemodynamic stability by restoration of the
for progression of clinical signs and the response to circulating blood volume. External hemorrhage will
treatment. be readily apparent but internal hemorrhage is less
easy to detect. The fracture hematoma alone may
DIAGNOSTIC TESTS account for substantial blood loss, especially when the
The most important part of the assessment of the femur or pelvis is involved or where there are fractures
trauma patient is the physical examination; however, of multiple bones. Unfortunately, measurement of the
some ancillary testing is frequently indicated. All cats packed cell volume (PCV) in acute trauma cases will
that have sustained major trauma should have thoracic not reflect the severity of blood loss, since there is a
and abdominal radiographs once they are stable. If lag period of up to 24 hours while fluid moves into
urinary tract trauma is suspected, contrast studies are the circulation. Although overinfusion of fluids must
required to determine the location and nature of the be avoided, one of the greatest causes of mortality in
lesion. Laboratory investigations, such as blood gas cats requiring intensive care is underestimation and
analysis or a coagulation profile, may be indicated in underinfusion of intravenous fluids.
specific cases. Cats with arrhythmias or tachycardia Cats presenting with hypovolemic shock should
may have myocarditis secondary to myocardial trauma have their circulating plasma volume restored as quickly
and should have electrocardiographic evaluation, as possible. Crystalloids should be given routinely at
especially if anesthetic administration is contemplated. shock rates, and body temperature, urine output,
The onset of posttraumatic arrhythmia is delayed 1–5 peripheral perfusion, and blood pressure (if available)
days after the traumatic episode and is characterized should be monitored. The crystalloids of choice for
by ventricular premature contractions or, in severe acute hypovolemia are normal (physiologic) 0.9% saline
cases, ventricular tachycardia. or Hartmann’s (lactated Ringer’s) solution. Attempted
resuscitation with crystalloids alone carries a high risk of
RESUSCITATION AND significant pulmonary edema and accumulation of
STABILIZATION OF THE pleural fluid. Cyrstalloids are therefore usually used in
TRAUMA PATIENT combination with colloid solutions. Colloid solutions
OXYGEN THERAPY contain large molecules (e.g. dextrans, starch, or
Cats that appear to be in respiratory distress following albumin), which exert an osmotic effect that holds water
trauma should receive immediate oxygen therapy. within the plasma. Colloids therefore provide more
Supplementary oxygen can be given during the initial effective and prolonged expansion of the circulating
Management of the orthopedic trauma patient
27

volume than a similar quantity of a crystalloid solution. the nature of the blood group antigens on the
Rapid infusion rates of colloids are less well erythrocyte cell membranes. In worldwide studies type
tolerated in cats than in dogs, and excessive rates can A has consistently been found to be the most common
cause seizures and other adverse reactions. In severe type, whereas type AB cats are consistently uncommon.
cases of hypovolemic shock, a loading dose of fluid can The proportion of type B cats shows considerable
be given over a period of 5–10 minutes (10–20 ml/kg geographical and breed variation. Unlike dogs, in
isotonic crystalloid and 5 ml/kg of colloid). Infusion addition to blood group antigens, cats also have
rates of crystalloid of 40–60ml/kg/hour are acceptable naturally occurring serum antibodies to red cell antigens
for a short time to counter life-threatening hypo- known as alloantibodies9. These alloantibodies can
volemia. The same dose of colloid can be repeated as result in severe transfusion reactions in blood that has
necessary every 5–10 minutes if systemic arterial blood not been cross-matched. Type A cats generally have low
pressure remains low, and then maintained at anti-B antibody titers and, if given type B blood, may
10–40 ml/kg/day. Accurate administration of these develop mild clinically inapparent transfusion reaction
fluids requires the use of pediatric burettes or infusion with reduced red cell lifespan. All type B cats have high
pumps. The cat should be monitored closely and anti-A titers and, if given even a single transfusion of a
systemic arterial blood pressure, if available, should be small volume of type A blood, develop a severe
checked regularly to prevent volume overload. Should transfusion reaction10. Type AB cats have no naturally
pulmonary edema develop as a result of overinfusion, occurring anti-A or anti-B antibodies.
the infusion of crystalloid should be reduced, the colloid It is, therefore, vital that donor–recipient
should be stopped, and furosemide should be given at compatibility is established prior to first transfusion of
2– 4 mg/kg IV. all cats11. Ideally, compatibility should be ensured by
After the first 24 hours, hypovolemia and fluid both blood typing and cross-matching. A desktop
deficits should have been corrected. If the cat is blood typing kit has recently been developed, which
unwilling or unable to take oral fluids, then sufficient requires only 0.25 ml of blood in EDTA and is easy
fluid to fulfill normal maintenance requirements will to use (Rapid Vet-H Feline, DMS laboratories). The
be needed, together with fluid to replace any ongoing kit provides an accurate method by which feline blood
abnormal losses, for example, those incurred as a can be routinely typed in house12. Cross-matching is
result of fracture surgery. The maintenance fluid used to assess the effect that recipient serum
requirement in a healthy cat is 40–60 ml/kg/day. antibodies will have on donor cells (major cross-
match) and the effect that donor serum will have on
BLOOD TRANSFUSION recipient cells (minor cross-match). Cross-matching is
Blood transfusions in the cat and dog have been available at commercial laboratories, although, in an
reviewed7,8. Blood transfusion is indicated in the emergency situation, crude cross-matching can be
management of acute trauma if the patient performed in house.
has hypovolemic shock and cannot be stabilized by The ideal blood donor should be healthy, have a
administration of crystalloids and colloids alone. This lean body weight >5 kg, should be vaccinated, and
may occur if the blood loss has been severe or if there is should be negative on testing for feline leukaemia virus
ongoing hemorrhage. In the latter case, blood (FeLV), feline immunodeficiency virus (FIV), and
transfusion is performed in conjunction with surgical Haemobartonella felis. The donor should have a PCV
intervention to identify the source of hemorrhage at the high end of normal, preferably >35% (normal
and prevent further blood loss. The other common range 24–45%) and the blood group should be known.
indication for blood transfusion is in the stabilized A cat’s blood volume is estimated at 66 ml/kg.
patient that requires surgery and is moderately anemic Between 10% and 15% of a donor’s circulating blood
(PCV of 15–20% or less) as a result of previous blood volume may be safely removed, i.e. approximately
loss. Although cats appear to be more tolerant of anemia 35–50 ml for a 5 kg cat. If the volume exceeds 15%,
than dogs, transfusion is indicated, especially if further crystalloids should be given to the donor to prevent
blood loss is anticipated during surgery. Unfortunately hypovolemia.
transfusion is rarely performed in practice, probably The amount of blood required by the recipient can
because of the lack of a commercially available blood be calculated from the formula:
collection system, concerns about transfusion reactions,
and a lack of suitable donors. Blood needed (ml) = weight of recipient (kg) ×
Three blood types or groups have been identified in desired PCV – recipient’s PCV × 66
cats (A, B, and AB). The blood group is determined by donor’s PCV
28

As a rough guide, for every 2.2 ml of blood/kg coaxed to eat by hand feeding or offering different
body weight transfused, the PCV of the recipient will types of food. Appetite stimulant drugs can be
increase by 1%. helpful in some cases but are usually not effective in
Blood is collected from the jugular vein of the cats that are completely anorexic. The most
donor using a 50 ml syringe with a butterfly extension commonly used appetite stimulants are diazepam
set. The inside of the extension set and syringe should administered intravenously at a dose of 0.5 mg/cat
be coated with approximately 1.3 ml of acid citrate and cryptoheptadine administered orally at a dose of
dextrose (ACD) or citrate phosphate dextrose (CPD) 2 mg/cat twice daily.
per 10 ml of blood to be collected (removed from Provision of adequate nutrition is important,
a human blood transfusion pack). Sedation of the because undernutrition or malnutrition have a
donor is routinely performed, for example, using negative influence on morbidity and mortality in
ketamine combined with midazolam or diazepam (see critically injured patients16. Adverse consequences
Table 8). Hypotensive agents such as acepromazine for the orthopedic surgical patient include increased
should be avoided. The blood can be given susceptibility to infection, delayed wound and
immediately, via either the intravenous or intraosseous fracture healing, muscle weakness, major organ
routes, through a blood giving set or in-line filter to failure, and death17. Protein and energy under-
remove small clots. A maximum flow rate of nutrition is a common problem in the traumatized
20 ml/kg/hour is normally recommended for cat. The cat’s protein requirement is 50% higher for
hypovolemic patients, but much greater rates can be growth and more than 100% higher for maintenance
used in certain circumstances, such as when there is compared with that in the dog. Unlike in the dog,
ongoing hemorrhage. Blood not required for the urea cycle and hepatic transaminases have a fixed
immediate use can be stored for up to 4 weeks high rate of activity and therefore the cat cannot
provided it is kept refrigerated. adapt to the amount of protein consumed.
The recipient should be monitored closely for Nutritional support is indicated when the intake of
signs of an acute transfusion reaction, especially calories is reduced because a cat is unable or unwilling
during the first 15 minutes of administration. Severe to eat and in situations where there is an excessive
reactions are characterized by hemolysis and systemic demand for protein and calories. Common indications
anaphylaxis (tachycardia, hypotension, bradycardia, for nutritional support in the feline orthopedic patient
apnea, vomiting, and pyrexia). include:
• Substantial hemorrhage (traumatic and/or
Blood substitutes surgical).
Because of the difficulties associated with blood • Large open wounds.
transfusion in cats, the availability of a red blood cell • Fractures of the mandible or maxilla.
substitute would be invaluable. A hemoglobin-based • Multiple orthopedic injuries.
oxygen carrying (HBOC) solution is licensed for • Anorexia because of intercurrent medical
use in dogs and has been used in cats both conditions.
experimentally and clinically13–15. Because cats are • Cats that have been missing for several days.
more vulnerable than dogs to volume overload slow • Anorexia because of concurrent injury to other
infusion rates are advisable (0.5–2.0 ml/kg/hour), body systems.
with a total dose of approximately 30–40 ml/kg.
Administration of HBOC to clinical patients was Nutritional support can either be provided by the
documented in a retrospective study involving 72 parenteral route, using a central venous catheter
cats13. There was a high incidence of complications or peripheral vein18, or by the enteral route, by force-
ranging from those that were mild and clinically feeding or insertion of a feeding tube17. The
insignificant through to severe cardiovascular and parenteral route is rarely used since it is expensive and
respiratory effects. Higher infusion rates were has a high complication rate. Enteral feeding is more
associated with an increased risk of complications. physiologic, is inexpensive, and is easy to perform
with few complications. Additionally, owners can
NUTRITION perform feeding by this route at home. Methods for
It is not uncommon for feline patients to show delivery of enteral nutrients include placement
reluctance to eat or drink during a stay in hospital or of nasogastric, pharyngostomy, esophagostomy,
following discharge after surgery. Many cats can be gastrostomy, or jejunostomy feeding tubes19.
Management of the orthopedic trauma patient
29

Nasogastric or esopahgostomy feeding tubes are used PRE- AND POSTOPERATIVE


most commonly for feline orthopedic patients STABILIZATION OF FRACTURES
requiring nutritional support. Gastrostomy tube AND LUXATIONS
feeding may be indicated where it is anticipated that Bandages and splints (Tables 6 and 7 ) are frequently
longer-term nutritional support will be required used preoperatively to provide temporary immo-
(weeks to months) but are rarely used for orthopedic bilization and reduce swelling for fractures at or distal
patients. Methods of placement of these tubes have to the elbow and stifle. Bandages, splints, slings, and
been described20,21. Nasogastric tube feeding is well casts are often used to provide adjunctive fixation
tolerated by cats for short-term enteral feeding (up to postoperatively for fractures or after reduction of joint
10 days). The main advantages of nasogastric tubes luxations. In some cases external coaptation may be
are that they are simple to place and placement does used as the sole method of fracture fixation (see
not require the administration of a general anesthetic. Chapter 6). The principles and techniques for
The disadvantages are that feeding is restricted to application are the same as those for the dog and have
liquid diets because of the small bore of the tube and been well described elsewhere23.
an Elizabethan collar is almost always required to For fractures distal to the elbow and stifle
prevent premature removal. Esophagostomy tubes joints, a soft, padded bandage should be applied
are generally preferred for longer-term use. Because postoperatively to the limb to limit swelling. In most
of the larger bore of an esophageal tube, blended cases, this bandage is removed 1–2 days after surgery
commercial canned food can be used in addition to to allow early joint mobility. This also allows careful
commercial liquid diets. Long-term nutritional examination of the limb for signs of neurologic
support using esophageal tube feeding is well dysfunction or vascular impairment, and the initiation
tolerated by cats and has been associated with of physical rehabilitation techniques. If the bandage is
minimal complications22. The surgeon should not left in place for a longer period of time, or when
hesitate to place a feeding tube at the time of surgery external coaptation is used for fracture fixation, the
if it is anticipated that there will not be a rapid return cat’s toes are observed for signs that the bandage is
to oral feeding postoperatively. Tube feeding is too tight.
started immediately after recovery from anesthesia In cats with external fixators, incorporating the
and continued until the patient is feeding voluntarily. frame and limb in a bandage will help reduce swelling,
It is possible for a cat to eat and drink normally with prevent the frame from catching on objects in the
a feeding tube in place. environment, and pad the frame and sharp points of

TABLE 6 EFFECT OF BANDAGES, SLINGS, SPLINTS, AND CASTS ON JOINT MOTION AND WEIGHT BEARING.
Region Weight bearing, Weight bearing, Nonweight-bearing, Nonweight-bearing,
joint still mobile joint immobilized joint still mobile joint immobilized
Shoulder - Spica splint Velpeau sling
Elbow Robert Jones/ Spica splint, - Velpeau sling
soft-padded bandage cast/splinted bandage
Carpus Robert Jones/ Cast/metasplint - -
soft padded bandage
Hip - - Ehmer sling, -
90/90 sling
Stifle Robert Jones/ Cast/ - 90/90 sling
soft padded bandage splinted bandage
Hock Robert Jones/ Cast/ - -
soft padded bandage splinted bandage
Digits Robert Jones/ Cast/ - -
soft padded bandage metasplint
30

TABLE 7 BANDAGES, SPLINTS, SLINGS, AND CASTS.


Type Indications Complications/Comments
Robert Jones bandage Pre- (and post-) operative for Circulatory impairment digits
fractures or luxations at or distal
to the elbow or stifle
Soft padded bandage Post- (and pre-) operative for Circulatory impairment digits
fractures or luxations at or distal
to the elbow or stifle
Cast Postoperative immobilization Circulatory impairment digits,
distal to the elbow or stifle (and pressure sores
primary treatment of selected fractures)
Spica splint Pre- and postoperative for scapular, Circulatory impairment digits,
shoulder, and humeral fractures, lateral not tolerated by some cats
shoulder luxation, elbow luxation
Velpeau sling Postoperative for surgery proximal Not well tolerated by most cats
to the elbow, medial shoulder luxation
Ehmer sling Craniodorsal hip luxation Circulatory impairment distal
to the sling, not well tolerated
by some cats
90/90 sling Postoperative for surgery proximal Circulatory impairment distal
to the stifle, femoral fractures to help to the sling, not well tolerated
prevent quadriceps contracture by some cats
Mason metasplint Pre- and postoperative immobilization Circulatory impairment digits
of distal extremities

the pins. In most cases, the pin–skin interface is left bulk and is wrapped tightly around the limb. The
exposed and monitored daily for drainage or signs of bandage must extend beyond the joints proximally
inflammation. In general, no cleaning is necessary. and distally to the fracture, but the distal aspect of the
However, if drainage develops, cleaning the pin–skin digits is left exposed to monitor swelling. Elastic
interface daily with a mild soap or chlorhexidine gauze is then tightly wrapped over the padding
solution may be beneficial. If the frame is bandaged, (distally to proximally) to provide compression. The
the foam portion from surgical scrub brushes can be tape stirrups are reflected proximally and stuck to the
dried and packed around the pins beneath the outer layer of gauze. Tightly wrapped cohesive
bandage. bandaging tape is then applied to cover the bandage.
If additional support is desired, a metal rod or
ROBERT JONES BANDAGE thermomoldable splint material (X-Lite, AOA
A Robert Jones bandage is a heavily padded, Kirschner Medical Corp.) can be incorporated into
bulky bandage often used preoperatively to provide the bandage before the Vetrap is applied. The splint
temporary stability and reduce swelling in fractures at material is generally placed on the lateral aspect of the
or distal to the elbow and stifle joints (9). Tape fore- and hindlimb or the plantar aspect of the
stirrups are placed on the limb to apply traction while hindlimb.
the bandage is placed and to prevent the bandage
from slipping. Roll cotton or orthopedic wadding is SOFT PADDED BANDAGE
applied to the limb, beginning distally and A soft padded bandage, or modified Robert Jones
progressing proximally. In cats orthopedic wadding is bandage, is similar to a Robert Jones bandage but uses
often easier to apply than roll cotton. Each wrap less padding. Because it is less bulky than the Robert
should overlap the previous one by approximately Jones bandage it provides less immobilization of the
50%. A large quantity of padding is used to provide limb. It is used primarily for support and control of
Management of the orthopedic trauma patient
31
9 10

10 A completed Spica splint.

Spica splints may be used to immobilize fractures prior


to definitive repair, as ancillary support after internal
fixation, or to stabilize luxations of the shoulder or
elbow. They are occasionally used as a primary means
B
of fracture fixation. Unfortunately, some cats become
agitated when a Spica splint is applied.
Stirrups are applied to the distal limb to provide
traction while the splint is applied. The elbow and
shoulder joints should be slightly flexed and the limb
placed in a normal standing angle. Several layers of
cast padding are applied to the limb from the digits to
the axillary region. Application is continued around
the torso, wrapping both cranially and caudally to the
opposite shoulder in a modified figure-of-eight
pattern. Thermomoldable splint material (X-Lite,
AOA Kirschner Medical Corp.; Veterinary
C Thermoplastic (VTP), IMEX Veterinary Inc., or
9 Application of a Robert Jones bandage. Orthoplast, Johnson & Johnson) is then placed on the
A Application of stirrups and cotton roll. lateral aspect of the limb from just proximal to the
B Application of conforming bandage. The stirrups are digits to the dorsal mid-line. Alternatively, fiberglass
folded back before application of the final layer. casting material can be used. Elastic gauze is then
C Application of Vetrap bandage. placed to anchor the splint and conform it to the limb
and torso as it hardens. Cohesive tape or elastic tape is
placed to cover the bandage.
postoperative swelling at or distal to the elbow or stifle
joints. The procedure for application of the bandage is SLINGS
the same as the Robert Jones bandage except that less Slings are rarely used for primary fracture fixation, but
orthopedic wadding or roll cotton is used. Splint they may be used to prevent weight bearing after
materials can be added as described above. fracture repair and to stabilize joint luxations.

SPICA SPLINT Velpeau sling


A Spica splint can be applied if immobilization of the Velpeau slings are indicated as a primary or
scapula, shoulder, humerus, or elbow is desired, adjunctive stabilization to maintain reduction of
incorporating the entire forelimb and torso23 (10). medial shoulder luxations and to immobilize
32
11 12

11 Velpeau sling application. The forelimb is flexed and 12 Ehmer sling application. A small padded bandage is
adducted against the body wall. Cast padding material is applied to the metatarsus and phalanges. The hock and
applied, followed by roll gauze and Vetrap or elastic stifle joints are flexed and adhesive tape is applied in a
adhesive tape. The bandage encircles the torso and the figure-of-eight pattern (the adhesive tape must not encircle
flexed forelimb, wrapping cranial and caudal to the either the thigh or the distal limb). The tape is applied
opposite forelimb to prevent slippage. The material from the bandaged foot, medial to the stifle joint, and over
should not be placed too tightly. the cranial and lateral aspects of the thigh, medial to the
tarsus, back to the foot.

fractures of the scapula (11). To apply the Velpeau stabilize the hip joint. If greater abduction of the limb
sling, the forelimb is flexed and adducted against the is required to prevent reluxation of the hip, tape from
thorax. The limb is incorporated into a bandage (cast the sling can be extended over the dorsal mid-line to a
padding, roll gauze, cohesive tape) that encircles the band of tape placed around the caudal abdomen. This
torso. The bandage is placed cranial and caudal to is not necessary when prevention of weight bearing is
the opposite limb to prevent slippage. The bandage the goal and is often poorly tolerated by cats.
should allow the cat to breathe normally, but must The most common problem with the sling is that it
be snug to prevent movement of the affected limb. is prone to slip off the cranial aspect of the stifle because
Velpeau slings are not well tolerated by most cats. of the mobility of the skin in this region. Other
complications are discomfort, soft tissue trauma to the
Ehmer sling metatarsal or thigh region, and swelling of the toes. The
Ehmer (figure-of-eight) slings are used primarily to sling is not generally applied for longer than 10 days.
prevent weight bearing on the hindlimb and to
stabilize craniodorsal hip luxations after closed 90/90 sling
reduction24 (12). A light bandage is placed on the paw The 90°/90° flexion sling is a variation on the Ehmer
over the metatarsus and phalanges (to protect soft sling. It prevents weight bearing on the hindlimb by
tissues and reduce swelling of the toes). The hock and maintaining the stifle and hock flexed at right angles
stifle joints are then flexed and adhesive tape is applied (13). It is used primarily on cats at high risk
around the limb in a figure-of-eight pattern. The tape of quadriceps contracture after repair of femoral
is placed from the bandage on the paw, medial to the fractures25. Application is similar to the Ehmer sling
stifle between the thigh and inguinal area, over the except that the material is simply wrapped circumfer-
cranial and lateral aspects of the thigh, and then medial entially around the thigh and metatarsus rather than
to the tarsus to the bandage on the paw. Several passes being placed in a figure-of-eight fashion. To apply, cast
are needed to maintain the limb in a flexed position. padding is first placed around the metatarsus to protect
Adhesive tape sticks to the cat’s hair and reduces the soft tissues and minimize swelling of the toes. The
slippage of the sling. Gauze may be used instead and is hock and stifle joints are positioned in 90° of flexion.
easier to remove, but is more likely to slip prematurely. Elastic adhesive tape is placed around the thigh and
In addition to maintaining flexion of the hindlimb, an metatarsus to maintain flexion. Slings should not
Ehmer sling also rotates the femur internally to generally be maintained for longer than 10 days.
Management of the orthopedic trauma patient
33
13 prevents further contamination of the fracture from
the environment.
1. A sterile bandage or dressing is applied to protect
the wound from further contamination and
reduce the likelihood of nosocomial infections.
Sterile gloves should be worn at all times when
treating the wound.
2. The cat is examined thoroughly and treated
appropriately for shock and any concurrent injuries.
Particular attention should be paid to thoracic
trauma (pneumothorax, hemothorax, pulmonary
contusions), neurologic injuries (cranial trauma,
13 90/90 sling application. The hock and stifle joints are spinal fractures/luxations), abdominal injuries
placed in 90° of flexion. Cast padding material is placed (hemorrhage, bladder ruptures, hernias), and
around the metatarsal region to help reduce swelling of concurrent orthopedic injures (fractures, luxations).
the toes. Adhesive tape is applied circumferentially around 3. The fracture site is radiographed to document the
the femur and metatarsus to maintain flexion. severity of the orthopedic injury and aid selection
of the appropriate fracture fixation method.
4. When the cat is stable, the initial evaluation of
METASPLINTS the wound is begun. Sedation or short-acting
Metasplints (Mason metasplints) are used to immobilize anesthesia may be required to allow proper
the extremities distal to the mid-antebrachium in treatment. Under aseptic conditions, the
the forelimb and distal to the hock in the hindlimb. bandage is removed and a swab is taken from
These splints are not suitable for immobilization of the wound for bacterial identification and
the proximal radius and ulna, the elbow joint, or the sensitivity testing. Both aerobic and anaerobic
talocrural joint. cultures are indicated28,29.
5. Broad-spectrum antimicrobial drugs are
INITIAL TREATMENT OF administered intravenously30. It is important to
FRACTURES begin antimicrobial therapy soon after the injury to
CLOSED FRACTURES reduce the likelihood of subsequent bone
Fractures proximal to the elbow and stifle joints are infections31. Intravenous administration of
typically not immobilized prior to definitive repair26. fluoroquinlones is contraindicated because they
Scapular, humeral, pelvic, and femoral fractures are may induce retinal degeneration and these drugs
generally closed because of the greater soft tissue should be used with caution in cats with impaired
coverage. The cat is simply confined (and sedated if renal function32. Several antibiotics are appropriate
necessary) to limit activity, reduce pain, and prevent for the initial treatment of open fractures, including
closed fractures from becoming open. If preoperative cephalosporins (cefazolin at 22 mg/kg IV every 8
immobilization of a proximal forelimb fracture is hours) and clindamycin (11 mg/kg IV every 12
required, a Spica splint may be used. Closed fractures hours)33,34. A combination of a cephalosporin and
distal to the elbow and stifle joints are placed in a an aminoglycoside may also be used to increase
Robert Jones bandage to reduce swelling and pain, efficacy against Gram-negative organisms35. The
minimize further soft tissue injury, and to prevent use of gentamicin (6.6 mg/kg IV or SC every
penetration of the skin by bone fragments24,27. A 24 hours) has been recommended36, but
splint may be incorporated into the bandage for aminoglycoside therapy should be used with
additional support if required. caution in traumatized cats to avoid renal
complications. In grade IIIb and IIIc fractures,
OPEN FRACTURES penicillins or metronidazole may also be given to
For information on the classification of open fractures improve efficacy against anaerobic organisms37.
see Chapter 4. Antibiotic therapy is continued for 3–5 days and
Early, aggressive treatment of open fractures altered, based on the results of sensitivity
is begun immediately to prevent contamination of testing30,31,38. In many cases, bacteria isolated from
the site becoming a deep infection of the bone open fractures are strains from the hospital where
and soft tissues. Cleaning and bandaging also the limb is being treated.
34

6. The wound is filled with sterile lubricating jelly and granulation tissue. A 1% or 0.1% povidone–iodine
the surrounding hair is shaved. The wound is solution (10% solution diluted 1:10 or 1:100 in
lavaged copiously to remove hair and debris; 1–2l saline) may also be used for wound lavage and has
of fluid are recommended for most wounds, broad-spectrum antimicrobial activity. Many cats
although more lavage may be necessary in severely have contact hypersensitivity to povidone–iodine
contaminated wounds. A pulse-jet lavage system and stronger solutions can interfere with wound
may be used if available. Alternatively, a lavage healing41. Tap water should not be used as a lavage
system comprised of a 1l bag of fluid, a sterile solution because its hypotonicity may cause
intravenous administration line, a sterile three-way additional cellular trauma37.
stopcock, and a 60 ml syringe attached to a 7. All debris and devitalized tissues are removed from
19 gauge needle can be used (14). By adjusting the the wound (taking care to avoid damaging vessels
stopcock, the lavage solution is drawn into the and nerves) with forceps, scissors, and the
syringe from the fluid bag and then injected mechanical action of the lavage solution42. Little
through the needle to lavage the wound. This debridement is usually necessary in grade I open
allows the clinician to maintain sterility, lavage the fractures; however, extensive debridement may be
wound with adequate pressure, and avoid excessive necessary in grade III open fractures. Where
force that can drive debris deeper into the wound37. possible, tissues that are grossly contaminated,
Sterile saline or lactated Ringer’s are most discolored, fail to bleed when cut, or are obviously
commonly used for wound lavage. The addition of dried or devitalized are removed. Fat and
antibiotics to the lavage solution is controversial and subcutaneous tissues are excised with minimal
probably provides negligible benefit39. However, consequence in most wounds. Excessive use of
the use of a 0.05% chlorhexidine solution has been electrocautery is avoided to minimize the amount
shown to reduce contamination and improve of devitalized tissue in the wound. Muscle is
wound healing40. It is prepared by adding 12ml of assessed by color, consistency, circulation, and
chlorhexidine solution (2%) to 500ml of sterile contractility to determine its viability43. If the
water, saline, or lactated Ringer’s37. A precipitate viability of a tissue is in question, it may be left in
will form when chlorhexidine is mixed with saline. situ and removed later if it becomes devitalized. In
More concentrated lavage solutions are avoided severely traumatized or contaminated wounds,
since they may damage tissues and inhibit progressive debridement over several days may be
required to achieve a clean wound. In gunshot
injuries, accessible bullet fragments are removed;
14 however, healthy tissue should not be traumatized
in an effort to remove deeper bullet fragments. The
decision to remove or leave cortical bone fragments
can be difficult. Fragments that are devoid of soft
tissue attachments and not essential to fixation of
the fracture are removed so that they do not
become sequestra. Articular fragments and those
essential to fracture stabilization may be left in
place and lavaged. The wound is lavaged again after
the debridement is completed.
8. The fracture is stabilized surgically as soon as
possible. Early stabilization preserves existing
blood supply, promotes ingrowth of new
vasculature, and helps prevent infection. In many
cases, the fracture is stabilized at the time of
14 Lavage system used for treatment of open wounds. The initial debridement44. If the fracture cannot be
system consists of a 1 l bag of lactated Ringer’s solution, a immediately stabilized, a dressing is applied to the
sterile IV administration line, a sterile three-way stopcock, wound and a sterile bandage is placed over it
and a sterile 60 ml syringe attached to a 19 gauge needle. until fixation can be performed. A splint may be
A 0.05% chlorhexidine solution may be used to reduce incorporated into the bandage to provide support
contamination and improve wound healing: 12 ml of and improve comfort. Wet-to-dry dressings
chlorhexidine solution (2%) is added to each 500 ml of changed daily can be used to aid in debridement
lactated Ringer’s solution. of the wound during bandaging.
Management of the orthopedic trauma patient
35

PRE- AND PERIOPERATIVE fractures47–51. The cat’s cardiovascular status should


ANALGESIA be carefully monitored when analgesics are used.
The assessment of pain in cats is notoriously difficult Preemptive analgesia is preferred to control pain in
because overt signs may be subtle. In one survey, only cats scheduled for surgery. It prevents so-called ‘wind-
one of 15 cats was given any analgesia after surgery45. up’, which is sensitization of the central nervous
Assessment of pain is best made subjectively, by a system from afferent nociceptive stimuli. If possible,
trained observer, on the basis of observation and balanced (multimodal) analgesia is used. This involves
interaction46. Cats that are in pain typically become the simultaneous administration of two or more
inactive, sit at the back of their cage, and avoid human analgesic techniques to achieve a synergistic effect,
interaction. They tend to resent or avoid handling and reduce drug dosages, and minimize complications49.
may show signs of aggression. Occasionally a cat will Many drugs can be administered systemically to
thrash around the cage violently, a reaction that is seen provide analgesia in cats, including opioid drugs,
more commonly in young animals. α2-adrenergic agonist drugs, and nonsteroidal
Analgesic drugs should be administered to antiinflammatory drugs (NSAIDs) (Table 8).
increase comfort and reduce stress in all cats with Multimodal analgesia is usually achieved by

TABLE 8 ANALGESICS.
Drug Dose (mg/kg) Routes Duration (hours) Comments
Buprenorphine 0.01–0.02 IV, IM, SC 4–8 For mild to moderate pain
Butorphanol 0.1–0.3 IV 0.5–1 For mild to moderate pain
0.1–0.6 IM, SC 2–3
Carprofen 2.0–4.0 IV, SC 24 Only one treatment,
for mild to moderate pain
Fentanyl 0.002–0.005 IV bolus <0.5 Short duration unless given as
constant infusion
0.002–0.004 kg/hour Constant rate During infusion For moderate to severe pain
infusion + 0.5
0.025 (25 µg) patch Transdermal 72 Not recommended for
cats <2.0 kg (<4.4 lb)
Hydromorphone 0.5–0.1 IV, IM, SC 2–4 For moderate to severe pain
Ketoprofen 1.0–2.0 IV, IM, SC 24 Maximum 3 days;
contraindicated with renal disease,
hypovolemia, coagulopathies.
For mild to moderate pain
1.0 PO once daily Maximum 5 days
Medetomidine 0.001–0.01 IV, IM, SC 0.5–2 Monitor for cardiac depression,
reversible
Meloxicam 0.3 SC 24 Only one treatment,
for mild to moderate pain
0.1 (1 drop/kg) for 5 days PO once daily 24 Liquid palatable
followed by 0.02–0.04
(1–2 drops/cat)
Morphine 0.1–0.3 IM, SC 3– 4 Moderate to severe pain
0.06–0.12 kg/hour Constant rate During
infusion infusion
Oxymorphone 0.02–0.05 IV 3– 4 For moderate to severe pain
0.05–0.1 IM, SC 2–6
Xylazine 0.1–1.0 IV, IM, SC 0.5–2 Monitor for cardiac depression,
reversible
36

the administration of an opioid and an NSAID, Epidural analgesia


although consideration should also be given to the use Epidural administration is usually reserved for cats
of local and epidural analgesia. that are already anesthetized in preparation for an
Opioids are suitable for moderate to severe orthopedic procedure. Epidural administration of
pain control. They have a rapid onset of action bupivacaine alone provides 4–6 hours of pain relief
and block central sensitization and autonomic (Table 9). A single epidural injection of preservative-
responses to surgery, but are short acting with the free morphine can provide effective analgesia for
exception of buprenorphine. Fractious cats may be procedures on the hindquarters for up to 24 hours.
given buprenorphine orally by squirting the injectable Bupivacaine may also be combined with morphine
solution into the mouth so that it is absorbed for epidural injections. A recent study compared
through the oral mucosa. NSAIDs are suitable for the analgesic effects of epidural morphine with a
mild to moderate pain control. They have a slower combination of morphine and bupivacaine in cats
onset of action than opioids, are long acting, reduce undergoing onychectomy52. The combination of
peripheral pain sensitization, and have long-lasting drugs allowed a significant reduction in the quantity
antiinflammatory effects at the surgery site. of inhalation agent required to maintain general
The drug gabapentin, originally licensed as an anesthesia compared with morphine alone and gave a
anticonvulsant, is clinically effective as a neuropathic longer duration of analgesia. The authors concluded
analgesic in humans. Based on anecdotal reports, the that preemptive epidural administration of morphine
drug shows promise in cats. The suggested dose is with or without bupivacaine provided better
2.5–5.0 mg/kg twice daily. control of postoperative pain than repeated
injections of oxymorphone and ketoprofen. The
REGIONAL ANALGESIA analgesic effects of epidural fentanyl and medeto-
Epidural and local administration of analgesic agents midine have also been described53. Oxymorphone is
can also be used to provide regional analgesia in cats. an opioid drug with similar properties to morphine
when used for epidural analgesia but with a shorter
Local infusion duration of action.
Local infusion of bupivacaine (1–2 mg/kg) at the The analgesic effects of drugs administered
surgery site can be used to provide 2– 4 hours of by epidural injection are both volume- and dose-
analgesia. The total dose of bupivacaine for a healthy dependent. A volume of 1 ml/5kg calculated on the
cat should not exceed 2 mg/kg (1.6 ml of a 0.5% basis of lean or ideal body weight will generally
solution for a 4 kg cat). provide analgesia to the level of the first lumbar

TABLE 9 DRUGS USED FOR EPIDURAL ANALGESIA.


Drug Dose (mg/kg) Dose (ml/kg)* Onset of analgesia Duration of
(minutes) analgesia (hours)
Bupivacaine (0.5%)+ 0.5–0.75 0.1–0.15 10–15 3–6
Morphine (10 mg/ml)+ 0.1–0.3 0.01–0.03 20–60 10–24
Morphine (10 mg/ml)+ 0.1 0.01 10–15 24
+Bupivacaine (0.5%)+ 0.1–0.2 0.02–0.04 - -
Oxymorphone (1 mg/ml) 0.05–0.1 0.05–0.1 20–40 7–10
Fentanyl (0.05 mg/ml) 0.004 0.08 5–30 2–5
Medetomidine (1 mg/ml) 0.01 0.01 5–10 1–8

* The drugs are diluted with normal saline to achieve a total volume of approximately 0.2ml/kg.
+ Preservative-free morphine and bupivacaine are preferred. For intrathecal injection it is essential to use
preservative-free bupivacaine without epinephrine.
Management of the orthopedic trauma patient
37

vertebra. The analgesic agent is diluted with normal the needle the injection can be made intrathecally but
saline to achieve the desired volume for injection. the calculated dose is reduced by 40–50%52. A
Contraindications to epidural analgesia number of methods have been described for
include thoracolumbar and lumbosacral fractures and confirming the location of the needle in the epidural
luxations. The reported incidence of complications space. The simplest method involves the injection of
after epidural administration of morphine in a series of 0.5 ml of air. If the needle is correctly located, the
dogs and cats was 0.75%54. injection will proceed with no resistance and no visible
For a more detailed description of the technique leakage of air into the subcutaneous tissues.
of epidural analgesia the reader is referred
elsewhere53,55,56. Generally a single injection is made Transdermal patches
with a 40 mm 22 gauge spinal needle between L7 and Transdermal fentanyl patches are suitable for use in
S1 (15). The cat is placed in lateral recumbency and cats over 2.0 kg body weight50,57–61. The application
the area is clipped and prepared. For unilateral of a 25 µg/hour patch provides relatively consistent
procedures the cat should be placed with the surgical analgesia for up to 72 hours after application. Plasma
site nearest the table. The injection is made in the concentrations reach effective levels 7 hours after
mid-line at the center of the lumbosacral depression. application61. To apply the patch, the skin over the
The dorsal spinal processes of L7 and S1 are palpated dorsal or lateral thorax is clipped and gently cleaned.
and the injection is made between these two points. Scrub solutions and alcohol are avoided. The patch is
The spine is flexed at the lumbosacral junction by handled by the edge or gloves are worn to avoid
drawing the hindlimbs cranially. The needle is contact with the membrane. The adhesive backing on
advanced perpendicular to the skin through the the patch is placed directly on the skin and held in
ligamentum flavum. If bone is encountered the needle place for 1–2 minutes. A bandage may be placed to
is withdrawn slightly and walked cranially or caudally cover the patch and prevent inadvertent removal;
along the bone as appropriate to find the space. Slight however, this is not always required. Transdermal
resistance is encountered as the ligamentum flavum is fentanyl patches can provide a steady-state opioid
penetrated and the needle is advanced a further concentration within the therapeutic range without
2 mm until there is loss of resistance. The stylet is the need for repeated injections or oral drug
removed and the needle hub is observed for blood or administration. However, fentanyl concentrations
cerebrospinal fluid (CSF). If blood is encountered, may vary significantly in individual patients and cats
the needle is removed and the procedure is repeated. should be monitored for signs of insufficient
It is not uncommon for the needle to enter the analgesia or adverse reactions, such as respiratory
subarachnoid space in the cat. If CSF flows from depression.

15

1/3

S2 S3
L4 L5 L6 L7 S1

15 Diagram showing the site for epidural injection. The dorsal spinous process of
the first sacral vetebra (S1) is more prominent in the cat than the dog. Using L7
and S1 dorsal spinal processes as palpable landmarks the injection site is
approximately in the caudal third.
38

PRE- AND PERIOPERATIVE with opioids given at the same dosages that
SEDATION are recommended for use with alpha 2 agonists.
Sedative drugs are usually administered as Ketamine, in combination with acepromazine and
premedication before general anesthesia (Table 10). diazepam or midazolam, provides effective sedation
Sedative drugs may be administered to stable cats that and low doses of this combination are suitable for very
are refractory to handling or intolerant of confinement ill cats. Inclusion of both the acepromazine and the
or bandages47,62. Sedation is often required during benzodiazepine components of the mixture
radiography and bandaging procedures. Acepromazine increases its efficacy with no increase in the adverse
alone is not very effective and combinations of drugs effects. Atropine (0.04 mg/kg) or glycopyrrolate
are usually preferred. Acepromazine combined with an (0.005–0.01mg/kg) may also be administered to
opioid will provide mild to moderate sedation and this control bradycardia during sedation.
combination is frequently used for premedication.
Alpha 2 agonists, such as medetomidine and xylazine, POSTOPERATIVE CARE
used alone have adverse effects on cardiopulmonary Postoperative management is an important
function and are only used for healthy patients. The component of treatment of the orthopedic trauma
addition of an opioid agent to the alpha 2 agonist may patient. Immediate concerns include monitoring and
reduce some of these adverse effects. Benzodiazepines, supporting respiratory and cardiovascular systems
such as diazepam or midazolam, given alone can during the anesthetic recovery period. Fatal
provide satisfactory sedation in cats that are very pulmonary fat embolism has been reported as
ill and these agents may also be used in combination a complication of fracture repair and may be a cause of

TABLE 10 SEDATIVES.
Drug Dose (mg/kg) Routes Duration (hours) Comments
Acepromazine 0.01–0.03 IV 1–2 Avoid if history of seizures
0.05–0.1 IM, SC 2–6
Acepromazine 0.05 Avoid if history of seizures
+Butorphanol or 0.1–0.3 IM 2–5
+Buprenorphine or 0.005–0.01 IM 4–8
+Morphine 0.1–0.2 IM, SC 2–6
Medetomidine 0.05–0.08 IV, IM, SC 0.5–2 Monitor for cardiac depression,
reversible with atipamezole
Medetomidine 0.025–0.05
+Butorphanol or 0.1–0.2 IV, IM 2–3
+Buprenorphine 0.005–0.02 IV, IM 2–4
Xylazine 0.1–1.0 IV, IM, SC 0.5–2
Xylazine 0.2
+Butorphanol or 0.1–0.2 IV, IM 1–3
+Buprenorphine 0.005–0.02 IV, IM
Ketamine 2.5 Profound sedation for 12–20
minutes
+Diazepam or midazolam 0.25 IV
Ketamine 2.5–7.5 Lower doses of acepromazine and
ketamine are used in ill cats
+Midazolam and 0.25
+Acepromazine 0.05–0.1 IM
Diazepam 0.1–0.5 IV 0.5–1
Management of the orthopedic trauma patient
39

unexplained chronic progressive postoperative are usually adequate. However, for longer procedures,
respiratory failure63. Cats lose body heat rapidly in or if contamination is present (or occurs during
comparison with dogs because of their high surface surgery), therapeutic administration of antibiotics may
area to volume ratio. Attention must be paid to be necessary after surgery. If possible, the choice of
thermoregulation, especially in cats that have received antibiotics is based on the results of culture and
sedative or anesthetic drugs. Analgesia is routinely sensitivity testing.
continued into the postoperative period to alleviate
pain and reduce stress. Other aspects of postoperative RESTRICTED ACTIVITY
management include radiography, antibiotic The cat’s activity is restricted while the fracture is
theapy, bandaging, nutritional support, and physical healing. Although early return to limb and joint
therapy64. The importance of good nursing care function is beneficial, excessive loads should be
should not be underestimated. avoided. Restriction is usually achieved by confining
the cat to a small room in the house, with good
RADIOGRAPHY footing, where it cannot run or jump. Confinement to
Radiographs are obtained immediately after surgery a small cage may be required in cases where stability at
to confirm reduction and implant positioning. the fracture site is suspect. Sedation is rarely needed to
Complications, such as the placement of implants limit activity in cats. Cats with external fixators are
in joints, severe malalignment, or evidence confined to ensure the fixator frame does not become
of inadequate stabilization may necessitate an caught on furniture, fences, or other objects in the
immediate return to the operating theater to correct environment.
the problem. If available, intraoperative radiographs
are extremely helpful to monitor implant placement PHYSICAL REHABILITATION
during the procedure. Follow-up radiographs are Postoperative physical rehabilitation is helpful to
obtained every 3–4 weeks until the fracture is healed, encourage early limb function and prevent muscle
to monitor healing, check for signs of infection, and contracture66. Rehabilitation can be difficult in some
observe for implant complications. Radiographs can cats because of their independent nature and
be obtained more frequently if complications reluctance to be handled during therapy67. The
develop and additional monitoring is indicated. procedures should be performed in a quiet room away
from loud noises and distractions. Cold compresses
ANALGESIA are applied to the limb 3–4 times a day (10–15
Analgesic drugs are administered during recovery minutes) for the first 24 hours after surgery. Warm
from anesthesia and the cat is carefully observed for compresses are then applied several times daily for the
signs of pain (see Table 8). Long-acting agents are next week. Limited exercise and passive joint motion
preferred for postoperative analgesia. For moderate to are introduced gradually as the patient becomes
severe pain control in the immediate postoperative more comfortable. Passive range-of-motion exercises
period a continuous intravenous infusion of an opioid (10 repetitions) can be performed several times daily,
or a transdermal fentanyl patch can be used. along with mild massage of the muscles of the affected
Analgesics are continued as necessary during fracture limb. Controlled activities and games may also be
healing, although many cats are quite comfortable used to encourage limb function. NSAIDs help
after a few days and medications can be reduced or reduce inflammation and pain and increase the cat’s
discontinued. NSAIDs should be used with caution in tolerance for physical therapy. Rehabilitation exercises
cats. Carprofen, ketoprofen, meloxicam, and should be performed carefully so as not to cause
tolfenamic acid have been shown to provide pain or disrupt the fixation. Aquatic therapy or
effective short-term analgesia when administered hydrotherapy can also be performed, using the same
perioperatively to cats65. selection criteria and protocols that are used in dogs,
but is not tolerated by all cats.
ANTIBIOTICS
Antibiotics are not administered routinely after closed POSTTRAUMATIC OSTEOMYELITIS
fracture repair or after open stabilization under aseptic Posttraumatic bacterial osteomyelitis is uncommon
conditions for procedures lasting less than 2 hours in cats and usually occurs after open reduction
(unless other factors dictate their use). The of fractures, treatment of open fractures, or bite
prophylactic antibiotics administered during surgery wounds. In comparison with dogs, local extension of
40

soft tissue wound infections involving the as expected after fracture repair may be an indication
distal extremities is a more frequent cause of of infection. A persistent fever may be present in
osteomyelitis. Staphylococcus sp., Streptococcus sp., some cats. With chronic infections, muscle atrophy
and Escherichia coli are common isolates from and muscle fibrosis may be observed. Eventually,
infected bones. Proteus sp., Klebsiella sp., draining tracts may develop in the skin over the
Pseudomonas sp., Pasteurella sp., and anaerobes, such infected bone.
as Actinomyces sp., Clostridium sp., Bacteroides sp., Radiographic signs of osteomyelitis depend on
and Fusobacterium sp., are frequently isolated the chronicity and severity of the infection (16).
from bone infections caused by bite wounds28,68. Radiographs obtained early in the disease process may
Multiple organisms may be present. Young male cats be inconclusive, as signs may be difficult to distinguish
are overrepresented, reflecting the disproportionate from the normal healing process. However, as the
incidence of fractures and bite wounds in this section infection progresses, loss of the normal trabecular
of the cat population. pattern, bone lysis, sclerosis, and a periosteal response
separate from the healing callus may be appreciated69.
DIAGNOSIS With the passage of time, coalescence of adjacent foci
The diagnosis of bacterial osteomyelitis is based on of lysis leads to larger irregular areas of bone loss.
clinical signs, characteristic radiographic findings, Bone resorption is most marked around implants and
culture of samples collected from the site by aspirate at the fracture site. Eventually, sequestration of bone
or biopsy, and, in some cases, blood culture. Clinical may occur. Sequestered bone maintains its increased
signs of osteomyelitis may include pain, swelling, density and sharp borders and thus appears denser
erythema, and poor limb function. Initially, these than the surrounding bone. A more radiolucent
signs may be difficult to distinguish from early region comprised of infected exudate usually
recovery from fracture repair or an incision surrounds the sequestrum. Surrounding this is the
complication, although an acute onset of more involucrum, comprised of new bone and fibrous tissue
severe lameness or failure of the patient to improve laid down as the body attempts to isolate the

16

A B C D E
16 Osteomyelitis of the long bones. A Lateral radiographic view of an ulna with osteomyelitis secondary to a bite wound.
Sclerosis and a bony sequestrum are visible. B Lateral radiographic view of a stifle joint with osteomyelitis affecting the tibial
tuberosity. C Lateral radiographic view of a humerus with osteomyelitis of the proximal metaphysis and diaphysis. Note
the bony sclerosis and periosteal proliferation. D Craniocaudal radiographic view of a humerus with pyogranulomatous
osteomyelitis. Note the bony lysis and loss of the normal trabecular pattern in the proximal humerus. E Lateral radiographic
view of a tibia, with osteomyelitis secondary to a bite wound. Lysis, periosteal reaction, and sclerosis are evident in the
diaphysis and distal metaphysis.
Management of the orthopedic trauma patient
41

infection. Unfortunately, radiography alone is neither adequate dosages, debridement and lavage of the
highly sensitive nor specific in the diagnosis of infected site (including removal of dead bone), and
osteomyelitis. Nuclear scintigraphy, although not rigid stabilization of the fracture (including the
specific, is very sensitive and can be helpful. placement of cancellous graft in bone deficits).
If infection is suspected, confirmation should
always be sought by culture of the wound. Culture Antimicrobial therapy
and sensitivity testing is performed on samples Systemic antibiotic therapy is indicated in all cats with
collected by deep aspirates of the infected site or bacterial osteomyelitis. The selection of drugs is based
biopsy samples of bone or periosteum collected on culture and sensitivity testing.
during surgical debridement. Aspiration of the site is • Gram-positive organisms cause the majority of
performed using a 20–21 gauge needle following infections and cefazolin or amoxicillin/clavulanate
aseptic surgical preparation of the skin. The sample is are often used pending sensitivity results.
placed in blood culture medium for culture and • Metronidazole or clindamycin may be administered
sensitivity testing. The efficacy of this technique is in cases where anaerobic infection is identified or
supported by a study in dogs in which its use resulted suspected. Long-term or high-dose therapy with
in bacterial growth in 86% of cases. The samples metronidazole should be restricted to refractory
should be examined for aerobic and anaerobic cases because of potential neurotoxicity70.
bacteria28,68,69. Cultures from draining tracts usually • Aminolgycoside or fluoroquinolone antibiotics
isolate contaminant or opportunistic bacteria and should only be used for refractory infections
provide little information about the organism caused by Gram-negative organisms, because of
affecting the bone. Blood cultures are rarely needed the potential for toxicity.
but can be helpful in identifying the pathologic • Fluoroquinolones are chondrotoxic in immature
organism in cats with osteomyelitis. cats and long-term administration should be
avoided in geriatric cats or cats with impaired renal
PREVENTION function because of potential retinal toxicity32.
Prevention of bacterial osteomyelitis is better than
cure and all bite wounds and abscesses should be Systemic antibiotic therapy is continued for 5–7 weeks
treated aggressively, especially in locations where there or until clinical and radiographic signs of active
is underlying bone. Further soft tissue trauma during infection have resolved. Rarely, the infected site is
fracture repair should be minimized by appropriate re-cultured after several weeks of treatment to identify
debridement and the use of an atraumatic surgical resistant organisms that may have developed
technique. The vascularity of bone fragments should during prolonged antibiotic therapy, particularly if
be preserved by avoidance of periosteal stripping and radiographic and clinical signs of infection are not
by leaving muscle attachments to bone fragments improving or worsen during the course of therapy. Cats
undisturbed. Intraoperative inoculation by bacteria should be monitored carefully for complications
occurs when there is a breach in aseptic surgical associated with long-term antibiotic treatment. In cases
technique. Prolonged operating time, associated with of severe chronic osteomyelitis, local antibiotic therapy
attempted anatomic reconstruction of comminuted may be used in conjunction with systemic treatment by
fractures, increases the extent of bacterial placing polymethylmethacrylate beads impregnated
contamination of wounds and also has a detrimental with gentamicin or tobramycin into the infected site37.
effect on the vitality of the soft tissues around the
fracture. Metallic implants and suture material Debridement and lavage
should be used judiciously where there is wound All necrotic tissues are surgically excised. In chronic
contamination or infection. External fixators are osteomyelitis, dead fragments of bone (sequestra) may
useful for the treatment of open fractures and shearing be present and are often surrounded by a pocket of
injuries, especially those distal to the elbow and stifle infected fluid and a layer of fibrous tissue and new
joints. Avascular bone fragments should be removed bone (involucrum). All sequestra are removed and the
unless they make a significant contribution to the involucrum is debrided to healthy, bleeding bone.
stability of the reconstructed fracture. Previously placed orthopedic implants that do not
contribute significantly to fracture stability are also
TREATMENT removed. Stable implants may be left in place until
Treatment of osteomyelitis requires long-term healing is complete. The wound is lavaged with sterile
systemic antibiotic therapy using appropriate drugs at saline or Ringer’s solution.
42

Fracture stabilization closure of the incision over a drain may be


Infected fractures will generally heal if they are stable preferred71. The orthopedic implants are removed
and have adequate blood supply. If the fracture has once the fracture is healed, since they may act as a
not been previously stabilized (or if previously placed nidus for infection, by harboring bacteria, and prevent
implants were removed during debridement), rigid complete resolution of the osteomyelitis. Culturing
fixation is applied. In most cases, an external fixator is from the implants at the time of removal may help
used since it can be applied with minimal disruption to determine whether there is a need for longer
the fracture site’s blood supply and the transfixation antimicrobial therapy.
pins are placed remote from the infected fracture site.
Plates are occasionally used because they provide rigid PROGNOSIS
fixation for the long period of time required for The prognosis for osteomyelitis is variable depending
infected bone to heal. However, the extensive soft on the stage and extent of the infection. Low-grade
tissue dissection required to position the plate osteomyelitis may be resolved with appropriate
properly can be a disadvantage when stabilizing antibiotic therapy and delayed removal of implants.
infected fractures. Intramedullary pins and cerclage More severe and extensive infection carries a much
wires are not recommended for stabilizing infected more guarded prognosis and may require prolonged
fractures. and expensive treatment with an uncertain outcome.
Once the fracture is stabilized, cancellous bone Such cases may require multiple surgical procedures for
graft is placed in all bone defects. Alternatively, removal of sequestra, fracture stabilization, cancellous
grafting can be delayed until the initial inflammation bone grafting, and eventual removal of all metallic
and suppuration is resolved71. The wound or incision implants. Even if the infection can be resolved, the
made to place implants can be closed primarily (after legacy of infection and chronic disuse may be poor
thorough debridement and lavage) in most cases. In limb function associated with muscle atrophy and
more severe cases, open wound management or fibrosis, soft tissue adhesions, and joint stiffness.
43

CHAPTER 4
FRACTURE CLASSIFICATION,
DECISION MAKING, AND
BONE HEALING
FRACTURE CLASSIFICATION examples of fractures often caused by indirect trauma.
Numerous systems have been devised to classify Fractures caused by repeated low-grade trauma (stress
fractures, including cause, anatomic location, severity, fractures) are uncommon in cats.
fracture configuration, and contamination1. In most
cases, more than one classification system is used to Pathologic
describe fully a given fracture. Accurate and complete Pathologic fractures occur when a disease process
description of a fracture provides useful information weakens the bone. Causes may include neoplasia,
when selecting repair options and facilitates infection, and nutritional or metabolic bone diseases.
communication among clinicians.
ANATOMIC LOCATION
CAUSE The location of a fracture in a long bone may be
Traumatic (direct or indirect) described as diaphyseal, metaphyseal, or epiphyseal.
Direct trauma to a bone is the most common cause of Other anatomic nomenclature is often used to describe
fractures and frequently occurs when the cat is hit by specific fractures more completely, including terms
an automobile or falls from a significant height. such as condylar, supracondylar, subtrochanteric, and
Indirect trauma to bone may lead to fractures by articular.
transmitting force through bones or surrounding Physeal fractures involve the growth plate in
muscles, tendons, and ligaments. Femoral neck immature animals and are described using the
fractures and avulsion fractures of the calcaneus are Salter–Harris classification system (17)2.

17

A B C D E

17 Salter–Harris classification of growth plate injuries.


A Type I involves the growth plate only.
B Type II involves the growth plate and the metaphysis.
C Type III involves the growth plate and the epiphysis.
D Type IV involves the growth plate, metaphysis, and epiphysis.
E Type V is a compression injury of the growth plate.
44

SEVERITY OF FRACTURE FRACTURE CONFIGURATION


Incomplete Transverse
The fracture involves only one cortex of the bone The length of the fracture line is approximately equal
and displacement is minimal (e.g. fissure fractures that to the diameter of the bone (19A).
disrupt a single cortex and often course longitudinally
in a bone) (18A). Short oblique
The length of the fracture line is less than two times
Complete the diameter of the bone (19B).
The fracture disrupts the entire circumference of
the bone and may lead to significant displacement Long oblique
(18B). Displacement of a fracture is described based The length of the fracture line is greater than two
on how the distal fragment moves relative to the times the diameter of the bone (19C).
proximal fragment.
Spiral
Comminuted This is a long oblique fracture in which the fracture
Multiple fragments are present (18C). Comminuted line curves around the diaphysis (19D).
fractures can be further characterized by the number
of fragments and whether or not reduction of Impacted
the fracture results in contact between the primary The fracture fragments are compressed together.
proximal and distal ends of the bone.
Avulsion
Segmental The origin or insertion site of a tendon or ligament is
There are two or more separate fractures in the bone pulled from its parent bone (19E). The greater
and the fractures lines do not connect (18D). trochanter, tibial tuberosity, calcaneus, and olecranon
are sites where avulsion fractures occur in cats.

CONTAMINATION
Closed fracture
No communication exists between the exterior and
18 the fracture site. The skin is intact, although
contusion may be present.

Open fracture
A communication exists between the exterior and the
fracture site3.
• Type I: a small puncture (<1 cm) is present in the
skin. The puncture occurs from the inside when
a fragment of bone briefly penetrates the skin.
• Type II: a wound (>1 cm) is present and
communicates with the fracture site. The wound
is a result of external trauma. Contusion of the
surrounding soft tissues is common.
• Type III: an extensive wound is present and is
caused by high-energy external trauma. Soft
tissues surrounding the fracture site are severely
damaged or absent.
• Type IIIa: significant soft tissue injury is
present, but adequate tissue remains to allow
A B C D closure of the wound.
• Type IIIb: extensive soft tissue injury with
18 Fracture classification based on the severity of bone insufficient skin and soft tissue remaining to
disruption. A Incomplete. B Complete. C Comminuted. allow primary wound closure (i.e. degloving
D Segmental. injuries).
Fracture classification, decision making, and bone healing
45

• Type IIIc: extensive soft tissue injury with FRACTURE DECISION MAKING
compromised vascular supply to the distal Fractures are diagnosed based on the cat’s history,
extremity. Loss of the limb may occur physical examination findings, and radiographs of the
without immediate intervention. affected limb. In many cases, fracture stabilization is
delayed to allow treatment of trauma-related injuries,
AO VET FRACTURE CLASSIFICATION SYSTEM such as shock, hypothermia, cachexia, external
The AO Vet has adopted a numerical fracture wounds or hemorrhage, thoracic injuries, abdominal
classification system modeled after the one used by injuries, neurologic injuries, and concurrent ortho-
the AO/ASIF for computerized documentation of pedic injuries5,6 (see Chapter 3).
human fractures4. The long bones are referred to by Two orthogonal radiographic views of the
number: fractured limb are obtained to document the type and
• Humerus = 1. location of the fracture and gather information on
• Radius/ulna = 2. feasible repair options. Sedation or short-duration
• Femur = 3. general anesthesia may be required to obtain
• Tibia/fibula = 4. radiographs without causing pain. If necessary,
radiography should be delayed until the cat is stable.
The fracture location is also referred to by number: In some instances, a single radiographic view of the
• Proximal = 1. fracture site can be obtained without sedation and can
• Shaft = 2. be used to confirm the fracture location, help
• Distal = 3. determine appropriate repair options, and provide the
owner with an estimated cost for treatment. The
Fracture severity is classified as follows: second view is then obtained prior to treatment.
• A = simple. Oblique views are occasionally helpful to identify the
• B = wedges. presence of articular fractures or to further delineate
• C = complex fracture configuration.
• Each further graded from 1–3 based on the Fractures occur when intrinsic or extrinsic forces
degree of fragmentation. are applied that exceed the material and structural
properties of the bone. The configuration of the
This classification system is used in some veterinary fracture depends on the magnitude, speed, and
literature to classify fractures and in reported data on direction of the force applied7,8. The bone’s inherent
fracture treatment methods. strength and any loads applied to the bone at the time

19 Common fracture configurations. 19


A Transverse.
B short oblique.
C Long oblique.
D Spiral.
E Avulsion.

A B C D E
46

of injury also influence the fracture configuration. methods8,9. Each repair method chosen must provide
Compressive, tensile, bending, torsional, and shear adequate stabilization while preserving blood supply
forces may act alone or in combination to disrupt the and soft tissue attachments to the bone. When selecting
support function of the bone (i.e. cause fracturing), the most appropriate repair method for a given fracture,
and may cause instability once the fracture is the surgeon must understand the ability of each
repaired (20)7,8. available fixation technique to neutralize disruptive
Successful fracture repair requires knowledge forces (Table 11). Bone plates, external fixators, and
of regional anatomy (including blood supply), an interlocking nails can counteract all disruptive forces
understanding of basic bone healing physiology, when properly applied. Intramedullary pins do not
information on the fracture type and the forces acting adequately control rotational forces when used alone,
at the fracture site, and familiarization with the so cerclage wires or an external fixator should be added
advantages and limitations of all available repair to provide adequate stabilization. External coaptation

20 20 Forces acting on bone.


A Compression (collapse
and overriding).
B Tension(distraction).
C Bending (angulation).
D Torsion (rotation).
E Shear (collapse and
overriding).

A B C D E

TABLE 11 FRACTURE REPAIR METHODS AND CONTROL OF DISRUPTIVE FORCES.


Disruptive forces acting on the fracture site
Fixation method Bending Shear Torsion Compression Tension
External coaptation (casts/splints) + – +/– – –
Single intramedullary pin + +/– – – –
Multiple intramedullary pins (stacked pins) + +/– +/– – –
Full cerclage wire alone – + + – –
Hemicerclage wire alone – + + – +/–
External fixators (linear and circular) + + + + +
Bone plates + + + + +
Lag screws alone – – – – –
Plate rod fixation + + + + +
Interlocking nail + + + + +
+ = good control of the disruptive force; +/– = partial control; – = poor control
Fracture classification, decision making, and bone healing
47

devices may reduce forces applied to the fracture site FRACTURE HEALING
(depending on the fracture location and configuration), Bone healing is affected by mechanical factors
but may not completely neutralize disruptive forces9. In (reduction, stability) and biological factors (blood
comminuted fractures, disruptive forces acting at supply, fracture location, soft tissue injury)10,11. Bone
the fracture site may be quite large, particularly healing can be classified into a number of types.
if weight-bearing load is not shared between the bone
and the implants after fracture reduction. Fracture INDIRECT BONE HEALING
configuration, available implants and equipment, Indirect healing (secondary healing or classical healing)
surgeon preference and experience, expense, and owner of cortical bone is by callus formation and occurs when
compliance with postoperative care procedures are also small gaps or instability exist at the fracture site (21).
considered when selecting an appropriate repair The bridging callus exists as medullary callus,
method. intercortical callus, and periosteal callus. Typically,

21

Hematoma

Granulation Connective
tissue tissue

A B C

Fibrocartilage
Haversian
remodeling

Woven
Cancellous bone
bone

D E F

21 Indirect bone healing. Fracture healing occurs by progressive bridging of the fracture gap by more strain-tolerant tissues.
A Hematoma. B Granulation tissue. C Connective fibrous tissue. D Fibrocartilage, which mineralizes to form cancellous
bone. E Woven bone. F Cortical bone forms by Haversian remodeling and the callus is eliminated.
48

indirect bone healing occurs when fractures are prevent motion and high strain levels that may prevent
immobilized by external coaptation. bone formation in the gap. Excessive strain can lead to
The fracture gap is first filled with a hematoma. tissue rupture and delayed healing. When larger gaps
Pluripotential mesenchymal cells in the region then are present between fragments, strain is distributed
proliferate to form a ‘fracture callus’, comprised over a larger area, thus reducing the strain on
sequentially of granulation tissue, fibrous connective individual cells. If rigid fixation is impossible due to
tissue, cartilage, mineralized cartilage, woven bone, the fracture configuration, a bigger fracture gap is
lamellar bone, and, finally, cortical bone. This process preferred to distribute strain over a larger area and
is regulated by the amount of interfragmentary strain reduce strain on each cell within the gap. The
placed on tissues in the fracture gap and by numerous resorption of fragment ends that occurs in fractures
cellular mediators, chemoattractants, and growth that are reduced, but not completely stable, has the
factors12,13. Repair tissues within the fracture gap are effect of reducing interfragmentary strain. As the
subjected to interfragmentary strain when motion callus matures, there is gradual replacement of each
occurs at the fracture site13. Strain is defined as the tissue type by progressively stiffer and stronger tissue
ratio between the change in gap width to the total gap until bony union is completed. In unstable fractures, a
width during this motion. Various tissue types can large callus forms to provide early stability to the
withstand differing levels of strain: fibrous tissue fracture site. The potential drawback of indirect bone
tolerates up to 20% strain, cartilage tolerates up to healing is the slow return to function that may be
10% strain, and bone tolerates up to 2% strain7,11. associated with instability of the fragments during the
Thus, the level of interfragmentary strain determines healing process; this predisposes to the development
the tissue types that may form within the gap. Strain- of fracture disease (muscle atrophy, joint stiffness,
tolerant tissues, like granulation tissue and fibrous disuse osteopenia, soft tissue adhesions).
tissue, will survive in a gap under conditions of high
strain, while bone will not. Thus, strain-tolerant DIRECT BONE HEALING
tissues initially form in fracture gaps where motion Direct healing (primary healing) of cortical bone
exists and strain is high. As interfragmentary strain is occurs when bone ends are in contact (<0.1 mm gap)
reduced by increasing callus size or strength (or by and under compression, as may be achieved with bone
fracture fixation), less strain-tolerant tissues, like plating (22). Internal remodeling of the Haversian
cartilage and bone, begin to form. systems unites the apposed cortical ends (rather than
Clinically, when a fracture is well reduced (small callus formation). Metaphyseal fractures involving
gap), it is essential to provide rigid stabilization to cancellous bone heal by increased osteoblastic activity

22

<0.1mm gap <1.0 mm gap

A B

22 Direct bone healing.


A Contact healing occurs when the bone ends are compressed together and rigidly fixed (<0.1 mm gap). Healing occurs
by Haversian remodeling.
B Gap healing occurs when the bone ends are apposed with a <1.0 mm gap. The gap fills with lamellar bone oriented
perpendicular to the longitudinal axis, which then undergoes Haversian remodeling to restore normal bone architecture.
Fracture classification, decision making, and bone healing
49

and the deposition of new bone on existing bony 23


trabeculae. Gap healing is a type of direct healing
that occurs under similar prerequisite conditions to
contact healing but where the fractured bone
fragments are separated (<1.0 mm gap). The gaps are
filled with lamellar bone oriented perpendicular to the
longitudinal axis, which is then integrated into the
normal architecture of the bone during the process of
remodeling.
Although direct bone union was once considered
to be the ultimate goal of fracture repair, it is now
recognized that it is not a panacea. There are, in
fact, a number of disadvantages associated with this
approach. Rigid stabilization and compression of
fractures requires an invasive surgical procedure for
the application of a plate, with a consequent
disruption of the blood supply and soft tissue
envelope. Bone strength is regained very slowly with
direct healing, so implants need to be left in place for
a long time and the rigid stability they provide may
protect the bone from stress and lead to osteopenia. 23 Craniocaudal radiograph of a
The main advantage lies in an earlier return to tibial fracture stabilized with an
function since the bone fragments are stable in external fixator to achieve biological
compression. The limb can therefore be loaded while fixation and bridging osteosynthesis.
the bone is healing, thus fracture disease is avoided.
Direct bone healing should be the goal when dealing disturbance to the fracture hematoma, the soft tissue
with intraarticular fractures and simple transverse envelope, and the blood supply to the bone. Thus
fractures of long bones where compression can be interfragmentary strain is reduced and the fracture is
achieved readily by means of a plate. encouraged to heal in an environment of relative
stability where there is sufficient micromotion to
BRIDGING OSTEOSYNTHESIS stimulate bone callus formation.
The concept of bridging osteosynthesis has arisen in Stability can be achieved by application of an
an attempt to harness the rapid bone healing that external fixator in a closed fashion or by using a
occurs with indirect bone healing whilst reducing the minimally invasive (or biological) ‘open but do not
risk of fracture disease (23)14. Bridging osteosynthesis touch’ approach in which the fracture site is inspected
is most applicable to comminuted mid-diaphyseal for reduction of the main fragments without
long bone fractures where there are multiple small interfering with the intermediate fragments. A plate
fragments that are not amenable to reconstruction. (with or without an intramedullary pin) or an
The two ends of a fractured bone are immobilized in interlocking nail can also be applied using the same
their correct anatomic positions relative to one principles. Plates specifically designed for this purpose
another, without stabilization of the intervening generally have a central solid section to avoid placing
fragments. Implants are applied with minimal empty screw holes over the fracture site.
50

CHAPTER 5
INSTRUMENTS AND
IMPLANTS

The armamentarium of the feline orthopedic surgeon in the standard instrument pack for fracture
must include a range of instruments and implants that repair and joint surgery including retractors,
have been designed to be suitable for use on the bones rongeurs, bone-cutting forceps, bone-holding
of the cat. Injuries to the distal extremities, in forceps, Hohmann retractors, and periosteal
particular, pose a challenge owing to the small size of elevators. A minimum of two pairs of small self-
the bones, which may compromise both implant retaining Gelpi retractors is invaluable in the surgical
application and implant security. It is essential that a approaches to most bones and joints. Small, serrated
range of the correct sizes and types of implants is bone-holding forceps, small pointed fragment or
available if adequate implant security is to be achieved, reduction forceps, and mini Kern bone-holding
whilst minimizing the risk of iatrogenic fracture. forceps are ideal for the manipulation of feline long
bones and small bone fragments. In addition,
INSTRUMENTS instrument sets are required for the application of
Fracture repair requires the correct instrumentation to intramedullary pins, cerclage wire, 2.7 mm, 2.0 mm,
approach and surgically expose fractured bone. In and 1.5 mm plates and screws, external fixators, and
addition, various instruments are required to achieve interlocking nails, if available.
and maintain fracture reduction before implants can A power drill is needed to drill a hole in the
be applied. cortical bone to allow screw insertion. Air-powered,
Cat bone cortices are relatively thin and can easily electrical, and battery-powered drills are available.
be fractured or fissured when being manipulated1. The drill must be properly sterilized using steam or
Bone holding forceps should be the correct size and gas, or it may be placed into a sterile shroud to
must be designed to be able to grip without crushing prevent contamination of the surgical site. Drill bits,
(24, 25). Similarly, bone-cutting instruments should drill guides, cortical taps, a measuring device to
be sharp to avoid inadvertent crushing of bone. Many determine the appropriate screw length, instruments
of the instruments designed specifically for dogs or to contour the plate to the bone surface, and a screw
adapted from human surgery are too large and driver are also required. Many of these instruments are
cumbersome and are unsuitable. specific for the size of screw and plate being used.
A range of small instruments should be included

24 25 24 Very small fragment (reduction)


forceps with step down tips
(Veterinary Instrumentation). The
forceps are used to hold small bone
fragments in position while the
permanent fixation is being applied.
25 Small serrated bone holding
forceps (Veterinary Instrumentation).
The tips are sharp and may be used as
small fragment forceps.
Instruments and implants
51

IMPLANTS longitudinal fins to increase rotational stability


A variety of implants is available for use in cats. (Rotec Medizintechnik) (26). The smaller diameter
Implants are commonly made of stainless steel or nails (3 mm, 4 mm, and 5 mm outer diameter) are
titanium. Details of those that are appropriate are suitable for repair of diaphyseal and metaphyseal
given below. A more detailed description of their use fractures of the humerus, femur, and tibia. The
is given in Chapter 6. results of fracture repair using the technique has
been described in a large series of cases, which
INTRAMEDULLARY PINS included 62 cats2.
Intramedullary or Steinmann pins are available from
various manufacturers and are usually 300 mm in KIRSCHNER WIRES, ARTHRODESIS WIRES, AND
length. Pin diameters from 1.6 mm, up to a maximum SMALL FRAGMENT PINS
of 4.8 mm, are suitable for fracture repair in cats. Pins Kirschner wires and arthrodesis wires are like small,
with a smooth shaft and a trocar point at each end are flexible intramedullary pins. They are 120 mm long
preferred. and are available in 0.9 mm, 1.1 mm, 1.4 mm,
1.6 mm, and 2.0 mm diameter. Kirschner wires have
TRILAM NAIL a bayonet point at one end and a trocar point at the
The Trilam nail is a new type of intramedullary pin other, whereas arthrodesis wires have a trocar point
that has been modified by the addition of three at each end. Threaded small fragment pins are
2.0 mm in diameter and have a threaded portion
ranging from 5–20 mm in length (Veterinary
Instrumentation). A small fragment pin washer is
26 available, which can be used to give the pin a screw-
like function.

ORTHOPEDIC WIRE
Orthopedic wire is available as a spool or with a
preformed loop at one end in a wide range of
diameters. Wire is used for cerclage and
hemicerclage, for interfragmentary fixation, and as a
tension band. The ideal size wire for most
applications in the cat is 0.8 mm (20 American wire
gauge [AWG]) but a range of diameters between
0.5 mm and 1.0 mm (24–18 AWG) should be
available. Gauge sizes are not universal since there
are two different systems of measurement in
common usage (Table 12).
26 Trilam nail. Instruments and implants set (Rotec
Medizintechnik).

TABLE 12 THE DIAMETER AND RESPECTIVE STRENGTHS OF WIRE USED IN CATS.


Diameter (mm) Gauge AWG Gauge SWG Relative tensile strength*
1.0 18 19 1.0
0.8 20 21 0.64
0.6 22 23 0.36
0.5 24 25 0.25

AWG = American wire gauge


SWG = Imperial standard wire gauge
* The tensile strengths are given in a ratio that compares the other sizes to 1.0 mm diameter wire.
52

BONE PLATES buttress fashion by using the drill guide with the
Plates that are suitable for use in the cat include round arrow pointing away from the fracture line. When
hole and dynamic compression plates (DCPs), which using DCPs in buttress fashion, plate holes
are available to accommodate 2.7 mm, 2.0 mm, and positioned over the fracture gap must be left empty
1.5 mm screw sizes (27). The Mini Bone Plating Set and plate failure can occur at the empty holes.
and Small Bone Plating Set (Veterinary Orthopedic A graft is placed in the defect to speed healing and
Implants Inc.) provide plates that take screws ranging the cat’s activity is restricted to prevent premature
from 1.5–3.5 mm and includes small DCPs and failure through empty screw holes.
cuttable plates. The Mini Fragment Instrument and A 1.5 mm/2.0 mm hybrid DCP has recently
Titanium Implant Set (Synthes) includes 1.5 mm, 2.0 been introduced for performing carpal arthrodesis
mm, and 2.7 mm straight and T plates. Lengthening (Veterinary Instrumentation). The plate allows for the
(Synthes) and biological healing plates (Veterinary placement of 2.0 mm screws in the radius and 1.5 mm
Instrumentation) are produced in 2.0mm and 2.7mm screws in the metacarpal bone, and it is also narrower
versions, and 1.5 mm and 2.0 mm mini plates are and thinner distally.
available, in a variety of shapes, including T, L, and
acetabular. Biological healing and lengthening plates Reconstruction plates
have a central solid section to avoid placing empty Reconstruction plates have small notches on each
screw holes over the fracture site; these are available in side of the plate between the oval screw holes (29).
4 sizes that are suitable for cats (2.0 mm/8 hole and They are available for use with 2.7 mm screws and are
2.7 mm/6, 7, 8 hole (Veterinary Instrumentation) quite easily contoured to fit the bone surface. They
(28). These plates can be used for nonreconstructable are most commonly used for stabilization of pelvic
mid-shaft long bone fractures. For certain fractures.
metaphyseal fractures it may only be possible to
achieve stable fixation with a plate by customizing the
plate. Conversion of the veterinary cuttable plate
(VCP) into a hook plate for use in cats has been 27
described3. Human maxillofacial mini plates have
been used to stabilize fractures of small bones in cats4.
Similarly bone plates may be applied to very small
bones using the human Modular Hand System
(Synthes). These plates are available as DCPs (straight
and T plates) in 1.0 mm, 1.3 mm, 1.5 mm, 2.0 mm,
and 2.4 mm sizes5. Limited-contact dynamic
compression plates (LC-DCPs) that accommodate
2.4 mm screws are also available and are useful for
repair of long bone fractures (Synthes).

Dynamic compression plates 27 Bone plates commonly used in cats: 2.7 mm DCP,
DCPs accommodating 1.5 mm screws (Veterinary mini-dynamic compression plate, T plates, L plates,
Orthopedic Implants Inc.) and 2.0 mm and 2.7 mm tubular plate, acetabular plate.
bone screws (Synthes) are often used in feline long
bone fractures. They are available in various lengths
and may be applied in neutralization, buttress, or
compression function. To create compression, the 28
plate screw is placed eccentrically in the oval screw
hole, causing the plate to slide as the screw is
tightened. When DCPs are used in buttress function
to span defects in the bone, a drill sleeve is used
(rather than the DCP drill guide) to position the
hole near the steep wall of the plate hole (as opposed
to the neutral or compression position). This rigidly 28 A 2.0 mm biological healing plate (Veterinary
fixes the plate and screw to minimize collapse of the Instrumentation) used to repair a simulated femoral
fracture gap. LC-DCPs may also be applied in fracture.
Instruments and implants
53

Tubular plates Veterinary cuttable plates (VCPs)


One-third tubular plates with 2.7 mm bone screws VCPs are a unique and versatile specialty plate
are useful in the repair of many cat long bone indicated for repair of long bone fractures in
fractures1. Tubular plates are relatively thin, which cats7–9. They are available in numerous different
facilitates closure of the soft tissues over the plate, sizes, can be custom cut to the appropriate length
particularly when the plate is placed on the distal at the surgery table, and accommodate either
extremities. However, they have relatively high 2.7/2.0 mm screws or 2.0/1.5 mm screws (30)
torsional and bending strengths because of their
partial tubular shape. They can be flattened
somewhat, if necessary, to conform to the bone
surface; however, the partial tubular shape should be
preserved over the fracture site, to maintain
mechanical strength. The screw holes in the plate are
further apart than in most other bone plates, so they
can be used to span defects without placing empty
screw holes over the fracture site.
29
Mini plates
Mini plates are designed for use with 1.5 mm and
2.0 mm cortical screws6. Several types of mini plates
are available, including mini DCPs, round-hole plates
of various lengths, T plates, L plates (angled mini
plates), acetabular plates, and cuttable T plates
(Veterinary Orthopedic Implants Inc.; Synthes). The 29 A 2.7 mm reconstruction plate.
mini T plates and L plates are designed for use in
metaphyseal fractures of cats where only a small
epiphyseal fragment is present. The use of these plates
allows the surgeon to place two screws into very small 30
bone fragments. Specialized handles are used to hold
the smaller drill bits, taps, and screwdriver used to
insert the 1.5 mm and 2.0 mm screws. The specialized
screwdriver has a +-shaped tip. Care is taken while
drilling, tapping, and inserting these small screws to
prevent stripping (in most cases, the holes are drilled
and tapped by hand rather than with power tools).
Traditional and self-tapping screws are available in
both titanium and stainless steel.

AO/ASIF maxillofacial mini plates


Maxillofacial mini plates (Synthes) are specially A
designed, very small titanium plates available in a
variety of shapes and lengths. The plates are only
0.7 mm thick. Screws used with this system have a
thread diameter of only 1 mm (core diameter
0.7 mm) and are self-tapping. These plates are too
small for long bone fixation, but they have been used
successfully to stabilize mandible and metatarsal
fractures in cats4. B
30 Veterinary cuttable plates (Synthes).
A Large cuttable plate (top) that accommodates 2.7 mm
or 2.0 mm screws and small cuttable plate (bottom) that
accommodates 2.0 mm or 1.5 mm screws.
B Two cuttable plates stacked to increase stiffness.
54

(Table 13). The versatility of VCPs provides several or longer plate is placed on the bone and the shorter or
advantages when repairing fractures in cats. While thinner plate is stacked on top. This method gradually
other small bone plates accepting 1.5 mm or 2.0 mm transmits load from the implants to the bone at the
screws are often too short or too weak to stabilize plate ends. The cuttable malleable plate is a notched
long bone fractures, the VCP can be custom cut to version of the VCP that is similar to the reconstruction
achieve the proper plate length. Regular bone plates plate (Veterinary Instrumentation). This plate can be
accepting 2.7 mm screws are often too thick or readily contoured to irregularly shaped bones in the cat.
require too large a screw hole for repair of small bone
fragments; the VCP accepts various screw sizes. BONE SCREWS
Additionally, the VCP has more screw holes per unit Bone screws are made of stainless steel or titanium and
length of plate, allowing the placement of more consist of a head, a shank, and the threads. Nonself-
screws in a small bone fragment than would be tapping screws, 1.5 mm, 2.0 mm, 2.4 mm, and 2.7 mm
possible with a 2.7 mm plate. diameter, are most often used in cats and they are
Another advantage of VCPs is that they can available in many lengths. Screws with self-tapping flutes
be ‘stacked’ to achieve a variety of thicknesses have recently become available for use with the same
(1.0–3.0 mm for Synthes plates) and strengths (30). instrumentation as the nonself-tapping screws. The use
This is particularly important when VCPs are used in of self-tapping screws is likely to become commonplace
buttress fashion9. Mechanical testing of individual in the future.
and stacked cuttable plates found them to be more Cortical screws are designed to maximize holding
resistant to bending than mini plates and 2.0 mm in rigid cortical bone and have a thick shaft with many
DCPs, although they are still weaker than 2.7 mm small threads per unit length. Cancellous screws have a
plates10. When the plates are stacked, they should be wider thread pitch and provide holding power in
contoured simultaneously to ensure the holes remain trabecular bone. The appropriate screw size is selected
aligned. The smaller plate then dictates the proper based on the plate being applied and the size of the
screw size. Stacking plates of different lengths can also bone. Screws are usually inserted by first drilling a hole
be used to alter the rigidity of the fixation. The thicker in the bone the same size as the shank of the screw.

TABLE 13 CUTTABLE PLATES FOR USE IN CATS.


Plate type Plate width Plate thickness Screws accepted Initial plate length
(mm) (mm) (mm) (number of holes)
Synthes
7.0 1.0 1.5/2.0 50
7.0 1.5 2.0/2.7 50
Veterinary Orthopedic Implants Inc.
3.8 0.8/1.0 1.5 20
5.0 1.0 2.0 20
5.0 1.5 1.5/2.0 25
6.5 1.8 2.0/2.7 25/40
7.0 1.0 1.5/2.0 50
7.0 1.5 2.0/2.7 50
Veterinary Instrumentation
5.0 1.4 1.5/2.0 30
6.0 2.0 2.0/2.7 24
Securos Veterinary Orthopedics
5.0 1.2 1.5/2.0 20
5.0 1.2 2.0/2.7 20
Instruments and implants
55

The depth of the hole is measured to determine the is protected within the medullary cavity. Positive
proper screw length. A tap is then passed through profile pins are those in which the threads are added
the drill hole to cut threads into the bone matching the to the shank, thus increasing the diameter of the
threads on the screw. The correct diameter drill pin. Positive profile pins have significantly greater
bit and tap are used to ensure the screw is tight holding power in bone and their use can help
(Tables 14, 15). The screw is then inserted and tight- prevent premature pin loosening11,13,14.
ened with the screwdriver. Self-tapping screws cut The size of pin most suitable for the cat has
threads in the bone as they are inserted and do not a shank diameter of 2.0 mm with a thread profile
require the hole to be pretapped. designed for cortical bone. These pins are used with
the mini (IMEX Veterinary Inc.) or small (Securos
EXTERNAL SKELETAL FIXATORS Veterinary Orthopedics and Kirschner–Ehmer) fixa-
Transfixation pins penetrate the bone, stabilize tor system. Because of their larger diameter, the use
fragments, and attach to the external frame of these positive profile pins is sometimes limited to
(connecting bars). The diameter of transfixation pins the metaphyseal regions of the long bones in adult
used for linear external skeletal fixation is limited by cats16–18. For kittens and for the small bones of the
the small size of the bones. It is generally accepted
that there is a risk of iatrogenic fracture if the diameter
of the pin exceeds 25–30% of the diameter of the
bone. Small diameter pins reduce the risk of iatrogenic
fracture but there is a trade off in terms of reduced 31
frame strength. Pins 1.2–2.0 mm in diameter are most
often used in cats. Smooth pins, end-threaded pins,
and centrally threaded pins are available (31).
Threaded pins may have either a negative or
a positive (enhanced) profile11–15. Negative profile
pins are those in which the threads are cut into the
pin surface. The junction between the smooth and
threaded portions of pin is a weak area susceptible
to breaking. Ellis pins have a negative profile thread 31 Transfixation pins used for external fixation: (from top
at the tip of the pin. This tip is inserted into the to bottom) acrylic half pins, negative profile end-threaded
transcortex (second cortex) such that the junction pin (Ellis pin), positive profile centrally-threaded pin,
between the smooth and thread portions of the pin positive profile end-threaded pin, smooth pin.

TABLE 14 DRILL BIT AND TAP SELECTION FOR STANDARD CORTICAL SCREWS (HEXAGONAL HEAD)*.
1.5 mm cortical screws 2.0 mm cortical screws 2.7 mm cortical screws
Drill bit diameter – thread hole 1.1 mm 1.5 mm 2.0 mm
Tap diameter 1.5 mm 2.0 mm 2.7 mm
Drill bit diameter – glide hole 1.5 mm 2.0 mm 2.7 mm

TABLE 15 DRILL BIT AND TAP SELECTION FOR CORTICAL SCREWS (CRUCIFORM HEAD)*.
1.0 mm 1.3 mm 2.4 mm
Drill bit diameter – thread hole 0.8 mm 1.0 mm 1.8 mm
Tap diameter – 1.3 mm+ 2.4 mm+
Drill bit diameter – glide hole 1.0 mm 1.3 mm 2.4 mm
+ For hard cortical or cancellous bone
* Synthes
56

distal extremities, smaller diameter pins must be used or arthrodesis wires and 1.0 mm stopper wires
to avoid iatrogenic fracture. Small positive profile, (IMEX Veterinary Inc.). It can be used on its own or
usually end-threaded pins are preferred for this as a hybrid device in combination with components
purpose. These are available as Miniature Interface™ from a linear fixator.
fixation half pins (IMEX Veterinary Inc.) or as part of Transarticular external skeletal fixation is the
the Small External Skeletal Fixator System (Securos temporary placement of a frame across a joint. The
Veterinary Orthopedics). Miniature Interface™ addition of a hinge (Hofmann s.r.l.) to form a hinged
fixation half pins are designed for use with acrylic transarticular external skeletal fixator may avoid many
frames and have a central roughened area on the pin of the detrimental effects of prolonged joint
shank to enhance acrylic grip. These pins are immobilization by allowing joint motion and early
available in a range of diameters (0.9 mm, 1.2 mm, weight bearing19.
1.6 mm, 2.0 mm, and 2.4 mm). They have a smaller Recommended pin diameters for adult cats of
diameter thread profile than the standard average lean body weight (4–5 kg) are given
transfixation pins. (Table 17). The metaphyseal regions of some long
Predrilling is recommended when inserting positive bones (the proximal humerus and tibia and the
profile pins using a drill bit a size smaller than the proximal and distal femur) may accommodate larger
shank of the pin (Table 16). Smooth pins (Kirschner diameter pins. Pin diameters should always be assessed
wires or arthrodesis wires) are available in diameters from preoperative radiographs and size selection
including 0.9 mm, 1.1 mm, 1.4 mm, and 1.6 mm, and adjusted accordingly. Pins with a slightly larger
are commonly used as transfixation pins, but they are diameter shank can be used if they are smooth or have
not ideal. In many cases, a combination of smooth and a negative thread profile. Larger diameter pins may
threaded pins is used to improve holding power while also be used, with less risk of fracture where the pins
reducing cost. Trocar and chisel point pins are the are introduced into the metabones because the stress
most frequently used to repair fractures in cats. is distributed through multiple bones. The metatarsals
A circular external fixator is now available in a size are larger than the metacarpals and can, therefore,
which is suitable for use in cats with fractures or limb accommodate larger pins. Smaller transfixation pins
deformities. The Miniature Circular External Fixator are used if external fixation is used in combination
(IMEX Veterinary Inc.) provides 35 mm rings and with an intramedullary pin, for femoral, humeral, and
accommodates 0.9 mm and 1.1 mm Kirschner wires tibial fractures, to allow space for the pin.

TABLE 16 DRILL BIT SELECTION FOR IMEX TABLE 17 RECOMMENDED POSITIVE PROFILE
VETERINARY INC. POSITIVE PROFILE TRANSFIXATION PIN SHANK DIAMETERS FOR
TRANSFIXATION PINS. LINEAR FIXATORS.
Shank Thread ^Drill bit Bone Pin shank
diameter (mm) diameter (mm) diameter (mm) diameter (mm)
0.9* 1.2 - Femoral diaphysis 2.0
1.2* 1.4 1.0 or 1.1 Tibial diaphysis 2.0
1.6* 1.8 1.5 Calcaneus 1.6
2.0* 2.3 1.5 Metatarsals 1.6
2.0 2.5 2.0 Humeral diaphysis 2.0
2.4* 2.9 2.0 Humeral condyle 1.6
2.4 3.2 2.3 Radius (craniocaudal placement) 1.6
* Miniature Interface fixation half pins suitable for use Radius (mediolateral placement) 1.2
with acrylic frames Radial carpal (mediolateral placement) 1.2
^ Recommended drill bit diameter for predrilling Radial carpal (dorsopalmar placement) 0.9
Metacarpals 1.2
Instruments and implants
57

INTERLOCKING NAILS TOTAL HIP REPLACEMENT


Small diameter interlocking nails (4.0 mm and A modular cemented hip prosthesis system
4.7 mm) are available in seven different lengths (BioMedtrix CFX™ Micro hip system) suitable for use
(68 mm, 79 mm, 91 mm, 101 mm, 112 mm, 123 mm, in cats has recently become available. The system
134 mm) and are suitable for repair of femoral, comprises specialized instrumentation for implanta-
humeral, and tibial diaphyseal fractures (Small tion of the prostheses, a choice of three sizes of
Interlocking Nail System, Innovative Animal Products acetabular component (12 mm, 14 mm and 16 mm),
LLC.) (32). Each nail accommodates either standard and two sizes of femoral prosthesis.
2.0 mm cortical bone screws or 2.0 mm solid cross- The surgical technique is basically the same as for
locking bolts in three or four interlocking holes. Bolts larger dogs receiving a cemented total hip
are stronger and stiffer than screws because they do replacement except that the patient is smaller. Cats
not have a thread cut into their surface. The four-hole with a body weight less than 4 kg are unlikely to be
nails have two screw holes at each end (spaced 11 mm suitable candidates for total hip replacement.
apart). The three-hole nails have either a single
proximal or a single distal screw hole. Three-hole nails
are applicable where there is a small distal or proximal
bone fragment, a situation that is commonly
encountered in the cat. The 4.7 mm interlocking nail
is most frequently used for femoral fractures and the
4.0 mm nail for humeral and tibial fracture repair.
Interlocking nails function like an intramedullary plate
but require a more limited surgical approach. They
provide adequate axial and rotational stability and,
because they are placed at the neutral axis of the bone,
they provide better bending stiffness than comparable
bone plates20.

32

32 Interlocking nail. 4.0 mm and 4.7 mm instruments and


implants set (Innovative Animal Products LLC.).
58

CHAPTER 6
FRACTURE FIXATION
METHODS: PRINCIPLES
AND TECHNIQUES
PREOPERATIVE CONSIDERATIONS should be present in the operating room or casting
ANALGESICS room for reference during the reduction and
Analgesic drugs are administered to increase comfort stabilization procedure. Intraoperative radiographs, if
and reduce stress in all cats with fractures. available, are extremely helpful in assessing reduction
Preemptive balanced analgesia is used before and alignment and confirming implant positioning.
surgery to prevent the ‘wind-up’ of pain, reduce drug
dosages and complications, and achieve a synergistic ASEPTIC PREPARATION FOR SURGERY
analgesic effect. Opioids, α2-adrenergic agonists, and After induction of anesthesia, the fractured limb is
nonsteroidal anti-inflammatory drugs (NSAIDs) are clipped and aseptically prepared for surgical reduction
often used (see Chapter 3)1–7. and stabilization. Sufficient hair should be removed to
provide a generous surgical field and to allow collection
ANTIBIOTICS of autogenous cancellous bone graft if needed.
The use of prophylactic antibiotics in fracture repair Chlorhexidine gluconate and povidone-iodine are
is controversial, but antibiotics are commonly commonly used scrubbing solutions. A hanging-limb
administered for open fractures, when severe trauma has preparation is preferred for most limb fractures and
occurred, and when surgical intervention is required allows the entire limb to be draped into the surgical field
(particularly if anticipated surgical time exceeds and manipulated during surgery (33).
2 hours). Cefazolin (22 mg/kg) is the antibiotic most
often used prophylactically during fracture repair, FRACTURE REDUCTION
although other antibiotics may be equally effective. The CLOSED TECHNIQUE
chosen antibiotic should be effective against common Closed reduction is indicated when a fracture is to be
bacteria isolated from surgical wounds, including stabilized by external coaptation, closed intramedullary
coagulase-positive Staphylococcus spp. and Escherichia pinning, or the application of an external skeletal fixator.
coli. To achieve and maintain adequate blood levels Reduction may be difficult (particularly in fractures that
during surgery, antibiotics are typically administered are several days old) and requires careful traction,
intravenously when the patient is anesthetized and the countertraction, and manipulation of the limb. Muscle
dose is repeated every 2–4 hours throughout the relaxants may be helpful but are rarely needed in cats.
surgical procedure. Antibiotics are not continued after During reduction, soft tissue trauma should be
surgery (except in open fractures) unless contamination minimized to avoid damaging vessels, nerves, and
occurred during the procedure. muscles. Reduction is best achieved by slowly applying
constant steady pressure to fatigue the muscles until the
RADIOGRAPHS fragments are realigned. Initially, traction can be
Two orthogonal views of the fracture site are obtained achieved using gravity by tying the distal aspect of the
to classify the fracture accurately and to determine the fractured limb to the ceiling or an infusion stand. The
appropriate fixation options. In most cases, radiographs table is then lowered such that the patient is partially
obtained to diagnose the fracture are adequate. In some ‘hanging’ by the limb. Muscles are usually fatigued in
cases, additional films are taken once the cat is 15–30 minutes and this facilitates reduction. During
anesthetized to improve positioning, enhance detail, or application of traction to the limb, the soft tissue
collect views not previously attainable. Radiographs envelope surrounding the bone will guide fragments
Fracture fixation methods: principles and techniques
59
33

A B C
33 Hanging-limb technique for preparing limbs prior to surgery.
A Tape stirrups are applied to the foot and the limb is suspended for clipping and scrubbing.
B After draping, the foot is wrapped in sterile bandage material and the limb is released.
C The entire limb is in the sterile field and can be manipulated during surgery.

into an anatomic position. In some cases, the bone joints proximal and distal to the fracture site. They
segments can be toggled into proper alignment. should prevent rotation, angulation, and collapse of the
With closed fixation techniques, perfect anatomic fracture site and maintain proper alignment and
reduction of the fragments is not necessary for fracture reduction during healing. Minimally displaced fractures
healing. The goal is to achieve rotational alignment, axial respond well to external coaptation, as do fractures in
alignment, and normal limb length. Ideally, the primary younger animals. The location and configuration of
bone segments should be in contact after reduction to a fracture dictates how effective external coaptation will
prevent collapse at the fracture site. Fifty percent overlap be at providing stability. External coaptation is used
of the primary bone fragments is preferred. Reduction primarily for fractures distal to the elbow or stifle joint.
and alignment are confirmed radiographically. Fractures of the femur and humerus are not amenable to
repair using external coaptation.
OPEN TECHNIQUE A major advantage of using external coaptation
Open reduction is used when internal fixation of the devices to stabilize fractures is that the fracture site,
fracture is indicated and in articular fractures where surrounding soft tissues, and blood supply to the
anatomic reduction is essential. Open reduction may fragments are not disturbed by surgical manipulation.
also be necessary in older fractures that cannot be External coaptation may also be a less expensive means of
adequately reduced closed. The bone segments are stabilizing some fractures if the coaptation device is
manipulated into alignment using bone forceps and applied properly, well cared for, and does not require
digital pressure. Levering fragments with a periosteal frequent changes. However, external coaptation devices
elevator is also helpful, although care is needed to may not adequately control all of the forces acting on the
prevent fracturing the bone. As with closed reduction, fracture site, which may lead to instability, increased pain,
slow, steady, constant pressure is the most effective reluctance to use the limb, and delayed healing14.
means of moving bone segments. It is imperative to Potential complications associated with the use of
preserve soft tissue attachments and blood supply to external coaptation include prolonged immobilization
the bone fragments during reduction and fixation. of joints leading to joint stiffness and osteoarthritis,
muscle contracture, soft tissue trauma such as cast sores,
FRACTURE STABILIZATION and inadequate stabilization of the fracture site15.
METHODS Frequent cast changes may be required in growing
EXTERNAL COAPTATION animals or if the cast gets wet or soiled. Some cats are
Bandages, casts, splints, and slings can be useful in repair intolerant of casts, bandages, splints, and slings. They
of many types of fractures, particularly in the tibia, may refuse to walk for a period of time or may roll and
radius/ulna, and more distal fractures8–13. Casts and struggle to remove the coaptation. Mild sedation may
splints stabilize fractures by controlling motion of the be used until the cat becomes accustomed to the device.
60

Casts 50%. Sufficient padding is placed to protect the limb and


Full-limb casts are usually applied as a primary fixation prevent cast sores. However, too much padding will
after closed fracture reduction or as ancillary stabilization prevent the cast material from conforming to the limb
following open reduction and internal fixation11,12. and may cause motion beneath the cast, instability of the
Fiberglass resin-impregnated casting tape is commonly fracture, and trauma to the skin. Care is taken to ensure
used and is lightweight, easy to apply, and resistant to all bony prominences are adequately padded. Roll gauze
impact. Fiberglass casts are also radiolucent, so the may be applied over the cast padding but this is optional.
fracture is readily monitored for complications and The fiberglass casting material is immersed in water and
healing without removing the cast. It also dries readily squeezed to remove excess water. The cast material will
should it become wet after application. For fractures of harden more slowly if cold water is used and more
the radius/ulna or tibia, the cast is placed from the toes quickly if warm or hot water is used. The cast material is
to the level of the mid-humerus or mid-femur. For more gently wrapped circumferentially around the limb,
distal fractures, the cast is placed from the toes to the beginning at the toes and progressing proximally,
level of the proximal radius/ulna or tibia. The fracture overlapping each wrap by 50%. The distal portions of
should be reduced and the limb should be in a functional phalanges 3 and 4 are left exposed to monitor for
position before application of the cast. Placing joints in swelling. Two or three layers of casting material may be
a hyperextended position should be avoided. used to ensure the cast is sufficiently strong. The cast
should be applied quickly enough to allow the layers to
Application laminate together for added strength. Care is taken not
Tape stirrups are first placed to apply traction on the limb to pinch or squeeze the cast as it is hardening, or
and to prevent the cast from slipping. Long hair is shaved depressions in the cast may place focal pressure on the
if necessary. A small stockinette is placed over the limb underlying skin. When the cast material is in place, the
extending from the toes to the proximal extent of the stockinette is folded over proximally and distally to cover
cast. Care is taken to eliminate folds in the stockinette the ends of the cast and the stirrups are reflected and
that may cause pain or pressure on the underlying skin. stuck to the outside of cast. Elastic adhesive tape or
Cast padding is then placed around the limb from distal Vetwrap (3M Animal Care Products) may be placed over
to proximal with each wrap overlapping by approximately the cast (34).

34

C E
34 Full-limb cast application technique.
A Tape stirrups are placed medially and laterally on the foot and traction is applied. B A stockinette is placed over the limb.
C Cast padding material is applied. Avoid excessive padding or the cast will be loose. Roll gauze may be placed over the cast
padding if desired. D Casting material is applied and conformed to the limb. Overlap each wrap by 50%. Additional layers
are applied as needed for strength. E The tape stirrups and stockinette are reflected and a layer of elastic adhesive tape or
Vetrap is applied to cover the cast. The distal aspects of the 3rd and 4th phalanges are left exposed to monitor for swelling.
Fracture fixation methods: principles and techniques
61

Care of casts Mason metasplints (metal or plastic) are commonly


After application, the cast is kept clean and dry and the used and have a ‘spoon’ shape to fit the distal aspect
toes are monitored for swelling. The cast is checked of the limb. Alternatively, thermomoldable plastics
regularly for odor. The cat should be confined and (X-Lite, AOA Kirschner Medical Corp.; Veterinary
must not be permitted to lick or chew the cast. Thermoplastic (VTP), IMEX Veterinary Inc.; or
If possible, the cast remains in place until healing is Orthoplast, Johnson & Johnson) can be used to
complete, since loss of fracture reduction may occur if customize a splint for each individual cat. Splints are
the cast is removed prematurely. However, the cast placed on the lateral aspect of the hindlimb for
must be replaced if it becomes loose or causes irritation fractures distal to the stifle. Fiberglass casting tape or
to the skin. The cat is sedated and the cast is cut thermomodable plastics may be used to create a splint
medially and laterally with an oscillating saw (bivalve). that conforms to the limb.
The two halves of the cast can then be removed. The
skin is treated appropriately and the bivalved cast is Application
re-applied. Tape can be used to hold the two halves of Tape stirrups are placed on the limb followed by cast
the cast together. In some case, only one half of the padding. Excessive padding should be avoided. Roll
bivalved cast is reapplied and this serves as a splint. gauze is then applied, ensuring the bandage is not too
tight. The commercial or custom-made splint is
Splints positioned and secured to the limb with elastic
Various types of splint are available and may be used adhesive tape or Vetwrap (3M Animal Care Products).
to stabilize fractures distal to the elbow and stifle The stirrups are folded up and stuck to the outer
joints. Splints are placed on the caudal/palmar aspect wrap. If possible, the distal aspect of phalanges 3 and
of the forelimb for fractures distal to the elbow. 4 are left exposed to monitor for swelling (35).

35

C E
35 Splint application technique.
A Tape stirrups are applied to the limb. B Cast padding material is applied (ensuring that all bony prominences are well
padded) with the limb in a functional position. C Roll gauze is applied. Avoid applying the material too tightly. D The tape
stirrups are reflected and the splint is placed. Commercially available splints or custom splints made from casting material or
thermomoldable plastics may be used. E Elastic adhesive tape or Vetwrap (3M Animal Care Products) is used to attach the
splint securely. The distal aspects of the 3rd and 4th phalanges are left exposed to monitor for swelling.
62

Care of splints to provide stability (‘stack pinning’)25. In some


Care of splints is identical to that recommended fracture configurations in cats, it may be easier to
for casts. Splints are easier to change than casts and insert two smaller pins without disrupting the
are particularly useful for fractures of the fragments than to insert a single large pin. However,
metacarpals, metatarsals, and phalanges and when stack pinning has not been shown consistently to
wounds are present that necessitate frequent improve rotational stability25–28. This is particularly
bandage changes. true when both pins exit the cortex through the same
hole and function essentially like a single pin. A
INTRAMEDULLARY PINS, KIRSCHNER WIRES, modified intramedullary pin has recently been
AND CERCLAGE WIRES described for use in cats that has three lamellae along
Intramedullary pins, Kirschner wires, and cerclage wires its shaft, giving it a triangular cross-sectional shape
are commonly used to repair fractures in cats. The (Trilam Nail, Rotec Medizintechnik) (26)29. The
straight medullary cavity typical of most cat bones lamellae engage the inner cortical bone to control
makes them very amenable to intramedullary pin rotation.
placement. Pins and wires are relatively inexpensive
and easy to implant with minimal equipment. Pin insertion
Intramedullary pins provide axial alignment and resistance Intramedullary pins are inserted in a closed or open
to bending but do not control rotational forces. The fashion20,23. When open pinning is used, a limited
friction between the pin and the bone provides limited approach is made to the fracture site to achieve
control of compressive and tensile forces. Therefore, reduction and ensure proper pin placement while
intramedullary pinning can result in a slower return to minimally disrupting the fragments. This is the more
limb function and may involve more aftercare than commonly used method to place an intramedullary
bone plating16. Intramedullary pins and full cerclage pin and allows anatomic reduction of the fragments
wires work well for fractures of the tibia, femur, and and the application of cerclage wires. Intramedullary
humerus. Placing an intramedullary pin in the radius is pins may be inserted in either normograde or
discouraged because of the oval shape of the bone, retrograde fashion depending on the bone being
the limited medullary cavity, and the likelihood of repaired. For normograde insertion, the pin is
damaging the elbow or radiocarpal joints during inserted from one end of the bone, across the fracture
insertion. site, and into the opposite bone segment. For
retrograde insertion, the pin is started at the fracture
Intramedullary pins site and directed out of the proximal cortex of the
Intramedullary pins are often used to stabilize fracture bone. The fracture is reduced and the pin is then
of the humerus, femur, and tibia in cats13,17–24. driven in the opposite direction and seated into the
Steinmann pins are the most common type of distal segment of bone.
intramedullary pin used. They are round, come in Intramedullary pins are typically inserted with
a variety of lengths, and are 1.5 mm to 6.5 mm in a hand-chuck, using a smooth internal and external
diameter. Pins with a ‘trocar’ point have better cutting rotation of the wrist and forearm to minimize
action and are used most often for intramedullary ‘wobble’. They may also be inserted with a power drill,
pinning. Threaded pins are of little value as but care is needed to prevent thermal necrosis of the
intramedullary pins and are susceptible to breaking at bone, inadvertent penetration of the cortex, and
the junction of the threaded and smooth portions of entrance into a joint. The pin is inserted until it
the pin. engages the cancellous bone at the far side of the
Selection of the appropriate pin depends on the fracture. The depth of the pin can be estimated by
size of the intramedullary cavity, the bone being placing a pin of the same length along the outside of
repaired, the fracture configuration, and whether the bone. The joints on either end of the long bone
ancillary methods of fixation are to be used. Pin should be manipulated through a full range of motion
diameters of 1.6 mm to 4.8 mm are suitable for use in and evaluated for crepitus indicative of pin penetration
most cats. Generally, when a single intramedullary pin into the joint. Final pin position is evaluated
is to be placed, it should be large enough to fill at least radiographically.
60–70% of the medullary cavity at its narrowest point. Once the pin is in place, the end of the pin is cut
Larger pins provide greater resistance to bending short and should not protrude from the skin.
forces and are preferred in straighter bones. In larger Alternatively, the pin can be partially precut with
bones, two pins may be placed in the medullary cavity a saw based on the preoperative radiographs of the
Fracture fixation methods: principles and techniques
63

normal contralateral bone. Following insertion the sticking into the far cortex. The stability provided by
pin is snapped off flush with the bone surface and pins placed in Rush fashion depends on the elasticity
left in situ. This prevents soft tissue injury, pain, and of the pins and proper positioning within the
seroma formation. medullary cavity.

Dynamic intramedullary pinning (Rush pinning) Kirschner wires


Dynamic intramedullary pinning or Rush pinning is Kirschner wires and arthrodesis wires are small,
a modification of the intramedullary pinning flexible pins shaped much like Steinmann pins. They
technique23,30. Rush pins are specifically designed are available in a range of sizes, 0.9–2.0 mm in
intramedullary devices originally used in humans. They diameter. They can be inserted by hand-chuck or with
have a hook on one end and are flat and skid-like on a power drill and are used in several ways to stabilize
the opposite end. A pair of these pins is inserted from fractures.
the end of a long bone into the medullary cavity to
create dynamic compression (36). In cats, small Figure-of-eight skewer technique
Steinmann pins or Kirschner wires can also be inserted The figure-of-eight skewer technique is a modification
in ‘Rush fashion’. This technique is used primarily for of the hemicerclage wiring technique (37)31.
metaphyseal or epiphyseal fractures. A Kirschner wire is placed across the fracture line
To insert pins in Rush fashion, pilot holes are with the ends of the Kirschner wire protruding
drilled medially and laterally near the end of the approximately 2 mm from each cortex. The Kirschner
bone. The pins are inserted at an angle 20° to wire is positioned either perpendicular to the fracture
the long axis of the bone. The fracture is reduced and line or perpendicular to the long axis of the bone,
the pins are alternately advanced across the fracture whichever will provide the greatest fracture stability.
line. Each pin should cross the fracture line, glance A cerclage wire is then placed in a figure-of-eight fashion
off the far cortex, and bend back toward the cortex in around the tips of the Kirschner wire, against the outer
which it was inserted. Blunting the ends of the pin, cortex of the bone. The wire is tightened, with care
placing a slight bend in the pin prior to insertion, and taken to keep even tension on the two wire ends. The
tapping the pin into the bone rather than twisting it protruding ends of the Kirschner wire can be bent to
can aid insertion and prevent the tip of the pin from help retain the cerclage wire and prevent slippage.

36 Pins placed in ‘Rush fashion’ 36 37


to repair a distal femoral
fracture.

37 Figure-of-eight skewer technique. A Kirschner wire is


placed perpendicularly across the fracture (black line). Wire
is placed in a figure-of-eight fashion around the protruding
ends of the Kirschner wire and tightened. The ends of the
Kirschner wire are bent over to prevent slippage and
reduce soft tissue trauma.
64

Cross pinning 0.8 mm [20 AWG]) is placed in a figure-of-eight


The cross pinning technique is commonly used to pattern (through the hole and around the
stabilize metaphyseal and physeal fractures. The protruding ends of the Kirschner wires) and twisted
distal femur, proximal tibia, distal tibia, and distal to tighten. A single or double twist can be placed in
radius are sites where cross pinning is often the figure-of-eight wire. The protruding ends of the
employed. Two Kirschner wires are inserted across Kirschner wires are then bent over, cut, and rotated
the fracture line from the epiphysis into the to prevent soft tissue irritation (38).
metaphysis. The joint surface is avoided when
starting the pins. The Kirschner wires should cross Cerclage wires
on the metaphyseal side of the fracture line and not Cerclage wiring is a useful and versatile technique
directly in the fracture32,33. used for fracture repair19,23,34. When applied
properly, cerclage wires neutralize specific forces at
Tension band wire fixation the fracture site and do not compromise cortical
Tension band wiring is used to stabilize avulsion blood supply or interfere with bone healing35.
fractures or osteotomies of the olecranon, greater However, when used alone, cerclage wires are unable
tubercle of the humerus, greater trochanter of the to withstand load-bearing and muscle-generated
femur, tuber calcaneus, tibial tuberosity, and the forces. Therefore, they are typically applied in
medial and lateral malleoli34. Distractive forces conjunction with other fixation methods, including
applied to the bone by tendon or ligament intramedullary pinning or plate fixation. Cerclage
attachments are converted to compressive forces by wires are used alone only in certain situations, such as
the tension band fixation. The avulsed fragment is in the repair of mandibular fractures. The key to
reduced and two Kirschner wires are inserted across successful cerclage wiring is careful case selection and
the fracture line to maintain alignment and strict attention to proper application techniques. The
neutralize shear forces. The pins should be parallel to most common wire used in cat fracture repair is
each other. A hole is drilled transversely across the 0.8 mm (20 AWG), although 0.6 mm (22 AWG) and
parent bone. Orthopedic wire (0.6 mm [22 AWG] or 0.5 mm (24 AWG) wires are occasionally needed

38

A B
38 A Tension band wire fixation for stabilization of an olecranon fracture.
B Lateral radiographic view of an olecranon fracture repaired with tension band wire fixation.
Fracture fixation methods: principles and techniques
65

(see Chapter 5). Cerclage wire is available as a spool may be cut into the cortical bone and the cerclage
of wire or with preformed loops on one end (loop wire placed in the notch as it is tightened. If
cerclage). cerclage wires are used to stabilize fragments prior
to application of a bone plate, the knot in the wire
Full cerclage wires should be placed such that it does not interfere with
Full cerclage wires are placed completely around the proper plate positioning.
long bone. They are used to stabilize fissure fractures
and long oblique and spiral fractures, where the Hemicerclage wires
fracture line is at least twice the diameter of the bone. Hemicerclage wires are placed through the holes
If a full cerclage wire is placed on a short oblique drilled in the bone and are tightened to create
fracture, shear forces are created and the fracture will compression. Overtightening may damage the bone
be unstable. The wire is likely to loosen and can slide where the wire exits the drill hole. These
into the fracture line where it will interfere with interfragmentary wires should be placed perpendicular
healing. Full cerclage wires are not used on transverse to the fracture line to maximize compression between
fractures. The application of full cerclage wires to the fragments and prevent wire movement and
a long oblique fracture creates interfragmentary loosening. In most cases, hemicerclage wires provide
compression and enhanced stability. Several important little rotational stability and their use is limited to
principles should be followed when applying full specific situations, such as stabilization of nonweight-
cerclage wires: bearing bones, such as the mandible or maxilla.
• The cerclage wires are placed perpendicular to
the long axis of the bone. If the wire is not Tightening cerclage wires
perpendicular, it is likely to shift and become Loop cerclage wires are tightened by placing the free end
loose. Loose wires provide no mechanical support of the wire through a preformed loop (‘eye’) created in
and interfere with revascularization and healing.
• Disruption of the soft tissues surrounding the
bone is minimized. Forceps or a wire-passer are
used to position the wire around the bone,
ensuring the wire is against the periosteal surface TABLE 18 OPTIONS FOR REPAIR OF DIAPHYSEAL
of the bone and that soft tissue, vascular FRACTURES IN CATS.
structures, and nerves are not entrapped. Transverse/short oblique fractures
Entrapped soft tissue will suffer necrosis, leading Bone plate
to loosening of the wire. Interlocking nail
• Wires must be tight! Intramedullary pin with an external fixator
• A minimum of two full cerclage wires are placed External fixator
on each fracture line. A single wire simply creates
a fulcrum around which the fragments can move. Long oblique fractures
Bone plate
• Wires are placed a minimum of 0.5 cm from the
Bone plate and cerclage wires or lag screws
end of the fracture line and 1 cm apart along the
Interlocking nail
entire fracture line. Cerclage wires should never
Intramedullary pin and cerclage wires
be placed within the fracture line itself.
Intramedullary pin and external fixator
Full cerclage wiring is often used to stabilize
External fixator
comminuted fractures (along with an intramedullary
pin, external fixator, or bone plate) (Table 18). The
full circumference of the cortical shaft must Comminuted fractures
Bone plate in buttress fashion
be reconstructed for the wires to be effective. If
Bone plate and intramedullary pin (plate-rod)
the reconstruction is incomplete, the fragments will
Interlocking nail
simply collapse into the medullary cavity as the wire
External fixator (rigid frame configuration)
is tightened. If cerclage wires are placed on a bone
Bone plate and cerclage or lag screws
that is conical in shape, they may tend to shift
Intramedullary pin and cerclage wires
toward the narrower portion of the bone, resulting
Intramedullary pin and external fixator
in a loose wire. Placing a small Kirschner wire
Autogenous cancellous bone graft in all defects
through the bone at the level of the cerclage wire
can prevent slippage. Alternatively, a small notch
66

the opposite end (39). A specially designed tightening is secured simply by bending the wire, loop cerclage wires
device is available that creates maximum tension on the may be susceptible to premature loosening.
wire around the bone. Once the wire is tight, the free end Twisting the two ends of the wire is a common
of the wire is bent 180° to lock it in place, and the excess method of securing a cerclage wire (40). Several
is removed. Loop cerclage wires can be placed more instruments are available for this purpose: a strong pair
tightly than twist type wires36,37. However, since the knot of needle holders is commonly used. Tension is applied

39 39 Loop cerclage wire.


A Loop cerclage wire positioned
in the AO wire-tightening
device. The handle on the
tightening device is turned to
put tension on the wire.
B Loop cerclage wire placed on
a long bone. The end is bent
over to lock the wire in place.

A B

40

A B C
40 Twist cerclage wire. A The proper method to tighten the cerclage wire. Tension is applied by pulling
perpendicularly away from the bone surface as the wire is twisted. Equal tension is applied to both strands of wire to
create an interlocking twist. B Improper twist: one strand of wire is wrapping around the other. C Bending the wire
twist significantly reduces the tension and often results in a loose cerclage wire. Instead, the wire should be cut leaving
two to three twists in place.
Fracture fixation methods: principles and techniques
67

by pulling perpendicularly away from the bone surface fracture site. In some cases, a limited open approach to
as the twist is created. The tension in the wire and the the fracture site is performed to improve reduction and
securing knot are thus created at the same time. Equal alignment. If the fracture site is opened, cortical defects
tension is applied to both strands of wire to create an are filled with autogenous cancellous bone graft. Typical
interlocking twist in which each strand of wire wraps components of an external fixator system include the
around the other. Wires secured using this twist- knot transfixation pins, clamps, and connecting bars.
method provide only 40–60% of the static tension
created when using a loop cerclage38. Twist-knots are, Transfixation pins
however, significantly more resistant to slippage37. Transfixation pins penetrate the bone, stabilize
After completing the twist, the wire is cut leaving two fragments, and attach to the external frame (connecting
to three twists in place. Cutting the twist has been bars). Pins 1.2–2.0mm in diameter are most often used
shown to reduce the wire tension by up to 21%, but in cats. They are inserted through small stab incisions in
bending the twist over decreases tension by as much the skin and must penetrate both cortices of the bone or
as 70%34. In most cases, this small projection causes they will loosen prematurely. Pins that penetrate the skin
minimal soft tissue injury. If a twist wire must be bent on only one side of the limb are termed ‘half pins’. Pins
because of minimal soft tissue coverage at the fracture that penetrate the skin on both sides of the limb are
site, it is best to continue to twist the wire as the termed ‘full pins’. A minimum of two transfixation pins
bending motion is applied. are inserted on each side of the fracture line, although
Anatomic reconstruction of the fragments and three or four pins are preferred if space allows.
proper wire positioning are essential to prevent Knowledge of the regional anatomy and careful
premature loosening. Once a wire is placed, it is palpation are important to ensure pins are not placed in
checked to ensure it is tight. It is not uncommon for the fracture line and to avoid damaging vessels, nerves,
a wire to become loose as other wires are tightened and muscles48. When placed after open fracture
along the bone. Frequent checks and replacement reduction, pins are inserted through separate stab
of all loose wires are essential. Complications from the incisions rather than through the surgical incision.
use of cerclage wires generally result from the use of Transfixation pins 25–30% of the diameter of a bone can
undersized wire, use of a single wire on a fracture, or be inserted without significantly weakening the
from technical errors in application31. Most technical bone44,49–52. Positive profile threaded pins have
errors result in loose wires that can migrate into the significantly greater holding power in bone than smooth
fracture lines, disrupting vascular ingrowth and pins and their use can help prevent premature pin
delaying the healing process. Wires can become loose loosening49,53–55. However, their larger diameter may
if they are not tightened sufficiently, are not placed limit their use to the metaphyseal regions of the long
perpendicular to the long axis of the bone, or if the bones. A combination of smooth and threaded pins may
underlying bone fragments are not reduced be used to improve holding power while reducing cost.
adequately. The wire knots should not be placed Transfixation pins should be inserted using slow-
where they may damage vessels and nerves. speed power insertion (<150rpm) with a variable speed
power drill56,57. High-speed power insertion results in
EXTERNAL SKELETAL FIXATORS thermal necrosis of the bone and premature pin
External skeletal fixators are a versatile method of loosening. Predrilling the hole in the bone with a drill
fracture repair39–45. Both linear and circular fixation bit one size smaller than the transfixation pin will also
systems are available for use in the cat44,46,47. They are reduce the heat created during pin insertion58,59
easily customized into a variety of configurations (see Table 16). A hand-chuck may also be used to insert
to stabilize almost any type of fracture, require little the pins, but the slight wobble that occurs when pins are
additional equipment for proper placement, are well inserted in this manner can lead to premature pin
tolerated by most cats, and are ideal for stabilization of loosening. ‘Backing-up’ the pin once it is inserted
comminuted, infected, and nonunion diaphyseal should be avoided, as this can also cause pin loosening60.
fractures (Table 18). External fixators may be used as a
primary means of stabilization or in conjunction with Linear fixator systems
internal fixation methods. Fixators can control all forces The small Kirschner–Ehmer (KE) fixator system is,
acting on a fracture site and are easily removed when perhaps, the fixator system most often used for
fracture healing is complete. When possible, external fracture stabilization in cats. A 3.2 mm diameter steel
fixators are applied in a closed manner to minimize connecting bar is used and the clamps (used to
disruption of the soft tissues and blood supply at the attach the transfixation pins to the connecting bar)
68

will accommodate pins up to 2 mm in diameter. • Using larger diameter transfixation pins (up to
Unfortunately, positive profile threaded pins cannot 30% of bone diameter).
be inserted through the KE clamps, and additional • Placing the innermost transfixation pins close to
clamps cannot be added to the bar once the proximal the fracture site and the outermost pins near the
and distal pins are attached. The small Secur-U bone ends.
External Fixator Clamp (Securos Veterinary • Increasing the number and size of the connecting
Orthopedics Inc.) can be used with the 3.2 mm bars.
connecting bar and will accommodate 1.6–2.3 mm • Placing the connecting bars closer to skin. The
transfixation pins. These clamps can be added to the connecting bar is typically placed approximately
bar between previously placed clamps and they are 1–2 cm from the skin surface to allow for
more resistant to slippage than KE clamps61,62. The postoperative swelling. In some situations, the
mini IMEX-SK System (IMEX Veterinary Inc.) uses connecting bar is slightly contoured to fit the
a 3.2 mm diameter connecting bar. The mini SK patient better.
clamp has a two-piece design that can be • Reducing the fracture so that the fixator frame
disassembled to allow the addition of a clamp shares load with the bone segments.
between two existing clamps on the connecting bar.
It accommodates transfixation pins from 0.9–2.5 mm Fixator application techniques
in diameter. Type Ia frame
1. A hanging-limb technique is used for preparing
Frame configurations and draping the limb. This will fatigue the
Various frame configurations can be used when muscles, provide distraction, and facilitate fracture
applying a linear fixator (41)12: reduction. In many cases, the limb is left hanging
• Type Ia: a unilateral frame in which half pins are during the initial steps of the application process
placed in a single plane. to maintain proper limb length.
• Type Ib: a unilateral frame in which half pins are 2. The proximal and distal transfixation pins (half
placed in two planes (two type Ia frames placed pins) are inserted through small stab incisions in
60–90° to each other). The two frames can be the skin near the ends of the long bone. Placing
connected to increase stiffness. these pins parallel to the joint surfaces
• Type IIa: a bilateral frame (connecting bars used will help ensure proper alignment. Positive profile
on both sides of the limb) in which all of the end-threaded pins may be used if their diameter is
transfixation pins are full pins (penetrating the less than 30% that of the bone. Predrilling the
skin on both sides of the bone). holes with the appropriate sized drill bit will
• Type IIb: a bilateral frame in which both full pins reduce the incidence of thermal necrosis and pin
and half pins are used. loosening.
• Type III: bilateral and biplanar frame (the most 3. Empty clamps are placed on the connecting bar
rigid of the frame configurations). (to accommodate the expected number of
• Tie-in configuration: a connecting bar is used to additional pins to be placed) and the
attach the external fixator frame to an connecting bar is loosely attached to the
intramedullary pin. Used in femoral and humeral proximal and distal pins.
fracture repair. 4. The fracture is reduced (ensuring proper bone
length and alignment of the joints proximally and
Frame stiffness distally) and the clamps on the proximal and
Stiffer fixator frames enhance stability at the fracture distal pins are tightened. This will hold
site and reduce the incidence of pin loosening and pin the fracture in reduction while additional
sepsis59. Type III frames are stiffer than both type transfixation pins are inserted through the empty
I and II frames. Type II frames are approximately clamps on the connecting bar.
twice as stiff as type I frames63,64. Type I and type II 5. A minimum of two pins is inserted in each bone
frames are commonly used in cats, while type III segment, using three or four pins if the size of
frames are only occasionally required65. Several the fragments will permit. The pins can be
techniques can be used to increase the stiffness of any inserted at an angle 20° to the long axis of the
fixator configuration59,66,67: bone if preferred.
• Increasing the number of transfixation pins in 6. Adequate alignment and reduction of the fracture
each fragment (three to four pins is ideal). are confirmed using radiographs and careful
Fracture fixation methods: principles and techniques
69

palpation, then all of the clamps are tightened. diameter of the medullary cavity is used to
If necessary, minor adjustments in fracture allow room to insert the transfixation pins. If
reduction can be made by loosening the clamps an open approach is used for a comminuted
and manipulating the fragments. fracture, absorbable suture can be used to pull
Type Ia frame and intramedullary pin68,69 the bone fragments gently into alignment, or
1. The fracture is reduced and the intramedullary cerclage wires can be placed to stabilize the
pin is inserted using either a closed or an fragments. Cancellous bone graft is placed in
open technique. A pin less than 70% of the any defects.

41

A B C D

E F G
41 Fixator frame configurations. A Type Ia frame. B Type Ia frame with double connecting bar.
C Type Ib frame. D Type IIa frame. E Type IIb frame. F Type III frame. G Tie-in configuration.
70

2. The intramedullary pin is cut below the skin to align the fragments and place cancellous bone
surface. graft if necessary.
3. The type Ia external fixator is applied (as 5. The four clamps are tightened. This rectangular
described). The transfixation pins are placed frame will maintain reduction while the remaining
through stab incisions in the skin (not through pins are inserted.
the surgical incision). 6. The remaining full pins are inserted through stab
incisions in the skin. To ensure the full pins
Type Ia frame and intramedullary pin, tie-in contact the connecting bars bilaterally:
configuration70–72 • An aiming device is used to direct the pins61.
1. The fracture is reduced and the intramedullary (Secur-Aim Fixator Pin Application Tool,
pin is inserted using either a closed or an open Securos Veterinary Orthopedics Inc.). The
technique. A pin less then 70% of the diameter of device is attached to the fixator frame and
the medullary cavity at its narrowest point serves as a guide to allow placement of pilot
is used. holes in the bone. Additional transfixation pins
2. The proximal end of the intramedullary pin is left are then inserted through the guide (and pilot
exposed (2–3 cm) above the skin surface. holes) in the proper orientation to contact
3. The type Ia external fixator frame is placed (as both connecting bars.
described). • An additional connecting bar (with empty
4. Clamps and a connecting bar are used to attach clamps) is attached to the proximal and distal
the intramedullary pin to the fixator frame, or the pins, forming a ‘double bar’ on one side of the
proximal end of the frame’s connecting bar is limb. Since the three connecting bars are in the
contoured so that it contacts the intramedullary same plane, transfixation pins inserted through
pin (connected with a clamp). the empty clamps on the double bar (and then
through the bone) will connect with the empty
Type Ib frames clamps on the opposite side of the limb.
A type Ia frame is applied to the fracture as described. 7. At least two full pins are inserted in each bone
A second type Ia frame is placed approximately segment (3–4 pins are preferred).
60–90° degrees to the first. The two frames can be 8. All the clamps are tightened.
attached using short connecting bars to increase 9. The additional connecting bar is removed (or it
stiffness. may be left in place as a double bar if additional
stiffness is required).
Type IIa frames
1. A hanging-limb technique is used for preparing Type IIb frames
and draping the limb. This will fatigue the Type IIb frames are placed in the same manner as
muscles, provide distraction, and facilitate fracture type IIa, except that an additional connecting bar or
reduction. The limb can be left hanging during aiming device is not needed. Once the rectangular
the initial steps of the application process to frame is in place, and the fracture is reduced, half pins
maintain limb alignment. (rather than full pins) are inserted through the empty
2. The proximal and distal pins (full pins) are clamps on the two connecting bars. The half pins can
inserted through stab incisions in the skin near be inserted at an angle approximately 20° to the long
the ends of the long bone. The pins are placed axis of the bone.
parallel to the joint surfaces. Centrally threaded
pins may be used to enhance holding power. Type III frames
Predrilling the holes with an appropriate sized Type III frames (bilateral and biplanar) are the most
drill bit will ease insertion and reduce thermal rigid of the frame configurations and are rarely required
injury to the bone. in cats. However, they may be used to stabilize severe or
3. The connecting bars (with the necessary infected fractures of the distal extremities (particularly
allotment of empty clamps) are clamped to the tibia) when delayed healing is expected65. The
the two transfixation pins on each side of fracture is reduced and a type II frame is placed from
the limb. medial to lateral on the limb. A second frame (type I) is
4. The fracture is reduced, ensuring proper limb placed on the cranial aspect of the limb, at approximately
length and rotational and angular alignment. 90° to the type II frame. Clamps and connecting bars
A minimal surgical approach may be used gently are used to connect the two frames together.
Fracture fixation methods: principles and techniques
71

Acrylic frame fixators tubing, pediatric anesthetic tubing, or silastic tubing


Acrylic frame fixators (rather than those of metal or (Silastic Medical Grade Tubing, Dow Corning) is
carbon fiber rods) may be used as connecting bars to often used. The appropriate diameter of the tubing
grip the transfixation pins and stabilize the frame depends on the bone being repaired, fracture
(42). Acrylic frames are particularly useful in cats configuration, frame configuration, and the size of the
because they are lightweight, less bulky, and can be cat. A 2 cm diameter acrylic bar is stronger than the
contoured to any shape bone or fracture configu- medium sized metal KE bar73.
ration. Positive profile threaded pins can be inserted Numerous products can be used to create the acrylic
anywhere along the frame without passing through connecting bars, including dental-grade nonsterile
clamps, and the connecting bar can be of any shape, methylmethacrylates and dental acrylics (LB Caulk
so transfixation pins need not be aligned in a single Co.), methylmethacrylates used for prosthesis
plane to attach properly. Pins of various sizes can also implantation or hoof repair (Simplex-P, Howmedica
be used in the same frame19,41,73,74. International; Technovit, Jorgensen Laboratories), and
Smooth or threaded pins can be used with acrylic various epoxy putties73,75. Most acrylic materials have a
fixators. The external portion of the pin is often bent liquid and a powder component that are mixed
or slightly notched with a pin cutter so that the acrylic together and injected into the tubing using a catheter-
can grip the pin more firmly. Specially designed pins tipped syringe. Alternatively, the acrylic is allowed to
are available for use with acrylic fixators; they have reach a doughy stage and is molded to the transfixation
a roughened surface to strengthen the interface pins (free-form). The acrylic undergoes an exothermic
between the pin and the acrylic (Miniature reaction as it hardens, which can cause thermal injury to
InterfaceTM fixation half pins, IMEX Veterinary Inc.). soft tissues and bone by conduction along the
Flexible tubing of the appropriate diameter is placed transfixation pins76,77. Placing the acrylic bar at least
over the external portion of the transfixation pins to 1 cm from the skin surface and lavaging the pin/acrylic
contain the acrylic as is hardens. Thin-walled, flexible interface with saline during the exothermic reaction
tubing is preferred and rubber or polyvinyl medical reduces thermal injury73.

42

A B C
42 Acrylic external fixators.
A Free-form acrylic fixator. Acrylic material or PMMA is allowed reach a doughy state and applied to
the ends of the transfixation pins.
B Acrylic fixator formed by placing flexible tubing on the transfixation pins. Acrylic or PMMA fills the
tubing and is allowed to harden, forming rigid connecting bars.
C Acrylic fixator on a cat femur.
72

When performing open reduction of the fracture, 43


the use of a commercially available acrylic fixator kit
(APEF System, Innovative Animal Products LLC.)
simplifies the procedure because the necessary tubing
and acrylic are sterile. Transfixation pins are inserted
into the bone at the locations desired for maximum
stability and minimal soft tissue injury. The fracture is
reduced and stabilized using the alignment frame
clamps and bars, which temporarily attach to the
transfixation pins close to the skin. If open reduction
was necessary, the skin incision can be closed at this
time. The corrugated tubing is then impaled on the
external ends of the transfixation pins outside the
alignment frame. The pins may be shortened to ensure
that only one wall of the tubing is penetrated. Acrylic is
then mixed within its plastic bag and poured into one
end of the tubing. The other end of the tubing is
occluded using plugs to prevent leakage. Once the
acrylic has hardened (10–12 minutes) the temporary
alignment frame is removed.
When using nonsterile acrylic or polymethyl-
methacrylate (PMMA), care must be taken to avoid 43 Transarticular external fixator used to stabilize a distal
contamination of the fracture site13. The transfixation femoral fracture. The articular component of the fracture is
pins are inserted and flexible tubing of the appropriate repaired with a lag screw to ensure a congruent joint surface.
diameter is placed over the pins. The tubing must be
sterilized if it is to be used during open fracture
reduction, or the incision is closed before handling the repair. Triangular frame configurations can be used or
tubing or nonsterile PMMA. The fracture is reduced the connecting bars (metal or acrylic) can be bent to
and a temporary connecting bar is placed on some of immobilize the joint in a weight-bearing position78. It
the pins (outside of the tubing) to maintain reduction. may be difficult to slide the clamps onto the bars once
The PMMA is mixed to liquid phase, placed in a large the bar is bent, so the surgeon should ensure the clamps
catheter-tipped syringe, and injected into one end of are properly positioned first. The transarticular fixator is
the tubing. The other end of the tubing is occluded removed as soon as healing is complete and physical
with gauze or cotton to prevent leakage. Leakage therapy is initiated to restore joint motion and prevent
through the holes in the tubing created by the pins is permanent joint injury. Ideally, the joint is immobilized
also controlled with gauze or cotton to prevent cement for a only a short period of time to minimize joint
from contacting the skin. Alternatively, the PMMA can injury79.
be mixed until it reaches a doughy phase and then
conformed on to the pins. When the PMMA has Circular fixator frames
hardened, the temporary connecting bar is removed Circular external fixators available for use in cats are
and the pins are cut short against the PMMA bar. The based on the ring fixator system used by the Russian
bar is wrapped to cover the cut ends of the pins. surgeon Gavriil A Ilizarov (IMEX Ring Fixator
System, IMEX Veterinary Inc.; Small Bone Fixator,
Transarticular fixators Hofmann s.r.l.)47,80,81. Circular frames are applied
Transarticular fixators are used for joint arthrodesis and in a closed fashion and are very stiff under shear
to stabilize metaphyseal or epiphyseal fractures where and bending loads. However, they allow axial
insufficient bone length is available to immobilize the micromotion at the fracture site, which encourages
fracture fragments adequately using internal fixation healing10,43. Circular fixators can be used to stabilize
(43)78. When transarticular fixators are used to stabilize very small fragments and they are extremely adjustable
articular fractures, the fracture involving the articular after application.
surface is reduced and stabilized using internal fixation The basic circular frame consists of metal rings,
and a transarticular fixator is applied to minimize partial rings, or arches interconnected by threaded
loading of the fracture site and protect the internal rods and nuts. Wires (1.0 mm wires are preferred in
Fracture fixation methods: principles and techniques
73

cats) are placed through the bone and attached to 44


the rings with slotted or cannulated bolts. One or
two rings (with two wires per ring) are placed on
each side of the fracture. Many variations of the basic
frame are possible and they are readily adjusted after
application, making circular external fixator systems
very useful in stabilizing complex fractures,
transporting bone segments to fill defects, or
correcting angular and rotational deformities (44). A
common variation is to combine components of a
circular fixator with those of a linear fixator (‘hybrid
fixator’)46,47. These hybrid frames are particularly
useful when stabilizing fractures with short segments
near joints or repairing fractures proximal to the
elbow or stifle.
A B
Complications of external fixators 44 Circular external fixator.
Complications are common with the use of external A Circular external fixator on a cat tibia.
skeletal fixation, but are easily avoided or managed B Hybrid circular external fixator on a cat tibia.
with proper care (Table 19)16,43,45,77,82. Limb function (Photograph courtesy of Dr. Robert Radasch.)

TABLE 19 COMPLICATIONS OF EXTERNAL FIXATORS.


Complication Prevention/treatment
Pin tract sepsis/premature Use proper pin insertion techniques:
pin loosening • Place pins through stab incisions to reduce skin tension
• Place three to four pins on each side of the fracture
• Reduce thermal necrosis by predrilling holes and using slow-
speed power insertion (rather than hand insertion or high-speed
power)
• Avoid placing pins in fissures or fractures
Use adequately stiff frame configuration
Reduce the fracture so that the bone and fixator are load sharing
Prevent thermal bone injury when using acrylic fixator frame
Restrict patient activity after surgery
Daily cleaning of pin/skin interface or bandage to reduce pin/skin
movement
Limited limb function Avoid penetrating muscles and tendons during pin insertion
Focal osteomyelitis, ring sequestrum Avoid by using proper pin insertion techniques
Treat by removing the loose pin, systemic antibiotics, and curettage of
the necrotic bone. A cancellous graft is placed in the defect.
Pressure necrosis of skin Place frame 1–2 cm from skin surface
Reduce limb swelling with hot compresses or bandage
Iatrogenic fractures Avoid placing pins in fissures
Avoid placing pins too close to fracture
Use pins <25–30% of the diameter of the bone
Delayed or nonunion Place cancellous graft in bone defects
Use proper pin insertion techniques to avoid premature pin loosening
Select adequately stiff fixator frame
Staged removal of the fixator to encourage healing
Frame disruption Confinement and restricted activity
Bandage the fixator and limb
74

may be decreased after fixator application to the femur Plating principles


or humerus if the transfixation pins penetrate large • Aspetic technique is important since infection
muscles. Pin sepsis and premature loosening is a around the implants can lead to delayed healing,
common complication, particularly in comminuted nonunions, draining tracts, and pain.
fractures where the fixator frame bears most of the load • The disruption of soft tissue attachments and
or when a fixator is applied across a mobile joint. blood supply to the bone should be minimized.
Restriction of the patient’s activity after surgery and • Appropriate sizes and shapes of implants should
strict owner compliance are important to prevent be used.
premature loosening at the pin–bone interface and to • Placing screws in the fractures lines should be
ensure the frame is not damaged in the patient’s avoided.
environment. Drainage from the pin tracts is often • A minimum of three screws (five to six cortices)
a sign of pin loosening. Nonunion or delayed union of should be placed though the plate on each side of
the fracture may occur if the fracture is inadequately the fracture line to ensure stable fixation. Longer
stabilized or if the fracture site is infected43,82. Delayed plates distribute the stresses over more of the
healing may also occur if frame stiffness is excessive83. loaded bone and should be used where possible.
Staged removal of the frame can gradually transmit • Autogenous cancellous bone graft (or substitute)
load to the bone and encourage healing. should be placed in all defects if possible.

BONE PLATES AND SCREWS Screw functions (45)


Bone plates and screws are commonly used to Plate screws
stabilize simple and comminuted fractures in cats Plate screws are used to secure the plate to the
(see Table 18). One of the primary advantages of plate bone surface87. The screw passes through a hole in
fixation is that early return to limb function is the plate, compressing the plate to the bone and
expected and encourged. Early limb function providing stability. Cortical screws are used in
minimizes complications such as muscle atrophy, most cases, but cancellous screws may also be used as
joint stiffness, and muscle contracture. It is also plate screws. The stability and rigidity of plate
important in cats with multiple injuries when early fixation is dependent on the number of cortices
use of the fractured limb is essential. grasped by the screw threads. A minimum of three
Plates and screws are available in a variety of sizes screws on each side of the fracture lines is preferred to
and shapes, and when properly applied will control all ensure adequate fixation. The appropriate screw size
of the forces acting on the fracture site (see Chapter 4). is selected for the plate being used.
Plate and screw selection depends on the size of the
bone and the fracture configuration. Specific fracture Lag screws
configurations may require the use of specialized plates Screws placed in lag fashion compress two fragments
or plating techniques. Knowledge of the basic together and provide the stability needed for
techniques and when to use special implants or healing85,87. They are commonly used to stabilize
methods are the keys to successful bone plating. articular fractures and secure butterfly fragments in
Plate application requires that the surgeon expose long bone fractures. Lag screws may be placed through
a large portion of the fractured bone, which can a bone plate or separately from the plate. Both cortical
significantly disrupt soft tissue attachments and blood and cancellous screws may be placed in lag fashion. The
supply. When deciding to use plating techniques for principle of a ‘lag screw’ is that the threads engage only
a given fracture, the advantages of rigid stabilization the cortex on the side of the fracture line opposite the
and early return to limb function must be weighed screw head. The threads engage the far cortex while the
against the disadvantage of delayed healing caused by screw head engages the near cortex. As the screw is
surgical invasion of the fracture site. Plate failure is tightened, the two fragments are compressed.
rarely a result of applying a plate in the ‘wrong’ Partially threaded screws are readily placed in lag
situation, but rather a result of improper implant size fashion because they have threads on only the distal
or errors in application. Plates and screws can be end of the screw. Fully threaded screws are placed in
applied to almost all fracture types, but successful lag fashion by overdrilling the near cortex (‘glide
repair still requires the use of proper surgical hole’) so that the threads do not engage the bone.
technique and strict attention to the principles of The far hole is drilled and tapped to allow the threads
plate/screw fixation84,85. In most cases, plates are not to grasp the bone (‘thread hole’). A drill sleeve is
removed after healing unless complications develop86. inserted into the glide hole when drilling the thread
Fracture fixation methods: principles and techniques
75

hole to ensure it is properly centered. The size of drill tightened, the fragments are fixed in position by the
bits used to create a glide and thread holes varies with threads engaging both fragments.
screw size (see Tables 14, 15). When lag screws are not
placed through a plate, countersinking the near cortex Bone plates
maximizes contact between the screw head and the Bone plates are made of stainless steel or titanium
bone and decreases stress concentration. When and come in a variety of sizes and shapes (see
possible, lag screws are placed perpendicular to the Chapter 5)88–94. Plates vary in length, width,
fracture line. thickness, number of holes, shape of the holes (round
Apophyseal or avulsion fractures can also be or oval), and shape of the plate. Commonly, 2.7 mm
stabilized with lag screws. The screw will compress plates are used to repair femoral, tibial, and humeral
avulsion fractures and counteract the distractive forces fractures in cats. 2.0 mm plates are often used to
created by tendon or ligament attachments. stabilize radial fractures. The application of 2.4 mm
limited-contact dynamic compression plates
Position screws (LC-DCP) may be advantageous in many cats because
Position screws are used to maintain fragment of the reduced bone contact and the smaller screw size
position and prevent bone fragments from collapsing compared with the 2.7 mm implants. Depending on
into the medullary cavity during fracture repair. The how they are applied, plates are used to neutralize
fracture is reduced and a thread hole is drilled and forces, compress fractures together, or bridge gaps in
tapped in both of the fragments. When the screw is the bone.

45

A B

D E F

45 Screw functions. A Plate screws anchor the plate to the bone. B Position screw. Threads engage both fragments and
maintain position, preventing collapse of the fragment into the medullary cavity. C Lag screws compress fragments
together. The screw threads engage only the cortex opposite the screw head (thread hole). The near cortex is overdrilled
(glide hole). D Bone fragments are stabilized with lag screws to reconstruct the shaft of the bone. A neutralization plate is
then applied. E A lag screw is placed through the plate to compress the oblique fracture. F A lag screw is used alone to
stabilize a humeral condylar fracture.
76

Plate functions (46) occurs. Plates placed in buttress fashion are often
Neutralization used to repair severely comminuted fractures when
Plates are applied in neutralization fashion to ‘neutralize’ reconstruction of the fragments is impossible, would
forces across the fracture site86. They are used when the be too time consuming, or would significantly disrupt
fracture is reduced or when fragments are anatomically the blood supply to the fracture site (Table 18). When
reconstructed using lag screws or cerclage wires. The this technique is employed, normal bone length is
plate is then applied over the reconstructed bone to share maintained, less time is spent reducing the fragments,
load and protect the fracture fragments and implants and disruption of the fracture site and its blood supply
from excessive loads generated during weight bearing. is minimized.
Many types of plates can be used in buttress fashion
Compression in cats, including DCP plates and cuttable plates.
Plates are applied in a compression fashion when the Screw holes positioned over the fracture gap must be
fracture segments are reduced, and compressing the left empty, and plate failure through the empty holes
fragments together enhances stability. This is most can occur. Autogenous cancellous bone graft should
often achieved through proper use of the oval holes be placed in all fracture defects to encourage healing
in a dynamic compression plate (DCP). The screw is before plate failure occurs. Specially designed
eccentrically placed in the oval hole, causing the plate lengthening plates are also available for use in buttress
to shift as the screw is tightened. As the plate shifts, fashion (2.0 mm, 8 hole and 2.7 mm, 6, 7, 8 hole
the bone ends are compressed to enhance stability. Biological Healing Plates, Veterinary Intrumentation).
The central portion of the plate is devoid of holes to
Buttress (bridging) prevent implant failure through empty plate holes.
Plates are applied in buttress fashion to bridge defects A plate also serves as a ‘buttress plate’ when used
in a long bone fracture, support joint fractures, and to stabilize joint fractures. The plate supports the
restore normal limb length after malunion or angular metaphyseal portion of the bone and maintains proper
limb deformity. When a gap exists at the fracture site joint alignment during fracture healing.
such that bone fragments do not share in load
bearing, the plate supports the fractured bone and Plate and screw application techniques
maintains normal limb length by preventing collapse Simple fractures
at the fracture site. The plate bears the entire The fracture segments are identified and reduced,
functional load applied through the bone until healing avoiding disruption of the soft tissues and vascular

46 46 Plate functions.
A Plate used in bridging (buttress)
fashion to prevent collapse of the
fracture gap.
B Plate applied in compression fashion
to stabilize a transverse fracture.
C Plate applied in neutralization
fashion after reconstruction of the
fracture with lag screws.

A B C
Fracture fixation methods: principles and techniques
77

supply. Care is also taken to prevent further fissuring Metaphyseal fractures


of the fragments. Once the bone ends are reduced Metaphyseal fractures can be stabilized using T plates
and properly aligned, a plate is applied in compression or L plates (47). These specialized plates are designed
fashion to compress the fracture ends together, for use on fractures located near the ends of long bones,
increasing stability and promoting healing. The when only a small fragment of bone exists between the
stability provided by such rigid internal fixation allows fracture site and the joint. The plate allows several
early return of limb function. screws to be placed in the small fragment of bone.

Comminuted fractures Articular fractures


In comminuted fractures, several options exist for Interfragmentary compression at the articular surface of
plate stabilization: the fracture is achieved with lag screws or with screws
• The fragments are reduced and stabilized with lag placed through a buttress plate. Placement of a buttress
screws or cerclage wires and a neutralization plate plate on the metaphyseal region of a bone to support an
is applied. Care must be taken to avoid damage articular fracture can be difficult because of the limited
to the blood supply and surrounding soft tissues. bone available for screw placement. T plates, L plates,
• If the comminuted area constitutes a small area of and cuttable plates may be used. The plate must be
the overall bone length, the primary fracture ends carefully contoured to ensure the articular fracture is
can simply be apposed and plated (compression not displaced when the plate is applied.
plate) without significantly shortening the limb.
The small, comminuted fragments are discarded Irregularly shaped bones
or packed around the fracture site as bone graft. Fractures of curved or flat bones like the ilium, scapula,
• If the area of comminution is too great to allow and mandible can be stabilized using regular DCP
shortening of the bone and too severe to permit plates, the more easily contoured reconstruction plates,
reconstruction, a plate is applied in buttress mini plates, cuttable plates, or cuttable malleable plates.
(bridging) fashion. Fragments are left in place if
they have a blood supply or can be gently moved Plate–rod fixation
closer to the fracture site using absorbable suture A combination of an intramedullary Steinmann pin
material. Alternatively, they can be morselized using and a bone plate may be used to stabilize severely
a rongeur and used as graft to fill the defect. comminuted diaphyseal fractures (Table 18) (48)95–97.
Autogenous cancellous graft is placed in the defect. This technique provides adequate stability while

47 48

47 T plate applied to the proximal tibial metaphysis. 48 Plate-rod fixation of a femoral fracture. An
intramedullary pin and plate are used in combination.
78

minimizing trauma to the fragments and soft tissues at 2.0 mm solid self-tapping cross-locking bolts
the fracture site. The intramedullary pin is first (Innovative Animal Products LLC.) (see Chapter 5).
inserted normograde to restore proper bone length
and alignment, and to maintain distraction while the ILN insertion technique
plate is applied. A pin that fills 35–40% of the Radiographs of the contralateral, unfractured bone are
medullary cavity is used. This smaller pin provides used to determine the size of the medullary cavity and
room to insert the plate screws and prevents excessive select the appropriate diameter and length of nail. The
rigidity of the plate–rod construct, which can delay larger 4.7 mm nail will fit into the medullary cavity in
healing. The bone fragments and fracture hematoma some cats. However, the smaller 4.0 mm nail will
are not disturbed. However, if large fragments are far generally fit more easily (particularly in the tibia),
from the bone column, they may be gently brought preserving endosteal blood supply and reducing
closer using absorbable suture material. No attempt is iatrogenic trauma to the bone during insertion102. The
made to reduce the fragments anatomically. A bone nail should be long enough to ensure that the screws
plate is then contoured to the tension surface of the can be placed through the ILN on both ends of the
bone and applied in buttress fashion. Radiographs of bone and that the screw holes are 1–2 cm from the
the contralateral normal bone may be helpful when fracture site. For fractures near the ends of the long
contouring the plate. The most proximal and distal bone, ILNs with a single hole are used to avoid placing
screws are inserted to engage both cortices of the a screw hole near the fracture site. Using a single screw
bone (bicortical). The remaining screws need only at one end of the nail does not significantly alter the
engage the near cortex (monocortical). A minimum stability provided at the fracture site and is preferred
of three monocortical screws and one bicortical screw over placing a screw too close to the fracture100.
should be used on each side of the fracture. The pin The fracture is exposed via a limited surgical
reduces the strain on the plate and increases fatigue approach. The proximal cortex and medullary cavity are
life of the plate as the bone heals. opened using the nail or a Steinmann pin of the same
diameter. For many fracture types, it is easier to create
INTERLOCKING INTRAMEDULLARY an opening into the medullary cavity by using
NAIL FIXATION a Steinmann pin drilled through the proximal cortex in
Interlocking nails (ILNs) are inserted into the a retrograde fashion from the fracture site. A series of
medullary cavity like an intramedullary pin98–102. They pins with increasing diameters is used until a hole is
provide greater bending stiffness than plates and screws created large enough to accommodate the desired nail.
because the nail is placed in the medullary cavity along This retrograde approach is more disruptive to the
the neutral axis of the bone102. The ILN can also be fracture site, but often facilitates proper nail insertion19.
inserted through a limited approach, reducing injury to The extension rod and insertion handle are then
soft tissues and blood supply at the fracture site. The attached to the nail and it is introduced into the cavity
relatively long, straight bones of the cat are well suited in a normograde fashion. Ideally, the nail is placed
for fracture repair using intramedullary fixation (49). with minimal disruption of the fracture site. The ILN
Small nails (4.7 mm and 4.0 mm diameter) are is passed across the fracture line and seated distally
available for stabilization of simple and comminuted without penetrating the articular surface. Another nail
fractures of the femur, tibia, and humerus in cats (Small of the same length can be used to estimate the depth
Interlocking Nail System, Innovative Animal Products of insertion. Careful examination of the radiographs
LLC.)101–104. The nails are made of 316L stainless steel and visualization of the fracture may also help ensure
and have a trocar point on one end for normograde that the nail is inserted to the proper depth. The
insertion. They are solid except for the screw holes proximal end of the nail should be seated below
drilled near each end. Using a specially designed the proximal cortex. This is important in femoral
insertion guide, screws are inserted through the bone fractures to prevent sciatic entrapment and seroma
and the nail to provide axial and rotational formation; and in tibial fractures to avoid trauma to
stability98–100. The nails are available in 68 mm, the articular cartilage of the femoral condyles.
79 mm, 91 mm, 101 mm, 112 mm, 123 mm and Once the nail is adequately seated, the insertion
134 mm lengths. Each has either four screw handle is removed and the drill-aiming guide is
holes (two proximal and two distal) or three screws attached to the nail via the extension rod. The
holes. Three-hole nails may have a single distal or extension rod allows the nail to be fully seated within
proximal screw hole. The holes are 11 mm apart and the bone while still attached to the aiming device.
accommodate either 2.0 mm diameter screws or The drill-aiming guide lies parallel to the nail, on
Fracture fixation methods: principles and techniques
79

the outside of the limb, and has guide holes corre- (1.5 mm for screws and 2.0 mm for bolts) are then
sponding to the screw holes in the nail. This allows the inserted into the same hole in the aiming device.
surgeon to drill a hole accurately through the cortical A hole is drilled, with the bit passing through the near
bone that is in line with the holes in the intramedullary cortex, the hole in the nail, and through the far cortex
nail. Special sleeves fit into the holes in the aiming guide of the bone. The surgeon must be careful not to allow
to allow the surgeon accurately to drill, tap, and insert the drill bit to ‘walk along’ the bone surface before
the screws without visualization of the holes in the nail. engaging the cortex, or the misplaced screw or bolt
The distal screw or bolt is generally placed first via may miss the hole in the ILN. The depth of the drill
a small stab incision over the appropriate portion of hole is then measured with a depth gauge, the hole is
the bone. The trocar guide and sharp trocar are tapped if using a screw with a 2.0 mm tap, and the
inserted through the appropriate hole in the aiming appropriate length screw or bolt inserted through the
guide, which corresponds to the distal screw hole in bone and ILN. After insertion of one of the distal
the nail. The sharp trocar separates the soft tissues to screws or bolts, the fracture reduction is checked.
allow access to the bone. It is pushed against the bone Proper rotation, alignment, and axial bone length are
surface to create a starting point for the drill bit. Care confirmed and the remaining implants are inserted.
is taken not to move the aiming device during this The extension rod and aiming device are removed
procedure. The drill sleeve and appropriate drill bit from the proximal end of the ILN.

49

A B C
49 Interlocking nail fixation.
A Interlocking nail attached to the extension rod and drill-aiming guide. Holes in the aiming guide are aligned with the
screw holes in the interlocking nail.
B Screw placement in the interlocking nail. The nail (1) is attached to the extension rod (2) and inserted in the medullary
canal. The drill-aiming guide (3) is attached. A drill bit is passed through the drill sleeve (4) to create a hole in the bone
that is in line with the screw hole in the nail.
C Interlocking nail in the femur secured with two screws proximally and distally.
80

When repairing comminuted fractures, the collected from the same patient and have the
fragments can be left in situ and the nail serves as advantage of early revascularization and early
a buttress function to maintain bone length. osteoinduction105–110. Allografts are also available
Alternatively, the fragments can be anatomically (Veterinary Transplant Services Inc.). Cancellous and
reduced with cerclage wires and the nail inserted into corticocancellous grafts do not provide structural
the distal portion of the fracture (neutralization support like cortical grafts, but they do promote
function). In many cases, it is preferable to avoid using bone healing by osteogenesis, osteoinduction, and
cerclage wires unless they contribute significantly to osteoconduction. Osteogenesis is the term given to the
the repair. Autogenous cancellous bone graft can be graft’s ability to promote healing by delivering live,
placed at the fracture site if desired, or small fracture bone-producing cells to the fracture site. A small
fragments can be morselized using a ronguer and percentage (approximately 10%) of the transplanted
packed around the fracture. The incision is closed bone cells survive the transfer and produce new bone in
routinely and the fracture radiographed to confirm the recipient site. The percentage of cells that is viable
reduction and ILN placement. after transplantation depends on proper collection
Postoperatively, the patient’s activity must be methods and care of the graft material. Osteoinduction
restricted until bony union is confirmed radiogra- is the term given to the graft’s ability to promote
phically. Radiographic evaluation at 4 and 8 weeks is healing by encouraging undifferentiated cells at the
recommended. The implants are generally not fracture site to produce bone. Components of the graft
removed unless complications occur; however, a nail recruit mesenchymal cells in the recipient site to
extractor is available should removal be necessary. differentiate into cartilage or bone-forming cells. Bone
Removal of screws or bolts from the end of the nail will morphogenic protein and other vital components of
allow dynamic loading of the fracture site and can be the graft are likely to be responsible for inducing bone
used to encourage healing102. production at the fracture site. Osteoconduction is
the term given to the graft’s ability to encourage bone
Complications of interlocking nails healing by providing a scaffold for ingrowth of
Complications reported with ILN fixation include capillaries and osteoprogenitor cells from the
breakage of the nail at the screw holes, breakage of surrounding bone and soft tissues110.
the screws, missing the screw holes during screw/bolt
placement, and delayed healing99,101,102. Failure at the INDICATIONS
screw holes is usually associated with using an Cancellous and corticocancellous bone grafts are
undersized ILN or placing screw holes too near the commonly used to encourage healing of comminuted,
fracture site. Missed screw holes in the nail usually delayed union, and nonunion fractures and to promote
occurs distally and is avoided by attaching the aiming arthrodesis of joints111. They have also been described
guide tightly to the nail, ensuring the aiming device for use in the treatment of chronic osteomyelitis. In
does not shift during drilling, using a sharp drill bit, and fracture repair, autogenous bone graft is indicated to fill
marking the cortex with the trocar to prevent the drill gaps at the fracture site, replace missing bone fragments,
bit from slipping on the cortical surface when drilling19. or promote healing by being placed around the fracture
Delayed union can occur with any fixation method site. Cancellous and corticocancellous bone grafts are
and can be minimized by disrupting the fracture particularly helpful in fractures that have the potential
hematoma and the bone’s soft tissue attachments as for delayed union or nonunion. Unlike cortical bone
little as possible during the surgical procedure. Careful grafts, cancellous grafts can be placed in contaminated
technique and attention to the rules of biologic fixation fracture sites without concern for sequestration.
is perhaps the best way to prevent delayed healing.
Sciatic neuropathy can occur when using an ILN to AUTOGENOUS GRAFT COLLECTION
stabilize femur fractures and is prevented by inserting An autogenous bone graft must be collected properly
the nail completely into the trochanteric fossa. to maximize its effectiveness and prevent complications.
If a graft collection is anticipated, the donor site (or
CANCELLOUS AND sites) must be selected and prepared before surgery.
CORTICOCANCELLOUS Collection of graft from several sites may be required if
BONE GRAFTING a large quantity of graft is needed. The sites selected
Cancellous and corticocancellous bone grafts are may depend on the amount of graft required, the sites
used to fill cortical defects or are placed around the that are readily accessible when the patient is positioned
fracture site to promote healing. Autogenous grafts are on the surgery table for fracture repair, and any
Fracture fixation methods: principles and techniques
81

morbidity associated with the donor site. The sites must sponge. A sponge moistened with blood is ideal. The
be clipped and scrubbed to prevent infection of the graft should not be allowed to desiccate and should not
donor site during collection. In most cases, the graft is be immersed in fluid. The graft should be placed in the
collected just before it is needed. However, if the recipient site as soon as possible after collection, as
recipient site is infected or contains neoplastic cells, the minimum storage time ensures maximal graft survival.
graft can be collected first to prevent contamination of The graft is gently packed into the recipient site and the
the donor site. A separate surgical pack or a separate surrounding soft tissues help hold the graft in place.
surgery team may be used to collect the graft. Overfilling the defect with cancellous bone does not
In cats, autogenous cancellous graft may be enhance healing114. Once a sufficient quantity of graft
collected from the greater tubercle of the humerus, the is collected, the incision over the donor site is closed
proximal tibia, the proximal femur, and the iliac crest routinely. Cancellous or corticocancellous allografts or
(50)108,109,112,113. These areas contain sufficient graft substitutes may be used instead of autograft
quantities of cancellous bone and are readily accessible. placement. In some cases, allografts or graft substitutes
The proximal humeral site provides more graft than the are used as extenders for autografts in cats115.
tibia and has been found to heal more quickly after graft
collection. For some surgeons, the iliac crest is the COMPLICATIONS
preferred site for graft collection in cats. Complications after collection of autogenous
A small incision is made in the skin and cancellous graft are rare. Infection of the donor site,
subcutaneous tissues over the donor site. A trephine, seroma formation, or fracture of the donor bone are
Steinmann pin, or drill bit is used to create a hole in potential risks but are uncommon if the collection is
the near cortex of the bone. When collecting graft performed properly. Collection of the graft may also
from the iliac crest, a saw, rongeur, or osteotome may increase operative time if a separate surgical team is
be used to remove the dorsal cortex and permit access not available.
to the medullary cavity. A bone curette is used to
remove the cancellous bone from the medullary cavity
(51). Corticocancellous graft is readily collected from
the iliac crest. The cortical bone removed from the iliac 51
crest to gain access to the medullary cavity is saved. It
is morselized using a bone rongeur and mixed with the
cancellous bone removed from the medullary cavity. In
some cases, small bone fragments from the fracture site
can be used as corticocancellous graft.

GRAFT PLACEMENT
The autogenous bone graft is immediately placed in the
recipient site or stored briefly by wrapping it in a moist
A B

50

C
51 Technique for collection of autogenous cancellous
bone graft.
A A small surgical approach is made to the bone and
a hole is drilled in the cortex with a pin or drill bit.
50 Cat skeleton showing the proper collection sites for B Cancellous bone is removed with a small bone curette.
cancellous graft: greater tubercle of the humerus, proximal C Autogenous cancellous bone removed from the greater
tibia, proximal femur, and iliac crest. tubercle of the humerus in a cat.
82

IMPLANT REMOVAL interfere with healing. Complications that may warrant


Staged removal of external fixator pins may be used plate removal include infections, stress protection of
to destabilize the frame gradually, thus increasing the the bone by the rigid implants, implant failure, and
load on the bone and preventing stress protection. lameness that occurs in cold weather when plates are
This is particularly helpful in cats where rigid frame applied to the distal extremities86.
configurations can slow healing83. Staged removal is
advocated when fracture healing is slow and would be DELAYED AND NONUNION
stimulated by gradually loading the fracture site. FRACTURES
Otherwise, the external fixator pins are simply Delayed unions and nonunions occur infrequently
removed when healing is complete. In most cases, the in cats. The reported incidence ranges from approxi-
fixator can be removed with the patient under mately 2–4.3%116,117. Nonunions occur most often in
sedation, although a short-acting general anesthetic fractures of the tibia and proximal ulna116. Delayed
may be needed to remove positive profile pins. unions are those fractures that are healing slowly and
During fracture healing, loose pins may need to be have failed to unite in the expected period of time.
removed if they cause pain and tissue reaction50. Nonunion fractures are those in which the bone ends
Internal implants (plates, screws, intramedullary have failed to unite and all signs of repair (osteogenic
pins, and wires) may be removed when healing activity) have ceased118,119. The cat’s age, the length of
is complete, but are often left in place unless time since repair of the fracture, and the fixation
complications develop, since removal requires addi- method employed are considered when distinguishing
tional surgery and added expense. Complications that a delayed union from a nonunion.
may warrant removal of intramedullary pins include
pin migration, seroma formation, soft tissue irritation, NONUNION FRACTURES:
and persistent lameness. Sciatic irritation after CLASSIFICATION (52)120
intramedullary pinning or interlocking nail fixation of Biologically active or viable
the femur necessitates implant removal. Pins should • Hypertrophic – a large, nonossified callus is
also be removed if they become loose and interfere present, caused by motion at the fracture site.
with fracture healing. Cerclage wires are rarely • Moderately hypertrophic – a callus is present but
removed unless they become loose or break and is not overly large.

52

A B C D E F G

52 Nonunion fracture classification system described by Weber/Cech.


Biologically active (viable) nonunions include:
A Hypertrophic nonunion with a large, nonossified fracture callus. B Moderately hypertrophic nonunion.
C Oligotrophic nonunion with minimal fracture callus. Biologically inactive (nonviable) nonunions include:
D Dystrophic nonunion. E Necrotic nonunion. F Defect nonunion. G Atrophic nonunion.
Fracture fixation methods: principles and techniques
83

• Oligotrophic – the fracture callus is minimal Implants are more likely to loosen in an infected
or absent. Oligotrophic nonunions are distinguished fracture site, leading to instability. Proper wound care
radiographically from nonviable nonunions by the and surgical technique are essential in preventing
irregular, hazy appearance of the bone ends infection during fracture treatment.
indicative of vascularity.
Other causes
Biologically inactive or nonviable Other less common causes of delayed and nonunion
• Dystrophic – fragments fail to heal because of fractures in cats include osteopenia, neoplasia, radia-
a loss of blood supply. tion therapy, glucocorticoid medication, metabolic
• Necrotic – fragments fail to heal because of abnormalities, and nutritional deficiencies.
infection or sequestration.
• Defect – fragments fail to heal because of an DIAGNOSIS
excessive fracture gap. Delayed union and nonunion fractures are diagnosed
• Atrophic – as nonviable nonunions progress, by physical examination and radiography. Physical
they may become osteoporotic and lose blood examination findings can include disuse muscle
supply and osteogenic activity. Resorption of atrophy, lameness, limb deformity (angular,
the bone ends occurs. rotational, or shortening), pain, and reluctance to
use the limb. Drainage from the fracture site may
CAUSES OF DELAYED AND NONUNION occur if infection is present. Delayed unions are
FRACTURES characterized radiographically by the presence of a
Delayed and nonunion fractures are typically caused by fracture gap, although signs of progressive healing
biologic or biomechanical factors (or a combination of (i.e. callus formation) are evident. Common
both). Predisposing factors include the severity radiographic features of nonunion fractures include
of initial trauma, the extent of soft tissue injury, sclerotic fracture ends, the presence of a gap between
comminution, bone loss, devascularization of fracture fragments, and smooth, well defined fracture
fragments, poor reduction, poor fixation, and surfaces (53). Radiographs should be evaluated for
infection118,119. Nonunions are more likely to occur in
older cats and heavier cats116.

Inadequate stabilization of the fracture 53


Instability is the most common cause of delayed
unions and nonunions in cats and is generally a result
of selecting an inadequate fixation method or
improper application of the implants. Premature
loosening of orthopedic implants may also lead to
instability and poor healing.

Large fracture gap


Repair tissues are unable to bridge large fracture gaps
caused by bone loss, surgical resection, or distraction.
The resultant gap fills with fibrous tissue or cartilage
and fails to mineralize.
A B C
Loss of blood supply to the fragments 53 Radiographs of a nonunion radius and ulna fracture in a
Devascularization caused by the initial trauma, surgical cat. A Lateral radiograph obtained 4 months after an
intervention, excessive periosteal stripping, soft tissue intramedullary pin was inserted in the radius to stabilize
retraction, desiccation of soft tissues and bone, and a diaphyseal fracture. The cat was nonweight-bearing on the
liberal use of electrocautery can contribute to a loss of limb. B Lateral radiographic view after removal of the pin.
blood supply to the fracture site. No callus is evident and the fracture has failed to heal. The
bone ends are sclerotic and atrophied. C The nonunion
Infection of the fracture site fracture is stabilized with a compression plate applied to the
Bone fragments will heal in the presence of infection cranial surface of the radius. Autogenous cancellous bone
only if they are stable and have adequate blood supply. graft was packed around the fracture during surgery.
84

evidence of infection when a nonunion is suspected. compression is not possible. External fixators can also
Varying degrees of callus are present at the fracture be used to stabilize viable nonunions.
site in viable nonunions. In nonviable nonunions,
the bone ends may appear atrophied and Nonviable nonunions
osteopenic 118,120. Nuclear scintigraphy can be Treatment of nonviable nonunions requires proper
helpful to determine whether bone ends are alignment and stabilization of the fracture site and
vascularized. steps to promote the biological healing process by
encouraging revascularization of the fragments. Bone
TREATMENT OF DELAYED UNION plates (and occasionally external fixators) are used to
In many cases, delayed unions are managed by simply stabilize the fracture rigidly. Revascularization of the
allowing more time for healing to occur. The cat’s fracture site is enhanced by opening the medullary
activity is restricted to prevent implant failure and the cavity with a Steinmann pin or drill bit, placing
fracture is monitored radiographically. If instability at autogenous cancellous bone graft at the fracture site,
the fracture site is contributing to delayed healing, and drilling holes in dense cortical bone to allow
additional support may be provided using an external vascular ingrowth. Onlay bone grafts may also be used
fixator or external coaptation device. However, to encourage healing and provide stability. The
if instability is severe, an entirely new fixation method surrounding soft tissues are handled with care during
should be applied to the fracture. Autogenous surgery to preserve blood supply. Electrical stimulation
cancellous bone graft can also be placed to stimulate has also been used to promote healing of nonunions,
more rapid healing. Infection is controlled by since bone growth is associated with electronegativity
antibiotic therapy (based on culture and sensitivity and an electrical current may encourage bone
testing) if indicated. deposition. However, the lack of clinical trials, and the
additional expense, has limited the use of electro-
TREATMENT OF NONUNION FRACTURES stimulation to treat nonunions in cats.
Successful treatment of a fracture nonunion is In infected nonunions, rigid fixation and pres-
contingent upon correcting the biomechanical and ervation of blood supply are very important.
biological factors that influence bone healing118,119. Additionally, all dead bone (sequestra) must be removed
and infected bone is debrided using rongeurs and
Viable nonunions curettes. Infected soft tissues, draining tracts, and fistulas
Viable nonunions often result from instability. are debrided and aerobic and anaerobic samples are
Treatment involves neutralization of the forces acting collected for culture and sensitivity testing. Rigid
on a fracture site by proper internal fixation. In some fixation is applied, the wound is lavaged, and autoge-
cases, the existing fixation method can simply nous cancellous bone graft is placed at the fracture site.
be enhanced to provide additional stability. For Delayed grafting may be indicated if infection is severe.
example, an external fixator can be applied to provide Appropriate antibiotics are administered systemically.
rotational support in a fracture previously repaired Local therapy with antibiotic-impregnated methyl-
with intramedullary pin. This is most beneficial if methacrylate beads may also be used. The wound is
performed before the healing process ceases, however, closed if possible; however, open wound management
and may be inadequate to encourage healing once may be preferred in some cases. The surgical implants
a nonunion has developed. In other cases of viable may be removed when the fracture heals or if they
nonunion, the initial fixation method is abandoned become loose.
and rigid fixation is applied, often using a bone plate Early return to function, proper physical therapy,
(53). Sufficient callus is removed to position the plate appropriate antibiotic treatment (if indicated), and
properly and the callus and bone are compressed. owner compliance are essential for a successful
Debridement of the fibrous pseudoarthrosis between outcome. Many patients will require multiple surger-
the bone ends and opening the medullary cavity is not ies to provide stability, place additional cancellous
essential but may be performed if it is required to grafts, and remove implants.
achieve adequate reduction, if it will not interfere with
blood supply, and does not result in significant ARTICULAR FRACTURES
shortening of the limb. In some cases, the bone ends Articular fractures are treated with open reduction and
are simply removed with a bone saw and the resultant internal fixation to achieve proper alignment, ensure
transverse fracture is plated under compression. stability necessary for early postoperative motion, and
Stable, rigid fixation should be achieved even if restore normal joint function. Malarticulation,
Fracture fixation methods: principles and techniques
85

osteoarthritis, joint pain, and limited function may reduction. Fragment stabilization is provided using one
result if articular fractures are poorly reduced or of several methods (54):
unstable. Adequate surgical exposure is created to • Ideally, screws are placed in lag fashion to provide
visualize the joint and the fractures fully. Small interfragmentary compression and counteract
cartilage fragments devoid of subchondral bone are shearing forces at the fracture site; 2.7 mm screws
removed. Articular fragments with attached subchon- are preferred, although 1.5 mm or 2.0 mm screws
dral bone are manipulated into reduction, taking care are often used for small fragments. The screws are
not to damage the articular cartilage. Large gaps or placed through the subchondral bone, avoiding
steps in the articular surface are prevented by accurate damage to the articular surface. If necessary, the

54

A B C D E

F G H I

54 Repair of intraarticular fractures. A A transcondylar lag screw is inserted to compress the intraarticular fracture.
Accurate anatomic reduction is required to prevent gaps or steps in articular surface. B A transcondylar lag screw is
inserted to stabilize the intraarticular fracture. The supracondylar portion of the fracture is stabilized with cross pins.
C A lag screw is inserted from the metaphysis into the articular fragment. The screw does not penetrate the articular
surface. D A lag screw is inserted from the articular surface. The screw head must be countersunk below the cartilage
surface. E Kirschner wires are inserted from the metaphysis into the articular fragment. Interfragmentary compression is
not achieved with pin fixation. F A single Kirschner wire inserted through the femoral neck and into the osteochondral
fragment to stabilize a fracture of the femoral head. G Two Kirschner wires inserted from the articular surface. The wires
are countersunk below the cartilage surface to reduce trauma to the opposing cartilage. H A plate is applied to the
metaphysis of the bone to buttress the articular surface. A plate screw may be placed in lag fashion through the plate to
compress the fracture line. I A transarticular external fixator is applied to protect the internal joint fixation during healing.
86

screws can be inserted through the articular the progression of osteoarthritis is often slow and most
cartilage and the heads countersunk below the cats function well, with limited range of motion. Cats
surface. However, damage to the opposing rarely require arthrodesis for adequate, pain-free
articular surface may occur. function even if moderate osteoarthritis develops.
• Kirschner wires may be used to maintain
reduction of very small fragments, but they do JOINT ARTHRODESIS
not provide compression. If Kirschner wires are Joint arthrodesis (fusion) is rarely required in cats. It
inserted through the articular cartilage, they must may be an alternative to limb amputation in some
be countersunk below the surface to avoid trauma cases to preserve function in cats with compli-
to the opposing cartilage. cated intraarticular fractures or joint luxations, painful
• If necessary, a plate or external fixator may be joint instability, severe osteoarthritis unresponsive to
used to support (buttress) the joint fixation medical therapy, or postural abnormalities caused
during healing. Transarticular fixators may be by neurologic dysfunction122,123. Various techniques
applied if needed, but are removed once initial used for arthrodesis of specific joints are discussed in
healing has occurred to allow joint motion. the pertinent chapters. The steps to achieve arthrode-
sis of any joint include:
Joint motion is encouraged soon after surgery to 1. Removal of the articular cartilage with curettes,
preserve function and cartilage health. Early joint rongeurs, power driven burrs, or a bone saw to
function without disruption of the fracture site expose the subchondral bone. Sclerotic
obviously requires adequate internal fixation of subchondral bone is removed to expose bleeding
osteochondral fragments and restoration of normal cancellous bone.
ligamentous structures and joint capsule. Passive 2. Placement of autogenous cancellous bone graft at
motion exercises may be used until the cat is able to the arthrodesis site to promote bony union across
bear weight on the limb. If fracture fixation is the joint.
inadequate to permit early joint function, the joint is 3. Application of rigid fixation. Bone plates, external
immobilized with a splint, cast, sling, or external fixators, lag screws, and, in some cases, Kirschner
fixator to protect the repair until partial healing has wires can be used. Where possible, compression
occurred. Typically, the external support can be should be applied between the exposed
removed in 3–4 weeks121. subchondral bone surfaces to enhance healing.
Complications after an articular fracture repair may The joint should be fused in a weight-bearing
include implant failure, reduced range of motion, and position.
osteoarthritis. Osteoarthritis is more severe in cases 4. Support of the fixation with external coaptation
with malalignment of the cartilage surface. Fortunately, or a transarticular external fixator if necessary.
87

CHAPTER 7
ARTHROLOGY

Feline arthrology has been an overlooked subject in term osteoarthritis is reserved for the specific type of
the past with most reviews of joint disease in small DJD that affects diarthrodial synovial articulations.
animals focusing on the dog. However, cats are now Diseases of synovial joints can conveniently be
known to suffer from many different types of joint divided into degenerative arthritis and inflammatory
disease and, although there are many similarities with arthritis on the basis of the predominant pathologic
the dog, there are also many features that are unique process (Table 20). Degenerative arthropathies are the
to the feline patient. most common types and include traumatic arthritis and
osteoarthritis. Inflammatory arthropathies are less
CLASSIFICATION OF JOINT DISEASE common than degenerative arthropathies and have
The terms arthritis and arthropathy literally mean joint either an infective or immune-mediated etiology.
inflammation and joint disease, respectively. These terms Infective arthritis caused by bacterial infection (septic
are used interchangeably in this chapter to describe arthritis) is the commonest type of inflammatory arthritis
a number of well defined joint diseases characterized in the cat. Septic arthritis is classed as an erosive type of
by a combination of inflammatory and degenerative arthritis because there is destruction of articular cartilage
changes. The terms degenerative joint disease (DJD) in joints infected by bacteria. Immune-mediated
and osteoarthritis are also often used synonymously. In arthropathies can be subdivided into both erosive
this chapter, DJD is used as a general descriptive term to and nonerosive forms. Differentiation between the
encompass degenerative changes in any joint in the infective and immune-mediated forms of inflammatory
axial or appendicular skeleton, including synovial, arthritis is essential since the therapeutic approaches
cartilaginous, and fibrous types. When DJD affects the to these conditions are diametrically opposed.
fibrocartilaginous intervertebral joints of the spine, it is Inappropriate treatment of an infective arthritis with
known as spondylosis deformans (see Chapter 11). The immunosuppressive drugs will have disastrous results.

TABLE 20 CLASSIFICATION OF JOINT DISEASE.


Degenerative Inflammatory Miscellaneous
arthritides arthritides joint disorders
Infective Immune-mediated Synovial sarcoma
Osteoarthritis arthritides arthritides Secondary neoplasia
Traumatic Primary Bacterial (septic) Systemic lupus erythematosus Hypervitmainosis A
arthritis Secondary Bacterial L-form Polyarthritis/meningitis Osteochondroma
Mycoplasmal Idiopathic Synovial osteochondromatosis
Calicivirus Periosteal proliferative Synovial cysts
Lyme disease Rheumatoid Patellar malformation
Tubercular Meniscal calcification
Fungal Osteochondritis dissecans
Osteochondrodysplasia in
the Scottish Fold cat
88

INVESTIGATION OF JOINT DISEASE then to stop interpreting the radiograph before the
SYNOVIOCENTESIS whole film has been assessed. All three components of
For details of synoviocentesis and analysis of synovial the joint should be evaluated radiographically: the
fluid see Chapter 2. bones, the soft tissues, and the joint space. The specific
features that should be examined are the bony anatomic
RADIOGRAPHY relationships, subchondral bone plates and subchondral
Radiography is the most frequently used ancillary bone of the epiphyses, the width and contents of the
diagnostic aid in the investigation of joint disease. joint space, the articular margins and periarticular
Radiographs should be interpreted in the light of the regions, and the periarticular soft tissues. The
clinical findings and not used as a substitute for a radiographic appearance of some disorders that are
correctly performed clinical examination. Radiography familiar to the canine clinician may differ in the cat. For
is usually used to confirm a suspected clinical diagnosis example, the predominant radiographic signs of feline
or to differentiate between two or more joint diseases hip dysplasia are a shallow acetabulum with remodeling
that have similar clinical characteristics. However, of the craniodorsal margin but with minimal
radiographic surveys of multiple joints might be remodeling of the femoral neck (55)1.
indicated to evaluate the overall status of the patient in • The anatomic relationships of the bones making
conditions that are frequently polyarticular, such up the joint may be altered with joint luxation,
as osteoarthritis or immune-mediated arthritis. subluxation, and intraarticular fracture. Reference
Radiographs of other body regions may be indicated; to a radiographic atlas, a file of normal cat
for example, in cats with joint trauma or neoplasia or radiographs, or a radiograph of the contralateral
some of the immune-mediated arthritides to check for joint may be helpful, especially for the smaller
evidence of lesions elsewhere. more complex joints of the distal extremities.
Feline joints are small so it is essential to obtain high • The subchondral bone plate should appear as a
quality radiographs if they are to be of diagnostic value. thin radiopaque line parallel to and adjacent to
Radiographs of joints should be correctly collimated to the joint space. Erosion of the subchondral plate
minimize scatter and obtained using fine detail screens
in two orthogonal planes (i.e. at right angles to
each other). Human mammography film/screen
combinations are especially useful for radiographs of the 55
distal extremities. Additional stress views may be
performed in the evaluation of joint instability. Oblique
projections and special views to outline certain
structures are performed less frequently in the cat than
in the dog. It is often useful to radiograph the
contralateral joint to provide a normal radiograph for
comparison or because some conditions occur
bilaterally. General anesthesia or heavy sedation is usually
required for optimal positioning.
Radiographic interpretation must be thorough and
complete so that each structure is assessed according to
its Roentgen signs. Radiographic lesions in feline joint
disease are often subtle and the use of a magnifying
glass and a bright light in addition to a normal viewer is
recommended. The radiologist should be familiar with
normal feline osteology and with the radiographic
appearance of normal feline joints. Accessory centers of
ossification and sesamoid bones may be present in or
around joints and these ossicles should not be confused
with chip fractures. For example, an accessory center of
ossification may be present as a normal anatomic variant
in the shoulder joint on the caudal or medial rim of the 55 Ventrodorsal radiograph of the pelvis of a cat with
glenoid. Methodical examination is essential; the most coxofemoral osteoarthritis secondary to hip dysplasia. Note
common error is to find the expected abnormality and the remodeling of the cranial margins of the acetabula.
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89

occurs with erosive immune-mediated or infective example joint sprain, whereas thickening is a
arthritides, osteomyelitis, and joint neoplasia. chronic change most often associated with joint
Localized areas of sclerosis and remodeling of the instability, such as chronic cranial cruciate
subchondral plate may be seen at the margins of ligament (CrCL) rupture. It is not possible to
destructive lesions, such as osteomyelitis. differentiate between thickening and swelling
However, sclerosis is more commonly seen as a radiographically. Mineralization of periarticular
generalized change in chronic osteoarthritic joints tissue is a rare occurrence. It is occasionally seen
where there is loss of articular cartilage and as a sequela to chronic inflammation, for example
eburnation of the opposing joint surfaces. bacterial infective arthritis, and is also a feature of
• The subchondral bone of the epiphysis synovial osteochondromatosis.
subadjacent to the subchondral plate should have
a homogenous appearance. In comparison with Contrast arthrography
the dog, the cancellous bone of cats has a coarse Contrast arthrography is rarely performed in the cat.
trabecular pattern. Osteomyelitis, neoplasia, and Positive contrast arthrography involves the injection of
articular fracture will cause an alteration in the a contrast agent into a joint space so that it mixes with
internal architecture of the trabecular bone. the synovial fluid and delineates the internal margins of
Subchondral cysts are occasionally seen in the joint. The contrast agent of choice is iohexol
osteoarthritic joints in cats as discrete radiolucent (Omnipaque 300; Nycomed), which is diluted 50:50
defects in the subchondral bone. with sterile water to give a concentration of 150 mg of
• Joint space width may be increased with joint iodine per ml. The technique is most useful for
subluxation or luxation. Narrowing of the joint investigation of shoulder joint pathology. The volume
space is indicative of loss of articular cartilage but of contrast agent required for suspected articular
cannot be appreciated on normal nonweight- cartilage lesions (0.5–1.0 ml) is less than that required
bearing radiographs. to detect capsular defects or to outline the biceps
• Joint space structures are contained between the tendon of origin (2.0–3.0 ml).
subchondral bone plates of the opposing bones
that comprise the joint. This space, therefore, SONOGRAPHY
includes the articular cartilage, synovial fluid, and Ultrasonography has potential value for the
intracapsular fat (and intraarticular ligaments, investigation of joint disease but there are few reports
menisci, and synovial effusion when present). of its use in cats3–5. The evaluation of bone is limited
Intraarticular structures are only visible when they because of the inability of ultrasound to penetrate
become mineralized2 or when increased joint mass osseous tissues. However, sonography may be useful
results in distension of periarticular soft tissues or in the identification of joint effusion, joint
alteration of other intraarticular structures. An thickening, articular or bone destruction, and joint
example of the latter would be a reduction in size instability using a dynamic examination. Periarticular
of the infrapatellar fat pad in the stifle, associated soft tissue structures that may be examined with
with a synovial effusion. Differentiation between ultrasound include muscles, tendons, abscesses, cysts,
increased joint mass associated with the presence foreign bodies, and tumors. Use of the technique is
of soft tissue or fluid cannot be made likely to remain restricted to specialized centers
radiographically and requires synoviocentesis. because of the small size of the structures under
• The articular margins and the periarticular areas investigation and the difficulty in the interpretation
where ligaments and tendons attach should have of the images obtained.
a regular, smooth cortical outline. Osteophytes
generally develop at the articular margins where ARTHROSCOPY
they appear as characteristic bony outgrowths. Arthroscopy is rarely used in the investigation and
Osteophytes are most commonly associated with treatment of feline joint disease. Examination of the
osteoarthritis. Osteophytes that develop at the shoulder and stifle joints is possible6,7 but so far there
site of bony attachment of the joint capsule or at are mostly only anecdotal reports of its success. There
ligament or tendon insertions are known as is one report of the successful evaluation and
enthesiophytes. debridement of the elbow joints of a cat with
• Periarticular soft tissues are assessed for swelling, intraarticular osteochondral fragments8. Application
thickening, and mineralization. Swelling most of arthroscopy to other feline joints is likely to remain
commonly occurs as a result of acute trauma, for limited because of their small size.
90

LABORATORY TESTS and disruption of articular cartilage. Intraarticular


A minimum database for investigation of a suspected osseous and/or cartilage fractures are associated with
inflammatory arthropathy would include a bio- the more severe traumatic injuries and may occur in
chemistry and hematology panel and tests for feline isolation or combined with joint luxation or
leukaemia virus (FeLV) and feline immunodeficiency subluxation. Following a traumatic incident there will
virus (FIV). This may help to identify cats that are be hemorrhage within the joint and synovitis, which
immunosuppressed or those that have involvement of may be localized to the site of injury.
other body systems, such as may be seen with some
immune-mediated arthritides, (systemic lupus Clinical signs
erythematosus and idiopathic polyarthritis types II, Clinical signs include lameness, joint swelling, joint
III, and IV). Further investigation of joint disease deformity, and pain on manipulation. Crepitus will be
requires synoviocentesis and synovial fluid analysis present if there is fracture or luxation.
(see Chapter 2). Individual tests, such as measurement
of titers for rheumatoid factor, antinuclear antibody, Diagnosis
or antibodies to Borrelia burgdorferi, may be indicated If fracture or luxation is suspected, radiography
in appropriate circumstances. These tests are discussed should be performed. Joint instability and ligamentous
more fully with the relevant joint disorders. disruption are evaluated by manipulation under
general anesthesia and stress radiography. Injury to
SYNOVIAL MEMBRANE BIOPSY individual ligaments is most commonly encountered in
Biopsy of the synovial membrane or synovium is rarely the stifle and tarsocrural joints. Joint sprains are
performed in the cat. The procedure can provide an classified according to the severity of the ligamentous
invaluable insight into the pathology affecting a joint injury as first, second, and third degree.
and is the only way of achieving a definitive diagnosis
in some cases. Samples are usually collected by means Treatment and prognosis
of an arthrotomy and should be obtained from several A more detailed discussion of the treatment of
different sites to ensure that the changes seen are traumatic disorders relating to specific joints can be
representative of the pathologic process in the entire found in Chapters 8 and 9. In general, treatment
joint. of joint trauma depends on the severity of the injury.
The histologic appearance of feline and canine First degree sprains are mild and only require rest
synovial membrane is similar9. Histopathologic and/or anti-inflammatory medication. Second and
examination can provide precise information about third degree sprains and more severe types of joint
the extent and type of cellular infiltrate, allowing injury such as intraarticular fracture usually require
differentiation between degenerative and inflam- external coaptation or surgical repair. Osteoarthritis
matory joint disease. Although there is considerable will occur as a sequela to traumatic arthritis if there are
overlap between diseases, the nature of an inflam- repeated mild to moderate episodes or if a single
matory cell infiltrate may help in determining the type episode is severe enough to cause significant damage to
of inflammatory arthritis. Histopathology is the only the joint.
way of achieving a definitive diagnosis of joint
neoplasia. Samples of the synovium can also be OSTEOARTHRITIS
submitted for bacterial culture and may be more likely Osteoarthritis is a type of DJD that is defined as a
to yield organisms than synovial fluid. disorder of diarthrodial synovial articulations
characterized by degeneration of articular cartilage,
DEGENERATIVE ARTHRITIDES bone remodeling, pathologic changes in periarticular
TRAUMATIC ARTHRITIS tissues, low-grade nonpurulent inflammation, and the
Cause and pathogenesis formation of new bone at the articular margins.
Traumatic arthritis follows a single acute joint injury Osteoarthritis may be classified into primary and
caused, for example, by vehicular trauma, an awkward secondary forms. Primary osteoarthritis is thought to
fall, gunshot wounds, or fights with other animals. occur as a consequence of an inherent defect in the
The least severe form of injury is a joint sprain, in articular cartilage so that it is unable to cope with
which there is variable stretching or tearing of normal joint forces, whereas secondary osteoarthritis
ligaments and joint capsule. Joint luxation involves a is secondary to some other joint disorder. Most
more severe disruption of peri- and intraarticular osteoarthritis is thought to be secondary in the cat. In
structures, with tearing of ligaments and joint capsule a recent retrospective study of cats over 1 year of age
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91

radiographed for any reason, 22% showed evidence of dystrophic calcification or synovial metaplasia.
osteoarthritis of an appendicular synovial joint, Degenerative enthesiopathy and intraarticular or
although this was not clinically apparent in 67% of periarticular soft tissue mineralization often accompany
cases10. In another study of 100 cats over osteoarthritis, but may also occur independently. Other
12 years of age, radiographic evidence of DJD was pathologic changes include thickening of the joint
found in 90% of cats and severe osteoarthritis was capsule, an increase in vascularity with hypertrophy and
found in 17% of elbow joints11. The realization that hyperplasia of the lining layer of the synovial
osteoarthritis is a common clinical problem in the cat membrane, and degeneration of intraarticular menisci.
is a relatively recent phenomenon12. The degeneration of articular cartilage that occurs in
osteoarthritis may be associated with the formation of
Cause and pathogenesis osteocartilaginous bodies that remain free in the joint,
Osteoarthritis as a cause of chronic pain is common in disappear, or become embedded in the synovium.
the geriatric cat, but it may be seen in any cat with joint Subchondral cysts are an occasional feature of
abnormality or following injury. It is postulated that osteoarthritic joints in cats. A cyst develops when there
the inciting cause is repeated joint trauma associated is replacement of subchondral bony trabeculae by
with the cat’s agile life style and ability to jump. In mixed connective tissue.
accordance with this theory, some studies have found
that the shoulder and elbow joints of geriatric cats are Clinical signs
preferentially affected. Osteoarthritis may also be Osteoarthritis is an emerging disease of the older cat.
secondary to gross trauma, such as joint fractures, Osteoarthritis has long been recognized
luxations, and ligamentous disruption. Developmental radiographically in cats but, because the disease may
diseases, such as hip dysplasia or patellar luxation, may be asymptomatic, the changes were often considered
lead to osteoarthritis. Osteoarthritis has been reported incidental. The lack of attention to feline
in multiple joints as part of feline mucopolysac- osteoarthritis may be explained by a tendency to
charidosis VI13 and associated with acromegaly in extrapolate information from the dog where the
middle-aged cats caused by a pituitary adenoma14. The cardinal sign of osteoarthritis is lameness. It is now
pathogenesis of acromegalic arthropathy is not fully believed that behavioral changes reflecting chronic
understood but it is thought that cartilage hypertrophy pain are more relevant to the diagnosis of
may interfere with cartilage metabolism, thereby osteoarthritis in the cat. Because cats are small, light,
causing cartilage degeneration. and agile they compensate well for musculoskeletal
Despite multiple etiologies, the pathologic changes disease and are able to adapt by redistributing weight-
of osteoarthritis share a final common pathway bearing forces to other limbs. Additionally, because
that serves to perpetuate the degenerative processes. the cat’s lifestyle prevents critical analysis of the gait by
Attention usually focuses on the articular cartilage but, the owner, mild lameness or joint stiffness usually
typically, all of the joint structures are involved. passes unnoticed. Behavioral changes reported by
Cartilage becomes fibrillated and ultimately may be owners of cats with osteoarthritis are nonspecific and
completely lost, exposing the underlying subchondral include those associated with attitude (hides away,
bone, which responds by becoming thickened. The resents handling, bad tempered, less playful) and
other main feature of osteoarthritis is the production of those associated with disability (reduced grooming,
osteophytes, which initially develop outside the cannot jump, inactive). Lameness and stiffness
epiphysis of the joint, but eventually become associated with osteoarthritis typically have an
incorporated into the joint, so that the joint assumes a insidious onset and are chronic and progressive in
different shape. This process is known as remodeling nature. As in other species, signs are worse on rising
and is thought to be a mechanism that allows the joint after a period of rest following exercise and initially
to cope better with the altered stresses placed on it. wear off after the animal warms up. The signs may
Osteophytes are usually thought of as a chronic change tend to wax and wane and are usually exacerbated by
in osteoarthritis, but they have been shown to start to cold and damp weather. Acute flare-ups of the signs of
develop within 1 week of experimental induction established osteoarthritis may occur as part of the
of joint instability15. Enthesiophytes are soft tissue natural history of the disease or be associated with
mineralizations that develop when there is pathology of joint sprain or sepsis. Osteoarthritic joints are
the entheses, which are osseous insertion sites of susceptible to trauma and are also at increased risk of
ligaments and tendons. Additional soft tissue infection spread hematogenously from a septic focus
mineralization may occur as a result of capsular elsewhere in the body.
92

Diagnosis feature is the presence of osteophytes. These are


In advanced cases the diagnosis of osteoarthritis may visualized as roughening of the joint margins, as
be obvious, especially if there is overt lameness. obvious bony masses (spurs or exostoses) projecting
Affected joints will be thickened on palpation owing beyond the normal bony outline, or as irregular bony
to bony remodeling, joint capsule fibrosis, and densities when superimposed on the normal osseous
synovial effusion. It is not usually possible to architecture. There will be secondary soft tissue
appreciate this in the shoulder and hip joints because swelling with thickening of the joint capsule and there
of the surrounding soft tissues. Manipulation of a may be an increase in joint mass owing to synovial
joint with osteoarthritis will usually be resented and effusion. Although enthesiophytes and/or soft tissue
there may be crepitus and a reduced range of joint mineralizations are commonly seen in osteoarthritic
motion. The subtler behavioral changes associated joints, these features alone are not indicative of
with osteoarthritis may be caused by many other osteoarthritis. With advanced osteoarthritis there will
diseases, and careful assessment of the geriatric cat is be changes in bone shape due to remodeling,
required to establish their significance. This may accompanied by sclerosis of subchondral bone and,
include radiographic and laboratory evaluation to occasionally, subchondral bone cysts visualized as
confirm the presence of osteoarthritis and rule out discrete radiolucent defects.
intercurrent disease. Analysis of the synovial fluid from affected joints
The radiographic changes of osteoarthritis are can be performed to rule out inflammatory joint
similar to those of the dog (56). The most striking disease. The fluid from joints with osteoarthritis is

56

A B D
56 Osteoarthritis. A Plantarodorsal radiograph of a cat with osteoarthritis of the hock joint secondary to previous trauma.
B Plantarodorsal view of the contralateral normal hock joint. C Mediolateral radiograph of a cat with osteoarthritis of the
elbow. D Craniocaudal view of the joint in C.
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93

normal or has only a slight reduction in viscosity and Weight loss is essential if the cat is obese and use of
a minimal increase in cell numbers, with macrophages a commercial low-calorie diet is recommended.
and lymphocytes predominating. Conversely, geriatric cats that are underweight should
be fed a calorie-dense diet, since osteoarthritis will
Treatment and prognosis worsen if they stop exercising as energy levels decline.
The approach to the management of osteoarthritis in Pain control in cats with osteoarthritis has been a
the cat is similar to that for dogs. Options include problem in the past because of a lack of drugs
exercise modification, weight control, the use of specifically licensed for long-term use in the cat
drugs, and surgical intervention. Potential problems (Table 21). Cats are more susceptible than other
with the management of osteoarthritis include lack of species to the adverse effects of nonsteroidal
familiarity with the disease in cats, difficulties with antiinflammatory drugs (NSAIDs) because of a
lifestyle modification, and the toxicity of available deficiency of glucuronide conjugation. Slower drug
drug therapies. Despite this, the prognosis for metabolism and a longer half-life lead to accumulation
osteoarthritis is generally better than that for the dog of toxic amounts much faster in cats than other
because cats are smaller and more athletic. species16,17. Currently the only drugs for which safe
Modification of a cat’s exercise regimen may be chronic doses have been established by clinical usage
difficult but some control is possible; for example, by are aspirin and meloxicam. Even with these drugs it is
altering the environment or by only allowing the essential that dosing is performed accurately if
cat out at set times each day. Strategies used in the dog, toxic effects are to be avoided18,19. Aspirin is
such as restricted leash exercise and aquatic therapy, are only available in human formulation and it is not
sometimes appropriate for the cat. Lameness associated commonly used in the cat for the treatment of
with flare-ups of osteoarthritis should be managed by osteoarthritis. Meloxicam is available in an injectable
enforcing strict confinement for a few days. form and as a syrup, which is palatable to cats and

TABLE 21 ORALLY ADMINISTERED DRUGS AND NUTRACEUTICALS USED IN THE MANAGEMENT OF


OSTEOARTHRITIS.
Drug Dose (mg/kg) Dose (5 kg/cat) Remarks
Meloxicam 0.1 mg/kg once daily 5 drops once daily Suspension is
1.5 mg/ml suspension for 5 days then for 5 days then 1–2 palatable
0.02–0.04 mg/kg drops once daily
Tolfenamic acid 4 mg/kg 20 mg once daily Do not exceed
20 mg tablet 3 days’ use
Ketoprofen 1 mg/kg 5 mg once daily Do not exceed
5 mg tablet 5 days’ use
Flunixin 1 mg/kg 5 mg once daily Do not exceed
meglumine 5 mg tablet 3 days’ use
Aspirin 15 mg/kg 75 mg every May cause
75 mg & 300 mg tablets 48 hours gastrointestinal
side-effects
Prednisolone 0.1–0.5 mg/kg 0.5–2.5 mg once Taper to every
1 mg & 5 mg tablets or twice daily 48 hours
Butorphanol 0.5–1 mg/kg 2.5–5.0 mg two Sedative side-effects
5 mg tablets or three times daily
Cosequin 1 capsule once Contains glucosamine,
regular strength daily for 6 weeks chondroitin sulphate,
then once daily glycosaminoglycans,
or 1 every 48 hours manganese ascorbate
94

facilitates accurate dosing in the food. Meloxicam is pharmaceutical drugs22. Most nutraceutical products
currently only licensed for use in cats as a single marketed for osteoarthritis contain glucosamine and
injection for reduction of postoperative pain and as chondroitin sulphate as the main ingredients. Their
an antipyretic. The clinical efficacy of the syrup has mode of action is not fully understood but products
been demonstrated for cats with acute and chronic such as Cosequin (Nutramax Laboratories Inc.) may
painful locomotor disorders20. The authors have have some benefits in the treatment of cats with
found the oral form of the drug to be both safe and chronic pain due to osteoarthritis23. Although their
effective when administered at a loading dose of efficacy is not proven, they appear to be safe. They can
0.1 mg/kg (1 drop/kg) once daily for 5 days, be used in combination with NSAIDs when they may
followed by a maintenance dose of 0.02–0.04 mg/kg have the effect of reducing the minimum effective dose
(1–2 drops/cat). This dosage can be used safely of the NSAID.
long term, but, like all NSAIDs, meloxicam should Joints that are poorly responsive to medical
preferably be used strategically for a few weeks at a therapy may benefit from irrigation with sterile
time. In cases where medication is required on a normal saline or lactated Ringer’s solution. The
permanent basis, the lowest effective dose is titrated procedure can be combined with synoviocentesis and
against the clinical signs, if necessary, by reducing the is performed by insertion of an intravenous cannula
frequency of administration. into the joint under general anesthesia followed by
The use of glucocorticoids is controversial in the lavage with up to 200 ml of fluid. This may be
treatment of osteoarthritis and there is evidence that beneficial because of the temporary removal of joint
high doses cause deterioration by promoting cartilage debris and inflammatory mediators.
degeneration. However, glucocorticoids are well The goal of surgical intervention should be the
tolerated by the cat and obvious clinical improvement correction of the underlying causes of osteoarthritis,
can often be produced by the use of relatively such as cruciate rupture or intraarticular fracture,
low doses for short periods of time. Prednisolone in order to prevent or slow the progression of
or prednisone at a dose rate of 0.1–0.5 mg/kg the disease. Joints that are chronically painful and
once or twice daily is the drug of choice for nonfunctional may be salvaged by arthrodesis, or
severe osteoarthritis unresponsive to NSAIDs or for excision arthroplasty in the case of the hip or
acute flare-ups when infection has been ruled out. If mandibular condyle. These procedures are discussed
long-term administration becomes necessary, the drug in detail in the relevant chapters.
should be administered on an alternate day basis and
the minimum effective dose should be titrated against INFECTIVE INFLAMMATORY
the clinical signs. The combined administration of ARTHRITIDES
glucocorticoids and NSAIDs confers no therapeutic An infective arthritis is a type of inflammatory
advantage and is contraindicated because of the arthropathy caused by a living microbial agent, which
greatly increased risk of side-effects. can usually be isolated from the joint. The microbial
The use of the so-called matrix supplements or agent in cats may be a bacterium, mycoplasma, virus,
viscosupplements is poorly documented in the cat. The fungus, or spirochaete.
injectable drugs, pentosan polysulphate and
polysuphated glycosaminoglycans, are unlicensed for BACTERIAL ARTHRITIS
use in the cat, although the authors have used them Bacterial or septic arthritis is the most common type
with some success. Pentosan polysulphate is of infective arthritis. The bacteria involved are those
administered at a dose rate of 3 mg/kg subcutaneously commonly found in the oral cavity (Pasteurella
(SC) on four occasions 5–7 days apart. These drugs multocida, Streptococcus spp., Staphylococcus spp.,
should not be combined with NSAIDs since they have coliforms, anaerobes).
anticoagulant properties that are potentiated by
NSAIDs. In one trial no short-term problems were Cause and pathogenesis
identified when polysuphated glycosaminoglycan was Septic arthritis is usually the result of a bite wound
administered to healthy cats21. There is also a number sustained in a fight with another cat. Cat bites are a
of nutritional supplements available for oral common occurrence contributing to 4.7% of all feline
administration that are recommended for use in the cat consultations in one North American study24. Other
for the treatment of osteoarthritis. These preparations causes include traumatic injuries, such as vehicular
are classed as nutraceuticals and are not subject to the trauma, extension of infection from adjacent soft
same rigorous licensing procedures applied to tissues, hematogenous spread, or iatrogenic following
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95

joint surgery. Intervertebral disc joints are rarely Synovial fluid should be obtained from any joint
affected causing discospondylitis. In line with the when infection is suspected. Suppurative fluid will be
etiology the joints of the distal extremities, particularly increased in quantity, turbid, and watery, and may
the carpus, are most commonly affected. be hemorrhagic. White blood cell numbers will be
Hematogenous spread from an infected focus increased and these will be predominantly degenerate
elsewhere in the body is uncommon. This type of septic neutrophils. Culture of synovial fluid may reveal the
arthritis is usually mono-articular and infection is more organism, although organisms cannot be grown in
likely to localize to a joint that is already damaged. some cases. The likelihood of a positive culture is
Bacterial arthritis may thus be a complication of much greater if the sample is inoculated into blood
traumatic joint injury, such as a sprain, and culture medium and if prior antibiotic therapy has not
osteoarthritic joints are predisposed to infection. been given.
Multiple joint involvement may occur secondary to
bacterial endocarditis, although this is very rare in the Treatment and prognosis
cat. Young kittens occasionally suffer from polyarticular Cat bites involving a joint or adjacent to a joint should
septic arthritis as a result of hematogenous spread from be treated aggressively, using lavage and drainage, if
an infected umbilicus or associated with postparturient necessary, to prevent infection becoming established
metritis or mastitis. in the joint. Bacterial cultures of deep tissues should
be performed to determine appropriate antibiotic
Clinical signs therapy. Joints that are already septic should be
The main presenting sign is lameness of a single limb, lavaged copiously under anesthesia with normal saline
which is usually acute and severe. If septic arthritis or Ringer’s solution, either percutaneously or via a
follows a cat bite, initial lameness may fail to resolve or mini arthrotomy. If infection is more chronic, an
there may be relapse after initial improvement. In some arthrotomy is performed and a drainage tube placed
cases the primary injury may have passed unnoticed by in the joint to permit continued drainage and
the owner and evidence of a bite wound may only be irrigation of the joint. Antibiotic therapy, preferably
discovered on closer inspection. The affected joint will
be hot, swollen, and painful, with a reduced range of
motion. In advanced cases there may be crepitus 57
indicating extensive damage to articular cartilage and
bone. The cat is often, but not invariably, systemically
ill and pyrexic. In chronic cases there may be secondary
ligament rupture and disuse atrophy of the muscles of
the limb, and joint ankylosis may eventually develop.

Diagnosis
Diagnosis is based on the history and clinical findings,
radiography, and synovial fluid examination.
Radiography in the early stages shows nonspecific
changes associated with the accumulation of exudate,
soft tissue swelling, and joint distension. Osseous
changes become evident within a few weeks. Loss of
articular cartilage may be evident as a loss of joint
space, although changes in joint space are difficult to
assess in nonweight-bearing radiographs. Periarticular
osteophytes develop and these may be extensive. In
more chronic cases there is destruction of bone, with A B
erosion of the subchondral plate and, eventually, 57 A Dorsopalmar radiograph of a cat with septic arthritis
complete loss of bone with an irregular widening of of the carpus with osteomyelitis in the adjacent radial
the joint space. Osteomyelitis may extend into the metaphysis.
metaphyses of the adjacent bones, with a mixed B Mediolateral view of the carpus of the same cat. Lysis,
pattern of lysis and sclerosis as attempts are made to periosteal reaction, and sclerosis are evident in the distal
wall off the infection (57). Bony ankylosis of the joint radius. Note the soft tissue swelling and loss of the
may eventually develop. radiocarpal joint space.
96

guided by culture and sensitivity, is continued for a the organism from the synovium or the synovial fluid
minimum of 4 weeks. Commonly used antibiotics may be possible on special media. A tentative diagnosis
include cephalexin, potentiated amoxicillin, is possible if the organism can be visualized by
clindamycin, fluoroquinolones, and metronidazole. light microscopy after staining with Wright–Leishmann
The prognosis is dependent on the degree of or Giemsa. Treatment with tylosin, erythromycin,
permanent damage to the joint. If there has been tetracycline, or gentamycin may be successful.
considerable destruction of articular cartilage, joint
function will be poor and excision arthroplasty, CALICIVIRUS ARTHRITIS
arthrodesis, or even amputation may be necessary. Cause and pathogenesis
Persistent low-grade lameness may be a sequela Calicivirus is a cause of acute arthritis in cats, either
because of osteoarthritis or synovitis caused by the following natural infection or live virus vaccination.
presence of nonviable bacterial antigens. In the latter The role of calicivirus in chronic arthritis is unknown.
case glucocorticoids may be beneficial provided The arthritis may be infective, associated with
bacterial infection has been completely eliminated. intraarticular live virus, or immune-mediated,
These drugs also help to relieve joint stiffness associated with intraarticular nonviable virus antigens.
associated with soft tissue swelling and fibrosis. Disease is most commonly seen in cattery kittens
infected with field strains of calicivirus. It can occur in
BACTERIAL L-FORM ARTHRITIS spite of vaccination since immunity to at least one
Bacterial L-forms are a rare cause of inflammatory strain of calicivirus is not conferred by the more
polyarthritis in cats. Subcutaneous abscesses and commonly used vaccine strains. Lameness has been
arthritis associated with a probable bacterial L-form reproduced experimentally using two separate strains
have been described25. Clinical signs were seen in of calicivirus in young kittens28. Viraemia was
three cats from one household and included pyogenic demonstrated but no lesions were found in muscles,
subcutaneous abscesses, inflammatory joint disease, joints, or the central nervous system; increased
pyrexia, and systemic illness. The infection spread numbers of macrophages were found in the synovial
locally and hematogenously to involve other joints fluid. In the past, vaccine-associated calicivirus
and subcutaneous sites. The exudate was arthritis was commonly seen associated with certain
characterized by pyogranulomatous inflammation. strains of calicivirus included in live vaccines. This is
Radiography of affected joints revealed destructive now a rare cause of disease since manufacturers have
changes consistent with erosive joint disease. removed these strains from their vaccines.
Bacterial L-forms are bacteria that lack a cell wall
and are resistant to many broad-spectrum antibiotics, Clinical signs
although they are susceptible to tetracycline. A Infective arthritis associated with certain field strains
number of reasons for the loss of the cell wall have of calicivirus is seen mainly as a transient lameness and
been proposed, including therapy with certain pyrexia in kittens between the ages of 6 and 12
antibiotics and interaction between the host’s immune weeks29,30. Affected kittens are usually ill for 1–2 days
system and the bacterium. Because of the lack of cell and demonstrate a stiff gait with pain on manipulation
wall the bacterial L-forms cannot be identified using of affected muscles and joints. Less than half of the
routine light microscopy. The organisms are very kittens have, or subsequently develop, ulceration of
difficult to grow in the laboratory and routine cultures the tongue or hard palate. Kittens experimentally
of joints and abscesses will be negative. infected displayed generalized hyperesthesia with
evidence of joint pain on manipulation and, in some
MYCOPLASMAL ARTHRITIS cases, cutaneous erythema over the tarsal joints28.
Mycoplasmas are found naturally in the upper Immune-mediated arthritis is seen mainly as a
respiratory and urogenital tracts of healthy cats. There polyarthropathy 5–7 days after vaccination with live
are a number of reports of the organisms causing vaccines containing feline calicivirus31,32. Affected cats
polyarthritis and tenosynovitis, usually in debilitated or have a shifting lameness, a stiff gait, and pyrexia. Signs
immunosuppressed individuals26,27. Affected cats are generally occur after the first vaccination and most
presented with lameness, swollen limbs, painful joints, affected cats are less than 6 months of age.
and pyrexia.
The synovial fluid is watery and turbid, and cytology Diagnosis
reveals large numbers of white blood cells with Diagnosis is generally attempted on the basis of
nondegenerate neutrophils predominating. Culture of clinical signs and, in the case of the vaccine-associated
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97

form of arthritis, the history of recent inoculation. disease is difficult. A positive serologic test merely
Serology is generally unhelpful because of the signifies exposure to the organism and is not proof
widespread presence of antibody as a result of that the clinical signs are caused by the spirochaete.
vaccination. Cytology of synovial fluid from In two North American studies serum samples taken
affected joints may reveal an increased number of from cats that had been infected with ticks were
macrophages, many of which contain phagocytosed positive for antibodies to the organism in 14%35 and
neutrophils28. 15%36 of cases. The proportion of positive results was
the same irrespective of lameness. In the UK 4.8% of
Treatment and prognosis cats, screened as clinical patients, were seropositive37.
The prognosis for infective calicivirus arthritis is good None of the seropositive cats in the latter study had
since the disease is self-limiting and only symptomatic clinical signs of lameness.
therapy is indicated. Immune-mediated calicivirus
arthritis is also usually transient, although some Treatment and prognosis
cats develop a more protracted inflammatory Therapy for Lyme disease is given empirically because
polyarthropathy. Disease is usually self-limiting but of the difficulty in making a definitive diagnosis. The
administration of glucocorticoids may be indicated for organism is susceptible to a number of antibiotics but
persistent cases. This form of polyarthritis is similar to doxycycline (10 mg/kg twice daily for 4 weeks) is
type II idiopathic polyarthritis. currently the drug of first choice for adult cats.
Clinical improvement should always be viewed with
LYME DISEASE suspicion because the clinical signs may be
Cause and pathogenesis intermittent or may resolve spontaneously. Based on
Lyme disease is a multisystemic inflammatory disorder the information available from other species, prompt
of humans and domestic animals caused by infection improvement in clinical signs is to be expected with
with the tick-borne spirochaete Borrelia burgdorferi. appropriate antibiotic therapy. Treatment is more
Lyme disease was first recognized in the United likely to be successful if antibiotics are given in the
States, where it is endemic in certain areas, but has initial acute phase of the infection.
since been described worldwide. Cats appear to be
resistant to the development of clinical signs of Lyme TUBERCULAR ARTHRITIS
borreliosis. Although they can become infected and Tubercular arthritis is an occasional manifestation
develop high levels of serum anti-borrelia antibodies, of tuberculosis. In a recent series of cats diagnosed
the natural disease has not been described as a distinct with tuberculosis, one cat presented with
clinical entity in the cat. involvement of an elbow joint38. There was a history
of malaise, weight loss, and forelimb lameness.
Clinical signs Diagnosis was made by radiography and biopsy of the
Clinical signs were not observed in experimental cats synovium. The cat was successfully treated with
inoculated by various routes with laboratory-derived isoniazid, rifampicin, and streptomycin, although
strains of Borrelia33. In contrast, when cats were there was residual lameness.
inoculated with the organism directly from ticks they
developed polyarthropathy and had joint, lymphoid, FUNGAL ARTHRITIS
pulmonary, and central nervous system inflammation Histoplasma capsulatum and Crytococcus neoformans
on postmortem examination34. In acute infections in are rare causes of hematogenously disseminated
dogs, clinical lameness is frequently localized to infective arthritis39. There is usually multisystemic
one or more joints, although chronic nonerosive involvement and multiple joints may be affected.
polyarthritis is the main finding in more prolonged Histoplasmosis is discussed in Chapter 13;
infections. The course of disease may be intermittent cryptococcosis is discussed in Chapter 11.
and spontaneous resolution may occur. There is no
information on the clinical manifestations of natural IMMUNE-MEDIATED
infection in cats but clinical signs are likely to be INFLAMMATORY ARTHRITIDES
similar to those described in the dog. Immune-based arthritides are uncommon causes of
lameness in the cat. There are a number of different
Diagnosis types but they are all characterized by chronic
The clinical signs are often vague and infection can synovitis affecting multiple joints in a bilaterally
be asymptomatic, so accurate diagnosis of Lyme symmetrical fashion. Although the underlying cause
98

of these disorders is unknown and they are classed as 1. There should be multisystemic involvement,
noninfective, persistent intraarticular microbial although it is rare to have more than two body
antigens may play a role in their etiopathogenesis. It is systems affected at any one time. Common
useful to subdivide them into erosive and nonerosive manifestations include polyarthritis,
types based on the degree of damage to bone thrombocytopenia, hemolytic anemia, leucopenia,
and articular cartilage40. Joint inflammation in pyrexia, dermatitis, glomerulonephritis, and
nonerosive immune- mediated polyarthritis is thought meningitis.
to be due to the deposition of immune complexes of 2. There should be a positive antinuclear antibody
antibody, antigen, and complement in the synovial (ANA) titer. A 1:40 titer is considered positive in
membrane. Treatment of the various types of cats. The ANA test is very sensitive but has poor
immune-mediated polyarthritis is similar and is specificity. The background level of ANA is
discussed at the end of this section. relatively high in the cat and false positive results
may occur during the acute phase of infectious
NONEROSIVE TYPES diseases such as FeLV, FIV, and feline infectious
Systemic lupus erythematosus (SLE) and idiopathic peritonitis (FIP). It should be noted that a
polyarthritis are both more common in young adult diagnosis of SLE cannot be made by positive
cats. The clinical signs of cats with nonerosive immune- ANA alone, regardless of titer.
based polyarthritis are very similar irrespective of type 3. The immunopathologic features should be
and generally have a rapid onset. Affected cats typically consistent with the clinical involvement. For
appear very stiff and uncomfortable and may have a example, antibodies against red blood cells or
history of shifting lameness. They are usually reluctant platelets should be demonstrable in cats with
to exercise, resent handling, and may be uncooperative anemia or thrombocytopenia; immune complex
and bad tempered. There is usually inappetence, deposition should be shown in tissue biopsies of
malaise, and pyrexia unresponsive to antimicrobial the synovial membrane or kidney in cats with
therapy. Affected joints are painful on manipulation polyarthritis or glomerulonephritis respectively.
and distal limb joints may be obviously thickened and
swollen. In some cases it may be more difficult to Polyarthritis/meningitis syndrome
appreciate synovial effusion or periarticular thickening. Polyarthritis/meningitis syndrome (PMS) is a rare
Cats with SLE and idiopathic polyarthritis may show condition with clinical manifestations similar to SLE.
other signs of immune complex disease reflecting However, there is joint and central nervous system
involvement of other body systems. Idiopathic type II involvement only and affected cats test negative for
cats may show signs of infection elsewhere in the body, serum ANA. The typical presentation is an immature
type III cats will have gastrointestinal signs, and type or young adult cat with neck pain, depression,
IV cats may have signs relating to an underlying pyrexia, and stiffness in addition to polyarthritis.
neoplasm. Cats with type IV idiopathic polyarthritis Cerebrospinal fluid (CSF) analysis reveals increased
usually have myeloproliferative disease, which can be protein and pleocytosis.
diagnosed by bone marrow biopsy. A proportion of
these cases will be positive for FeLV. Idiopathic polyarthritis
Cats with polyarticular noninfective inflammatory joint
Systemic lupus erythematosus disease that does not satisfy the diagnostic criteria for
SLE is a multisystemic disease in which nonerosive other types of polyarthritis are included in this broad
polyarthritis may be a feature. The antigen involved in classification. Idiopathic polyarthritis is the commonest
the pathogenesis of the polyarthritis, dermatitis, and of the immune-mediated arthritides in dogs but is rarely
glomerulonephritis that may be seen with SLE is reported in the cat41–43. Idiopathic polyarthritis can be
believed to be nucleic acid. In one study, definite SLE subdivided into four types based on the presence of
was diagnosed in only two of 31 cats with polyarthritis concurrent disease:
and it is a rare cause of joint disease41. • Type I: uncomplicated idiopathic polyarthritis.
• Type II: reactive idiopathic polyarthritis
Diagnosis associated with infection elsewhere in the body;
Three criteria must be satisfied to diagnose definite for example, urinary or respiratory tract infection,
SLE. Criteria 1 and 2 must always be satisfied; if chlamydial conjunctivitis.
criterion 3 is not fulfilled a diagnosis of probable SLE • Type III: enteropathic idiopathic polyarthritis
is made. associated with gastrointestinal disease.
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99

• Type IV: neoplasia-related idiopathic polyarthritis 58


associated with neoplastic disease.
All types are believed to be the result of immune
complex hypersensitivity reactions. The different
associations in types II through IV may represent the
antigenic source for the immune complexes or may be
coincidental. Multisytemic involvement occurs in
some cats; these cases may resemble SLE but they are
consistently negative for ANA. Some cases of type I,
and occasionally type II, may eventually progress to
an erosive rheumatoid or periosteal proliferative A
polyarthritis.

EROSIVE TYPES
Erosive immune-mediated arthritis is also known as
chronic progressive polyarthritis44,45. There are two
types of disease: a more common periosteal
proliferative type and an uncommon deforming type
with many of the features of human and canine
rheumatoid arthritis46. With both types of disease the
clinical signs have a tendency to wax and wane.

Periosteal proliferative polyarthritis B


Periosteal proliferative polyarthritis (PPP) is seen in
young entire and neutered male cats less than 5 years
of age.

Cause and pathogenesis


The etiology is uncertain but there may be links with
FeLV, FIV, and feline syncytia forming virus (FeSFV)
infections45,47. It has been suggested that FeLV-
(or FIV-) induced immunosuppression allows multipli-
cation of FeSFV in the joints of predisposed
individuals, which causes the disease. However, an
increased incidence of FeLV or FIV virus in infected
cats has not been demonstrated. It has also been
reported that all cats with PPP are infected with
FeSFV48. It has not, however, been possible to C D
reproduce the disease experimentally45 and the virus 58 A Mediolateral radiograph of the hock joint of a cat
can be cultured from the joints of many normal cats. It with early changes of PPP. Note the erosive changes on
is possible that the presence of FeSFV is incidental, the tuber calcis and the periarticular periosteal new bone
since an already inflamed joint with many actively formation on the plantar aspect. (Radiograph courtesy of
dividing cells is an ideal environment for the virus to Davies Veterinary Specialists.)
multiply. B Mediolateral radiograph of the elbow joint of the cat
in A showing erosive changes in the olecranon.
Clinical signs (Radiograph courtesy of Davies Veterinary Specialists.)
There is typically an acute onset of pyrexia and malaise C Mediolateral radiograph of the elbow joint of a cat
with a stiff gait, joint effusion, and joint pain. There with advanced changes of PPP. Note the extensive
may also be generalized muscle atrophy and generalized remodeling of the joint and the periarticular periosteal
or localized lymphadenopathy. Within several weeks of new bone formation.
this early acute phase the disease enters a more chronic D Marked swelling and thickening of the hock joints of
phase in which there is extensive periosteal new bone the cat in C.
formation, especially around the hocks and carpi (58).
100

Rheumatoid arthritis DIAGNOSIS OF IMMUNE-MEDIATED


Rheumatoid arthritis is a rare chronic progressive ARTHRITIDES
destructive polyarthritis. Radiography
All clinically affected joints should be radiographed.
Cause and pathogenesis In cats with suspected multisystemic involvement,
The pathogenesis of the synovitis involves the radiography of other body regions may be indicated;
production of autoantibodies against immunoglobulin for example, the thorax for evidence of respiratory
(rheumatoid factor). The synovitis is caused by the infection in idiopathic type II polyarthritis. The
formation of immune complexes, including rheumatoid radiographic changes seen in the joints of cats with the
factor and immunoglobulin, within the joint. However, different types of immune-mediated arthritis are very
there is not always serologic evidence of rheumatoid similar, especially in the early stages of disease.
factor and its presence is not specific for rheumatoid Common features of both erosive and nonerosive
arthritis. arthritis are periarticular soft tissue swelling,
distension of the joint capsule, and loss of
Clinical signs intraarticular fat shadows. With chronicity the erosive
Cats with rheumatoid arthritis have generalized forms show a more characteristic combination of
stiffness, progressive lameness, and debility of destructive and proliferative changes.
increasing severity over a period of many months. The In rheumatoid arthritis the destructive changes
onset is generally gradual and, unlike PPP, there is predominate. There is erosion of the joint margin
no malaise and no significant synovial effusion. visualized as an increased irregular joint space or an
Palpation reveals joints that are thickened and painful, overall loss of mineralization of the bones forming the
with crepitus and reduced range of motion on joint. In comparison with the dog, the coarse trabecular
manipulation. pattern of feline bones may make it more difficult to
appreciate the destructive changes in the early stages.
Diagnosis In PPP there are also destructive changes but the
The criteria used to diagnose rheumatoid arthritis proliferative changes predominate. PPP is characterized
in cats are based on those used in human by periarticular periosteal new bone formation, which is
rheumatology: so extensive in some cats that affected joints become
1. Stiffness after rest. partially or sometimes completely ankylosed. There are
2. Pain or tenderness on motion of at least one also erosive changes in the joints and bony deposits and
joint. erosions at the point of attachment of ligaments or
3. Swelling of at least one joint. tendons (enthesiopathies).
4. Swelling of one other joint within a period of Serial radiography is useful to monitor the
2 months. progression of the arthritis. For example, some
5. Symmetrical joint swelling. nonerosive forms may progress to erosive disease and
6. Radiographic changes suggestive of rheumatoid secondary osteoarthritis may become apparent as joints
arthritis. become more damaged and less stable.
7. Serologic evidence of rheumatoid factor.
8. Abnormal synovial fluid. Laboratory features
9. Characteristic histologic changes in the synovial In cats with multisystem involvement the laboratory
membrane. features will be consistent with the underlying nature
of the immune complex disease, such as anemia and
Characteristic radiographic changes include severe thrombocytopenia. There is generally a nonspecific
subchondral bone lysis, joint deformity, and joint absolute or relative increase in serum globulin levels.
subluxation or luxation. Subcutaneous nodules seen Synovial fluid should be obtained from multiple
in humans with rheumatoid arthritis have not yet been joints to confirm that there is an inflammatory
reported in the cat. Seven criteria must be satisfied to polyarthropathy. There is typically an increased volume
make a diagnosis of classical rheumatoid arthritis and of turbid synovial fluid, with reduced viscosity, a poor
five to make a diagnosis of definite rheumatoid mucin clot, and a positive fibrinogen clot test. The
arthritis. In addition, two of criteria 6, 7, and 9 should fluid has an increased white cell count, the majority of
be fulfilled and criteria 1–5 should have been present which will be nondegenerate polymorphonuclear cells,
for at least 6 weeks. and is negative on culture (see Chapter 2). If there is
Arthrology
101

still doubt about the diagnosis, multiple synovial remission is achieved, although prednisolone may be
membrane biopsies from different parts of one or more continued longer. Cyclophosphamide should never be
joints should be submitted for histopathologic given for more than 4 months because of the potential
examination. However, the histologic changes can be bladder toxicity.
variable and are not specific for one particular type of The response to treatment should be monitored by
inflammatory arthropathy. repetition of synovial fluid cytology 2 weeks after
Serologic tests are performed for suspected cases of starting treatment or introducing a different therapeutic
rheumatoid arthritis and SLE. Rheumatoid factor may regimen. A low white cell count with a preponderance
be present in the blood of cats with rheumatoid arthritis of mononuclear cells is a good prognostic indicator and
and ANA must be present in the blood of cats before the therapeutic regimen should be continued. If this is
SLE can be diagnosed. Cats with SLE may also show red not the case, the therapy should be modified; for
cell autoantibodies or autoantibodies against leucocytes example, by addition of cyclophosphamide. Complete
or platelets. It is important to check with the diagnostic blood counts should be performed weekly for cats
laboratory that species-specific reagents are available receiving cytotoxic therapy. If the white blood cell
before submitting samples for immunologic testing. count falls below 6.0 × 109/l the dose is reduced by one
quarter, if it falls below 4.0 × 109/l the drug should be
TREATMENT AND PROGNOSIS FOR stopped for one week and then reinstated
IMMUNE-MEDIATED ARTHRITIDES at half the original dose. It is also advisable to monitor
Nonspecific treatment of cats with immune-mediated the urine of cats receiving cyclophosphamide on a
arthritis is the same as that for cats with osteoarthritis weekly basis, for the presence of blood. Patients that are
(exercise restriction, weight control). immunosuppressed should be regularly checked for
Specific treatment is directed towards the and, as far as possible, protected from secondary
underlying cause in cats with idiopathic polyarthritis infections, especially of the urinary and respiratory
types II, III, and IV. Successful treatment of the tracts. Vaccination is advisable but should not be given
infective, gastrointestinal, or neoplastic process may until the immunosuppressive drugs have been stopped
resolve the arthritis without the need for additional or suspended.
immunosuppressive therapy. The prognosis is variable and differentiation
Cats with chronic PPP or rheumatoid arthritis are between types of immune-mediated arthritis is
usually treated with anti-inflammatory doses of essential when attempting to predict the likely
prednisolone for short periods when there is a flare-up outcome of treatment. The idiopathic polyarthritides
of the clinical signs. carry the best prognosis, with the exception of type
Immunosuppressive therapy with glucocorticoids IV, which is secondary to a neoplastic process. The
is the mainstay of treatment for all other types of prognosis tends to be worse for erosive than for
immune-mediated arthritis. The drug of choice is nonerosive forms, especially rheumatoid arthritis.
prednisolone administered at a starting dose of However, SLE often carries a poor prognosis because
4 mg/kg divided twice daily for acute cases. This dose of the involvement of other body systems.
is continued for 2 weeks and then gradually reduced
over a period of 8 weeks, provided the disease stays MISCELLANEOUS DISORDERS
in clinical remission. In some cats the drug can be OF JOINTS
discontinued but in others a continuous low dose is SYNOVIAL SARCOMA
required to maintain remission. The maintenance Feline synovial sarcoma is a rare articular tumor with
dose should preferably be given on an alternate day only three putative and two definite cases reported
basis to minimize side-effects. If remission cannot be in the English language literature49–53. Synovial
achieved, or can only be maintained with excessively sarcomata originate from mesenchymal synovioblastic
high doses, a combination of prednisolone and a cells in the joint capsule, tendon sheath, or bursa and
cytotoxic drug should be used. Cyclophosphamide at invade the joint cavity secondarily. Clinical signs include
a dose of 2.5 mg/kg is the most commonly used chronic progressive lameness, with periarticular soft
cytotoxic drug. The drug is administered orally once tissue thickening and swelling, pain on joint
daily on 4 consecutive days of each week in manipulation, and reduced range of motion. All
combination with prednisolone at an anti- reported cases have involved the joints of the distal
inflammatory dose of 1.0 mg/kg divided twice daily. extremities or the elbow. Radiography typically reveals a
Cytotoxic drugs are stopped 4 weeks after complete poorly defined periosteal reaction and multiple punctate
102

osteolytic lesions involving the epiphyses of more than to the stage of the condition. Initially there may be
one bone adjacent to the affected joint. Diagnosis may only soft tissue swelling as a result of the cartilaginous
be confirmed in some cases by cytologic examination of nodules and joint effusion. As the condition
synovial fluid53 but otherwise requires incisional biopsy. progresses, calcified deposits become visible in and
The tumor should be staged before surgery by around the joint and there will be evidence of
performing chest radiographs and needle aspiration of osteoarthritis (59). Treatment may be palliative using
the regional lymph node. Biopsy may suggest that the NSAIDs or surgical treatment may be attempted by
tumor is a benign synovioma, but, in those cases where total synovectomy with removal of all loose bodies. In
local excision was performed, the neoplasm advanced cases excision arthroplasty or arthrodesis may
recurred51–53. In dogs, survival may depend more on be performed. Synovial osteochondromatosis has been
the aggressiveness of treatment rather than on clinical reported affecting the elbow joint of a Bengal tiger61.
staging or tumor grading54 and the recommended
method of treatment is amputation. The metastatic SYNOVIAL CYSTS
potential of the tumor in cats is unknown, although in Synovial cysts have been reported affecting the elbow
dogs 41–54% of cases have metastases at the time of joints of four geriatric cats5,62. The etiopathogenesis of
diagnosis or will develop metastasis subsequently55,56. the condition in the cat is unknown, although in
humans it has been theorized that synovial cysts are
SECONDARY NEOPLASIA related to herniations of the joint capsule,
Periarticular and juxta-articular malignancies, such as inflammation, or osteoarthritis. All of the cats presented
osteosarcomata and fibrosarcomata, may arise from with fluid-filled swellings centered on the medial aspect
extraarticular tissues and invade joints secondarily. of a single elbow joint. Three of the cats had mild or
Transarticular involvement of fibrosarcoma has been moderate lameness and showed radiographic evidence
reported57. The presentation, diagnosis, and treatment of osteoarthritis. The osteoarthritis may have been the
of these tumors are similar to synovial sarcoma. cause of the lameness in these cases. Plain radiography
Metastasis of malignant tumors to joints is very rare. is inconclusive but contrast arthrography or
ultrasonography will outline the cystic extensions of the
HYPERVITAMINOSIS A synovial joint capsule. Confirmation of the diagnosis
The classical sign of vitamin A toxicity is neck stiffness requires aspiration of synovial fluid and biopsy. Surgical
associated with cervicothoracic vertebral lesions, but excision was curative in one case but not in three cases
exostoses of limb joints may cause lameness and, in treated by excision or drainage.
severe cases, joint ankylosis. The elbow is most
commonly affected but involvement of the stifle and
hips, with no spinal lesions, has been reported58.
(See Chapter 13.) 59

OSTEOCHONDROMA
Osteochondromas have been reported as a rare cause of
lameness especially in the Burmese breed. The condition
usually affects one or both elbows and originates from
the medial humeral epicondyle59. (See Chapter 13.)

SYNOVIAL OSTEOCHONDROMATOSIS
Synovial osteochondromatosis (also known as synovial
chondrometaplasia) is a rare condition characterized by
the formation of chondral or osteochondral nodules
within the synovial tissue of a joint, tendon sheath, or
bursa. Lesions resembling synovial osteochon-
dromatosis have been reported in the stifle and elbow
joints of two cats60. The condition is typically
monoarticular and is thought to occur as a primary 59 Mediolateral radiograph of the stifle joint of a cat with
idiopathic abnormality or secondary to joint disease. synovial osteochondromatosis. Note the extensive
There is chronic progressive lameness and joint intraarticular and periarticular mineralized deposits.
stiffness. The radiographic appearance varies according (Radiograph courtesy of Davies Veterinary Specialists.)
Arthrology
103

PATELLAR MALFORMATION recommended treatment for cats with CrCL rupture


Acute traumatic fractures of the patella are discussed in and concurrent meniscal calcification is meniscectomy
Chapter 9. Malformation is occasionally encountered, and stabilization of the stifle7.
usually as an incidental finding on stifle radiographs.
The bone is divided into two (bipartite), three OSTEOCHONDRITIS DISSECANS
(tripartite), or more (multipartite) parts and the There are two reports in the English language literature
abnormality may be unilateral or bilateral. In bilateral of cats with lesions resembling osteochondritis
cases it would seem most likely that the etiology is dissecans (OCD) of the proximal humerus, as
congenital. The lack of patella continuity is thought to commonly seen in dogs66,67. There is also a single
be associated with an area of reduced vascularity. In report of bilateral OCD of the lateral femoral condyle
some unilateral cases the lesion may represent chronic of the stifle joint68. All the reported cases were
nonunion patella fracture. immature cats that presented with lameness, which
resolved after surgical treatment.
MENISCAL CALCIFICATION
Calcification within the cranial pole of the medial OSTEOCHONDRODYSPLASIA IN THE SCOTTISH
meniscus is a common incidental radiographic finding FOLD CAT
in the stifle joint of cats2,63,64 and has also been Osteochondrodysplasia is an inherited defect in the
reported in the tiger65. It is thought to occur either as Scottish Fold cat caused by a simple autosomal
a normal anatomic variant or secondary to joint dominant gene69. The characteristic folding of the
trauma. The radiographic appearance, visualized on ears is due to an abnormality of the aural cartilage.
the mediolateral view, is of single or multiple foci of Kittens affected by osteochondrodysplasia develop
calcification in the cranial compartment of the an arthropathy of the hindlimbs with extensive
joint (60). The condition may be unilateral but is exostosis formation around the tarsal and metatarsal
frequently bilateral; it is sometimes associated with joints (61). The resulting lameness can be treated
lameness or may be seen in combination with other surgically either by excision of the exostoses70 or by
disorders of the stifle, such as CrCL rupture. In the performing bilateral pantarsal arthrodesis 71.
absence of any other cause of stifle lameness, Palliative radiation therapy has also been used to
medial meniscectomy may be curative63. The resolve the clinical signs of the disorder72.

60 61

A B
60 Mediolateral radiograph of the stifle joint of a cat 61 A Mediolateral radiograph of the hock joint of a
showing mineralization and cranial luxation of a meniscus. Scottish Fold cat with osteochondrodysplasia. Note the
extensive periarticular exostosis and ankylosis.
B Plantarodorsal view of the hock joint of the cat in A.
(Radiographs courtesy of Malcolm McKee.)
104

LIGAMENTS AND TENDONS direction of tension within the healing tissues.


In the musculoskeletal system ligaments Optimum healing of tendons and ligaments is
predominantly function to join bones and provide promoted by complete immobilization during the
support for joints. Ligaments may also perform initial stages of fibroplasia (4–6 weeks) and
other functions of importance to the orthopedic progressive loading of the tendon during the process
surgeon, such as the ligaments that are associated of maturation and organization of the healing tissue
with the menisci in the stifle joint. Ligaments that (6–8 weeks). The gliding function of severely injured
unite bones are strong bands consisting of tendons is often compromised by excessive formation
longitudinally oriented bundles of collagen fibers. of fibrous tissue. Loss of function can be minimized
The collagen fibers undergo a transition to by early repair, gentle tissue handling, control of
fibrocartilage where they attach to bone and are infection, and appropriate rehabilitation. Any delay in
known as Sharpey’s fibers. Ligaments supporting a surgical repair will increase the likelihood of
joint may be intraarticular, as in the case of the complications.
cruciate ligaments, or, more commonly, are found as
cord like thickenings incorporated into the joint REPAIR OF TENDONS
capsule or separated from it by extensions of the Tendon disorders are relatively uncommon in the cat
synovial lining, termed bursae. Injuries to ligaments with the exception of injury to the tendons of the
are known as sprains. When a ligament is avulsed distal extremities by sharp objects. In contrast to the
from its attachment site to bone with a small dog, disorders of the biceps tendon have rarely been
fragment of bone this is known as a sprain-avulsion reported73,74. Severed tendons are repaired by
fracture. Ligaments and tendons heal in a similar suturing using fine monofilament suture materials.
fashion, which is described below. The tendons that most commonly require suturing
Tendons function to attach muscles to bone and are the digital flexor tendons over the palmar and
may also provide ancillary support for joints. plantar aspects of the metacarpus and metatarsus
Although the terms are not synonomous, some parts respectively. Severance or avulsion of the common
of tendons are also known as ligaments. For calcanean tendon from its attachment on the tuber
example, the portion of the tendon of the quadriceps calcis is occasionally seen as a result of trauma and may
femoris muscle between the patella and the tibial be associated with a tendinopathy in older cats.
tuberosity is commonly known as the patellar Severance of digital flexor tendons can occur in
ligament. A muscle tendon unit (MTU) comprises a association with small wounds and it is important to
muscle belly, its origin and insertion, and the check the integrity of the tendons at the time of first
musculotendinous junction. Injury to any presentation. The main concern is usually hemorrhage
component of the MTU is termed a strain. Tendons and it is easy to overlook the tendon injury until the
consist of bundles of crimped collagen fibers and wound has healed. The wound should be enlarged, if
parallel rows of fibroblasts. The crimping of the necessary, to gain access to the severed ends of tendon
fibers confers a spring-like function so that so that they can be sutured. Polypropylene (Prolene,
deformation occurs in a nonlinear fashion when the Ethicon) is the suture material of choice but
tendon is loaded under tension. A sac containing absorbable suture (PDS, Ethicon) may be preferred
synovial fluid, known as a tendon sheath, surrounds where there are concerns about wound contamina-
the tendon where it crosses a joint. Nonsheathed tion. Size 3 metric suture is used for large tendons
tendons are enclosed in loose connective tissue such as the calcanean tendon, smaller diameter suture
known as the paratenon, which allows the tendon to may be required for other tendons. Several suture
glide. patterns are suitable for tendon repair, including the
Pennington locking-loop pattern, Bunnell–Meyer
HEALING OF TENDONS AND LIGAMENTS pattern, and the three-loop pulley pattern (62). The
Strains and sprains are associated with rupture of most commonly used suture pattern in the cat is the
collagen fibers and hemorrhage from torn blood locking-loop suture. The locking-loop is preferred
vessels. There is an inflammatory response with because it is the easiest to apply to small flat tendons.
neovascularization and invasion of fibroblasts, which The three-loop pulley causes less tendon distortion
lay down new collagen fibers. These fibers are at first and is stronger (as might be expected since there are
randomly oriented but become organized within six strands of suture material) than the locking-loop
about 12 weeks of the injury. The collagen fibers pattern. However it is more difficult to apply and is
regain their longitudinal orientation in response to the only suitable for large round tendons such as the
Arthrology
105

calcanean tendon. Tendon repairs should be pin. Unilateral linear TESF frames are used for
supported postoperatively by placing the limb in a immobilization of the stifle and elbow joints and
short splint or cast for 6 weeks. bilateral frames are used for the carpal and tarsal
joints. The addition of a hinge to form a hinged
REPAIR OF LIGAMENTS transarticular external skeletal fixation frame
The ends of torn or avulsed ligaments are repaired in (HTESF) allows continued joint mobility and weight
the same fashion as tendons using a locking-loop bearing of the affected limb. The use of HTESF on
suture pattern, Bunnell–Meyer suture, or continuous 8 cats with tarsal or stifle joint injuries led to good
cruciate suture pattern. Alternatively, when there is functional results75. The technique of transarticular
sufficient ligament substance remaining, the ligament pinning can be applied to the stifle and tarsal joints
is reattached to bone. If the ligament cannot be but is probably best reserved for the treatment of hip
sutured, it is substituted by a prosthetic ligament. luxation.
Similarly, ligament repairs are usually protected by
using nonabsorbable suture anchored by screws, MISCELLANEOUS TENDON DISORDERS
bone tunnels, or bone anchors placed at the origin Tendon avulsions, tendinopathies, and tendon
and insertion sites of the ligament. Additional displacements are relatively uncommon. This
protection of ligament repairs may be provided by the probably relates to the small size of the cat and the
use of a transarticular external skeletal fixator (TESF). low incidence of conformational abnormalities in
In cats there are many instances when ligaments are comparison with the dog. Tendon avulsions are
not repaired or substituted and joint function is known as strain-avulsion injuries. They occur when
restored by periarticular fibrosis alone. In the latter a tendon is pulled away from bone at its origin
situation, temporary joint alignment and stability or insertion, often with a small fragment of bone
may be provided by alternative means, such as the attached. Strain-avulsion fractures are most frequently
application of a TESF or by placing a transarticular seen in immature cats as physeal injuries. Common

62

5
3
3
5
3
1 1
1

6
4 4

2 2 2
i ii iii
A B

62 Two tendon suture patterns.


A Pennington locking-loop tendon/ligament suture. When placing the suture the needle should enter the cut end of the
tendon and exit at a distance from the cut end approximately equal to the width of the tendon. The transverse bites are
made superficial to the longitudinal bites.
B Three-loop pulley tendon suture. The three bites on the tendon should be rotated 120° from each other to completely
encircle the tendon. (i) The first bite is placed in a near–far pattern, (ii) the second is placed mid-way between near and
far, (iii) the third is placed in a far–near pattern.
106
63 64

63 Triceps tendinopathy. Flexed mediolateral radiograph 64 Calcanean tendinopathy. Mediolateral radiograph of the
of the elbow joint showing multiple mineralized fragments hock showing an enthesiophyte on the tuber calcis of a cat
proximal to the olecranon (arrow). with avulsion of the calcanean tendon of insertion (arrow).

sites of this type of injury are the supraglenoid bilaterally following trivial trauma. In these cases there
tubercle, the tibial tuberosity, and the olecranon is frequently a tendinopathy (or enthesiopathy) with
process. Physeal avulsion fractures are occasionally chronic degenerative changes in the tendon in
bilateral and symmetrical76. Less common strain- association with enthesiophytes on the tuber calcis
avulsion injuries include tendinopathies of the triceps (64). Tendon displacements are very rare in the cat.
insertion (63) and traumatic avulsion of the triceps There is one report in the English language literature
tendon from the olecranon77. of lateral displacement of the superficial digital flexor
Avulsion of the calcanean (Achilles) tendon is tendon, which was thought to have had a traumatic
occasionally seen in older cats and may occur etiology78.
107

CHAPTER 8
FRACTURES AND
DISORDERS OF
THE FORELIMB
PART 1: SCAPULA AND SHOULDER JOINT

SCAPULAR FRACTURES TREATMENT AND PROGNOSIS


CAUSE AND PATHOGENESIS Scapular fractures are managed with conservative
Scapular fractures occur as a result of trauma. therapy or surgery depending on their location and
degree of displacement.
CLINICAL SIGNS
The majority of cats with scapular fractures have Fractures of the body and spine
concurrent, trauma-related injuries, which may Fractures of the body and spine of the scapula are
include pulmonary contusions, rib fractures, usually managed conservatively. The surrounding
pneumothorax, and hemothorax1,2. Injuries to the musculature (subscapularis, suprapinatus, and
brachial plexus and suprascapular nerve may also infraspinatus muscles) provides internal support
occur. Forelimb lameness, pain, swelling, and crepitus and prevents severe displacement. Confinement
in the scapular region are common clinical signs. and restricted activity are adequate in most cases and
cats are typically walking well within 4 weeks of the
DIAGNOSIS injury. The limb may be immobilized in a Velpeau
The diagnosis is confirmed radiographically. sling for 2 weeks if the cat is in particular pain.
If displacement of the fracture fragments is marked,
internal fixation may be indicated to reduce the
fracture, provide stability, and minimize pain during
healing (65). In most cases, orthopedic wire (0.6 mm

65 Repair of scapular body fractures. 65


A Transverse scapular body fracture stabilized with
interfragmentary wires. Suture material may be used
instead of wire if desired.
B Scapular body fracture stabilized with a cuttable
bone plate applied to the base of scapular spine. The
screws are angled to maximize bone purchase
(insert).

A B
108

[22 AWG]) or monofilament suture material (size 0) is projects from the distal aspect of the acromion. The
passed through holes drilled in the fragments3,4. The suprahamate process projects caudally from the
wire (or suture) aligns the fragments and should not be proximal aspect of the acromion (66). When fractured,
overtightened or it will tear through the thin bone. the acromion is typically distracted distally by the
Occasionally, a cuttable plate is used to achieve stability acromial head of the deltoid muscle. Surgery is
of scapular body fractures. The plate is applied at the indicated to achieve anatomic reduction, stabilize the
base of the scapular spine where the bone is slightly fracture, and prevent the suprascapular nerve from
thicker. The screws are angled to maximize bone becoming entrapped in a fracture callus. The
purchase. Care is taken when placing the screws to suprascapular nerve courses beneath the acromion
avoid penetrating the thoracic wall with the drill bit. process and is protected during surgery. The acromion
The cat’s activity is restricted for 4 weeks after surgery. process in some cats can be stabilized using tension
band wire fixation. A single Kirschner wire is placed
Fractures of the acromion from the avulsed fragment into the spine of the scapula.
The acromion in cats has both a hamate and supra- The tension band wire is placed around the Kirschner
hamate (metacromion) process. The hamate process wire and through a holed drilled approximately 1–2 cm

66

2 1

2
3

A B
66 The feline shoulder joint.
A Lateral view. 1 Metacromion, 2 Hamate process.
B Craniocaudal view. Note the scapular spine. The hamate process
projects from the distal aspect of the acromion. The suprahamate
(metacromion process) projects caudally from the proximal aspect of the
acromion. (Photograph courtesy of Tom Thompson.) 1 Metacromion,
2 Hamate process, 3 Coracoid process.
Fractures and disorders of the forelimb
109

dorsally in the scapular spine. In cats too small to feels prominent on palpation4. The suprascapular
accommodate a tension band, the avulsed acromion nerve can be damaged during the trauma or by
process is reattached using orthopedic wire (0.6 mm the subsequent movement of bone fragments. If
[22 AWG]) or monofilament suture material (0 or 2-0) displacement is significant, internal fixation is
(67). The wire or suture should not be overtightened indicated to restore anatomic alignment and prevent
or it will tear through the bone. It is not essential, but the suprascapular nerve from becoming entrapped in
the limb may be immobilized in a Velpeau sling or Spica the healing callus. A craniolateral approach is used,
splint for 2–3 weeks after surgery to protect the repair. including ostectomy of the acromion process or
tenotomy of the acromial head of the deltoid5. The
Fractures of the scapular neck suprascapular nerve is protected during the
Fractures of the scapular neck are often transverse and procedure. Fixation is usually achieved using
are usually displaced medially. Pain and swelling are Kirschner wires placed in a cross-pin configuration
evident in the region and the acromion process (68). Careful pin placement is required to ensure the

67

A B

67 Repair of acromion process fractures.


A The avulsed acromion process is stabilized with interfragmentary suture or wire. The suprascapular nerve must be
preserved during fixation.
B The avulsed acromion process is stabilized with a tension band wire fixation.

68

A B C

68 Repair of scapular neck fractures.


A Scapular neck fracture stabilized with two Kirschner wires in cross-pin fashion. The wires should cross proximal to the
fracture line.
B Scapular neck fracture stabilized with a small cuttable plate.
C Scapular neck fracture stabilized with a mini T plate. The ostectomy of the acromion process is stabilized with
interfragmentary wires or suture.
110

pins engage the thin bone of the scapular body Fractures of the supraglenoid tubercle are usually
proximal to the fracture. Ideally, the Kirschner wires displaced by the tendon of origin of the biceps brachii
should cross proximal to the fracture line. muscle. Careful reduction is required to prevent gaps
Occasionally, a mini plate (T plate or L plate) or small or steps in the articular surface. A cranial approach is
cuttable plate is placed across the fracture line using performed and the avulsed tubercle is reattached
1.5 or 2.0 mm screws6. If an ostectomy of the using a 2.0 mm screw placed in lag fashion from the
acromion process was performed, it is reattached with tubercle to the scapular neck (69 B)3,5. The screw is
a tension band wire fixation or interfragmentary wire. oriented parallel to the biceps tendon to reduce
If a tenotomy was performed, a locking-loop or bending loads. Alternatively, the tubercle can be
Bunnel–Meyer suture pattern is placed in the acromial reattached using a tension band wire fixation (69 C).
head of the deltoid and sutured to holes drilled in the A craniolateral approach is used and two Kirschner
scapular spine. wires are inserted through the tubercle and into the
scapular neck. A tension band wire is placed around
Fractures of the glenoid and supraglenoid the Kirschner wires and through a hole drilled in the
tubercle cranial border of the scapular body. The tension band
Glenoid fractures involve the articular surface of the wire will cross over the suprascapular nerve, which
distal scapula. Extremely small fragments may simply must be carefully protected during surgery.
be removed. However, fragments large enough to After fixation, the limb is immobilized in a
accept implants are stabilized with small screws Velpeau sling for 2 weeks (if tolerated by the cat) and
(2.0 mm) placed in lag fashion or Kirschner wires the cat’s activity is restricted for 4–6 weeks. If the
(69 A)7. Anatomic reduction is important and care articular comminution is severe and irreparable, or if
is taken to avoid placing implants in the glenoid pain persists after fixation, excision arthroplasty or
cavity. shoulder arthrodesis may be indicated4,8,9.

69

A B C

69 Repair of glenoid and supraglenoid tubercle fractures.


A Glenoid fracture. A lag screw is placed to compress and stabilize the articular component of the fracture. The scapular
neck component of the fracture is stabilized with Kirschner wires in cross-pin fashion.
B Supraglenoid tubercle avulsion fracture stabilized with a lag screw. The screw is placed parallel to the biceps tendon to
reduce bending loads.
C Supraglenoid tubercle avulsion fracture stabilized with a tension band wire fixation. The suprascapular nerve must be
protected.
Fractures and disorders of the forelimb
111

DORSAL DISPLACEMENT OF body. Additional support can be provided by placing a


THE SCAPULA wire or suture through holes drilled in the caudal
CAUSE AND PATHOGENESIS scapular body and around an adjacent rib. The suture
Traumatic rupture of the serratus ventralis, material is passed cautiously around the rib to avoid
rhomboideus, and trapezius muscles can result in injury to the lungs or intercostal vessels. The limb is
dorsal displacement of the scapula4,10. The muscles immobilized in a Velpeau sling for 2 weeks and the
usually tear near their insertions on the scapula when cat’s activity is restricted for 4 weeks.
the cat falls or jumps from a significant height.
SHOULDER LUXATIONS
CLINICAL SIGNS AND DIAGNOSIS CAUSE AND PATHOGENESIS
The cat will typically have an acute, nonweight- Shoulder luxation results from trauma and is
bearing lameness that progresses to weight bearing uncommon in the cat4,11.
over time. The scapula visibly displaces dorsally when
weight is placed on the limb (70). CLINICAL SIGNS
Clinical signs may include pain in the shoulder region
TREATMENT AND PROGNOSIS and a nonweight-bearing lameness with the limb
Most cats eventually regain pain-free limb function flexed at the elbow.
after conservative therapy consisting of restricted
activity. The abnormal gait characterized by dorsal DIAGNOSIS
displacement of the scapular persists, however. A disparity in the relative positions of the acromion
Surgical intervention is required to stabilize the process and the greater tubercle is usually palpable,
scapula and restore normal gait. A craniodorsal although the diagnosis of shoulder luxation is
approach to the scapula exposes the damaged confirmed radiographically. Radiographs should also
muscles5. Primary repair of each muscle is performed be evaluated for concurrent fractures of the scapula
using monofilament, nonabsorbable suture material. and humerus12. A complete neurologic examination is
If the muscles are avulsed from the scapula, the suture important to detect brachial plexus or other nerve
is anchored to holes drilled through the scapular injuries.
Chronic mild shoulder joint instability has also
been reported in a cat13. With mild instability, laxity of
the shoulder joint in the craniocaudal or mediolateral
directions may be elicited by palpating the joint with
70 the cat under anesthesia.

TREATMENT AND PROGNOSIS


Closed reduction
Closed reduction is successful for the treatment
of shoulder luxation in most cats. The joint is
stabilized by external coaptation for 2–3 weeks and
the cat’s activity is restricted for 4–6 weeks. For medial
shoulder luxation, the limb is immobilized in a
Velpeau sling. The sling distracts the humeral head
laterally to maintain joint reduction. For lateral
luxations, the limb is immobilized in a Spica splint.
The humerus is positioned in slight abduction within
the splint to maintain shoulder reduction.

Surgical repair
70 Dorsal displacement of the scapula. Surgical repair is indicated if the joint is markedly
unstable after reduction, or remains unstable after
external coaptation, or if the cat will not tolerate
coaptation. Several surgical procedures may be used to
stabilize the shoulder joint in cats.
112

Transarticular pinning within the lateral and medial joint capsule13. The
The shoulder joint is reduced and placed in a normal medial glenohumeral ligament is torn more often than
weight-bearing position (approximately 110°). the lateral. Imbrication is often performed along with
A small Steinmann pin is inserted normograde other internal fixation methods to stabilize the
through a stab incision over the distal aspect of the shoulder joint.
greater tubercle, across the joint, and into the scapular
neck (71 A). The pin is cut short to reduce soft tissue Collateral support with suture
trauma. The limb is placed in a Spica splint for added The joint is explored through combined craniolateral
stability. The splint and pin are removed after and craniomedial approaches5. A hole is drilled from
2–3 weeks4,14. The cat’s activity is restricted for an lateral to medial through the center of the scapular
additional 2–3 weeks. Transarticular pinning is a neck, avoiding the suprascapular nerve. A second hole
relatively simple procedure, which is effective in is drilled from lateral to medial through the proximal
stabilizing the shoulder joint in cats, but damage to humerus, between the humeral head and greater
the articular cartilage is caused by pin placement. tubercle. One or two strands of suture material are
passed laterally to medially through the hole in the
Imbrication of the joint capsule and glenohumeral scapular neck and medially to laterally through the
ligament hole in the proximal humerus. The suture is tied
The torn joint capsule and glenohumeral ligaments under moderate tension on the lateral aspect of the
are sutured and imbricated with monofilament, humerus (71 C)16. Monofilament polybutester suture
absorbable suture material (2-0). A simple interrupted material (Novafil, Davis, & Geck) has been recom-
or continuous mattress pattern is used (71 B)14,15. mended for its elasticity16. The limb is placed in a
The glenohumeral ligaments are closely associated Velpeau sling or Spica splint for 2–3 weeks after
with the joint capsule and appear as thickened bands surgery.

71

110°

A B C D
71 Techniques for stabilizing shoulder joint luxation.
A Transarticular pinning. The joint is placed at an angle of 110° prior to pin placement.
B Imbrication of the joint capsule and glenohumeral ligament with monofilament absorbable suture material placed in an
interrupted mattress pattern (medial view).
C Collateral support. Suture material is placed through holes drilled in the scapular neck and proximal humerus and tied
on the lateral side.
D Prosthetic medial glenohumeral ligament replacement (medial view). Suture material is attached to the proximal
humerus just distal to the insertion of the glenohumeral ligament using a bone anchor or bone tunnel. Bone tunnels are
drilled through the scapular neck at the cranial and caudal origins of the glenohumeral ligament. The suture is passed
from medial to lateral through the caudal bone tunnel, beneath the infraspinatus and supraspinatus muscles, and then
from lateral to medial through the cranial bone tunnel. The suture is tied medially.
Fractures and disorders of the forelimb
113

Prosthetic medial glenohumeral ligament EXCISION ARTHROPLASTY


Medial glenohumeral ligament replacement is Excision arthroplasty is a salvage procedure per-
used to stabilize medial shoulder instability17,18. formed for shoulder injuries unresponsive to medical
A craniomedial approach to the shoulder is per- or other surgical treatments3,8. Excision arthroplasty
formed. A hole is drilled just distal to the insertion of is easier to perform than shoulder arthrodesis. A
the medial glenohumeral ligament on the proximal craniolateral approach is performed, with tenotomies
humerus. A suture anchor (Bone Biter, Innovative of the infrapinatus and acromial head of the deltoid
Animal Products LLC.) loaded with monofilament, muscle. The origin of the biceps brachii is removed
nonabsorbable suture material is inserted into the from the supraglenoid tubercle. The joint capsule is
hole. Alternatively, a bone tunnel is drilled to anchor incised close to the glenoid rim. An ostectomy of the
the suture to the humerus. Two bone tunnels are then glenoid is performed, using an oscillating saw or
drilled in the scapula at the origins of the caudal and osteotome, to remove the articular surface (72). The
cranial components of the glenohumeral ligament. ostectomy is made at an angle such that the lateral
The medial glenohumeral ligament is replaced by edge is slightly longer than the medial edge. The
tying the suture using one of two methods: suprascapular nerve and caudal circumflex humeral
• Two strands of suture are loaded in the bone artery are preserved. If desired, the proximal portion
anchor. One strand is passed through the cranial of the humeral head can also be removed with a saw
bone tunnel and tied. The second strand is passed or osteotome3. The infraspinatus is reattached. The
through the caudal bone tunnel and tied. teres minor is placed over the glenoid ostectomy site
• A single strand of suture is loaded in the bone and sutured to the biceps tendon and medial joint
anchor. The strand is passed through the caudal capsule. The acromial head of the deltoid muscle is
bone tunnel, beneath the infraspinatus and attached to the scapular spine using standard tendon
supraspinatus muscles along the lateral aspect of suturing techniques. Early use of the limb is encour-
the scapular neck, and back through the cranial aged after surgery to promote pseudoarthrosis.
bone tunnel (71 D). The suture is tied18.
SHOULDER ARTHRODESIS
Postoperative care Shoulder arthrodesis is indicated for traumatic joint
Postoperatively, the limb is supported in a Velpeau sling injuries, chronic subluxation unresponsive to surgical
for 2–3 weeks. Exercise is restricted for 4 weeks. If repair, severe degenerative joint disease, and
irreparable articular fractures are present, or instability congenital abnormalities9,19,20. The angle of fusion
persists after repair, excision arthroplasty or arthrodesis should allow advancement of the limb and weight
of the scapulohumeral joint may be required8,15. bearing without overextension of the elbow.

72 Excision arthroplasty of the shoulder 72


joint.
A Ostectomy sites for excision of the
glenoid and proximal humerus.
B The proper angle for ostectomy of
the glenoid. The lateral edge should be
slightly longer than the medial edge.
The suprascapular nerve and caudal
circumflex humeral artery are preserved. Suprascapular
nerve

Osteotome

A B
114

Arthrodesis of the shoulder joint in cats is usually contoured and applied to the cranial aspect of the
performed at an angle of 110°; however, the correct proximal humerus and the dorsocranial junction
angle is best determined by evaluating the cat of the spine and body of the scapula. One or two
preoperatively in a normal standing position19. of the screws is placed in lag fashion through the
The shoulder joint is exposed through a combined plate and across the joint19.
cranial and craniolateral approach, including ostectomy • Cross-pins and tension band wire fixation: two
of the acromion process and greater tubercle, and or three Kirschner wires are inserted in cross-
tenotomy of the biceps brachii, infraspinatus, and pin fashion from the distal scapula into the
deltoideus muscles5. The suprascapular nerve is proximal humerus. Orthopedic wire (0.8 mm
protected. The articular surfaces of the humeral head [20 AWG]) is placed in a figure-of-eight pattern
and glenoid are removed with an oscillating saw at the through holes drilled in the cranial border of
correct angle, using care to avoid lateral or medial the distal scapula and cranial surface of the
angulation of the ostectomies. The distal scapula and humerus. The wire serves as a tension band and
proximal humerus are opposed and temporarily fixed is tightened to help compress the ostectomy
with Kirschner wires. Autogenous cancellous bone sites together.
graft, collected from the ostectomized humeral head
and glenoid, is placed around the ostectomy site. After fixation, the ostectomized greater tubercle is
Several methods of arthrodesis are described in the re-attached with Kirshner wires or a small lag screw.
cat (73): The ostectomized acromion process is reattached
• Lag screw fixation: a lag screw is placed from the with wire or suture material. A Spica splint is applied
cranial aspect of the distal scapula into the to the limb for 4–6 weeks after surgery and exercise
proximal humerus to compress the cut surfaces20. should be restricted until union has occurred. In most
A 3.5 mm cortical screw or a 4.0 mm cancellous cases, function of the limb after arthrodesis is very
screw may be used in most cats. good. The mobility of the scapula on the body wall
• Bone plating: a dynamic compression plate allows the forelimb to move normally even after
(DCP) or cuttable plate (8–10 holes) can be arthrodesis.

73

110°

A B C D

73 Techniques for shoulder arthrodesis.


A The proper ostectomy sites on the distal scapula and proximal humerus. The arthrodesis angle is approximately
110° in cats. Osteotomies of the greater tubercle and acromion process are shown.
B Shoulder arthrodesis using a lag screw and a Kirschner wire. The ostectomized greater tubercle is reattached with
Kirschner wires or a small screw.
C Shoulder arthrodesis by plate fixation. Two of the plate screws are placed in lag fashion across the ostectomy site.
D Shoulder arthrodesis using cross-pins and a tension band wire fixation. The tension band wire is placed through
bone tunnels on the cranial surfaces of the scapula and humerus.
Fractures and disorders of the forelimb
115

PART 2: HUMERUS AND ELBOW JOINT

HUMERAL FRACTURES growth plates4. If displacement is minimal, the limb


CAUSE AND PATHOGENESIS can be immobilized in a Velpeau sling for 3–4 weeks.
Humeral fractures in cats generally result from trauma When fragments are displaced, internal fixation is
and most occur in the distal portion or aspect of the preferred to achieve anatomic reduction and fixation.
bone1,2.
Greater tubercle
CLINICAL SIGNS Avulsion of the greater tubercle in immature cats can
Clinical signs include lameness, reluctance to bear be repaired in a closed or open fashion. Reduction of
weight on the limb, swelling, and pain. the displaced tubercle is facilitated by extension of the
shoulder joint. The fracture is stabilized using two
DIAGNOSIS Kirschner wires driven through the tubercle into the
The diagnosis is confirmed radiographically. The cat medullary cavity of the humerus. The Kirschner wires
must be carefully evaluated for concurrent injury to are bent over and cut short to reduce irritation to the
the thorax and nervous system (brachial plexus, radial overlying soft tissues. In mature cats, a tension band
nerve, median nerve)3. wire fixation or lag screw may be used (74).

TREATMENT AND PROGNOSIS Humeral head


Proximal fractures Salter-Harris type I and II fractures of the humeral
Proximal humeral fractures are uncommon in the cat head are repaired using two Kirschner wires. The
and may involve the greater tubercle and the humeral fracture is reduced (open or closed) and the wires are
head. They generally occur in young cats with open driven from just distal to the greater tubercle, across

74
Supraspinatus
tendon

A B C D

74 Repair of fractures of the greater tubercle.


A Avulsion fracture of the greater tubercle.
B Stabilization of the greater tubercle in an immature cat with two Kirschner wires.
C Stabilization of the greater tubercle in a mature cat with a tension band wire fixation.
D Stabilization of the greater tubercle in a mature cat with a single lag screw and a Kirschner wire.
116

the physis, and into the humeral head. Care is taken Humeral head and greater tubercle
not to penetrate the articular surface. In mature cats, Fractures of the proximal humeral growth plate
fractures of the neck of the humerus are stabilized involving both the humeral head and the apophysis
with a lag screw (2.7 mm) and a single Kirschner wire of the greater tubercle occur rarely in cats. Open
(75, 76). or closed reduction is used to achieve proper
alignment. In immature cats, stabilization is achieved
by internal fixation using Kirschner wires placed from
75 the greater tubercle into the medullary cavity of the
humerus. In mature cats, Kirschner wires, lag screws,
or a tension band wire fixation may be applied (77).

Articular surface of humeral head


Fractures involving the articular surface of the
humeral head are rare. Fragments are reduced and
stabilized using Kirschner wires or a lag screw driven
from the humeral shaft or greater tubercle into the
base of the fragment. If the articular fragment is very
A B
small, the Kirschner wires can be inserted from the
75 Repair of humeral head fractures. articular surface into the subchondral bone and
A Growth plate fractures of the humeral head in immature countersunk below the articular cartilage using a small
cats are stabilized with Kirschner wires inserted from just nail-set (78)5. This technique injures the articular
distal to the greater tubercle, across the physis, and into
the humeral head.
B In mature cats, a lag screw and Kirschner wire are
inserted.

76

A B C D
76 Fracture of the humeral head and greater tubercle.
A Lateral radiographic view of a Salter–Harris type I fracture of the humeral head. The greater tubercle is mildly displaced.
B Craniocaudal radiographic view. Note the medial displacement of the proximal humeral epiphysis.
C Postoperative lateral radiographic view. The humeral head is reduced and stabilized with Kirschner wires inserted from
distal to the greater tubercle. A Kirschner wire is inserted across the greater tubercle.
D Postoperative craniocaudal view.
Fractures and disorders of the forelimb
117

surface and is used only when necessary. Migration of splints. The humeral diaphysis is exposed through
the implants into the joint can result in severe either a craniolateral or medial approach6–8. Care is
cartilage damage. taken to avoid injury to the radial nerve during the
lateral approach to the bone. In the cat, the median
Diaphyseal fractures nerve and brachial artery pass through the
Diaphyseal humeral fractures in the cat are typically supracondylar foramen, located on the medial surface
transverse or oblique. Open reduction and internal of the humerus just proximal to the medial
fixation is preferred in most cases since it is difficult to epicondyle. The nerve is easily damaged by bone
immobilize the humerus adequately with casts or fragments or implants and must be protected during

77

A B C D

77 Repair of proximal fractures of the humeral head and apophysis of the greater tubercle.
A Fracture involving the humeral head and greater tubercle.
B Stabilization in an immature cat using two Kirschner wires.
C Stabilization in a mature cat using a lag screw and a single Kirschner wire.
D Stabilization using a tension band wire fixation.

78

A B C

78 Repair of articular fracture of the humeral head.


A Kirschner wires are inserted from the great tubercle into the articular fragment. The articular surface is not penetrated
by the implants.
B A lag screw and Kirschner wire are placed to stabilize the articular fragment.
C Small Kirschner wires are inserted through the fragment from the articular surface and into the subchondral bone. The
wires are countersunk beneath the cartilage with a nail-set.
118

surgical repair of distal diaphyseal and metaphyseal 79


fractures. The ulnar nerve, located beneath the short
part of the medial head of the triceps brachii muscle,
must also be protected7. Stabilization of diaphyseal
humeral fractures can be achieved using several
methods.

External coaptation
External coaptation is indicated for stabilization of
nondisplaced fractures in immature cats. A Spica splint
or Velpeau sling is applied until the fracture is healed.
Complete immobilization of the proximal humerus is
difficult in mature and active cats.

Intramedullary pinning
Insertion of an intramedullary Steinmann pin is a
common and effective method of stabilizing humeral
fractures in cats9–11. The relatively straight humerus in
cats allows easy pin placement. Two important
anatomic features of the feline humerus must be
considered when placing an intramedullary pin:
• Narrow medullary cavity distally – a pin is
selected that will completely fill the distal aspect
of the medullary cavity.
• Supracondylar foramen – the location of the
supracondylar foramen precludes driving the pin
distally into the medial aspect of the condyle.
A B
Instead, the pin is positioned approximately 7–9
mm proximal to the medial epicondyle12. Pins 79 Normograde intramedullary pin insertion.
placed more distally can enter the supracondylar A The fracture is reduced and stabilized with bone clamps
foramen, damaging the median nerve and or cerclage wires.
brachial artery and penetrating the elbow joint13. B The pin is inserted at the proximolateral aspect of the
greater tubercle, driven distally across the fracture, and
Intramedullary pins may be inserted normograde seated into the distal humerus proximal to the
or retrograde into the humerus. For normograde supracondylar foramen.
insertion, the fracture is reduced and stabilized with
bone clamps or cerclage wires (if they are to be used)
(79). The pin is started at the proximolateral aspect of
the greater tubercle and driven distally across the
fracture and into the distal humerus (just proximal to
the supracondylar foramen). A second pin of identical For retrograde insertion, the pin is directed
length is used to determine how far distally the pin has proximally from the fracture site before final reduction
been placed, and the elbow is manipulated through a of the fracture (80). The pin should be inserted along
range of motion to ensure the pin has not penetrated the cranial surface of the medullary cavity to exit at the
the joint. Radiographs are also used to confirm tip of the greater tubercle. The pin is inserted until its
pin placement. The pin is then cut short to reduce soft distal end is just proximal to the fracture line. The
tissue trauma. Closed insertion of the intramedullary fracture is then reduced and stabilized with a bone
pin may be possible if the fracture is minimally clamp. Cerclage wires can be applied at this time if
displaced or if adequate reduction of the fragments is needed. The pin is driven distally and seated into the
achieved by palpation alone. Swelling of the soft distal humerus just proximal to the supracondylar
tissues surrounding the humerus and interposition of foramen. Proper insertion is confirmed and the pin is
soft tissues between the fragments may prevent closed cut short to reduce trauma to the soft tissue over the
reduction in some cases. tubercle.
Fractures and disorders of the forelimb
119

80 Retrograde intramedullary 80
pin insertion.
A The pin is directed proximally
from the fracture site and exits
the medullary cavity at the
greater tubercle.
B The pin is inserted until its
distal end is proximal to the
fracture line.
C The fracture is reduced and
stabilized with a bone clamp or
cerclage wires. The pin is driven
distally and seated into the distal
humerus just proximal to the
supracondylar foramen.
D Craniocaudal view of the
humerus depicting pin
placement from the greater
tubercle to the distomedial
aspect of the humerus proximal
to the supracondylar foramen.

A B C D

81 Intramedullary pin fixation 81


of humeral diaphyseal fractures.
A A single intramedullary pin
may be used alone if reduction
is good and interdigitation of
the fragments provides
rotational stability.
B Ancillary fixation with full
cerclage wires is indicated in
long oblique fractures to
control rotation.
C Ancillary fixation with
hemicerclage wires.
D Ancillary fixation with a type
Ia external fixator to prevent
rotation around the single
intramedullary pin and collapse
of the fracture site.
A B C D

Intramedullary pins may be used alone if reduction compressive forces at the fracture site (81). Application
is good and interdigitation of the fragments provides of cerclage wires is not feasible if the fracture is stabilized
rotational stability12. In many cases, however, ancillary in a closed manner, but is easily performed during open
fixation with full cerclage wires, hemicerclage wires, or fracture repair. A type I external fixator can be applied to
an external fixator is warranted to control rotational and prevent rotation if closed or open pinning is used. Stack
120

pinning (placing several pins into the medullary cavity) inserted with the dynamic intramedullary cross-pinning
does not completely prevent rotation but has been used technique achieve three-point fixation that provides
with success in cats (82)10,11. rotational and axial stability.

Dynamic intramedullary cross-pinning External fixation


(Rush pinning) A type I external fixator can be applied to the
Dynamic intramedullary cross-pinning is used to craniolateral aspect of the humerus as a primary means
stabilize fractures of the proximal or distal diaphysis and of fixation or in conjunction with an intramedullary
metaphysis in cats (83)14. Two Kirschner wires are pin9,15. Either acrylic or traditional connecting bars
inserted into the medullary cavity. For proximal may be used. A double connecting bar may be used
fractures, the first Kirschner wire is started at the for increased rigidity, although this is rarely necessary
proximolateral aspect of the greater tubercle and in cats. The fixator may be applied in a closed manner
the second wire is started the proximomedial aspect if the fracture can be reduced by palpation, or if
of the tubercle. For distal fractures, one wire is started intraoperative imaging is available to help ensure
just cranial to the medial epicondyle and the other just adequate alignment. Fixators may also be applied after
cranial to the lateral epicondyle. The wires are inserted open reduction (84).
at an angle to the median plane of the humerus so that
they will glance off the inner cortical wall and continue
in the medullary cavity (rather than penetrate the
cortex). The wires can be advanced by alternately
tapping them into place with a small mallet. 83
Alternatively, they can be inserted with a hand-chuck.
Minimal rotation of the hand-chuck is used to prevent
the wires from penetrating the cortex. Another means
of assuring the wires pass up the medullary cavity and
do not penetrate the humeral cortex is to blunt the tips
of the wires prior to insertion. This requires predrilling
of the insertion sites for each wire. Kirschner wires

82

A B
83 Dynamic intramedullary cross-pinning for repair of
proximal and distal diaphyseal or metaphyseal fractures of
the humerus.
A Proximal fracture repair (craniocaudal view). One
Kirschner wire is inserted from the proximolateral aspect of
the greater tubercle and the other from the proximomedial
aspect of the tubercle. The wires are inserted at an angle to
the median plane of the humerus and glance off the inner
cortical wall, continuing distally in the medullary cavity.
A B B Distal fracture repair (craniocaudal view). One wire is
82 Repair of a humeral diaphyseal fracture with stack inserted just cranial to the medial epicondyle and the other
pinning. just cranial to the lateral epicondyle. Kirschner wires
A Lateral view. inserted with the dynamic intramedullary cross-pinning
B Craniocaudal view. technique achieve three-point fixation that provides
rotational and axial stability.
Fractures and disorders of the forelimb
121
84

A B C D E

F G H I
84 External fixation of humeral diaphyseal fractures.
A Type Ia external fixator applied to the craniolateral aspect of the humerus to stabilize a short oblique fracture. Care is
taken to avoid entering the supracondylar foramen.
B Acrylic external fixator (type Ia frame) for stabilization of a transverse humeral fracture.
C Type Ia external fixator with double connecting bars for stabilization of a comminuted humeral fracture.
D Type Ia external fixator used in conjunction with an intramedullary pin.
E External fixator and intramedullary pin used in a tie-in configuration.
F Stabilization of a comminuted humeral fracture using a hybrid type I–II external fixator frame. The distal full pin is
attached to the lateral frame with a curved connecting bar.
G Lateral radiographic view of a comminuted distal humeral fracture caused by gun shot.
H Lateral radiographic view after stabilization with a hybrid type I–II external fixator with tie-in configuration.
I Photograph of a cat with a hybrid type I–II external fixator with tie-in configuration.
122

To apply the fixator, a half pin is inserted across the and median, ulnar, and radial nerves. Unfortunately, it
humeral condyle, starting just distal and cranial to is often difficult to place two transfixation pins distally
the lateral epicondyle. The pin is driven parallel to the in the cat humerus, particularly in comminuted distal
joint surface to a point just cranial and distal to fractures. The distal pin may also be inserted completely
the medial epicondyle. Pins 1.5–2.2mm in diameter are through the condyle (full pin). The pin exits the skin
recommended for transcondylar use13. A second half medial to the condyle and is attached to the lateral
pin is inserted in the proximal humerus. When the frame with an additional connecting bar9,17. This type
fixator is used in conjunction with an intramedullary of frame is often referred to as a hybrid type I–II
pin, this two-pin frame configuration is generally external fixator (84 F–I).
adequate (84 D). The pin helps maintain alignment and
protects the frame from bending forces. The external Bone plate and screw fixation
fixator controls rotational forces around the pin. For Bone plates and screws may be used to stabilize
additional stability, the external fixator frame can be diaphyseal humeral fractures in cats18. Dynamic com-
attached to the proximal portion of the intramedullary pression plates (2.7 mm), cuttable plates, and tubular
pin (tie-in configuration) (84 E)16. If the fixator is plates are commonly used12,19–21. For fractures
being used alone, particularly in comminuted fractures involving the proximal half of the humerus, the plate is
where the fragments do not share in load-bearing, a usually applied to the cranial surface of the bone, thus
more rigid frame is indicated. In these cases, a minimum avoiding the insertions of the pectoral muscles
of two transfixation pins are placed on each side of the (85 A). For mid-diaphyseal fractures, the plate may be
fracture line. Distally, the second pin is placed proximal applied to the lateral, medial, or cranial aspect of the
to the condyle. Care is taken to avoid entering the humerus (85 B–D). Lateral plating is achieved via a
supracondylar foramen or damaging the brachial artery craniolateral approach and requires that the plate be

85

A B C D
85 Plate application to the humeral diaphysis.
A Bone plate applied to the cranial humeral cortex to stabilize a proximal diaphyseal
fracture.
B Bone plate applied to the lateral humeral cortex to stabilize a mid-diaphyseal fracture.
C Bone plate applied to the medial humeral cortex. The median nerve and brachial
artery are protected during medial plate application.
D Bone plate applied to the cranial humeral cortex.
Fractures and disorders of the forelimb
123

positioned beneath the radial nerve and brachialis • Transverse fractures – the fracture is reduced and
muscle7,8. Plate contouring is often easier when the plate is contoured to the cortex, ensuring that
applying a plate to the medial cortex, but the median at least three screws can be placed proximal and
nerve and brachial artery must be protected as they distal to the fracture. A 2.7 mm DCP is commonly
pass through the supracondylar foramen6,14. For used. The oval holes in the DCP plates allow the
fractures involving the distal third of the humerus, the fracture line to be compressed to enhance stability
plate may be applied either laterally or medially6,14. and promote healing. Cuttable plates and tubular
However, contouring the plate to the distal aspect of plates may also be used (85 A).
the humerus in a cat can be difficult and other means • Oblique fractures – the fracture is reduced and
of fixation are often used to stabilize more distal temporarily stabilized with a bone clamp. The
fractures (see Supracondylar fractures and Condylar plate may be applied as described for transverse
fractures). fractures. Alternatively, a lag screw or cerclage
The plate needs to be long enough to ensure wires can be placed to compress the fracture line
the screws engage a minimum of five cortices on each and maintain reduction while the plate is applied
side of the fracture line. Plates may be used in (86). If the orientation of the oblique fracture
neutralization, compression, or bridging (buttress) line permits, one of the plate screws can be placed
function depending on the fracture configuration. in lag fashion across the fracture line.

86

A B C D
86 Stabilization of oblique humeral fractures with bone plates.
A Neutralization plate applied to the lateral cortex of the humerus after fracture reduction.
B The oblique fracture is stabilized with full cerclage wires and a neutralization plate is applied
to the lateral cortex.
C The oblique fracture is stabilized with a lag screw and a neutralization plate is applied to the
lateral cortex.
D Bone plate applied to the cranial surface of the humerus. A plate screw is applied in lag
fashion across the oblique fracture.
124

• Comminuted fractures – a bone plate can be cavity. The plate is contoured and applied in
applied in several ways to stabilize comminuted buttress fashion on the medial or lateral aspect
fractures of the humerus (87): of the humerus. The most proximal and distal
• Controlled collapse – if the area of screws engage both humoral cortices
comminution is small, the primary (bicortical). The remaining screws engage
fragments are apposed, as in a transverse only the near cortex (monocortical).
fracture, and the comminuted fragments A minimum of three monocortical screws and
are used as autogenous graft. This one bicortical screw are placed on each side of
results in minor shortening of the the fracture. Comminuted fragments and the
limb and clinical function is normal. fracture hematoma in the fracture site are not
• Fragment reconstruction – if the area of disturbed.
comminution is too large to permit
shortening of the bone, the fragments Interlocking nail fixation
may be reconstructed using cerclage wires The relatively long, straight humerus in the cat
or lag screws. The plate is then applied in makes it well suited for fracture repair using a
a neutralization function. This method 4.7mm or 4.0 mm interlocking nail (ILN)23. (Small
provides anatomic reduction and ensures Interlocking Nail System, Innovative Animal
load sharing between the plate and bone. Products LLC.) When possible, the ILN is inserted
However, it requires manipulation of normograde into the medullary cavity through a
the fragments and possible interference limited approach at the greater tubercle, thus
with soft tissue attachments and blood reducing injury to soft tissues and blood supply
supply. at the fracture site. ILNs are available in various
• Bridging (buttress) plating – the plate is lengths (see Chapters 5 and 6) and have either
applied in buttress fashion to bridge the four screw holes (two proximal and two distal) or
area of comminution. The proximal and three screws holes (a single distal or proximal screw
distal fragments are stabilized, leaving hole). For fractures near the metaphysis of the
the comminuted fragments undisturbed humerus, an ILN with three screw holes is preferred
within the fracture gap. This preserves to avoid placing a screw within 1–2 cm of the
soft tissue attachments and blood supply, fracture site.
but also requires the plate to bear additional Once the nail is inserted, the drill-aiming guide is
load until healing occurs. When applying a attached to the nail via the extension rod to allow
plate in buttress fashion, plate failure can placement of 2.0 mm diameter screws. The distal
occur through empty screw holes and screw is generally placed first via a small stab incision
the cat’s activity must be restricted over the appropriate portion of the humerus. The
postoperatively. Cuttable plates may be remaining screws are then inserted. For comminuted
stacked to increase rigidity when used in fractures, the fragments are typically left in situ and
buttress fashion19–21. Autogenous cancellous the nail serves a buttress function. Alternatively,
bone graft is placed in the defect to promote fragments can be anatomically reduced with cerclage
healing22. wires (requiring an open approach) and the ILN
• Plate–rod fixation – an intramedullary pin serves a neutralization function. It is preferable to
is placed in normograde fashion to maintain avoid using cerclage wires, however, unless they
length and alignment of the bone while the contribute significantly to the repair. Autogenous
bone plate is applied. The pin should fill cancellous bone graft can also be placed at the fracture
approximately 35–40% of the medullary site if desired.
Fractures and disorders of the forelimb
125
87

A B C D

E F G

87 Stabilization of comminuted humeral fractures with bone plates.


A Comminuted diaphyseal humeral fracture.
B The fracture site is collapsed and stabilized with a compression plate. Bone fragments are used as bone graft around the
fracture site.
C The comminuted portion of the fracture is stabilized with cerclage wires and a neutralization plate is applied.
D The comminuted portion of the fracture is stabilized with lag screws and a neutralization plate is applied.
E A DCP plate is applied in bridging (buttress) fashion to maintain bone length. The comminuted fragments are
minimally disturbed to preserve blood supply. Plate failure may occur through empty plate holes placed over the
comminuted fracture.
F A lengthening (biologic healing) plate is applied to bridge the comminuted fracture. The central portion of the plate is
devoid of screw holes to prevent failure through empty holes.
G Plate–rod fixation of a comminuted humeral fracture.
126

Supracondylar fractures segment cannot be reconstructed with cerclage


Supracondylar fractures are relatively common in wires, dynamic intramedullary cross-pinning may not
cats and often involve the supracondylar foramen. be feasible.
Many of the fractures are comminuted and can be
challenging to repair 24,25. A medial or lateral External fixator with an intramedullary pin
approach to the distal humerus is performed to A small Steinmann pin or Kirschner wire is driven into
expose the fracture 7. In many cases, the two the medullary cavity of the humerus from the medial
approaches are combined to allow reduction and aspect of the condyle24. In most cats, the pin must be
proper implant placement. When approaching the relatively small (less than 1.6 mm) to avoid entering
distal humerus in a cat, care is taken to protect the the supracondylar foramen13. If possible, the pin is
median nerve and brachial artery as they pass advanced up the medullary cavity to the greater
through the supracondylar foramen. Occasionally, tubercle. It is then recessed below the surface of the
the medial wall of the supracondylar foramen condyle to prevent injury to the ulnar nerve12. The
is excised with a rongeur to prevent nerve small pin maintains alignment while a type I or hybrid
entrapment12. The ulnar nerve, located beneath the type I–II external fixator is applied to the craniolateral
short part of the medial head of the triceps brachii aspect of the humerus17. Either acrylic or traditional
muscle, must also be protected7. Several techniques connecting bars may be used. A half pin is inserted
are described for repair of supracondylar fractures in across the humeral condyle (starting just distal and
cats (88)25. cranial to the lateral epicondyle) parallel to the joint
surface. If possible, a second transfixation pin is
Cross-pin fixation inserted distal to the fracture. One or two additional
The fracture is reduced and temporarily stabilized half pins are inserted in the humerus proximal to the
with pointed reduction forceps. If the fracture is fracture.
oblique, cerclage wires may be used to stabilize the
fracture line. Some comminuted fractures may also External fixator alone
be reconstructed using cerclage wires. Kirschner If an intramedullary pin cannot be positioned,
wires (1.1–1.6 mm) are then placed in cross-pin the external fixator may be used alone. A type I
fashion from the lateral and medial aspects of external fixator is used for most simple fractures. A
the condyle26. The wires are inserted from the hybrid type I–II external fixator provides greater
nonarticular portion of the condyle, just caudal to rigidity and is used for comminuted fractures. If the
the epicondyles, and advanced across the fracture supracondylar fracture is comminuted, several
line, exiting the metaphyseal cortex proximal to the options exist:
fracture line. The wires are cut and bent over against • The fragments may be stabilized with cerclage
the condyle to avoid soft tissue and ulnar nerve wire before application of the fixator.
irritation12. • The fracture site may be collapsed to appose the
primary fragments and the fixator applied,
Dynamic intramedullary cross-pinning resulting in minimal limb shortening.
Two Kirschner wires (1.1–1.6 mm) are started as • The fragments are left undisturbed and the
described above for the cross-pinning technique. fracture gap is maintained. The fixator is applied
The wires are inserted at an angle to the median to prevent collapse. Cancellous bone graft may
plane of the humerus so that they will glance off the be placed in the fracture site to encourage
inner cortical wall and continue proximally within healing.
the medullary cavity (rather than penetrating the
cortex as cross-pins). To prevent the wires from Condylar fractures
penetrating the cortex, the sites for wire placement The feline humeral condyle is relatively straight and
are predrilled and the tips of the wires are blunted. wide, and lacks the supratrochlear foramen seen in
The wires are advanced by alternately tapping them other carnivores9. As a result, fractures of the humeral
into place with a small mallet. A hand-chuck may be condyle are uncommon in cats. Open reduction and
used, although minimal rotation of the chuck internal fixation are required to reconstruct the
is required to prevent the wires from engaging articular surface accurately and stabilize the fracture.
the cortex. If comminution is present, the pins may A lateral approach is usually adequate. The medial and
enter the fracture site rather than glance off the lateral aspects of the condyle are reduced and held
cortex and continue proximally. If the comminuted with a bone clamp. Small pointed reduction forceps or
Fractures and disorders of the forelimb
127
88

A B C D

E F G H

88 Stabilization of supracondylar humeral fractures.


A Cross-pin fixation. The wires are inserted just caudal to the medial and lateral epicondyles and advanced across the
fracture line to exit the metaphyseal cortex proximal to the fracture line.
B Dynamic intramedullary cross-pinning. The wires glance off the inner cortical wall and continue proximally within the
medullary cavity.
C Type Ia external fixator and intramedullary pin. A small pin is used to avoid entering the supracondylar foramen.
D Hybrid type I–II external fixator and intramedullary pin.
E Type Ia external fixator. If possible, two transfixation pins are placed on each side of the fracture.
F Oblique supracondylar fracture stabilized with cerclage wires and a type Ia acrylic external fixator.
G A comminuted supracondylar fracture stabilized with a hybrid type I–II external fixator. The fracture gap is maintained
to preserve bone length.
H A comminuted supracondylar fracture stabilized by collapsing the fracture to appose the primary fracture segments and
applying a type Ia external fixator.
128

vulsellum forceps are effective. A small, transcondylar line to a point just cranial to the lateral
Kirschner wire may also be placed to provide epicondyle. The hole should be centered in the
rotational stability during screw placement. condyle and parallel to the articular surface. The
Stabilization of condylar fractures is achieved by hole may be drilled to the same size as the outer
placing a 2.0 mm or, preferably, a 2.7 mm cortical diameter of the screw if a lag effect is desired
screw across the humeral condyle (89)24. In most (and if overdrilling will not remove too much
cases, the screw is placed from lateral to medial using bone from the condyle). The fracture is then
one of two methods: reduced and temporarily stabilized with a clamp.
• The condyle is reduced and temporarily stabilized The drill bit is then passed through the hole
with clamps or a Kirschner wire. A drill bit is used drilled in the lateral condyle (using a drill sleeve if
to drill a screw hole, starting just cranial to the overdrilled) to begin drilling a hole in the medial
lateral epicondyle. The hole is placed parallel to condyle. The hole is measured (tapped if
the joint surface and exits the condyle just distal necessary) and the appropriate length screw is
and cranial to the medial epicondyle. Ideally, the inserted.
screw will be centered in the condyle. The hole is After placement of the transcondylar screw, a
measured (and tapped if necessary) and the Kirschner wire is placed to prevent rotation around
appropriate length screw is inserted. The screw the screw. The Kirschner wire may be positioned
will maintain the interfragmentary compression parallel to the screw (across the condyle) or inserted
created by the clamps. In larger cats, the screw from the condyle into the supracondylar portion of
can be inserted in lag fashion by ‘overdrilling’ the the humerus.
hole in the lateral condyle to the same size as the
outer diameter of the screw (glide hole). Combination supracondylar and condylar
However, in smaller cats, overdrilling to create a fractures
glide hole may remove too much bone from the Supracondylar and condylar fractures may occur
condyle12. simultaneously and are often referred to as T- or
• The intracondylar fracture line is exposed. A drill Y fractures. This type of fracture is rare in cats. Open
bit is used to drill a screw hole from the fracture reduction and internal fixation are required to restore

89 89 Repair of humeral condylar fractures.


A The fracture is reduced and temporarily
stabilized with a bone clamp. A 2.0 mm or
2.7 mm bone screw is inserted across the
humeral condyle, parallel to the joint
surface. In larger cats, the screw can be
inserted in lag fashion by drilling a glide
hole in the lateral portion of the condyle.
A Kirschner wire is inserted to prevent
rotation around the screw.
B Lateral view showing the proper screw
placement for repair of a condylar
fracture. The screw is inserted just cranial
to the lateral epicondyle and exits the
medial aspect of the condyle, just cranial
to the medial epicondyle.

A B
Fractures and disorders of the forelimb
129

joint function. Repair consists of combining reconstructed. A cortical bone screw (2.0 mm or
techniques used for each fracture type. A lateral 2.7 mm) is placed across the condyle as previously
approach to the elbow and distal humerus is usually described. Then, the supracondylar portion of the
adequate, although an additional medial approach fracture is stabilized using Kirschner wires placed in
may help in some cases7. First, the condylar fracture is cross-pin fashion, dynamic intramedullary cross-
repaired to ensure the articular surface is accurately pinning, an external fixator, or bone plating (90).

90

B C D E
A
90 Stabilization of T- or Y fractures of the distal humerus.
A Combination supracondylar and condylar fracture of the distal humerus.
B Repair using a 2.0 mm or 2.7 mm cortical bone screw inserted across the
condyle and two Kirschner wires inserted in cross-pin fashion to stabilize the
supracondylar portion of the fracture.
C Repair using a transcondylar screw and dynamic intramedullary cross-pinning.
D Repair using a transcondylar screw and a type Ia external fixator.
E Repair using a a hybrid type I–II external fixator.
F Craniocaudal radiographic view of a Y-fracture stabilized with a transcondylar
screw and two bone plates.

F
130

Placing a bone plate on the medial and lateral aspects 91


of the humerus may be indicated when stabilizing
severely comminuted fractures. Careful planning is
required to ensure all of the implants can be
positioned in the small, distal fragment without
penetrating the joint.

POSTOPERATIVE CARE OF HUMERAL FRACTURES


Postoperatively, the cat is restricted until bony
union is complete. Radiographic evaluation at 4 and
8 weeks is performed to assess healing and monitor for
complications. In most cases, external coaptation is
not used after internal fixation to allow limb function
and early joint motion. If it is necessary to augment
the fixation, however, a Velpeau sling or Spica splint
can be applied for 2–4 weeks (91). External fixators
are removed when healing is complete. Other
implants are left in place unless complications develop. 91 Spica splint applied to immobilize the elbow and
shoulder joints.
TRAUMATIC ELBOW LUXATION
CAUSE AND PATHOGENESIS
The elbow is a ginglymoid joint composed of
the humeroradial, humeroulnar, and proximal
radioulnar articulations (92). Weight-bearing force is
transmitted primarily across the humeroradial joint. The

92

A B C
92 Feline elbow joint.
A Lateral view.
B Medial view.
C Craniocaudal view.
Fractures and disorders of the forelimb
131

collateral ligaments and position of the anconeal process DIAGNOSIS


within the olecranon fossa provide stability. Elbow Lateral and craniocaudal radiographic views of the
luxation is relatively common in cats, generally as a elbow are obtained to confirm the presence of a
result of significant trauma. Lateral luxation is most luxation and evaluate for articular fractures or
common. The medial epicondyle is larger than fractures of the humerus, radius, or ulna (93).
the lateral epicondyle and the size and shape of
the medial epicondyle prevents medial movement of the TREATMENT AND PROGNOSIS
ulna27. Caudal luxation also occurs commonly in cats12. Joint reduction
The cat is stabilized and evaluated for other soft
CLINICAL SIGNS tissue, neurologic, and orthopedic injuries before
Cats with elbow luxation may have a history of recent joint reduction is performed. In acute injuries, closed
trauma. Most are acutely nonweight-bearing and hold reduction is attempted first and is usually successful
the limb with the elbow slightly flexed and adducted. in cats12,27. The cat is placed under general
The antebrachium is abducted and externally rotated. anesthesia and the limb suspended from a stand for
Palpation of the elbow region reveals reduced range of 5–10 minutes to fatigue the muscles and aid in
motion, pain, and swelling. reduction of the joint.

93

A B
93 Radiographic views of an elbow luxation.
A Lateral view.
B Craniocaudal view.
132

Lateral luxation Joint stabilization


The elbow is flexed to 110° and the antebrachium is After reduction of the luxation, the stability of the
abducted and pronated. Medial pressure is applied to joint is assessed. The collateral ligaments are evalu-
the caudal ulna to engage the anconeal process within ated by flexing both the carpus and elbow to 90°27.
the olecranon fossa, medial to the lateral epicondylar The foot is then internally and externally rotated and
ridge (94). The elbow is then extended slightly to the amount of rotation compared with the contralat-
engage the anconeal process fully, allowing it to be eral normal limb. The foot will rotate excessively
used as a fulcrum to lever the radial head into internally if the lateral collateral ligament is damaged;
position. The elbow is then slowly flexed and the and will rotate excessively externally if the medial
antebrachium is pronated and adducted while collateral ligament is damaged. The collateral
applying medial pressure to the radial head. Several ligaments may also be evaluated by placing valgus and
attempts may be required before the joint is varus stress on the antebrachium with the elbow joint
reduced28. After reduction, the limb is maintained in extended.
extension to prevent reluxation. Joints that are reasonably stable after closed
reduction are managed with external coaptation.
Caudal luxation Joints that cannot be reduced closed, or easily reluxate
In caudal luxations, the proximal radius and ulna after closed reduction, are managed with internal
are positioned caudal to the humeral condyle. fixation27.
Palpation of the relative locations of the epi-
condyles and the radial head will usually confirm the External coaptation
luxation. Reduction is often achieved when the limb is Lateral luxations are stabilized by placing the limb
suspended to fatigue the muscles. If this does not in a Spica splint for 2–3 weeks. Immobilizing the
occur, reduction may be achieved by placing traction limb with the elbow in approximately 140° of
on the antebrachium until the humeral condyle is extension places the anconeal process within
aligned with the ulnar notch. The elbow is then flexed the olecranon fossa for added stabililty. Caudal
to seat the condyle fully. After reduction, moderate luxtions are stabilized by placing the limb in
flexion of the elbow joint is usually required to a Velpeau sling for 2–3 weeks to maintain elbow
prevent reluxation. flexion12.

94

Engage anconeal
process
110°
Flexion
Pronation

Medial pressure on
radial head
A B
94 Closed reduction of a lateral elbow luxation.
A The elbow is positioned in 110° of flexion and then pressure is applied to the proximal
ulna to engage the anconeal process within the olecranon fossa of the humerus.
B The joint is then pronated, adducted, and slowly flexed while exterting medial pressure
on the radial head.
Fractures and disorders of the forelimb
133

Internal fixation locking-loop pattern. Severely damaged


Internal fixation is indicated when closed reduction is ligaments are replaced with suture material
unsuccessful or when elbow instability persists after (prosthetic ligament). This is achieved by
closed reduction. The joint is approached through a placing the suture through bone tunnels
lateral incision over the elbow. Hematoma, torn drilled at the origin and insertion sites of
remnants of the joint capsule, and muscle are removed the ligaments. Alternatively, bone anchors or
from the joint and the articular surfaces examined. screws and washers may be placed to affix the
The elbow is reduced as described for the closed suture in the proper anatomic location28.
methods. An olecranon ostectomy may be performed, Nonabsorbable suture material (2–0) in a
if necessary, to facilitate reduction, but is rarely figure-of-eight pattern is used. The radial and
required. (The olecranon is reattached using a tension ulnar nerves should be protected during
band fixation after the joint is stabilized.) The joint is reduction and stabilization of the elbow joint.
stabilized by reconstruction of the periarticular soft The limb is placed in a Spica splint for 2 weeks
tissues (with or without a transarticular pin) and after surgery. The cat’s activity is restricted
external coaptation (95). for 4 weeks after splint removal. Passive range-
• Soft tissue reconstruction – after joint reduction, of-motion exercises are used to restore full
the joint capsule and collateral ligaments are mobility to the joint.
reconstructed as needed to insure joint stability. • Transarticular pin – in some cats, soft tissue
Several interrupted mattress sutures are placed reconstruction alone is inadequate to maintain
in the joint capsule. Torn collateral ligaments are reduction. A transarticular Kirschner wire
apposed with nonabsorbable suture material in a (1.1–1.6 mm) may be inserted from the

95

A B C D

95 Surgical stabilization of elbow luxations.


A Soft tissue reconstruction with a locking-loop suture placed in the ruptured collateral ligament and several mattress
sutures in the torn joint capsule. The insert shows the locking-loop suture pattern. Nonabsorbable suture material in used.
B Soft tissue reconstruction using a prosthetic collateral ligament. Nonabsorbable suture material is placed in a figure-of-
eight pattern through bone tunnels drilled at the origin and insertion of the torn collateral ligament.
C Soft tissue reconstruction using a prosthetic collateral ligament. Bone screws and washers are used to anchor the suture
material in the proper location.
D Stabilization of an elbow luxation with a prosthetic collateral ligament, capsular inbrication, and a transarticular pin.
134

olecranon into the humeral condyle, or from the ELBOW ARTHRODESIS


humeral condyle into the radial head, as needed, Arthrodesis is an alternative to amputation for
to stabilize the joint12. The elbow should be in a treatment of irreparable comminuted intraarticular
functional position. The pin is cut but left long fractures, chronic luxation unresponsive to surgical
enough to allow removal in 2 weeks. The limb is stabilization, and severe degenerative joint disease29,30.
placed in a Spica splint for 2 weeks. The cat’s Unfortunately, limb function is significantly compro-
activity is restricted for 4 weeks after splint and mised after elbow arthrodesis. Alhough the joint is
pin removal. Passive range-of-motion exercises usually pain-free, most cats will use the limb only
may be helpful in restoring joint mobility after intermittently, and the limb is circumducted during the
implant removal. swing phase of each stride. Most cats function better
after amputation than after elbow arthrodesis27,30.
Prognosis The elbow is usually fused at 110–135°, but the
The prognosis after elbow luxation depends on the angle should be individualized for each cat based on
severity of cartilage and periarticular soft tissue injuries, preoperative evaluation29,30. The joint is exposed by a
chronicity of the luxation before repair, degree of combined lateral and caudal approach with ostectomy
stabilization achieved, and owner compliance with of the olecranon process7. Transection of the ulnaris
postoperative restriction and physical therapy. The lateralis, lateral collateral ligaments, and the joint
prognosis with elbow luxations is good to excellent if capsule allows removal of the articular cartilage from
treated early and physical therapy is begun soon after the radial head, humeral condyles, and the trochlear
reduction. Potential complications include reluxation, notch of the ulna using bone curettes or a power burr.
reduced range of motion, osteoarthritis, and infection. The joint space is filled with cancellous bone graft to
In cases of severe articular cartilage and periarticular promote fusion. Rigid fixation is achieved with one of
soft tissue injury, elbow arthrodesis may be considered. several described techniques (96).

96

A B C

96 Elbow arthrodesis. A Lag screw fixation. A small pin is placed from the ulna to the humerus to maintain reduction at
the desired angle. Lag screws are inserted from the lateral epicondyle into the radial head, from the olecranon process to
the humerus, and from the ulna to the medial epicondyle. B Plate fixation. An eight- to ten-hole 2.0 mm or 2.7 mm bone
plate is applied to the caudal surface of the distal humerus and proximal ulna. Two screws are placed in lag fashion
through the plate and across the joint space. The olecranon process is reattached lateral to the bone plate. C Transarticular
external fixator. A small pin is inserted from the ulna, across the elbow joint, and up the medullary cavity of the humerus,
exiting the bone at the greater tubercle. A second pin is inserted normograde into the ulna from the olecranon process.
Transfixation half pins are inserted in the radius, ulna, and humerus. Flexible tubing is attached to the exposed ends of the
pins and filled with acrylic.
Fractures and disorders of the forelimb
135

Lag screw fixation possible, screws are placed in lag fashion through the
A Steinmann pin is placed across the joint (from the plate and across the joint space. Separate lag screws
ulna to the humerus) to maintain reduction at the may also be placed outside the plate. The olecranon
desired angle. Stabilization is provided using lag process is reattached lateral to the bone plate using
screws. One screw is inserted from the lateral Kirschner wires or a lag screw. After surgery, the limb
epicondyle into the radial head. A second screw is is immobilized in a Spica splint for 2–4 weeks.
placed from the olecranon process to the humerus.
A third screw is inserted from the ulna to the medial Transarticular external fixator
epicondyle. An additional screw can be inserted from A Kirschner wire (1.6–2.0 mm) is inserted across the
the ulna to the humerus if sufficient room exists. After elbow joint from the ulna into the humeral medullary
surgery, the limb is immobilized in a Spica splint for cavity. The pin should exit the proximal humerus at
2–4 weeks. A transarticular external fixator can be the greater tubercle. Both ends of the Kirschner wire
applied to protect the repair during healing but is are left protruding from the skin. A second pin is
generally not required. Exercise must be restricted for placed normograde into the ulna from the olecranon
4–6 weeks after surgery or until radiographic evidence process30. Several transfixation pins (half pins) are
of fusion is observed. inserted in the radius, ulna, and humerus. Flexible
tubing is then placed to connect the exposed ends of
Plate fixation the transfixation pins, ulnar pin, and both ends of the
A 2.0 mm or 2.7 mm bone plate is applied to the humeral pin. The tubing is filled with acrylic and
caudal aspect of the distal humerus and proximal ulna allowed to harden. The fixator frame is wrapped. The
after ostectomy of the olecranon process30. An eight- connecting bar and pins are removed when fusion is
to ten-hole plate will suffice for most cats. Where complete.
136

PART 3: RADIUS AND ULNA

HEMIMELIA cases of unilateral radial hemimelia if limb function is


Radial hemimelia (also called radial agenesis) is poor or if trauma to the affected limb occurs.
a developmental anomaly characterized by the absence Neutering is advised because of the potential genetic
or severe hypoplasia of the radius (97). It is reported component of the disease.
rarely in cats1,2. Although the etiology of radial
hemimelia is unknown, in utero mineral deficiencies RADIAL HEAD LUXATION
(including copper, manganese, and zinc), trauma to the Luxation of the radial head is rare in cats and is
developing fetal skeleton, in utero drug toxicity, and associated with traumatic rupture of the annular
vaccination are potential causes. Genetics is also a likely ligament. Clinical signs include lameness and elbow
cause. A second breeding of the parents of kittens with pain. The displaced radial head is palpable in some
hemimelia produced another litter with affected kittens2. cases and the diagnosis is confirmed by radiographic
Most kittens have an obvious limb deformity at evaluation of the elbow joint (98). Treatment for
birth, characterized by shortening and curvature radial head luxation is open reduction and internal
of one or both forelimbs. The kittens are lame and stabilization. Once reduced, the radius is attached to
often have reduced range of motion of the elbow the ulna with a 2.0 mm cortical screw placed in lag
and carpal joints. Carpal joint deformities may fashion (99). In most cases, the screw does not appear
occur concurrently. No effective treatment has been to limit motion between the radius and ulna and
reported, though some kittens will use the limb to normal limb function is restored. The screw remains
ambulate. Forelimb amputation may be performed in in place unless complications develop.

97 98

A
98 Radial head luxation.
A Lateral radiographic
view.
B Craniocaudal
radiographic view.

A
97 A Cat with radial
hemimelia.
B Radiograph of
forelimbs from a cat
with radial hemimelia.

B B
Fractures and disorders of the forelimb
137

FRACTURES cases. In most cases, proximal radial fractures can


CAUSE AND PATHOGENESIS be stabilized with Kirschner wires placed in
Fractures of the radius and ulna usually occur together cross-pin fashion (100)5,6. The wires are inserted
as a result of direct or indirect trauma to the just medial and lateral to the articular surface of the
antebrachium. Most occur in the distal one-half of radial head and driven into the opposite cortex distal
the diaphysis or the distal metaphysis3,4. Open to the fracture site. If a portion of the articular surface
fractures occur infrequently. is involved, small screws (1.5mm or 2.0mm) are placed
in lag fashion to achieve interfragmentary compression.
TREATMENT AND PROGNOSIS If the epiphyseal fragment is large enough, mini T or L
In general, fractures of the radius are stabilized plates can be applied (Synthes, Inc.; Veterinary
preferentially over fractures of the ulna, since the radius Orthopedic Implants Inc.). The surrounding soft
is the primary weight-bearing bone in the antebrachium.
Ulnar fractures are often left untreated if radial fixation
alone provides adequate stability. However, cats are able
to pronate and supinate the antebrachium and forepaw 100
to a greater degree than dogs, and stabilization of only
one bone provides less stability4.

Proximal radial fractures


Fractures of the proximal radius may involve the
radial metaphysis, proximal radial growth plate, and the
radial head. The articular surface is involved in some

99

A A B
99 Surgical repair of a
radial head luxation.
A Lateral radiographic
view.
B Craniocaudal
radiographic view.

100 Repair of proximal radial fractures.


A Cross-pin fixation.
B Lag screw and Kirschner wire fixation.
B
C Mini T plate fixation.
138

tissues and collateral ligaments are sutured to ensure surgical approach to achieve fracture reduction8.
joint stability. The limb may be immobilized in a soft Because the feline radius is relatively flat in the
padded bandage or Spica splint for 2–3 weeks after craniocaudal plane, placement of the transfixation pins
repair for additional support; however, early joint from medial to lateral can be challenging. Therefore,
motion is encouraged if fracture stability permits. the pins are often inserted from craniomedial to
caudolateral8. The craniomedial aspect of the radius
Diaphyseal radial fractures has minimal soft tissue coverage, which facilitates
Diaphyseal fractures of the radius can be stabilized pin placement. A minimum of two transfixation pins is
with external coaptation, external fixators, or a bone placed proximal and distal to the fracture (101).
plate and screws. If stability is adequate, additional Type Ia external fixators (unilateral frame/half pins)
fixation of the ulna is not required in most cases. with a single connecting bar are easy to apply and are
effective for most radial fractures in cats7. A hanging-
External coaptation limb technique is used to fatigue the muscles, provide
External coaptation of radial and ulnar fractures is distraction, and facilitate fracture reduction. The
indicated if the fracture can be adequately reduced proximal half pin is inserted parallel to the radiohumeral
closed and the reduction is stable7. This is true of some joint through a stab incision in the skin over the
minimally displaced simple fractures, particularly those proximal, craniomedial aspect of the radius. The distal
in the distal half of the bone. External coaptation is very half pin is inserted parallel to the radiocarpal joint
effective in immature cats and in fractures in which the through a stab incision over the distal, craniomedial
ulna remains intact3. A cast or splint is placed from the aspect of the radius. These two pins are used to ensure
paw to the mid-humerus, immobilizing both the carpus proper rotational alignment of the fracture and may be
and elbow joints. Placing the splint on the lateral aspect used to provide distraction if needed. A connecting bar
of the limb will allow immobilization of the elbow joint (loaded with the desired number of empty clamps) is
at a functional angle. placed on the proximal and distal transfixation pins.
The fracture is reduced and the clamps are tightened to
External skeletal fixation maintain reduction. A double connecting bar may be
External fixators can be used to stabilize most fractures added if additional frame stiffness is desired. Additional
of the radial diaphysis3,7–9. They are particularly useful half pins are then inserted through the empty clamps at
for repair of open and comminuted fractures. Where an angle of 20° to the long axis of the bone and the
possible, the fixator is applied closed or after a minimal clamps are tightened.

101

A B C
101 External fixation of diaphyseal radial fractures.
A Type Ia external fixator. A minimum of two transfixation pins are applied to each side of the fracture.
B Type Ia acrylic external fixator. C Type IIb external fixator.
Fractures and disorders of the forelimb
139

If an acrylic connecting bar is to be used, the the radiohumeral joint. The distal full pin is
half pins are inserted and connected with flexible tubing inserted through the radius parallel to the radiocarpal
(APEF System, Innovative Animal Products LLC.). joint. Connecting bars (with the necessary allotment of
Special pins designed for use with acrylic fixators may empty clamps) are attached to the transfixation pins on
be used (Miniature Interface™ fixation half pins, IMEX each side of the limb. The fracture is reduced (using a
Veterinary Inc.). The fracture is reduced and the tubing minimal surgical approach if necessary) and the clamps
is filled with acrylic. A temporary metal connecting bar are tightened. Additional half pins are inserted
can be placed on the transfixation pins to maintain through the empty clamps on the two connecting bars
reduction while the acrylic hardens. and the clamps are tightened. Acrylic connecting bars
A type IIb fixator (bilateral frame/full and half may be used instead of clamps if desired.
pins) may be applied if additional stiffness is needed
to stabilize comminuted radial fractures (type III Bone plate and screw fixation
frames are rarely indicated in cats). The proximal Diaphyseal radial fractures are amenable to repair with
full pin is inserted through the radius parallel to bone plates and screws (102)3,4,7,10. The plate is

102

A
X

A B C D E F G

102 Plate fixation of diaphyseal radial fractures.


A Transverse fracture stabilized with a compression plate applied to the
cranial cortex of the radius.
B Transverse fracture stabilized with a compression plate applied to the
medial cortex of the radius.
C Oblique fracture stabilized with cerclage wires and a neutralization plate.
D Oblique fracture stabilized with lag screws and a neutralization plate.
E Comminuted fracture stabilized with a bridging plate.
F Comminuted fracture stabilized with a bridging plate and an
intramedullary pin in the ulna.
G Comminuted fracture stabilized with bridging plates applied to both the
radius and ulna.
H Lateral radiographic view of a diaphyseal radius and ulna fracture
stabilized with a bone plate applied to the medial aspect of the radius.
I Craniocaudal radiographic view of a bone plate applied to the medial
aspect of the radius.
H I
140

applied to the flat cranial surface of the bone through a olecranon process or retrograde from the fracture
craniomedial surgical approach11. Application of a bone site (following a minimal caudolateral approach to the
plate to the medial surface has also been described12. ulna). Alternatively, a bone plate may be applied to
Cuttable plates, 2.0 mm DCPs, and tubular plates can the ulna if additional support is needed. However, the
be applied to the radius in cats (Synthes, Inc.; small diameter of the distal ulna in the cat makes plate
Veterinary Orthopedic Implants Inc.)13–15. Cuttable application difficult. A soft padded bandage is applied
plates and tubular plates are relatively thin, which to the limb after surgery to reduce postoperative
facilitates closure of the soft tissues after plate swelling.
application. Cuttable plates can be custom-cut to the
appropriate length at the surgery table and can be Intramedullary pinning
stacked to achieve a variety of thicknesses (1.0–3.0 mm Intramedullary pinning is not recommended for repair
with Synthes Inc. plates) and strengths. of radial fractures7,16. The narrow medullary cavity of
In most cases, ulnar stabilization is not required the radius will accommodate only a very small, flexible
after radial plating. Occasionally, however, an pin that provides minimal stabilization and does not
intramedullary pin is placed in the ulna to provide control rotational forces. Additionally, insertion of the
additional support and to maintain reduction pin is difficult without damaging the carpus or elbow
of the radial fracture during plate application. joints (103).
The pin may be inserted normograde from the
Distal radial fractures
Fractures of the distal radius include Salter–Harris
fractures of the distal radial growth plate, metaphyseal
fractures, epiphyseal fractures, and articular fractures.
Most are stabilized with external coaptation,
Kirschner wires placed in cross-pin fashion, external
103 fixators, bone plates, or lag screws (104). Pancarpal
arthrodesis may be indicated for irreparable, severely
comminuted articular fractures of the distal radius17.

External coaptation
External coaptation is indicated for fractures that
can be reduced closed and are relatively stable after
reduction. Distal radial fractures in immature cats and
fractures in which the ulna is intact are particularly
amenable to cast or splint fixation. The cast or splint
is applied to the limb from the paw to the mid-
humerus, immobilizing both the carpus and elbow
joints. Comminuted fractures tend to collapse and are
not ideally stabilized by external coaptation.

Cross-pin fixation
Distal metaphyseal fractures and fractures of the distal
radial growth plate may be stabilized using two
Kirschner wires (0.9–1.6 mm) placed in cross-pin
fashion5,6,16. The wires are inserted from the medial
and lateral aspects of the distal radius, avoiding the
articular surface. Removal of the implants may be
necessary if pin migration or soft tissue irritation occurs.

External skeletal fixation


103 Intramedullary pin inserted into the radius. The pin A type Ia external fixator can be applied to the
was placed retrograde from the fracture site causing severe craniomedial aspect of the distal radius if the distal
damage to the radiocarpal joint. Intramedullary pinning fragment will accommodate at least two transfixation
for stabilization of radial fractures is not recommended. pins3,7. A lightweight acrylic bar is used to connect the
Fractures and disorders of the forelimb
141

pins externally. Threaded pins will strengthen the in a padded bandage for several days after surgery to
pin-bone interface and minimize premature loosening. reduce swelling. If additional support is needed, a
caudal splint can be applied.
Bone plate and screw fixation
A bone plate is applied to the cranial or medial cortex Ulnar fracture repair
of the radius if the distal fragment will accommodate Many ulnar fractures will heal after stabilization of
at least two screws12. A mini T plate or small cuttable the concurrent radial fracture. Primary repair of a
plate with 1.5 mm or 2.0 mm screws is used in most fractured ulna is performed if:
cases. • Stabilization is necessary to support a
comminuted radial fracture.
Lag screw fixation • The fracture involves the olecranon process or
Bone screws (1.5 mm or 2.0 mm) are placed in lag trochlear notch.
fashion to compress fracture lines, particularly for • The fracture involves the styloid process and
stabilization of articular fractures. The limb is placed carpal instability exists.

104

A B

C D E F G

104 Repair of distal radial fractures.


A Cross-pin fixation.
B Kirschner wire fixation.
C Tension band wire fixation.
D Lag screw fixation. A Kirschner wire may be placed to prevent rotation around the screw.
E Type Ia acrylic external fixator.
F Mini T plate applied to the dorsal cortex.
G Cuttable plate applied to the medial cortex.
142

Olecranon process fractures hole in the ulna and around the proximal ends of the
The fractured olecranon process is usually displaced intramedullary Kirschner wires.
proximally by the insertion of the triceps muscles. This Comminuted olecranon fractures are repaired by
distractive force must be controlled to allow fracture first reconstructing the fragments with Kirschner wires
healing. Most olecranon fractures are transverse or (or lag screws) and then placing a tension band wire.
oblique and can be stabilized using a tension band Alternatively, a bone plate may be applied to the
wire fixation (105)7,16. Reduction is facilitated by lateral or caudal surface of the ulna. A tubular plate,
extension of the elbow joint. Two Kirschner wires cuttable plate, or 2.0 mm DCP can be used.
(0.9–1.1 mm) are inserted from the tip of the
olecranon, across the fracture site, and into the Trochlear notch fractures
medullary cavity of the ulna. In smaller cats it may be Transverse and oblique fractures of the proximal ulna
difficult to position two Kirschner wires in the narrow involving the trochlear notch are repaired with a tension
olecranon. A single intramedullary pin may be placed band wire fixation or bone plate (105 B–E).
instead, but it will not control rotational forces in Comminuted fractures of the trochlear notch are
many fracture configurations. A transverse hole is then repaired with Kirschner wires or small lag screws to
drilled from lateral to medial through the ulna distal ensure the articular surface is anatomically reconstructed.
to the fracture to accommodate a strand of 0.8 mm A neutralization plate is then applied to the lateral
(20 AWG) orthopedic wire. The orthopedic wire is surface of the proximal ulna. If the joint surface cannot
placed in a figure-of-eight configuration through the be restored, the plate is applied in buttress fashion to

105

A B C D E

105 Repair of olecranon fractures.


A Tension band wire fixation (lateral and craniocaudal views). Two Kirschner wires are inserted normograde.
B Tension wire band fixation using a single intramedullary pin. This method provides less rotational stability at the
fracture site, but is often easier to apply to the narrow feline olecranon.
C Caudal plate fixation.
D Lateral plate fixation.
E Olecranon fracture with comminution of the trochlear notch. Fragments are stabilized with Kirschner wires or lag
screws prior to plate application.
Fractures and disorders of the forelimb
143

bridge the defect and prevent collapse of the fracture site. proximal and one distal to the fracture) as a tension
A tubular plate, cuttable plate, or 2.0 mm DCP can be band. Bone plate fixation may also be used to stabilize
used. A cancellous bone graft is placed in the defect. the ulnar fracture, and is particularly useful in
comminuted fractures. Stability of the ulna maintains
Monteggia fractures reduction of the radiohumeral joint if the radioulnar
Fractures of the ulna with concurrent radiohumeral joint is intact7. A splint or Robert Jones bandage may
luxation are termed Monteggia fractures7,18. In cats, be applied temporarily to the limb after surgery.
they usually result from a fall7. The ulnar fracture may If the radioulnar joint is luxated, the ulnar fracture
be simple or comminuted. The radioulnar joint is stabilized with an intramedullary pin or bone plate.
remains intact in some cases, while in others the The annular ligament and torn portion of the lateral
annular ligaments and a portion of the lateral collateral ligament are repaired with 2-0 monofil-
collateral ligament are torn, resulting in radioulnar ament, nonabsorbable suture material. If the
luxation. Internal fixation is recommended to stabilize ligaments cannot be repaired, a positional screw is
the ulnar fracture and restore joint congruence (106). placed through the ulna into the proximal radius to
If the radioulnar joint is intact, the ulnar fracture is stabilize the radiohumeral joint. In most cases, this
stabilized with an intramedullary pin placed screw does not significantly limit normal pronation
normograde or retrograde. A strand of 0.8 mm and supination of the antebrachium. However, if
(20 AWG) orthopedic wire is placed through two movement is restricted, the screw may be removed in
holes drilled in the caudal cortex of the ulna (one 3–4 weeks.

106

A B C D E F

106 Repair of Monteggia fractures (ulnar fracture with concurrent radiohumeral luxation).
A Monteggia fracture with an intact radioulnar joint.
B The ulnar fracture is stabilized with an intramedullary pin and tension band wire. The intact radioulnar joint maintains
reduction of the radiohumeral joint once the ulna is repaired.
C Stabilization using a lateral bone plate.
D Monteggia fracture with disruption of the radioulnar joint.
E The ulnar fracture is stabilized with a bone plate. The annular ligament and damaged portions of the collateral ligament
are sutured.
F The ulna is stabilized with a bone plate. A positional screw is inserted from the ulna to the proximal radius.
144

Diaphyseal ulnar fractures Styloid process fractures


Fractures of the ulnar diaphysis usually heal well after The styloid process is the origin of the ulnar collateral
reduction and stabilization of the concurrent radial ligaments in the antebrachiocarpal joint. Fracture of
fracture (107). However, if ulnar repair is necessary to the distal styloid process may be associated with joint
provide additional stability, an intramedullary pin or instability or luxation7. Minimally displaced fractures,
bone plate may be applied. The ulna is exposed particularly in immature cats, are immobilized in a
through a caudolateral surgical approach. Plate caudal splint for 4–6 weeks until healing is complete.
application is easier on the proximal ulna where the Styloid fractures may also be stabilized internally by
bone is larger. It may not be possible to apply a plate inserting a small Kirschner wire placed normograde
to the small distal ulna in many cats. A tubular plate, from the tip of the styloid process into the medullary
cuttable plate, or 2.0 mm DCP can be used. cavity of the distal ulna (108). A tension band wire is
Intramedullary pins may be inserted normograde or often applied to prevent distraction at the fracture
retrograde through the olecranon process. This can site. In most cats, only a single Kirschner wire can be
often be performed through a small incision (3–4 cm) inserted and small wire (0.5 mm [24 AWG]) is used
over the caudal aspect of the bone11. A pin of in a figure-of-eight pattern. Torn ligaments are
adequate diameter to fill the distal ulnar medullary sutured if possible. The limb is placed in a caudal
canal should be selected4. Intramedullary pin fixation splint for 3–4 weeks and the cat’s activity is restricted.
of the ulna is not recommended for stabilization of Severely comminuted styloid process fractures may be
radius/ulna fractures without concurrent radial repaired by attaching the distal styloid process to the
stabilization. The small medullary cavity of the ulna distal radius with a small lag screw. Pancarpal
can accommodate only small, flexible pins that arthrodesis may be required for irreparable styloid
provide inadequate bending and rotational stability process fractures accompanied by severe distal radial
when used alone. fracture.

107 108

A B C D

107 Repair of ulnar diaphyseal fractures. A B C


A, B Stabilization of the concurrent radial fracture with a
bone plate or external fixator allows healing of the 108 Repair of styloid process fractures of the ulna.
unrepaired ulnar fracture. A Styloid process fracture stabilized with a Kirschner wire
C A bone plate is applied to the radius. Inserting an inserted normograde.
intramedullary pin in the ulna provides additional stability. B Styloid process fracture stabilized with a tension band
D Plate fixation of an ulnar fracture. wire fixation.
C Comminuted styloid process fracture stabilized by
inserting a lag screw through the distal styloid process into
the radius.
Fractures and disorders of the forelimb
145

PART 4: CARPAL, METACARPAL, AND PHALANGEAL INJURIES

CARPAL JOINT INJURIES Swelling and joint instability may be palpated


The carpal bones are anatomically arranged in in the carpal region. Radiographs are indicated
two levels (109, 110)1. Proximally, the radial to identify fractures and joint luxations. Stress
and ulnar carpal bones articulate with the distal radiographs are helpful in confirming instability.
radius and styloid process of the ulna to form
the antebrachiocarpal joint (radiocarpal joint
and ulnarcarpal joint). The accessory carpal bone
articulates with the palmar surface of the ulnar carpal 109
bone and serves as the insertion point for the
flexor carpi ulnaris muscle. The small carpal bones
(I through IV) articulate proximally with the radial and
ulnar carpal bones to form the middle carpal joint, and
distally with the metacarpal bones to form the
carpometacarpal joint. The spaces between each of the
carpal bones on a given level are called intercarpal
joints. Numerous ligaments maintain stability yet
permit joint motion. On the palmar surface of the
carpus, the joint capsule, palmar carpal fibrocartilage,
and ligaments support the joint while bearing weight.
Carpal injuries in the cat typically result from
trauma caused by falling, jumping, or being hit by an
automobile. Combined fracture/luxation of the
carpus is more common than isolated fracture or A B
luxation2. The cat is usually in pain and does not bear 109 Bones of the feline carpus and metacarpus.
weight on the injured limb. A Dorsal view. B Lateral view.

110
Ulna
Ulna Radius
Radius

Accessory
carpal bone
Radial carpal
bone
5th First
Carpals metacarpal metacarpal
Proximal
Metacarpals phalanx
Distal
phalanx
Digits Proximal
phalanx
Middle
phalanx
Distal
phalanx
A B C D

110 Bones of the carpus, metacarpus, and phalanges in a cat. A Dorsal view. B Lateral view. C Medial view. D Palmar view.
146

CARPAL BONE FRACTURES bone fractures are managed with external coaptation
Cause and pathogenesis in a palmar splint, particularly if the fragment is
Carpal bone fractures are uncommon in cats; they minimally displaced. Displaced fragments are
usually occur as a result of falling, jumping, or a road excised through a dorsal approach to the carpus3.
traffic accident. The carpus is immobilized in a palmar splint for
2 weeks and then light exercise is encouraged. If the
Diagnosis fragment is large enough, it is reattached using a
Diagnosis is by palpation and radiography. 1.5 mm bone screw placed in lag fashion (111).
Small Kirschner wires countersunk below the
Treatment and prognosis cortical surface may also be used. The limb is
Fractures of the smaller carpal bones are managed by immobilized in a palmar splint for 3–4 weeks and the
closed reduction and external coaptation. The limb is cat’s activity is restricted for 6 weeks.
immobilized in a palmar splint (placed from the
phalanges to the proximal antebrachium) for 4 weeks. Accessory carpal bone fractures
A soft padded bandage is applied for an additional The accessory carpal bone is less prominent in cats
2 weeks after splint removal. The cat’s activity is than in dogs, and fractures of the accessory carpal
restricted for 6 weeks. bone are rare in cats (112). In most cases, the
fracture fragment is very small. If the fracture does
Radial carpal bone fractures not involve the articular surface (apical fractures) and
Most fractures of the radial carpal bone are small chip displacement is minimal, the limb is splinted with the
fractures of the dorsal surface. Small slab fractures carpus flexed 20–25°. The splint remains in place for
may also occur. Oblique fractures through the radial 3–4 weeks. A soft padded bandage may be applied
carpal bone are rare. Generally, radial carpal for an additional 2 weeks after splint removal if

111

A B C D E

111 Repair of radial carpal bone fractures.


A Doral slab fracture of the radial carpal bone.
B Lag screw fixation.
C Kirschner wire fixation.
D Chip fractures of the radial carpal bone. The fragments are excised via a dorsal surgical approach.
E Oblique fracture of the radial carpal bone repaired with a lag screw.
Fractures and disorders of the forelimb
147
112 CARPAL SHEARING INJURIES
Cause and pathogenesis
Shearing (degloving) injuries occur less frequently on
the forelimb than on the hindlimb. Most occur when
the cat is hit by a car.

Clinical signs
The medial aspect of the carpus and metacarpus
is abraded by the pavement, destroying variable
amounts of tissue, including skin, muscle, tendons,
ligaments, and bone. One or more of the carpal joints
may be open and contaminated.

Treatment and prognosis


Shearing injuries of the carpus are managed by1,4:
A B C 1. Carefully cleaning and debriding the wound.
2. Proper open-wound management.
112 Surgical repair of accessory carpal bone fractures. In 3. Early stabilization of the joints.
most cases, the fragments are small and treatment consists
of external coaptation or fragment excision. If the Initially, the wound is covered with a sterile bandage
fragment is large enough, internal fixation with a lag screw while the cat is stabilized and evaluated for other
or Kirschner wire is indicated. traumatic injuries. The cat is then anesthetized and the
A Distal-basilar fracture of the accessory carpal bone wound is examined under sterile conditions to assess
(involving the articular surface) stabilized with a 1.5 mm tissue damage. A sample is collected for culture
lag screw. and susceptibility testing and a broad-spectrum
B Proximal-basilar fracture of the accessory carpal bone antimicrobial drug is administered. Cephalosporins
stabilized with a lag screw. (cefazolin at 22 mg/kg IV every 8 hours) and
C Distal apical fracture of the accessory carpal bone clindamycin (11 mg/kg IV every 12 hours) have been
stabilized with a Kirschner wire. recommended5. The wound is filled with sterile
lubricating jelly and the surrounding hair is shaved.
Copious lavage, with sterile saline, lactated Ringer’s, or
a 0.05% chlorhexidine solution, is used to remove hair
and debris from the wound and open joint spaces6.
Surgical debridement is then performed to remove
debris and devitalized tissues from the wound. Vessels
and nerves must be preserved. With some minor
shearing injuries, the wound is converted to a ‘clean’
wound by lavage and debridement and can be closed
primarily if adequate tissue remains. However, in most
cases, insufficient soft tissue remains to permit
primary closure, and progressive debridement over
needed. The cat’s activity is restricted during the several days is required to achieve a clean wound.
healing period. If the fracture involves the articular These cases are managed as open wounds4.
surface of the accessory carpal bone (basilar Stabilization of the joint is performed once the
fractures), the fragment is removed through a wound is clean. Early stabilization encourages healing
palmarolateral approach3. Larger fragments are of the periarticular soft tissues. The collateral
uncommon and may be reattached with a Kirschner ligaments are repaired or replaced. Viable portions of
wire or a 1.5 mm lag screw. After surgery the limb is the ligaments can be sutured with monofilament
immobilized in a palmar splint with the carpus flexed suture material. In most cases, however, the collateral
20–25°. The splint remains in place for 2 weeks after ligaments are too severely damaged and are replaced
excision of bone fragments and for 4 weeks after with nonabsorbable, monofilament suture (2-0)
internal fixation. The cat’s activity is restricted for material placed in a figure-of-eight pattern. Bone
6 weeks. tunnels are drilled in the medial prominence of the
148

radial carpal bone and in the distal radius to anchor in 10–12 weeks. If adequate soft tissue is present, the
the suture (113). Alternatively, bone anchors or small wound may be secondarily sutured once a healthy
screws may be placed at the origin and insertion of the granulation bed has been established. Rarely, a skin
collateral ligament to attach the suture. If possible, the graft is required to cover unhealed soft tissue defects.
joint capsule is sutured after lavage. The carpus is then The cat’s activity is restricted until healing is
immobilized in a weight-bearing position with an complete.
external fixator. A type Ia fixator (unilateral/half pins) Arthrodesis is indicated in shearing injuries with
is adequate for most cats and is easily applied to the severe bone loss and irreparable damage to the distal
craniomedial aspect of the carpus. Transfixation pins radius, radial carpal bone, and articular cartilage.
are placed in the distal radius and the proximal Arthrodesis is achieved with an external fixator or bone
metacarpus. Small pins are used in the metacarpal plate (see Pancarpal arthrodesis). Bone grafting is
bones to prevent iatrogenic fracture7. An acrylic bar is delayed until the joint space is covered with
lightweight and can be contoured to allow proper pin granulation tissue. In some cases, arthrodesis is
placement. The fixator remains in place for 3–4 weeks performed only after primary treatment of the shearing
until granulation tissue covers the wound. A palmar injury has failed to restore adequate, pain-free
splint can be used to immobilize the joint rather than function.
an external fixator, but the splint must be removed
daily to allow treatment of the open wound. CARPAL LUXATIONS
The open wound is managed daily. Wet-to-dry Traumatic luxation or subluxation of the carpal joints
dressings are applied to remove debris and encourage is uncommon in cats, and may accompany shearing
granulation tissue formation8. Once granulation tissue injuries. Because cats are relatively lightweight, most
covers the wound, a dry nonadherent dressing is carpal injuries respond well to conservative treatment
applied. The bandage is changed less frequently and with external coaptation and restricted activity.
may incorporate a splint for added support once the Internal fixation is indicated if the joint cannot be
external fixator is removed. In most cases, the wound reduced closed or is markedly unstable after closed
heals completely by epithelialization and contraction reduction.

113

Insertional
bone
anchors

A B C D E

113 Stabilization of carpal shearing injuries. A Shearing injury of the medial carpus. The radial styloid process, medial
portion of the radial carpal bone, and collateral ligaments are absent. The joint is stabilized by prosthetic replacement of
the collateral ligament. B Nonabsorbable monofilament suture material (figure-of-eight pattern) placed through bone
tunnels drilled in the distal radius and radial carpal bone. C Bone anchors are used to attach suture material to the distal
radius and radial carpal bone. D Bone screws are placed at the origin and insertion of the collateral ligament to attach
suture material. E The carpus is immobilized with a type Ia acrylic external fixator.
Fractures and disorders of the forelimb
149

Radial carpal bone luxation include palmaroproximal luxation of the radial


Cause and pathogenesis carpal bone and collapse of the antebrachiocarpal joint
Luxation of the radial carpal bone occurs rarely in space (114).
dogs and has been reported in one cat9–11. The
luxation occurs secondary to a traumatic incident in Treatment and prognosis
which the antebrachiocarpal joint is hyperextended Anatomic reduction cannot be achieved with closed
with pronation, followed by supination, of the joint11. methods because of the rotation of the luxated radial
The short radial collateral ligament and dorsal joint carpal joint. Open reduction and internal fixation
capsule rupture and the radial carpal bone luxates in a are required. A dorsal approach to the carpus is
palmar direction. It also rotates 90° about its performed and visualization of the luxated radial carpal
dorsopalmar and mediolateral axes. joint is achieved by flexing the joint. Reduction is
achieved by first rotating the radial carpal bone about
Clinical signs its dorsopalmar axis and then about its mediolateral
Clinical signs include acute lameness, soft tissue axis. It is then repositioned by applying digital pressure
swelling, and joint effusion. from the palmar aspect of the joint while extending the
carpus. After reduction, a small Kirschner wire is
Diagnosis inserted from medial to lateral through the radial
The carpus and foot are displaced palmarly, making carpal bone and into the ulnar carpal bone. Clamping
the styloid process of the distal radius prominent on the radial and ulnar carpal bones together during wire
palpation. Manipulation of the foot causes pain, and insertion may prevent lateral displacement of the ulnar
flexion is limited. Hyperextension of the carpal joint carpal bone. Alternatively, a small lag screw can be
can be induced with palpation. Radiographic findings placed. The ruptured radial collateral ligament and

Luxated radial 114


carpal bone

A B

114 Luxation of the radial carpal bone.


A Dorsal and medial views depicting luxation of the radial carpal bone. The radial carpal bone is
displaced in the palmaroproximal direction and rotated about its dorsopalmar and mediolateral axes.
The carpus and foot are displaced palmarly, making the styloid process of the distal radius prominent
on palpation.
B Surgical stabilization of a radial carpal bone luxation. Reduction is achieved by rotating the radial
carpal bone about its dorsopalmar and mediolateral axes and then applying digital pressure to the
palmar aspect of the joint while extending the carpus. A Kirschner wire is inserted through the radial
carpal bone into the ulnar carpal bone. The ruptured radial collateral ligament and joint capsule are
sutured to restore joint stability.
150

joint capsule are sutured to restore joint stability. The Clinical signs
carpus is immobilized with a palmar splint or type Ia Clinically, the cat is lame.
external fixator for 4 weeks. The Kirschner wire may be
removed after 6 weeks if it causes complications or Diagnosis
migrates. Pain and crepitus may be elicited on palpation of the
Follow-up evaluation of the single reported feline carpal region. Medial instability is palpable if rupture
case of radial carpal bone luxation revealed that the of the collateral ligament is complete.
cat’s function was good, although osteoarthritis and
decreased carpal flexion were evident. If radial carpal Treatment and prognosis
bone luxation is accompanied by severe articular In most cases, the antebrachiocarpal joint is reduced
cartilage damage or irreparable joint laxity, carpal in a closed fashion and the limb is supported in a
arthrodesis should be considered. palmar splint placed from the phalanges to the
proximal antebrachium. The splint remains in place
Antebrachiocarpal joint luxation and subluxation for 4–6 weeks. Alternatively, a small transarticular
Cause and pathogenesis Kirschner wire can be placed percutaneously prior to
Trauma to the medial (radial) collateral ligament splinting2. The wire is removed in 3–4 weeks.
is the most common injury associated with If open reduction and internal stabilization are
antebrachiocarpal joint subluxation, resulting in required to maintain joint stability, a dorsal approach to
medial joint instability and palmar dislocation of the the distal radius and carpus is performed. If the joint is
radial carpal bone (115)12. In cats, the medial severely damaged, pancarpal arthrodesis is considered.
collateral ligament consists of a single branch that However, in most cases, the antebrachiocarpal joint can
originates dorsoproximally on the distal radius be reduced and stabilized using soft tissue
and courses obliquely in a palmarodistal direction to reconstruction or collateral ligament replacement:
insert on the radial carpal bone12. Complete • Soft tissue reconstruction – the torn radial
antebrachiocarpal luxation is rare. collateral ligament and joint capsule are repaired

115

A B C D

115 Repair of antebrachiocarpal luxation.


A Rupture of the radial collateral ligament resulting in medial joint instability.
B Stabilization of the antebrachiocarpal joint by primary repair of the torn radial collateral ligament and a transarticular pin.
C Stabilization of the antebrachiocarpal joint with a prosthetic ligament. Bone tunnels are drilled in the medial
prominence of the radial carpal bone and the distal radius. Monofilament, nonabsorbable suture material is placed in a
figure-of-eight pattern to replace the torn collateral ligament.
D Prosthetic ligament replacement using small screws placed at the origin and insertion of the collateral ligament to attach
the suture.
Fractures and disorders of the forelimb
151

with monofilament, nonabsorbable suture splint (with the carpus flexed 15°) for 4 weeks.
material (3-0 or 2-0). A locking-loop or The cat’s activity is restricted for 8 weeks.
mattress suture pattern is recommended in
the ligament. Suturing the small ligament can Middle carpal and carpometacarpal joint luxation
be difficult; and in many cases the ligament and subluxation
is too damaged to be sutured adequately. Luxation and subluxation of the middle carpal and
A transarticular pin may also be placed across carpometacarpal joints are rare.
the joint, but is not usually required if the soft
tissues are anatomically reconstructed. The limb Treatment and prognosis
is splinted for 4 weeks with the carpus in 15° of In most cases, the joint is reduced in a closed fashion
flexion. and the limb is placed in a palmar splint for 4–6 weeks
• Collateral ligament replacement - remnants of the with the carpus in 15–20° of flexion. The cat’s activity
torn collateral ligament are sutured primarily if is restricted for 8 weeks. If the joint is markedly
possible. A prosthetic ligament is then placed to unstable after closed reduction, internal fixation may
protect the repair and stabilize the joint. enhance stability. A dorsomedial approach is performed
A bone tunnel is drilled in the medial prominence and the medial aspect of the joint is exposed. Bone
of the radial carpal bone and distal radius. tunnels are drilled through the palmaromedial process
Monofilament, nonabsorbable suture material of the radial carpal bone and the base of metacarpal II.
(2-0 or 0) is placed in a figure-of-eight pattern Monofilament, nonabsorbable suture material (0 or
through the tunnels to replace the torn collateral 2-0) is placed through the tunnels in a figure-of-eight
ligament. Alternatively, bone anchors or small fashion and tightened (116). The limb is immobilized
screws may be placed at the origin and insertion in a palmar splint for 4–6 weeks with the carpus in 15°
of the collateral ligament to attach the suture. of flexion1. If pain and instability persist after closed or
The joint capsule is imbricated and the incision is open stabilization, partial carpal arthrodesis is
closed routinely. The limb is placed in a palmar considered13.

116

A B C

116 Repair of middle carpal joint luxation.


A Medial instability of the middle carpal joint (arrow) caused by ligament rupture.
B Stabilization of the middle carpal joint with suture material placed through bone tunnels drilled in the
palmaromedial process of the radial carpal bone and the base of metacarpal II.
C Medial view: prosthetic ligament replacement.
152

HYPEREXTENSION INJURIES OF THE CARPUS antebrachiocarpal and carpometacarpal joints in


Cause and pathogenesis flexion for 3–4 weeks. The carpal flexion bandage
Hyperextension injuries to the feline carpus are prevents weight bearing and allows healing of palmar
uncommon and typically occur when the cat falls or fibrocartilage. After bandage removal, the cat’s
jumps from a great height. The trauma causes tearing of activity is restricted for an additional 3–4 weeks.
the palmar carpal fibrocartilage and palmar ligaments. Jumping is discouraged during this period. Mild
Injury to any or all of the antebrachiocarpal, middle physical therapy exercises (including stretching and
carpal, or carpometacarpal joints can occur (117). passive range-of-motion exercises) may be instituted
to restore normal joint motion. This technique is
Clinical signs usually successful in cats, although it is not effective in
Hyperextension of the carpus is usually palpable and dogs. If hyperextension recurs after bandage removal,
the cat may walk with a palmigrade stance. carpal arthrodesis may be indicated if the cat’s
function is limited or pain persists13,14.
Diagnosis
Stress radiographs will confirm the hyperextension PANCARPAL ARTHRODESIS
injury and may be used to determine which joints are Pancarpal arthrodesis involves fusion of the antebra-
involved. Radiographs should be evaluated carefully chiocarpal, middle carpal, and carpometacarpal
for concurrent fractures. joints 15. Indications include luxation, hyper-
extension, debilitating osteoarthritis of the
Treatment and prognosis antebrachiocarpal joint, shearing injuries with
Carpal hyperextension injuries in cats are usually significant loss of articular cartilage, and postural
treated conservatively. The limb is bandaged with the deformity resulting from radial nerve paralysis16.

117

A B
117 Carpal hyperextension injury.
A Carpal hyperextension results from traumatic tearing of the palmar carpal fibrocartilage and palmar
ligaments. Increased separation between the palmar process of the ulnar carpal bone and the base of
metacarpal V may occur if the middle carpal joint is involved.
B A carpal flexion bandage for treatment of carpal hyperextension injury.
Fractures and disorders of the forelimb
153

A hanging-limb preparation is used. Hemorrhage is cancellous graft is placed in the joint spaces and a
controlled by tightly wrapping the limb with sterile palmar splint is applied for 6 weeks after surgery.
Vetwrap (3M Animal Care Products), beginning at Splinting will help reduce the incidence of
the toes and progressing proximally to the proximal metacarpal bone fracture 19. Alternatively, after
antebrachium. An incision is made through the preparation of the joint, a type IIb external fixator
Vetwrap and the joint is exposed via a dorsal with acrylic connecting bars can be applied instead
approach3. The articular cartilage is removed with a of a plate. However, premature pin loosening and
small bone curette or burr. The joint is reduced in a fractures of the metacarpal bones can occur.
weight-bearing position (10–12° of carpal Arthrodesis of the antebrachiocarpal joint alone
extension) and a bone plate is applied to achieve may result in the eventual breakdown of the
arthrodesis (118). The bone plate is applied to the remaining carpal joints and is not recommended.
dorsal surface of the radius, radial carpal bone, and
metacarpal III. Three screws are placed in the PARTIAL CARPAL ARTHRODESIS
radius, one in the radial carpal bone, and Partial carpal arthrodesis involves fusion of the middle
three in metacarpal III. Cuttable plates and carpometacarpal joints. Indications include
(1.5/2.0 mm, 7–8 holes) are sufficiently small for trauma, debilitating osteoarthritis, and luxation or
carpal arthrodesis in cats, accommodate several sizes hyperextension of the middle or carpometacarpal
of small screws, and can be cut to the desired length joints20. If the antebrachiocarpal joint is normal,
at the surgery table 17,18. If a DCP is used, partial carpal arthrodesis is preferred. After removing
compression can be created across the joint space. the cartilage from the joint surfaces, small
Care is taken during insertion of screws to avoid intramedullary Kirschner wires are inserted from
fracturing the small metacarpal bones. Autogenous metacarpals III and IV, across the joints, and into the

118

A B
118 Pancarpal arthrodesis.
A Dorsal and lateral views of pancarpal arthrodesis with a bone plate. The articular cartilage is removed
and the joint is plated in 10–12° of carpal extension. The bone plate is applied to the dorsal surface of
the radius, radial carpal bone, and metacarpal III. Three screws are placed in the radius, one in the
radial carpal bone, and three in metacarpal III. Autogenous cancellous graft is placed in the joint spaces
to promote arthrodesis.
B Dorsal view of pancarpal arthrodesis with a type IIb acrylic external fixator. Premature pin loosening
and metacarpal bone fractures are complications of external fixation for pancarpal arthrodesis.
154

radial carpal bone (119). A small slot is created cancellous bone graft is placed and the incision is
distally in the dorsal surface of the metacarpal bones closed routinely. The carpus is immobilized in a splint
to access the medullary cavity. The Kirschner wires are for approximately 6 weeks after surgery, or until
inserted with the carpus in full flexion to minimize radiographic evidence of fusion is present.
subluxation of the middle or carpometacarpal joints.
After insertion, the exposed ends of the Kirschner METACARPAL AND PHALANGEAL
wires are bent over to reduce trauma to the phalanges INJURIES
and soft tissues. This technique is extremely difficult METACARPAL FRACTURES AND LUXATIONS
because of the small size of the metacarpal bones. Fractures of the metacarpal bones and luxations of the
Alternatively, the Kirschner wires can be inserted in a carpometacarpal or metacarpophalangeal joint are
cross-pin configuration13. The medial Kirschner wire usually managed by splinting for 4–6 weeks. Spoon
is placed from the medial-dorsal aspect of metacarpal splints work well in most cats. Splinting of metacarpal
II into the ulnar carpal bone. The lateral Kirschner fractures is particularly successful if one of the
wire is placed through the radial carpal bone and metacarpal bones is intact and serves as an ‘internal
through the lateral-dorsal aspect of metacarpal V. The splint’. If all four of the metacarpal bones are
tip of the wire is countersunk below the articular fractured, care must be taken to avoid angular
surface of the radial carpal bone. Autogenous deviation of the paw within the splint. Metacarpal

119

II IV
III

II

A B

119 Partial carpal arthrodesis.


A Arthrodesis of the middle carpal and carpometacarpal joints with small intramedullary Kirschner wires inserted from
metacarpals III and IV, across the joints, and into the radial carpal bone. Slots are created distally in the dorsal surface of
the metacarpal bones to access the medullary cavity. The carpus is flexed during pin insertion. Autogenous cancellous bone
graft is placed in the joint spaces to promote arthrodesis.
B Partial carpal arthrodesis with Kirschner wires in cross-pin configuration. The medial Kirschner wire is inserted from the
medial-dorsal aspect of metacarpal II into the ulnar carpal bone. The lateral Kirschner wire is placed through the radial
carpal bone and through the lateral-dorsal aspect of metacarpal V. The tip of the wire is countersunk below the articular
surface of the radial carpal bone. Autogenous cancellous bone graft is placed in the joint spaces.
Fractures and disorders of the forelimb
155

fractures may also be stabilized by inserting small carpal pads if possible. A surgical drain may be placed.
intramedullary Kirschner wires (120)21. Typically, the The digital and carpal pads are apposed on the palmar
Kirschner wires are placed in metacarpal bones III and surface of the paw with interrupted sutures. The skin is
IV only. A small slot or hole is drilled distally in the apposed on the dorsal surface of the paw.
dorsal surface of the metacarpal bone to access the
medullary cavity. A small, flexible Kirschner wire is
inserted normograde from the hole, across the
fracture line, and into the proximal metaphysis.
Placement of these pins is challenging because of the 120 Repair of metacarpal 120
narrow medullary cavity. Retrograde insertion is not fractures. Internal fixation
recommended as it may cause damage to the joints with small intramedullary
proximal and distal to the metacarpal bones. After pin Kirschner wires placed in
placement, the foot is splinted for 4–6 weeks and the metacarpal bones III and IV.
cat’s activity is restricted. A slot is created distally in
the dorsal surface of the
PHALANGEAL FRACTURES AND LUXATIONS metacarpal bone and a
Fractures and luxations involving the phalanges are flexible Kirschner wire is
usually managed by closed reduction and splinting for inserted normograde from
4–6 weeks. Spoon splints work well in most cats. If the slot, across the fracture
severe trauma to the phalanges has occurred, the loss of line, and into the proximal
soft tissues (including skin, tendons, ligaments, and metaphysis. The foot is
joint capsule) may complicate repair. Fusion podoplasty splinted for 4–6 weeks.
may be performed as a salvage procedure in the
treatment of degolving injuries of the digits (121)22.
The traumatized soft tissues are debrided dorsally and
palmarly between the digits, preserving the digital and

121

A B C D

121 Fusion podoplasty technique for repair of severe phalangeal soft tissue trauma.
A, B Traumatized tissue between the digits is debrided dorsally and palmarly, preserving the digital and carpal pads if
possible.
C The digital and carpal pads are apposed on the palmar surface of the paw.
D The skin is apposed on the dorsal surface of the paw. A surgical drain may be placed prior to closure.
156

Digit amputation (declawing) (see Onchyectomy). The foot is clipped


Digit amputation may be indicated as treatment and aseptically prepared for surgery. Care is taken to
for comminuted fractures, nonunions, intraarticular clean adequately the nail beds, pads, and skin between
fractures, irreparable luxation, shearing injuries, the digits. A tourniquet is placed to control
neoplasia, or chronic infections of the digit. hemorrhage. An elliptical skin incision is made around
Amputation is usually performed at the metacarpo-/ the digit at the level of the amputation. The ellipse
metatarsophalangeal joint, although removal at the begins proximodorsally and ends distally on the
proximal or distal interphalangeal joint can also be palmar/plantar surface. The digital pad is preserved if
performed (122, 123). Amputation at the distal the level of the amputation is distal enough. Vessel
interphalangeal joint is as described for onychectomy ligation and electrocautery are used to control

122

A B C D

122 Digit amputation at the metacarpo-/metatarsophalangeal joint. A Diagram of bones of the foot depicting the
location of the elliptical skin incision made for amputation of the third digit at the metacarpophalangeal or
metatarsophalangeal joint. B Diagram of a cat’s foot depicting incision location. The elliptical incision begins
proximodorsally and ends distally on the palmar/plantar surface of the foot. C The metacarpo-/metatarsophalangeal joint
is disarticulated to remove the phalanges. The distal condyle of the metatarsal/metacarpal bone is excised with a rongeur.
D Subcutaneous tissues and skin are closed.

123 123 Digit amputation at the proximal interphalangeal joint.


Diagram of bones of the foot depicting the location of the elliptical skin incision made for
amputation of the third digit at the proximal interphalangeal joint. The joint is
disarticulated to remove the second and third phalanges (shaded area). The distal condyle
of the first phalanx is removed with a rongeur. The digital pad is preserved if possible and
sutured to the skin to close the defect.
Fractures and disorders of the forelimb
157

hemorrhage. The joint proximal to the desired level of ONYCHECTOMY (DECLAWING)


amputation is disarticulated by transection of the joint Declawing procedures are commonly performed in
capsule, collateral ligaments, and tendons traversing domestic cats in some countries to prevent damage
the joint. The condyle proximal to the site of or injury to furniture, other pets, the owners, and
amputation is also removed using a small rongeur. The the cat itself. The procedure is usually performed on
subcutaneous tissues and skin are closed. If the digital indoor cats between 3 and 12 months of age. In
pad remains, it is sutured to the skin to close the most cases only the front claws are removed.
defect. The foot is bandaged for 10 days and activity is Thousands of cats are declawed each year in North
restricted to allow healing. Most cats function very America. It is estimated that approximately
well after amputation of a single digit. Chronic 14 million of the 59 million owned cats in the
lameness may occur after amputation of more than two United States are declawed23. Other reports indicate
digits, particularly if the third or fourth digit is that as many as 45% of the owned cats are
removed. Preservation of the digital pad will improve declawed 24. Declawing procedures are not
postoperative function. performed in many countries23.
In some cases of severe phalangeal injuries, the The humane considerations of onychectomy are
digits may be amputated at the metacarpophalangeal controversial25. Proponents consider it a justifiable
joint and the metacarpal pad is advanced distally to option to prevent scratching, particularly if the cat
cover the distal palmar aspect of the foot, thus cannot be retrained and is in danger of being removed
preventing the need for a total limb amputation from the home. Opponents condemn onychectomy
(124)21. The phalanges are amputated at the on ethical grounds as a needless procedure
metacarpophalangeal joint (including excision of the (performed strictly for owners’ convenience) that
heads of the metacarpal bones). The carpal pad is renders the cat unable to engage in species-specific
preserved. A surgical drain is placed and a subcuticular behaviors, such as scratching, grooming, and self-
suture pattern is used to rotate the carpal pad distally to defense23. Alternatives to onychectomy should be
cover the ends of the metacarpal bones. The remainder discussed with cat owners prior to surgery.
of the incision is closed with mattress sutures in the
skin. A splint is applied to the limb for 4 weeks to allow SURGICAL TECHNIQUES
complete healing and reduce the likelihood of pad Onychectomy is the removal of the distal phalanx
injury caused by shearing motion between the pad and including the claw. Growth and development of the
the metacarpal bone during weight bearing. claw is derived from the basal germinal cell layer

124 Metacarpophalangeal amputation and 124


distal transfer of the metacarpal pad for
treatment of irreparable phalangeal trauma.
A The phalanges are amputated at the
metacapophalangeal joint, preserving the carpal
pad. The heads of the metacarpal bones are
excised.
B A surgical drain is placed and a subcuticular
suture pattern is placed to rotate the carpal pad
distally to cover the ends of the metacarpal
bones.
C The remainder of the incision is closed with
mattress sutures in the skin. The limb is
splinted for 4 weeks. A B C
158

(stratum germinativum) located on the ungual crest positioned palmarly, in contact with the skin distal to
of the distal phalanx (125)26. It is essential to remove the digital pad. The claw is lifted dorsally to rotate the
the entire ungual crest (and all germinal cells) during flexor process of the distal phalanx in a palmar direction.
surgery to prevent regrowth of the claw. When As the claw is rotated, the blade reflects the digital pad
possible, onychectomy is performed in young, proximally. The nail trimmer is closed to complete the
growing cats (often at the time of neutering). amputation after ensuring that the ring is positioned in
Generally only the claws on the front feet are the interphalangeal space dorsally and the digital pad is
removed. The procedure is performed with the cat reflected. The blade must be sharp to avoid crushing the
under general anesthesia. Analgesic drugs are tissues. Cutting the pad or the distal aspect of the
essential to minimize intraoperative and middle phalanx will lead to greater postoperative
postoperative pain. discomfort and lameness. With the distal phalanx
The cat is positioned in lateral recumbency and removed, the wound is inspected for complete excision
the front paws are scrubbed prior to surgery. The hair of the ungual crest. The distal articular surface of the
may be clipped in longhaired cats. A tourniquet is middle phalanx should be visible. In most cases, a small
applied to the proximal antebrachium, just tight remnant of the distal phalanx (the flexor tubercle)
enough to control hemorrhage and maintain a clear remains in the wound and is visible just palmar to the
surgical field. Tourniquets applied proximal to the articular surface of the middle phalanx. This remnant
elbow may provide insufficient hemostasis and can be left in situ without concern for claw regrowth26.
damage the radial, ulnar, or median nerves. However, if a large piece of the distal phalanx remains,
Tourniquets applied to the distal antebrachium may it may contain germinal cells of the ungual crest and
damage the radial nerve26. The limb is draped and claw regrowth is possible. It should be excised with a
the distal phalanx, including the claw, is excised from scalpel blade. All front claws are removed.
each of the front digits using one of several described
techniques. Disarticulation of the distal phalanx
Removal of the distal phalanx by disarticulation of the
Amputation of PIII with a guillotine-type distal interphalangeal joint is achieved using a scalpel
nail trimmer blade or surgical laser.
The claws are trimmed short to facilitate placement
of the sterile nail trimmer (Resco Nail Shears, Resco Scalpel method
Co.). The ring of the nail trimmer is placed over the The claw is grasped with a towel clamp or forceps.
claw into the dorsal interphalangeal space between the Pushing up on the digital pad will also help extrude
second and third phalanx (126). The claw is grasped the claw. A circumferential incision is made in the
with a towel clamp or forceps and traction is applied to hairless, cuticle-like skin along the dorsal aspect of the
open the joint space. The blade of the nail trimmer is claw with a number 11 or 12 scalpel blade (127).

125 First phalanax


Collateral ligaments

Common digital extensor tendon

Dorsal elastic ligament Superficial digital


flexor tendon
Ungual crest Second phalanx
Distal annular ligament
Deep digital flexor tendon

Third phalanx

Collateral ligaments
Flexor process of PIII
Digital pad

125 Feline phalangeal anatomy (lateral view).


Fractures and disorders of the forelimb
159
126
Second phalanx

Third phalanx

Ungual crest
Third phalanx
Second
phalanx

Flexor
process

A B

126 Onychectomy performed with a guillotine-type nail trimmer.


A The ring of the nail trimmer is placed over the claw into the dorsal interphalangeal space between the second and third
phalanx. The blade of the nail trimmer is positioned ventral to the distal phalanx, distal to the digital pad. Before
performing the amputation, the claw is lifted dorsally to rotate the flexor process of the distal phalanx ventrally while the
blade reflects the digital pad proximally.
B With a proper amputation (dashed line), the entire ungual crest is removed to prevent regrowth of the claw. Inspection
of the incision will reveal the distal articular surface of the second phalanx. A small remnant of the flexor process of the
distal phalanx is seen palmar to the articular surface of the second phalanx.

127 Onychectomy by disarticulation of the distal 127


phalanx – scalpel method. The claw is grasped with
forceps and a circumferential incision is made along the
dorsal aspect of the claw with a scalpel blade (dashed Common digital
extensor tendon
line). The common digital extensor tendon and dorsal
elastic ligaments are transected. The incision is continued Dorsal elastic ligaments
along both sides of the digit, transecting the skin, joint
capsule, and collateral ligaments. Ungual crest
The dissection continues in the palmar direction around
Second phalanx
the flexor process of the distal phalanx to transect the
deep digital flexor tendon. The distal phalanx is then Deep digital
dissected from the digital pad and other soft tissue flexor tendon
attachments. All of the distal phalanx, including the
Third phalanx
ungual crest and flexor tubercle, is removed. Collateral ligaments
Flexor process
Digital pad
160

The skin is retracted proximally away from the claw. second phalanx to transect the common digital
The scalpel blade is then used to transect the common extensor tendon and dorsal elastic ligaments. Care is
digital extensor tendon and dorsal elastic ligaments taken to avoid damaging the articular cartilage on
between the second and third phalanges. The incision the distal aspect of the middle phalanx. Burned
is continued along both sides of the digit (following tissue (char) is wiped away with a saline soaked
the contour of the proximal aspect of the distal gauze sponge. Next, the incision is continued along
phalanx), cutting the skin, joint capsule, and palmar the lateral and medial sides of the digit, transecting
collateral ligaments. The dissection continues in the the skin, joint capsule, and palmar collateral
palmar direction around the flexor tubercle of the ligaments between the second and third phalanx.
distal phalanx to transect the deep digital flexor Ventral traction is then applied to the claw to
tendon. The distal phalanx is then dissected from the subluxate the distal interphalangeal joint. The laser
digital pad and other soft tissue attachments. Cutting beam is directed distally from within the joint space
the digital pad is avoided. All front claws are removed. (in a slight right-to-left sweeping motion) to
transect the attachment of the deep digital flexor
Laser method tendon on the flexor tubercle of the distal phalanx.
Laser disarticulation of the distal interphalangeal Care is taken to avoid the digital pad. Finally, the
joint is performed like the scalpel method, except remaining skin is severed and the distal phalanx is
that the incisions are made with a carbon dioxide removed. Ideally, the distal phalanx is removed with
(CO2) laser (Luxar Corporation). The laser (light very little soft tissue attached. Burned tissue is
amplification by stimulated emission of radiation) removed with a moistened sponge.
emits an intense beam of light to concentrate energy
on the target tissue27. The energy is converted to WOUND CLOSURE
heat and instantly raises the intracellular water After amputation or disarticulation of each distal
temperature above the boiling point, thus phalanx from the front feet, the wounds on each digit
vaporizing or ablating the tissue. Minimal collateral are closed with suture material or cyanoacrylate tissue
damage is caused to surrounding tissues. Vessels are adhesive, or the paw is bandaged.
sealed by tissue contracture to decrease bleeding.
For this reason, tourniquets are often not required Suturing
during laser onychectomy. Nerve endings and One or two sutures are used to appose the skin
lymphatic vessels are also sealed, resulting in less edges. Chromic catgut (3-0) or monofilament,
pain and swelling after surgery27. In many cats, absorbable suture may be used2. Suturing after
postoperative discomfort after laser disarticulation is onychectomy is not mandatory but may reduce the
reduced. incidence of postoperative hemorrhage in adult
The paw is scrubbed prior to surgery and the and obese cats. A bandage is often applied after
skin and hair is soaked with saline (alcohol is not suturing. In most cases, the cat will remove the
used!). A tourniquet may be applied, but is often sutures 1–2 weeks after surgery. If the sutures remain
not needed. The surgeon and all assistants must don in place and cause irritation, removal is indicated.
protective eyewear and all routine safety measures Sedation may be required to allow suture removal in
for laser usage are followed. A moistened gauze some cats.
sponge may be used to protect the surgeon’s fingers
from burns caused by the laser during the Cyanoacrylate tissue adhesives
procedure. The CO2 laser is set on a continuous Cyanoacrylate tissue adhesives (isobutylcyanoacrylate
power setting of 6–8 watts. The claw is grasped with and n-butyl monomers) may be used to appose the
a towel clamp or forceps and traction is applied to skin edges after onychectomy26,28. Several brands
the digit. The hair and cuticle-like skin are retracted of tissue adhesive are available for use in cats
proximally from the dorsal aspect of the claw. (Nexaband, Tripoint Medical; Vetbond, Animal Care
A horizontal cut is made through the tissue on the Products/3M) and can decrease surgical time, avoid
dorsal aspect of the digit, proximal to the ungual complications associated with suturing, and often
crest and between the second and third phalanges. negate the need for bandaging after surgery. This is
The laser beam is directed obliquely toward the particularly useful in fractious cats where bandage or
Fractures and disorders of the forelimb
161

suture removal is problematic. The adhesive is used that the application of a transdermal fentanyl patch
sparingly and is applied to the skin edges only. (25 µg/hr) 18–24 hours prior to surgery is as
Cyanoacrylate adhesives placed subcutaneously can effective as butorphanol therapy for controlling
cause foreign body reaction, infection, delayed healing, postoperative pain34,35. A fentanyl patch is less
and lameness26,29. Cyanoacrylates undergo slow sedating and does not require repeated injections to
biodegradation (with 91% remaining after 156 days) control pain. Infiltration of a local anesthetic agent
and should not be used in infected surgical sites26,30. (bupivacaine) in a ‘ring block’ pattern around the
A bandage may be applied after wound closure with distal antebrachium or irrigation of the wounds with
adhesives, but is not required in all cases. bupivicaine at the time of surgery may also reduce
pain associated with onychectomy36. However, local
BANDAGING analgesia and wound irrigation should not be used
Bandages may be applied to the front feet for 18–24 as the sole means of providing postoperctive
hours after onychectomy. They are applied after analgesia in cats after onychectomy33.
closure of the wounds with suture or adhesive, or
are used alone in some cases. The bandage should COMPLICATIONS
cover the foot and extend to the proximal Complications are common after onychectomy
antebrachium. Placing bandages too tightly can and have been reported in up to 50% of cases25,29.
lead to swelling and necrosis of the foot. Mild Early postoperative complications occur in approx-
bleeding can occur at bandage removal. If bleeding imately 24% of cats and include hemorrhage and
persists, the bandage is reapplied for an additional pain26,29,37. Later complications occur in approx-
24–48 hours. Bandages are not usually required imately 20% of cats and include claw regrowth,
after laser onychectomy. chronic draining tracts, radial neuropraxia or paralysis
secondary to tourniquet use, infection, wound
POSTOPERATIVE CARE dehiscence, protrusion of the second phalanx, tissue
Litter is replaced with shredded paper or commercially necrosis from improper bandaging, palmigrade stance,
available paper litter for 2 weeks. Sutures are removed persistent lameness, and possibly behavioral changes.
in 10–14 days if not already removed by the cat. Complications are prevented or minimized by using
Antibiotics are not routinely administered after sterile technique, controlling hemorrhage, completely
onychectomy unless lameness persists or signs of excising the ungual crest, protecting digital pads
infection develop. In general, recovery to pain-free during surgery, and proper postoperative care.
limb function is faster in young cats than in older or
obese cats. Hemorrhage
Hemorrhage is common after declawing procedures
ANALGESIA and is usually controlled by application of a bandage
Analgesics are required to control pain after to the foot for 18–24 hours. Significant hemorrhage is
surgery 25,31,32. Cats given butorphanol most common in older cats and least common after
(0.2 mg/kg) IM before surgery, at extubation, and laser onychectomy and when the wounds are closed
every 4 hours for the first 12 hours after with suture material or tissue adhesive.
onychectomy bear weight sooner and eat better
than unmedicated cats. The incidence of severe Pain
lameness is also reduced with butorphanol Pain is managed with proper preemptive and
treatment 32. A recent study found that limb postoperative analgesic therapy (see Analgesia).
function is better in cats treated with a transdermal
fentanyl patch or intramuscular injections of Claw regrowth
butorphanol (0.4 mg/kg every 4 hours for the first Claw regrowth results from inadequate removal of
24 hours after surgery) than in cats treated with the ungual crest and the germinal tissue responsible
topical bupivacaine33. This study also indicated that for claw growth26. Regrowth may occur months to
limb function remained reduced 12 days after years after surgery and is more common after
onychectomy, suggesting that long-term analgesic amputation of the distal phalanx with a guillotine-
protocols may be warranted. Another study found type nail trimmer than after disarticulation26,29.
162

In most cases, the cat becomes lame and draining Oral antibiotics are administered until wound healing
sinuses develop on the dorsal axial and abaxial is complete.
surfaces of the affected digits. The drainage often
subsides with antibiotic treatment but recurs unless Radial neuropraxia or paralysis
the claw is excised. The newly developing claw Injury to the radial nerve is usually associated with
is usually palpable beneath the skin or, in some cases, use of a tourniquet during surgery. Clinical signs
will protrude through the skin, leading to concurrent can include obvious limb dysfunction after surgery
infection. If claw regrowth is detected in one digit, (dragging the limb, inability to extend the carpus) or
the others should be checked as well. Palpation and self-mutilation of the foot. In most cases, the nerve is
radiographic evaluation of the digits will confirm if a only temporarily injured (neuropraxia) and signs
portion of the third phalanx was not excised (128). If resolve within 6–8 weeks. Radial neuropraxia is
regrowth occurs, the claw and remaining ungual crest avoided by tightening the tourniquet only enough to
are excised with a scalpel blade and the wound is control hemorrhage. It should be placed on the
managed as an open wound. Antibiotics are proximal antebrachium where the radial nerve is
administered until the wounds are healed. adequately protected by overlying muscles.

Chronic draining tracts Infection


Draining tracts may occur as a result of claw regrowth Infection can occur after onychectomy if improper
or if cyanoacrylate tissue adhesive was placed sterile technique is used, if the wounds failed to
subcutaneously in the wounds after onychectomy. close after surgery, or as consequence of claw
The wounds are debrided and remaining portions of regrowth. Infections are more common after
the distal phalanx are excised with a scalpel blade. amputation with a guillotine-type nail trimmer than
The wounds are left open to heal by second intention after disarticulation26,29. The use of cyanoacrylate
and the foot is bandaged. Soaking the foot daily in tissue adhesive has also been associated with higher
dilute chlorhexidine solution has been advocated. infection rates. Cyanoacrylate adhesives placed

128

A
128 Radiographs of the foot from a cat with regrowth of the claws after
onychectomy.
A Lateral radiographic view.
B Dorsopalmar radiographic view. Large portions of the distal phalanx are
visible. The ungual crest of the distal phalanx was not properly excised during
surgery, allowing regrowth of the claw.

B
Fractures and disorders of the forelimb
163

subcutaneously may cause foreign body reaction Protrusion of the second phalanx
and infection, leading to delayed wound Protrusion of the second phalanx through the
healing26,29. Adhesives should be used sparingly and surgical wound may occur if the wound was not
applied to the skin edges only. Clinical signs of closed after surgery or if the wound dehisces. The
infection include pain, swelling, and drainage. exposed end of the second phalanx is visible and
Rarely, septicemia can occur in cats with abscessed palpable. Owners occasionally report hearing a
paws. Treatment consists of cleaning and debriding ‘clicking’ sound when the cat walks on a hard
the wound and allowing drainage by open wound surface. The cat is anesthetized and the area is
management. Intermittently soaking the infected cleaned. The distal end of the second phalanx is
digits in dilute chlorhexidine solution is often removed with a small rongeur and the wound is
advocated. Systemic antibiotics are administered closed with two interrupted sutures (3-0 chromic
until healing is complete. gut) placed in the skin edges. Lameness is often
prolonged after removing the distal end of the
Wound dehiscence second phalanx.
Wound dehiscence may occur if the sutures or tissue
adhesive fail to maintain reduction of the skin edges. Tissue necrosis
Wounds that are managed with bandages only Swelling and necrosis of the foot may occur if bandages
after surgery may also open. Occasionally, wound are placed too tightly or are left on too long (129).
dehiscence occurs when the cat licks or chews at the
surgical sites. The dehiscence rate is reportedly higher Palmigrade stance
after disarticulation with a scalpel blade than after A palmigrade or ‘flatfooted’ stance develops in some
amputation with a nail trimmer, perhaps due to longer cats after onychectomy, though it rarely causes
surgery time and greater soft tissue trauma26. The clinically significant signs. The cause is unknown, but
dehisced wounds are managed with open wound it may be associated with removal of the entire third
therapy and systemic antibiotics are administered. phalanx, inflammation, and tendonitis29.

129

129 Tissue necrosis of the paw after onychectomy


procedure. Bandages applied to the paws after surgery to
control hemorrhage were too tight. (Photograph courtesy
of Dr. O. Lanz.)
164

Persistent lameness Deep digital flexor tenectomy


Up to 50% of cats are lame for 1–54 days after The deep digital flexor tendon inserts on the flexor
onychectomy. Some cats demonstrate long-term tubercle of the distal phalanx. To extrude the claws
discomfort29,38. Acute lameness is more common from the sheath, the deep digital flexor muscle is
after disarticulation of the distal interphalangeal joint. contracted to flex the distal interphalangeal joint.
However, chronic lameness is more common after Surgical excision of a portion of the deep digital flexor
amputation of the distal phalanx with a nail tendon prevents flexion of the distal interphalangeal
trimmer26. Cutting the digital pad or distal aspect of joint and extrusion of the claw. Severing the tendon
the second phalanx can prolong lameness and pain does not affect the cat’s ability to walk normally. After
after onychectomy. Overall, persistent lameness is tenectomy, the claws continue to grow and often
identified in only 0.86% of cats23. Computerized gait become thickened and blunted. The nails must be
analysis of cats shows that bilateral forelimb trimmed regularly to prevent them from growing into
onychectomy does not result in abnormal vertical the digital pad37,43,44. Owners unable or unwilling to
forces in the forelimbs when measured more than trim the claws regularly should not elect tenectomy as
6 months after surgery39. an alternative to onychectomy.

Behavioral changes Surgical technique


Onychectomy has reportedly lead to physical and The palmar surface of each digit is clipped and
behavioral changes in some cats, including increased scrubbed from the digital pad to the metacarpal pad.
aggression, biting, and house soiling23,36,40. Other A tourniquet is applied to the proximal
studies of cats undergoing declawing procedures antebrachium and tightened just enough to control
suggest that declawing causes no significant hemorrhage. A 3–5 mm skin incision is made over
behavioral changes in most cats41–43. the palmar surface of each digit (beginning 3–5 mm
proximal to digital pad) to expose the deep digital
ALTERNATIVES TO ONYCHECTOMY flexor tendon (130). The tendon lies just beneath
Alternatives to declawing are offered to owners the skin and is identified by its white, glistening
that have humane concerns regarding surgical appearance. The tendon is isolated by blunt
removal of the claws or are concerned with potential dissection with a mosquito hemostat or curved iris
complications associated with onychectomy procedures. scissors. A 5 mm long segment of the tendon is

130

A B C

130 Deep digital flexor tenectomy.


A A 3–5 mm skin incision is made over the palmar surface of each digit to expose the deep digital flexor tendon.
B The deep digital flexor tendon lies just beneath the skin and is isolated with a mosquito hemostat or curved iris scissors.
C A 5 mm long segment of the tendon is exteriorized and excised with a scalpel blade. Surgical excision of a portion of
the deep digital flexor tendon prevents flexion of the distal interphalangeal joint and extrusion of the claw. After
tenectomy, the claws continue to grow and frequent trimming is necessary.
Fractures and disorders of the forelimb
165

exteriorized and excised with a scalpel blade. FORELIMB AMPUTATION WITH SCAPULECTOMY
Hemorrhage is usually minimal and can be Removal of the entire forelimb, including the scapula,
controlled by direct pressure or electrocautery. The provides excellent cosmetic results and is the preferred
edges of the skin incision are apposed and a single method of forelimb amputation in cats. The entire
drop of cyanoacrylate tissue adhesive is applied. forequarter is clipped and prepared for surgery19.
A bandage is not necessary44. A hanging-limb preparation is used to allow
manipulation of the limb intraoperatively. The skin
Complications incision begins at the dorsal border of the scapula and
Complications reported after deep digital flexor extends distally along the scapular spine to the
tenectomy include hemorrhage, infection, pain, shoulder joint. The incision is then extended
interphalangeal joint immobility and fibrosis, and circumferentially around the shoulder joint.
excessive nail growth37,44. Most cats appear in Electrocautery may be used to control small bleeding
significantly less pain 24 hours after tenectomy vessels. Ligation is used to prevent hemorrhage prior
(compared with onychectomy), but the incidence of to transection of larger vessels. The cephalic vein on
infection, persistent lameness, and minor behavioral the lateral aspect of the shoulder is ligated and
changes are the same for both procedures37. After transected. The omotransversarius muscle is sharply
tenectomy, the claws continue to grow and are transected from the cranial border of the scapular
usually thickened and rough. Frequent trimming is spine. The incision is continued dorsally along the
required to prevent claws from growing into the scapular spine, severing the cervical and thoracic
digital pads. Some cats can still use their claws portions of the trapezius muscle. The rhomboideus
after tenectomy, though the ability to scratch is muscle is removed from the dorsomedial aspect of the
limited36. Owner satisfaction rates of 70–94% are scapula. The ventral serratus muscle is elevated from
reported after tenectomy 37,43. If complications the scapula. The scapula is then abducted from the
after tenectomy are severe, onychectomy may be body wall to expose the axillary space. The fascia is
required. bluntly dissected to allow transection of the insertions
of the latissimus dorsi, teres major, and cutaneous
Behavior modification trunci muscles near the humerus. The thoracodorsal
Retraining or behavior modification techniques may artery and vein are identified and separately ligated
help prevent cats with claws from damaging furniture and divided. The thoracodorsal nerve is transected.
or scratching owners and other pets. The scapula is abducted further and rotated to
expose the axillary artery. It is double ligated and
Capping transected. The lateral thoracic artery is ligated and
An alternative to surgical declawing is to place a divided. The brachial and axillary veins are separately
vinyl cap over the tip of each claw (Soft Paws). The ligated and divided. The nerves of the brachial plexus
caps are attached with glue and must be replaced are then transected in a caudal to cranial direction.
approximately every 6–8 weeks as the claw grows. Branches of the superficial cervical artery are ligated.
Premature removal of the caps will also necessitate The scapula is further abducted to allow transection of
replacement. the ventral musculature. The deep and superficial
pectoral muscles are removed from their insertions on
FORELIMB AMPUTATION the humerus. The cleidobrachialis muscle is transected
Limb amputation is a salvage procedure indicated for to complete the amputation. Bupivacaine can be
irreparable fractures or when severe complications injected into the cut ends of the brachial plexus prior
occur after attempted fracture treatment. to wound closure. The fascia of the deep pectoral
Complications necessitating amputation may include muscle is sutured to the scalenus and latissimus dorsi
nonunion, osteomyelitis, severe muscle contracture or muscles. The fascia of the cleidobrachialis muscle is
joint dysfunction, and neurologic dysfunction. sutured to the fascia of the superficial pectoral muscle.
Neoplasia affecting the soft tissues or skeleton is also Fascia of the trapezius and omotransversarius muscles
an indication for amputation. The cat should be is sutured to the dorsal aspect of the latissimus dorsi
carefully evaluated to ensure the remaining three muscle. Subcutaneous tissue and skin are sutured.
limbs are healthy and can adequately support weight. Dead space is reduced during closure to minimize
Cats are typically able to ambulate well after seroma formation. A Penrose drain may be placed if
amputation of one limb. Amputation of two limbs has necessary and is removed 3–5 days after surgery. The
been described in cats. incision and body wall may be bandaged.
166

FORELIMB AMPUTATION MID-HUMERUS incision. Electrocautery may be used to control small


Removal of the forelimb at the mid-humerus is bleeding vessels. Ligation is used to prevent
easier to perform but provides less satisfactory hemorrhage prior to transection of larger vessels.
cosmetic results than amputation with scapulec- Medially, the brachial artery and vein are separately
tomy. The remaining proximal humerus and scapula ligated and transected proximal to the collateral ulnar
become prominent as the shoulder muscles atrophy artery. The median, musculocutaneous, and ulnar
after amputation, and the movement of these nerves are transected. The triceps tendon is transected
structures beneath the skin is concerning to some near the olecranon. The brachial and biceps brachii
owners. muscles are transected near their insertions distal to
The hair is clipped and the skin prepared from the the elbow joint. The cephalic vein is ligated and
dorsal mid-line to the ventral mid-line, and distally on divided. The radial nerve is cut. The brachiocephalicus
the limb to the carpus. A hanging-limb preparation is muscle is elevated from the humeral crest to expose
used. A lateral skin incision is made from the the humerus. The bone is cut at its mid-shaft using
cranial aspect of the brachium, distally to just proximal a power saw or wire saw. The distal aspect of the
to the elbow joint, and then proximally to the caudal triceps is sutured to the brachial and biceps brachii
aspect of the brachium19. The incision is continued in muscles to cover the cut end of the humerus. The
a straight line on the medial aspect of the limb to subcutaneous tissues and skin are sutured. A bandage
connect the cranial and caudal portions of the lateral may be applied to control swelling.
167

CHAPTER 9
FRACTURES AND
DISORDERS OF
THE HINDLIMB
PART 1: PELVIS

The pelvis is comprised of two bilaterally symmetrical the cat and occur most often in young animals (mean
hemipelves, each consisting of the ilium, ischium, age 16.8 months)3,5,6. In most cases, two or more of
pubis, and acetabular bones (131). Each ilium is the pelvic bones are fractured, leading to displacement
attached to the spine at the sacrum, forming the of the fragments and narrowing of the pelvic canal.
sacroiliac joints. Weight-bearing loads are transmitted Displacement is minimal if only one of the pelvic
from the femoral head to the acetabulum, along the bones is fractured, but this is uncommon. Pelvic
body of the ilium, and through the sacroiliac joint to fractures are rarely open because the pelvis is
the spine. completely surrounded by muscle and other soft
tissues.
PELVIC FRACTURES (GENERAL) Concomitant injuries occur in the majority of
CAUSE AND PATHOGENESIS cats (59–72%) with pelvic fractures6,7. In one report,
Trauma to the pelvis is common in cats, often a result 56.4% of cats with pelvic fractures had other
of being hit by a car or falling from a great height1–4. musculoskeletal injuries; these may include sacral
Pelvic fractures account for 20–22% of all fractures in fractures, coxofemoral luxations, femoral head and
neck injuries, and femoral fractures3,7,8. Ischial
fractures often occur concurrently with sacral
fractures6. Twenty-three percent of cats with pelvic
fractures had concurrent injuries to the thorax or
131 abdomen, including pneumothorax, hemothorax,
urinary tract injuries, gastrointestinal injuries,
abdominal hernia, diaphragmatic hernia, and rupture
of the prepubic tendon7,9. Twenty percent had
5 injuries of the nervous system, including lumbosacral
1 1 plexus injury and sciatic nerve damage7,10,11. Many
4 cats with pelvic fractures have injuries to multiple
3 body systems. A complete physical examination,
2 orthopedic evaluation, and neurologic examination,
4 and radiographs of the thorax and abdomen should be
obtained to identify concurrent injuries and allow
2 initiation of proper treatment.
3
A B CLINICAL SIGNS
Cats with pelvic fractures are often unwilling to stand
131 Normal pelvic anatomy. 1 ilium, 2 pubis, 3 ischium, or ambulate, particularly immediately after the
4 acetabulum, 5 sacrum. A Ventrodorsal view. B Lateral trauma. However, cats with unilateral injuries, more
view. chronic injuries, or fractures involving only the pubis
168

or ischium will stand but appear uncomfortable. In Conservative therapy


many cases, swelling, pain, and asymmetry are evident Conservative therapy is indicated for fractures of the
in the pelvic region. pelvis that do not involve the weight-bearing axis
(acetabulum, ilial body, sacroiliac joint). This includes
DIAGNOSIS fractures of the ishium, pubis, and ilial wings.
Pelvic fractures are readily diagnosed by physical Fractures of these bones are well supported by
examination and radiography. Palpation of the the pelvic musculature and typically heal without
greater trochanter, ischial tuberosity, and ilial wings surgical intervention. Conservative therapy is also
often reveals crepitus and malalignment. Digital used when there is minimal displacement of the
rectal examination is helpful in assessing the fracture fragments, or minimal narrowing of the pelvic
integrity of the pelvic canal, but can be difficult canal, or if financial considerations preclude surgery.
because the cat will be in pain and because of the cat’s Conservative therapy involves cage confinement
small size. for 4–6 weeks. Urination and defecation are
Pelvic fractures can be confirmed on ventrodorsal monitored and the cat is kept clean and dry to avoid
and lateral radiographic views. Oblique views prevent decubital ulcers. Oral administration of stool softeners
overlap of the two hemipelves and are often helpful. and laxatives may be used to ease defecation. Physical
Sacroiliac fracture/dislocation is best observed on the therapy, including passive range-of-motion exercises,
ventrodorsal radiographic view (132). can be used if tolerated by the cat. Analgesic
medications should be used if needed during the early
TREATMENT AND PROGNOSIS stages of healing, but caution is needed to avoid
The cat should be carefully evaluated for concurrent complications. Fracture healing is monitored
injuries and stabilized before initiating treatment for radiographically to ensure healing is progressing.
the pelvic fractures. Pelvic fractures are treated with Potential complications of conservative therapy for
either conservative medical therapy or open surgical pelvic fractures include prolonged pain during healing
stabilization. and entrapment of the sciatic nerve in the healing
callus. Additionally, malunion of the pelvic bones can
lead to persistent gait abnormality and chronic
narrowing of the pelvic canal, resulting in obstipation,
constipation, and, eventually, megacolon12–14.

132 Surgical therapy


Surgical intervention is indicated to reduce and
stabilize pelvic fractures if:
• The fractures involve the weight-bearing axis of
the pelvis.
• Significant narrowing of the pelvic canal is
present.
• The fracture involves the articular surface of the
acetabulum.
• Concurrent orthopedic injuries require
stabilization for the cat to ambulate.
• Extreme pain or neurologic deficits indicate nerve
injury.

Reduction and stabilization of fractures involving


the acetabulum, ilial body, and/or sacroiliac joint
allow earlier return to function and minimize
narrowing of the pelvic canal. Repair of acetabular
fractures ensures earlier weight bearing and helps
reduce the development of osteoarthritis. Surgery
132 Ventrodorsal radiographic view of the pelvis from a should be performed within 4–5 days of the injury
cat with bilateral sacroiliac luxation and a comminuted if possible, as longer delays can make proper
femoral fracture. reduction of the fracture fragments more difficult.
Fractures and disorders of the hindlimb
169

Surgical stabilization of ischial and pubic fractures is Surgical therapy


rarely indicated and most are managed with Several techniques have been described for surgical
conservative treatment. stabilization of sacroiliac fracture/dislocation in
cats8,13,16.
Postoperative management
After repair of pelvic fractures, the cat’s activity is Dorsolateral surgical approach
restricted for 4–6 weeks or until healing is A dorsolateral surgical approach to the sacroiliac
radiographically complete. Walking and limited activity joint allows anatomic reduction and stabilization of
are permitted to maintain muscle and joint health. If sacroiliac fracture/luxations (133)17,18. The ilial
the cat is unable to ambulate, a dry, well padded bed is wing, sacroiliac joint, and sacral body are visualized
important to prevent decubital ulcers. The patient to facilitate proper implant placement. The cat is
should be turned from side to side frequently.
Urination and defecation are monitored and the patient
is kept clean and dry. Stool softeners may be used to
ease defecation, though this is rarely needed if the pelvic 133
diameter is adequate. If neurologic deficits were
present, neurologic function is monitored regularly to
determine if function is improving. The fractures are
monitored radiographically to confirm healing and
observe for implant problems. The implants are not
removed unless complications develop.

SACROILIAC
A
FRACTURES/DISLOCATION
CAUSE AND PATHOGENESIS
Fracture/dislocation of the sacroiliac joint occurs when
the ilial body is displaced from its attachment to the
sacrum (132). This injury accounts for 19–27% of pelvic
injuries in cats15. The ilium is usually displaced cranially
and dorsally, although the degree of displacement can
Middle
vary from mild to severe. Fractures of the pubis and gluteal Sacrum
ischium are often present and allow displacement of the muscle
hemipelvis. Bilateral sacroiliac luxation is common
Wing of
(18–46% of cases) and often occurs without concurrent ilium
pelvic injuries8,11. Sacroiliac dislocation and ilial body Sacroiliac
fractures occasionally occur ipsilaterally, but in most joint
cases, one or the other is present.
Cranial gluteal
CLINICAL SIGNS artery, vein,
nerve
The injury is painful and is often associated with
neurologic deficits caused by injury to the lumbosacral
nerve trunk or sciatic nerve. B

TREATMENT AND PROGNOSIS 133 Dorsolateral approach to the sacroiliac joint. A The cat
Conservative therapy is positioned in ventral recumbency and an incision is made
Conservative therapy is indicated in cases with minor along the dorsal iliac spine. B Subcutaneous tissues are
displacement, when no neurologic deficits are present, incised and the origin of the middle gluteal muscle is
or when the cat is ambulating well. Because cats are elevated from the lateral surface of the ilial wing. The cranial
lightweight, many respond well to conservative gluteal vessels and nerve are avoided. The soft tissues
treatment. However, stabilization of the sacroiliac between the iliac crest and the sacrum are elevated.
joint may improve the cat’s comfort, allows earlier The ilium is rotated slightly to visualize the sacroiliac
return of limb function, and reduces repeated trauma joint, the articular surface on the medial aspect of the
to the lumbosacral nerve truck. ilium, and the sacral body.
170

placed in ventral recumbency and the area over the during insertion of the Kirschner wire is important
sacroiliac joint is prepared for surgery. The hindlimbs to ensure it is accurately positioned at the edge of
may be positioned such that the hips and stifles are the sacral body. The Kirschner wire thus provides
flexed and the cat is resting on its knees. A pad placed temporarily stabilization of the joint and serves as a
beneath the pubis will elevate the patient’s body and landmark for screw placement. A lag screw is then
ease reduction by removing pressure from the placed into the sacral body next to the Kirschner
sacroiliac joint. wire. It is important to angle the screw correctly to
The incision is made over the iliac crest along the avoid entering the lumbosacral disc space cranially,
dorsal iliac spine. Subcutaneous tissues are incised the spinal canal dorsally, or exiting the sacral body
and the origin of the middle gluteal muscle is ventrally15. The Kirschner wire may be left in place
elevated from the lateral surface of the ilial wing. The to prevent rotation around the lag screw. In most
cranial gluteal vessels and nerve are located near the cats, the sacral body is too small to accommodate
caudal iliac spine and are avoided. The soft tissues two lag screws. Another method of inserting the lag
between the iliac crest and the sacrum are elevated screw is to drill a ‘thread’ hole into the sacral body
using blunt and sharp dissection, exposing the before reduction of the fracture. A ‘glide’ hole is
sacroiliac joint. The ilium is rotated slightly to allow then drilled from medial to lateral through the ilial
visualization of the articular surface, located on its wing at the appropriate location. The screw is then
medial side just ventral to the dorsal iliac spine. This inserted through the ilium from lateral to medial.
also allows visualization of the sacroiliac joint and The fracture is reduced as the screw is directed into
identification of the sacral wing. Ventral retraction the predrilled hole in the sacral body. If desired, a
of the ilium with a Hohmann retractor will also Kirschner wire may be inserted parallel to the screw
improve exposure. The articular surface of the sacral to prevent rotation, though this is not necessary in
wing consists of a semilunar synovial portion (which most cats.
is located caudoventrally and is covered with hyaline
cartilage) and a fibrocartilagenous portion which is
located craniodorsally. Careful removal of some of
this fibrocartilage will improve visualization. The
proper location to insert the screw in the sacrum is
just cranial to the cresent shaped hyaline cartilage15.
A bone clamp is placed on the ilial wing to allow the
application of force in a caudal and ventral direction, 134
thus re-aligning the articular surfaces of the ilium
and the sacrum (134). Countertraction on the
sacrum with a hemostat or other blunt instrument
will ease reduction.
A lag screw is then placed through the ilium and
into the sacral body to achieve compression and
maintain reduction (135). In most cats, a 2.7 mm
cortical screw is used and placed in lag fashion.
A 2.0 mm or 3.5 mm cortical screw may used instead,
depending on the size of the sacral body. The screw
should be long enough to extend 60% of the distance
across the sacrum. Measuring the distance on the
ventrodorsal radiograph is helpful in selecting a
screw of sufficient length. It can be difficult to
position this screw properly in the sacral body
and avoid inserting it into the sacral wings alone
(which have less holding power), the lumbosacral
disc space, or into the spinal canal. This is made 134 Reduction of a sacroiliac luxation. A bone clamp is
more difficult by the small size of the sacral body in placed on the ilial wing and force is applied in a caudal and
the cat. One helpful technique is to place a Kirschner ventral direction until the articular surfaces of the ilium
wire through the ilial wing and into the sacrum once and the sacrum are aligned. Countertraction is applied to
the joint is reduced. Visualization of the sacral body the sacrum with a hemostat to facilitate reduction.
Fractures and disorders of the hindlimb
171
135

A B
Proper implant
placement Articular face

Cranial
Caudal Cranial
Articular face
Caudal
Proper implant
placement
C D

E F
135 Stabilization of a sacroiliac luxation.
A A 2.7 mm screw is inserted in lag fashion through the ilium and into the sacral body. The screw should extend at
least 60% of the distance across the sacrum. A Kirschner wire may be inserted to prevent rotation around the screw.
B Lateral view depicting proper placement of the lag screw in the sacral body.
C Lateral view of the sacrum depicting the proper anatomic location for inserting implants.
D Medial view of the ilium depicting the proper anatomic location for inserting implants.
E Ventrodorsal radiographic view of the pelvis after stabilization of the left sacroiliac joint with a single transsacral screw.
F Lateral radiographic view of the pelvis after transsacral screw placement.
172

Ventrolateral surgical approach elevated to allow digital palpation of the sacral body.
A ventrolateral surgical approach may be used to A lag screw and Kirschner wire are inserted as
visualize the ilium and allow stabilization of sacroiliac previously described, although visualization of the
fracture/dislocations (136)19. This approach is often sacral body is limited and care must be taken to place
used when repair of ilial fractures will be performed the implants properly.
concurrently, since it is easily combined with a lateral
approach to the ilium. Single transsacral screw
The cat is placed in lateral recumbency and a skin Bilateral sacroiliac fracture/dislocations can be
incision is made from the center of the iliac crest to repaired using separate surgical procedures to place
the greater trochanter. Subcutaneous tissues and lag screws bilaterally. Alternatively, a technique for
superficial fascia are reflected. The deep gluteal fascia is placing a single, long transsacral screw to stabilize
incised. The intermuscular septum, between the bilateral dislocations has also been described in
middle gluteal muscle and the tensor fasciae latae, is cats (137)20. The cat is positioned in ventral
incised from the ventral iliac spine to the cranial border re-cumbency after preparation of the dorsal lum-
of the biceps femoris muscle. The middle gluteal bosacral region for surgery. A dorsolateral approach
muscle is retracted dorsally to allow an incision to be is made to each sacroiliac joint. The first sacroiliac
made in its origin on the ilium, beginning at the joint is reduced and temporarily stabilized with a
caudoventral iliac spine and continuing cranially and transarticular Kirschner wire. From the contralateral
dorsally. A periosteal elevator is used to reflect the sacroiliac joint, a drill bit is placed in the center of
muscle and expose the lateral aspect of the ilial wing. the sacral body. The drill bit is advanced parallel to
Ligation of the iliolumbar vessels may be necessary to the surgery table and perpendicular to the spine,
control hemorrhage. The origin of the iliacus muscle is traversing the sacrum and the previously reduced ilial
incised along the ventromedial border of the ilium and wing. The hole is measured and tapped. A glide hole

136 137

Middle
gluteal
muscle

136 Ventrolateral approach to the sacroiliac joint. The cat


is positioned in lateral recumbency and a skin incision is
made from the center of the iliac crest to the greater
trochanter. Subcutaneous tissues and superficial fascia are
reflected. The deep gluteal fascia in incised. The 137 Stabilization of bilateral sacroiliac luxations using a
intermuscular septum between the middle gluteal muscle single transsacral screw. A dorsolateral approach is made to
and the tensor fasciae latae is incised from the ventral iliac each sacroiliac joint. The first sacroiliac joint is reduced
spine to the cranial border of the biceps femoris muscle. and temporarily stabilized with a transarticular Kirschner
The middle gluteal muscle is retracted dorsally to allow an wire. From the contralateral sacroiliac joint, a lag screw is
incision to be made in its origin on the ilium, beginning at placed across both ilial wings and the sacral body. The
the caudoventral iliac spine and continuing cranially and screw is placed in the center of the sacral body.
dorsally. A periosteal elevator is used to reflect the muscle
and expose the lateral aspect of the ilial wing. The arrow
indicates the proper location for screw insertion.
Fractures and disorders of the hindlimb
173

is then drilled in the proper location in the remaining the distance across the sacrum. Proper pin length is
ilial wing and a screw of sufficient length to pass determined from preoperative radiographs. Once the
through both ilial wings and the sacrum is inserted. pin is in place, the suture through the iliac crests is
A washer is placed over the screw prior to insertion. tied to form a tension band. The tension band
technique was successful in stabilizing 24 sacroiliac
Tension band technique luxations in 19 cats21. Complications were few and
A tension band technique has also been described included pin migration.
for stabilization of sacroiliac luxation in cats19. The cat
is placed in ventral recumbency and a dorsolateral Closed lag screw placement
approach is made to the injured sacroiliac joint. Using intraoperative imaging (C-arm), the sacroiliac
Another small approach is made to the contralateral luxation can be reduced and a lag screw placed
iliac crest. Holes are drilled from lateral to medial percutaneously22. This technique is less invasive than
through the craniodorsal aspect of each iliac crest the others described above, but requires specialized
(138). Using a straight needle, a strand of large equipment.
monofilament nylon suture is threaded through the
hole in one iliac crest, through the sacral muscles, and ILIAL FRACTURES
through the hole in the other iliac crest. The suture is CAUSE AND PATHOGENESIS
then passed dorsal to the iliac crests and back through Fractures of the ilium disrupt the weight-bearing axis
the sacral muscles. The sacroiliac luxation is reduced of the pelvis, leading to significant dysfunction. They
and a 1.5–2.0 mm Steinmann pin is inserted through are usually accompanied by fractures of the pubis and
the ilium and into the sacral body. The pin is oriented ishium, allowing the caudal segment of the fracture
parallel to the surgical table and perpendicular to the to collapse into the pelvic canal (139). Ilial fractures
spine. The pin is inserted to penetrate at least one-half in cats are typically oblique, although comminuted

138 139

138 Stabilization of a sacroiliac luxation with a tension


band technique. Holes are drilled through the craniodorsal
aspect of each iliac crest. A straight needle is used to place
a strand of monofilament nylon suture through the holes.
The sacroiliac luxation is reduced and a 2.0 mm
Steinmann pin is inserted through the ilium and into the 139 Ilial fracture. Ventrodorsal radiographic view
sacral body, extending at least one-half the distance across of a right ilial, pubic, and ischial fracture. The right
the sacrum. The suture preplaced in the iliac crests is tied side of the pelvis is collapsed medially into the
to form a tension band. pelvic canal.
174

fractures do occur. The sciatic nerve courses along gluteal muscles are reflected dorsally using a
the medial aspect of the ilial body and can be trauma- periosteal elevator to expose the ventral and
tized when the fracture occurs or during attempts at lateral surfaces of the ilium. The lateral circumflex
repair. femoral vessels and the cranial gluteal vessels and
nerve are preserved. The iliolumbar vessels course
TREATMENT AND PROGNOSIS ventral to the ilial wing and are transected as the
Surgical stabilization is recommended to restore limb exposure is extended cranially. The ventral portion
function, prevent narrowing of the pelvic canal, and of the gluteal attachment on the ilial wing is cut
prevent injury to the sciatic nerve caused by motion of to increase visualization of the cranial ilium. A
the fragments or exuberant callus formation. The cat Hohmann retractor is placed over the dorsal aspect
is positioned in lateral recumbency. An area from the of the ilium to maintain retraction of the gluteal
dorsal mid-line to the hock and from cranial to the muscles.
ilial wing to the perineum is clipped and prepared for In most cases, the caudal fracture segment is
surgery. A hanging-limb preparation allows the limb displaced medially and cranially. Reduction is achieved
to remain in the surgical field for manipulation as by traction, levering, and rotation of the caudal
needed during surgery. fracture fragment. Bone forceps placed on the ilium
A lateral surgical approach to the ilium is just cranial to the acetabulum allow the fragment to
performed, beginning with a skin incision from the be manipulated into alignment. In cases where the
iliac crest to the greater trochanter (140) 18. ischial attachment to the ilium is intact, a clamp can be
Subcutaneous tissues are incised to expose and allow placed on the ischial tuberosity (via a small surgical
separation between the middle gluteal and the approach) to allow manipulation of the caudal ilial
tensor fascia lata muscles. The deep and middle segment (141). Traction on the greater trochanter
may also be used to manipulate the caudal ilial
fragment into alignment. Placement of clamps and
140 manipulation of the fracture fragments are performed
Middle gluteal muscle
with care to avoid injuring the sciatic nerve. Once
Cranial gluteal
artery, vein, reduced, the fracture is temporarily stabilized with
and nerve bone clamps.
Several methods of stabilizing ilial fractures have
Shaft Deep gluteal
muscle been described, but plate fixation is preferred (141).
of ilium The bone plate is contoured to the lateral surface of
the ilium. It is important that the plate contour is
Sartorius concave to ensure the normal diameter of the pelvic
muscle canal is maintained. The plate should be positioned
and tensor
on the ilium such that a minimum of two to three
fasciae Lateral
latae Iliolumbar screws are placed cranial and caudal to the fracture
circumflex
muscle artery and vein femoral vessels site. Also, the cranial portion of the plate should
be positioned to allow a screw to be placed through
140 Lateral approach to the ilium. A skin incision is the ilium and into the sacral body. Since the bone of
made from the iliac crest to the greater trochanter. the ilial wing is relatively thin, placing a screw
Subcutaneous tissues are incised to expose the separation into the sacrum will increase the holding power of
between the middle gluteal and the tensor fascia lata the screw. Care is taken not to strip screws placed into
muscles. The deep and middle gluteal muscles are the thin bone of the cranial ilium. Various types of
reflected dorsally using a periosteal elevator to expose bone plates can be used on the ilium, including
the ventral and lateral surfaces of the ilium. The lateral 2.7 mm dynamic compression plates (DCPs), small
circumflex femoral vessels and the cranial gluteal vessels reconstruction plates, and cuttable plates. Mini
and nerve are preserved. The iliolumbar vessels course plates, T plates, and L plates are also used when small
ventral to the ilial wing and are transected as the exposure fragments prevent the insertion of at least two screws
is extended cranially. The ventral portion of the gluteal using a straight plate.
attachment on the ilial wing is cut to increase visualization In some cases, the fracture cannot be stabilized
of the cranial ilium. A Hohmann retractor may be placed with bone clamps after reduction. The plate is
over the dorsal aspect of the ilium to maintain retraction contoured appropriately. Evaluation of the intact
of the gluteal muscles. ilium on the ventrodorsal radiograph is helpful to
Fractures and disorders of the hindlimb
175

ensure the plate is properly contoured. It is then on the ischial tuberosity) as medial force is applied to
attached to the caudal fracture fragment. The fracture the cranial aspect of the plate (142). When the
is then reduced by placing lateral traction on the fracture is reduced and the cranial portion of the plate
greater trochanter (or manipulation of a clamp placed contacts the ilium, the cranial screws are inserted.

141

A B

141 Stabilization of an ilial fracture with a bone plate.


A The fracture is reduced by traction, levering, and rotation of the caudal fracture fragment. A bone forceps placed on the
ilium just cranial to the acetabulum, on the greater trochanter, or on the ischium may be used to align the fracture.
B Reduction is maintained with a bone clamp and the plate is applied to the lateral surface of the ilium. A minimum of
two to three screws are placed cranial and caudal to the fracture site.

142

A B
142 Plate fixation of ilial fractures. A If fracture reduction cannot be maintained with a bone clamp, the plate is contoured
appropriately and applied to the caudal fracture segment. B The fracture is reduced by applying traction to the greater
trochanter while the cranial aspect of the plate is pushed medially. When the fracture is reduced, the cranial aspect of the
plate contacts the ilium and the remaining screws are inserted.
176

Other reported methods of stabilizing ilial ACETABULAR FRACTURES


fractures include the insertion of lag screws from the CAUSE AND PATHOGENESIS
ventral border of the ilium, insertion of small pins, and Acetabular fractures are typically unilateral in cats, and
application of cerclage wires (143). The narrow width most (77%) are two-piece fractures6.
of the feline ilium makes placement of ventral lag
screws very difficult. Kirschner wires may be inserted TREATMENT AND PROGNOSIS
from ventral to dorsal across the ilium to stabilize Treatment options include conservative therapy,
fractures. The Kirschner wires are properly positioned femoral head and neck excision arthroplasty, or open
by inserting them through the soft tissues ventral to reduction and stabilization.
the ilium. Unfortunately, they provide less stability
than screws and tend to loosen before bone healing is Conservative management
complete. Full cerclage wires are difficult to place Conservative management is indicated when there
since the medial aspect of the ilium is not visualized is no displacement of the fragments evident
and blindly passing wires can endanger the sciatic radiographically, no narrowing of the pelvic canal, and
nerve and rectum. Hemicerclage wires may be placed no palpable crepitus with manipulation of the hip
on the lateral aspect of the ilium and anchored with joint23. Fractures involving the caudal third of the
screws or Kirschner wires. In most cases, pins and acetabulum are treated conservatively often, though
wires are used only in conjunction with plate this portion of the acetabulum is weight-bearing in cats.
stabilization, if at all. Restricting activity and preventing weight bearing by

143

A B

C D

143 Alternative methods for internal fixation of ilial shaft fractures.


A Plate fixation with mini T plates or L plates.
B Lag screw fixation. Two bone screws are inserted in lag fashion from the ventral ilial border. This technique is difficult in cats
because the ilium is narrow.
C Kirschner wires and cerclage wire fixation. The Kirschner wires are inserted through the soft tissues ventral to the ilium, across
the fracture line, and into the dorsal aspect of the ilium. Orthopedic wire is placed around the protruding ends of the Kirschner
wires and tightened.
D Alternatively, the orthopedic wire can be anchored using small bone screws.
Fractures and disorders of the hindlimb
177

placing the limb in a sling may allow healing. In most incision is made in the fascia lata along the cranial
cases, the cat will begin using the limb within 10–14 border of the biceps femoris muscle. The incision
days. Excision arthroplasty may be indicated in cats that necessary for adequate exposure is slightly longer in
fail to show improvement in pain level or limb function the cat than in the dog. The biceps femoris muscle is
after 10–14 days of conservative therapy23. retracted caudally (protecting the sciatic nerve) and
the superficial and middle gluteal muscles are
Femoral head and neck excision arthroplasty retracted dorsally. The deep gluteal muscle is also
Femoral head and neck excision arthroplasty is retracted dorsally, although a partial tenotomy of its
indicated if the fragments are displaced, if anatomic tendon of insertion will enhance exposure. An incision
reconstruction of the acetabulum is not feasible is then made in the joint capsule cranial to the femoral
(comminuted fractures), when the cost of repair is head. This incision extends from the acetabular rim
prohibitive, or in cats that fail to improve after and along the femoral neck to include a portion of the
2 weeks of conservative therapy23. The procedure is origin of the vastus lateralis muscle. The joint capsule
performed via a craniolateral approach to the hip and vastus lateralis muscle are elevated to expose
joint (144). the entire femoral neck. More subperiosteal elevation
The cat is positioned in lateral recumbency and the of the vastus lateralis muscle is needed in the cat than
hip area and hindlimb are clipped and prepared for in the dog to expose the femoral neck adequately. The
surgery. A hanging-limb preparation is used. A skin femur is externally rotated and curved scissors are
incision is made over the cranial aspect of the hip used to transect the ligament of the head of the femur.
joint. The subcutaneous tissues are incised. An The femur is then externally rotated 90° to luxate the

144

Incision in deep gluteal muscle

Middle gluteal muscle


Superficial gluteal muscle

Greater trochanter

Incision in origin of
vastus lateralis muscle
Articularis coxae
muscle

Biceps femoris
Rectus femoris muscle, retracted
muscle

Incision in
joint capsule

144 Craniolateral approach to the hip joint. A skin incision is made over the cranial aspect of the hip joint and the
subcutaneous tissues are incised. The fascia lata along the cranial border of the biceps femoris muscle is incised and the
biceps femoris muscle is retracted caudally (protecting the sciatic nerve). The superficial and middle gluteal muscles are
retracted dorsally. The deep gluteal muscle is retracted dorsally. A partial tenotomy of the tendon of insertion of the deep
gluteal improves exposure. The joint capsule is incised from the acetabular rim, along the femoral neck, and the incision
extends to include a partial tenotomy of the tendon of origin of the vastus lateralis muscle. The joint capsule and vastus
lateralis muscle are elevated to expose the entire femoral head and neck. The ligament of the head of the femur is cut and
the femur is externally rotated to luxate the femoral head from the acetabulum.
178

femoral head from the acetabulum and allow is closed with absorbable suture and the partial
visualization of the entire femoral head and neck. tenotomies of the deep gluteal and vastus lateralus are
In this position, the patella is pointing straight up and sutured. Interposition of soft tissues (deep gluteal or
the surgeon is seeing the cranial aspect of the femur biceps muscle) into the ostectomy site has been
through the incision. This exposure and positioning is described, but is probably of minimal benefit.
important to ensure a proper ostectomy is performed. After femoral head and neck excision arthroplasty,
A bone saw, sharp osteotome and mallet, bone cutter, exercise and movement of the hip are encouraged to
or rongeur is used to remove the femoral head and promote development of a pseudoarthrosis. However,
neck. The ostectomy should be performed on a line when excision is used for treatment of pelvic fractures,
from the lateral aspect of the intertrochanteric notch care is needed to ensure such activity does not
proximally to just proximal to the lesser trochanter interfere with healing or cause pain. Once the pelvic
distally to ensure removal of the entire femoral head fractures are stable, physical therapy and active
and neck (145). Care is taken not to perform the motion are encouraged to improve function of the
ostectomy along a line directed perpendicular to the pseudoarthrosis. The prognosis for pain-free limb
axis of the femoral neck, since this location does not function in cats after femoral head and neck excision
account for anteversion of the femoral head and will arthroplasty is excellent24.
fail to remove a portion of the caudal femoral neck. If
an ostectome is used, it should be the same width as Open reduction and internal stabilization
the femoral neck so that repeated cuts are not Open reduction and stabilization of acetabular
required to complete the excision. It must also be fractures are indicated when fragments are displaced,
sharp to avoid iatrogenic fracture of the femur. When crepitus is palpable, and surgical intervention will
the ostectomy is completed, the femoral head and adequately reconstruct the articular surface. In most
neck are grasped with forceps and the remaining soft cases, internal stabilization is reserved for fractures
tissues are excised. The ostectomy site is palpated to involving the cranial two-thirds of the acetabulum.
ensure it is smooth. A rongeur or small bone rasp can The goal of surgery is to reconstruct the fragments
be used to remove any bone spurs. The joint capsule anatomically to reduce pain, encourage early

145 145 Femoral head and neck excision


arthroplasty.
A The femur is externally rotated to visualize
the entire femoral head and neck. The
ostectomy is performed on a line from the
lateral aspect of the intertrochanteric notch
to just proximal to the lesser trochanter
(solid line). An ostectomy on a line
perpendicular to the axis of the femoral neck
A (dashed line) will fail to remove a portion of
the caudal femoral neck.
B The ostectomy is parallel to the sagittal
plane of the femur (rather than parallel to
the femoral neck) to avoid leaving a portion
the femoral neck in situ.
C Ventordorsal radiographic view of a
femoral head and neck excision arthroplasty.

B C
Fractures and disorders of the hindlimb
179

limb function, and minimize the development of Plate fixation


osteoarthritis. A dorsal approach to the hip by Plate fixation is commonly used and provides rigid
ostectomy of the greater trochanter is preferred by stabilization. A 2.0 mm bone plate, acetabular plate,
many surgeons and enhances visibility; however, many or L plate is contoured and secured to the dorsal
acetabular fractures can be stabilized via a craniolateral acetabular rim (146 B). The plate must be precisely
approach to the hip joint as previously described18. contoured to avoid displacement of the fracture site
The fragments are reduced and temporarily stabilized when the screws are tightened. Small Kirschner wires
using pointed reduction forceps. Manipulating the may be inserted across the fracture line to maintain
caudal fragment with a bone clamp applied to reduction while applying the plate. Care is taken to
the ischium through a small caudal incision may avoid inserting screws into the acetabulum.
facilitate reduction in some cases. The sciatic nerve
must be identified and protected throughout Lag screws
the procedure. Internal fixation is provided once the Oblique, two-piece fractures may be stabilized using
articular surface is anatomically reduced and no steps two lag screws placed perpendicularly to the fracture
or gaps are present in the articular cartilage (146). line (146 C).

146

A B C

D E F

146 Repair of acetabular fractures.


A The fragments are reduced and temporarily stabilized using pointed reduction forceps. A clamp may be applied to the
ischium to manipulate the caudal fragment and facilitate reduction.
B Plate fixation. A Kirschner wire is inserted across the fracture line to maintain reduction while applying the plate. The
plate is applied to the dorsal acetabular rim. It must be precisely contoured to prevent displacement of the fragments as
the screws are inserted.
C Lag screw fixation. Two screws are inserted in lag fashion perpendicularly to the fracture line.
D Tension band wire fixation. Two Kirschner wires are placed across the fracture line to prevent rotation. A figure-of-
eight wire is then placed on the dorsal aspect of the acetabulum, anchored by the protruding ends of the Kirschner wires.
E Alternatively, the figure-of-eight wire can be anchored to two screws inserted in the dorsal acetabular rim cranial and
caudal to the fracture line.
F Screw–wire–polymethylmethacrylate composite fixation. A tension band using screws, Kirschner wires, and a figure-of-
eight wire is applied to the dorsal acetabular rim. Polymethylmethacrylate is then applied over the implants. The sciatic
nerve is protected from the heat created as the polymethylmethacrylate hardens.
180

Tension band wire fixation markedly displaced by the origins of the biceps
Two-piece transverse fractures that are relatively stable femoris, semitendinosus, and semimembranosus
after reduction may be stabilized with a tension band muscles. Fixation of the displaced ischial tuberosity
wire. One or two Kirschner wires are placed across the may restore function and reduce pain. Fixation is
fracture line to prevent rotation. A figure-of-eight achieved using either a tension band wire fixation or
wire is then placed on the dorsal aspect of the interfragmentary wires (147).
acetabulum. The figure-of-eight wire is anchored to
the protruding ends of the Kirschner wires or to PUBIC FRACTURES
screws inserted in the dorsal aspect of the acetabulum Pubic fractures and pubic symphyseal separations in
(146 D, E). the cat rarely require surgical fixation. Stabilization of
Tension band wire fixation is not as rigid as plates fractures present in other bones of the pelvis will
or lag screw fixation, but is often adequate in cats. usually adequately reduce the pubic bones. Cage rest
and limited activity allow eventual bony union.
Screws–wire–polymethylmethacrylate (PMMA) Hobbles can be applied to the hindlimbs to prevent
composite fixation abduction during healing, but many cats tolerate them
A tension band fixation using screws, Kirschner wires, poorly. Rarely, interfragmentary wires are used to
and a figure-of-eight wire is applied as previously align and stabilize the pubis (148).
described. PMMA is applied over the implants on the
dorsal acetabular rim to enhance stability (146 F)25. PELVIC MALUNION FRACTURES
The sciatic nerve must be protected from the heat Unreduced pelvic fractures may heal as malunions.
created by the exothermic reaction as the PMMA Malunions of the pubis and ischium often cause no
hardens. clinical abnormalities. However, malunion fractures of
the acetabulum may lead to poor joint congruence
ISCHIAL FRACTURES and osteoarthritis (149). Malunions of the ilium often
Ischial fractures in the cat rarely require surgical cause gait abnormalities and marked narrowing of the
fixation. Most occur in conjunction with other pelvic pelvic canal, leading to recurrent bouts of constipation
fractures, and reduction of the concurrent injuries or obstipation. Pelvic collapse may also occur in cats
(sacroiliac luxation, ilial fracture, or acetabular with nutritional secondary hyperparathyroidism
fracture) usually aligns the ischial fracture as well. caused by eating a diet low in calcium or high in
However, in rare cases, the ischial tuberosity is phosphorus (as in all-meat diets) (150). In some

147 148

147 Repair of ischial fractures. The displaced ischial 148 Repair of pubic fractures and pubic symphyseal
fragment is reduced and stabilized using a tension band separations. Pubic fractures rarely require internal fixation,
wire fixation or two interfragmentary Kirschner wires. but they may be stabilized using interfragmentary cerclage
wires anchored through holes drilled in the bone.
Fractures and disorders of the hindlimb
181
149

A B
149 Radiographs of a pelvic malunion fracture involving the left ilium and acetabulum. Radiographic signs of
osteoarthritis are present in the left coxofemoral joint.A Ventrodorsal view. B Lateral view.

150 Treatment of pelvic canal 150


narrowing with pubic
symphysiotomy. A Ventrodorsal
radiographic view of the pelvis from a
jaguar with nutritional secondary
hyperparathyroidism. The pelvic canal
is collapsed causing obstipation. A
folding fracture of the right femur is
evident. B Surgical correction of the
pelvic collapse with pubic
symphysiotomy (intraoperative view).
A piece of high-density polyethylene
is wired to each half of the separated
A B C
symphysis to widen the pelvic canal
permanently. C Postoperative,
ventrodorsal radiographic view of the
pelvis after surgical correction of the
pelvic collapse. D Ventrodorsal
radiographic view of the pelvis from a
cat with pelvic canal narrowing
resulting from fracture malunion.
E Postoperative radiograph of the cat
after symphysiotomy and insertion of
a cortical bone autograft to widen the
pelvic canal. F Diagram depicting
symphysiotomy and placement of a
cortical autograft from the ulna or
D E F
ilium for treatment of pelvic collapse.
182

cases, stool softeners, proper diet, and occasional maintain separation17,26. Alternatively, a piece of
enemas may resolve the clinical signs. However, if sterile high-density polyethylene can be placed within
signs are persistent or recur frequently, surgical the symphysis and secured with wires (150)27.
intervention to widen the pelvic canal is indicated.
Widening the pelvic canal may not return defecation PARTIAL PELVECTOMY
to normal in cats with neurologic deficits, idiopathic A rectal examination is performed to ascertain the
megacolon, or where signs of obstipation have been location and volume of bone that must be removed
present for more than 6 months14. In these cases, to enlarge the pelvic canal. In most cases, portions
subtotal colectomy is recommended12. of the pubis and ischium are resected, leaving the
Splitting and separating the pubic symphysis, acetabula, ilia, and sacroiliac joints intact if possible
partial pelvectomy, and corrective ostectomy (151). Bilateral resection may be performed if
procedures can widen the pelvic canal in cats with necessary. Alternative procedures (symphysiotomy
obstipation secondary to pelvic malunion. In many and pelvic ostectomy) should be considered if repair
cases, continued medical therapy is required after of the collapsed pelvis requires removal of the
surgery. acetabulum and ilium, since resection of these
structures would necessitate concurrent limb
PUBIC SYMPHYSIOTOMY amputation.
A ventral approach is performed and an osteotome or The cat is positioned in lateral recumbency and
saw is used to separate the two halves of the pubis. a hanging-limb preparation is used to allow access to
Retractors are used carefully to spread the symphysis the entire hindlimb during surgery. A urethral
and widen the pelvic canal. The sacroiliac joints limit catheter is placed to facilitate identification and avoid
the amount of separation achieved by splitting the injury to the urethra during surgery. A purse-string
pubic symphysis. A cortical graft from the ilium or an suture is placed in the anus to reduce contamination
ulnar autograft can be collected and wired into place of the surgical site. Antibiotics (cefoxitin, 10 mg/kg)
between the two halves of the pubic symphysis to are administered intravenously before surgery and

151

A B C

151 Surgical treatment of pelvic malunion.


A Malunion of pelvic fractures causing narrowing of the pelvic canal.
B Partial pelvectomy. Portions of the pubis and ischium are excised.
C Pelvic ostectomy. An ostectomy is made in the body of the ilium and the pubis and ischium are either osteotomized or
partially resected. The acetabular segment is displaced laterally and stabilized with a bone plate.
Fractures and disorders of the hindlimb
183

every 2 hours during the procedure28. The portion of PELVIC OSTECTOMY


the pelvis to be resected is exposed, using caution to Pelvic ostectomy techniques may be performed alone
protect neurovascular structures. Hemostasis is or in conjunction with partial pelvectomy to widen
achieved with electrocautery and vessel ligation as the pelvic canal14,29. An ostectomy is made in the
needed. The soft tissues are carefully elevated from the body of the ilium and the pubis and ischium are either
bone with a periosteal elevator. The bone is removed osteotomized or partially resected. The resultant free
with a saw, rongeur, or osteotome and mallet. The acetabular segment is displaced laterally and stabilized
soft tissues are anatomically apposed to eliminate with a bone plate (151). Care is taken to protect the
dead-space. Closed suction drains may be placed sciatic nerve during the procedure. An ostectomy may
during surgery if necessary and are removed 24 hours be performed bilaterally if necessary to widen the
after surgery or when drainage is minimal28. pelvis adequately.
184

PART 2: COXOFEMORAL JOINT

COXOFEMORAL LUXATION CLINICAL SIGNS


CAUSE AND PATHOGENESIS Cats with coxofemoral luxations often present with a
The coxofemoral joint is a diarthrodial articulation history of observed or suspected trauma. A thorough
between the femoral head and acetabulum (152). It is physical examination is needed to confirm the hip
the most commonly luxated joint in cats. Luxations are luxation and identify concurrent trauma-related
generally a result of trauma and result in obvious injuries. The clinical findings in cats with coxofemoral
mechanical dysfunction. The majority of hip luxations luxation may include:
are craniodorsal (153). Ventral and caudal luxations • Pain in the hip region.
occur infrequently, and may be accompanied by • Lameness (usually nonweight-bearing initially).
avulsion fracture of the greater trochanter1. Articular • External rotation and adduction of the affected
cartilage damage may result from the initial trauma to limb.
the joint and from lack of lubrication and nourishment • Asymmetry of the hips due to displacement of the
normally provided by the synovial fluid. trochanter.

152 152 Feline coxofemoral joint.


(Photograph courtesy of Tom
Thompson.)

153 153 Radiographs of


coxofemoral luxation.
A Ventrodorsal view.
B Lateral view.

A B
Fractures and disorders of the hindlimb
185

• Increased distance between the greater trochanter coaptation or internal stabilization. Stability may not be
and tuber ischii. possible in dysplastic joints.
• Apparent shortening of the affected limb with
craniodorsal luxations. Closed reduction and stabilization
• Crepitus in the hip joint. Closed reduction is usually successful if performed in the
• Palpable laxity of the coxofemoral joint. This is first few days after luxation. The cat is placed under
best evaluated by placing a thumb in the ischiatic general anesthesia to relax muscles and eliminate pain
notch between the greater tochanter and ischial during hip manipulation. The cat is positioned in lateral
tuberosity. External rotation of the femur will not recumbency with the luxated limb uppermost. An
displace the thumb from the notch. This technique assistant places a small towel or rope in the cat’s inguinal
is also valuable for assessing the joint after closed area beneath the luxated hip to provide countertraction
reduction. With the femoral head seated in the and stabilize the pelvis during reduction. Initially, in
acetabulum, the thumb will be displaced from the cases of craniodorsal luxation, the femoral head is
ischiatic notch with external rotation of the femur. disengaged from the dorsal acetabluar rim by grasping
the hock and stifle and externally rotating the limb. The
DIAGNOSIS limb is then pulled distally and caudally to align the
Radiographic evaluation of the hip is required femoral head over the acetabulum. The limb is then
to confirm the luxation, determine the direction of internally rotated and abducted to reduce the joint.
the luxation, and evaluate for other abnormalities Digital pressure applied to the greater trochanter is
(acetabular fractures, femoral neck fractures, slipped helpful in directing the femoral head into the
capital physis, hip dysplasia). acetabulum. Alternatively, the limb may be internally
rotated and pulled distally while the femoral head is
TREATMENT AND PROGNOSIS guided into the acetabulum by pressure on the greater
Conservative treatment trochanter. Once the joint is reduced, medial pressure is
Conservative treatment of coxofemoral luxation can applied to the trochanter as the limb is manipulated
be successful in some cats2. Without reduction, through a full range of motion. This removes blood
a pseudoarthrosis may develop between the luxated clots, joint capsule, and other soft tissues from the
femoral head and the caudal ilium, allowing limited, acetabulum. The stability of the joint is also assessed
pain-free function. However, reduction and stabilization during this manipulation. Reduction is confirmed by
of the joint are recommended in cats that fail to bear radiography.
weight on the limb within 4–5 days of injury. Chronic After closed reduction, a nonweight-bearing sling
lameness often develops if the cats have not shown (Ehmer sling) is applied to maintain reduction
consistent improvement within the first 2 weeks. (154)2,4. Radiographs are obtained after the sling is

Reduction and stabilization


Closed or open reduction and stabilization of the 154
luxated joint are preferred in most cases. Joint
reduction should be performed soon after injury to
minimize destruction of cartilage and before muscle
spasticity and fibrosis prevent easy relocation. However,
diagnosis and management of concurrent injuries may
take precedence. Shock therapy, supportive care, and a
thorough evaluation (including thoracic radiographs)
should be performed in cats that have sustained recent
trauma. In most cases, closed reduction is attempted
first. Open (surgical) reduction is indicated if acetabular
or femoral head fractures are present, the joint reluxates
after closed reduction and internal stabilization is
required, other injuries require immediate return of hip
function, or if the luxation is chronic and visual 154 Ehmer sling applied to immobilize the limb after
evaluation of the cartilage is necessary3. After closed reduction of a craniodorsal coxofemoral luxation.
reduction, the hip joint is generally immobilized to The sling prevents weight bearing and internally rotates
maintain reduction. This may be achieved by external the femur to maximize stability of the hip joint.
186

applied to ensure the joint is still reduced. The sling is after closure (dorsal approach). Once the joint is
required for 10–14 days, until the joint capsule and reduced, stabilization techniques are used, alone or in
periarticular soft tissues are sufficiently healed to combination, to provide joint stability while the joint
maintain reduction. The sling must be monitored capsule and periarticular soft tissues heal. Open
closely for complications such as slipping, reluxation, techniques useful for stabilization of coxofemoral
and soft tissue trauma. Some cats are intolerant of luxation in cats include:
Ehmer slings. • Capsulorraphy. A craniolateral or dorsal
The insertion of an ischioilial pin (DeVita pin) has approach to the hip is performed and the torn
also been used to stabilize the hip joint after closed joint capsule is sutured to provide joint stability
reduction5. A Steinmann pin is placed from ventral to (155)8. Monofilament, nonabsorbable sutures
the ischium, over the femoral head, and imbedded in (2–0) are placed in a mattress or cruciate
the wing of the ilium. Unfortunately, the ilial wing in pattern. An Ehmer sling may be applied for
cats is relatively flat, making it difficult adequately to 10–14 days postoperatively to protect the
seat the pin cranially1. As a result, complications repair. Alternative methods will be required if
occur frequently and include pin migration, reluxa- the joint capsule is severely damaged or torn
tion, sciatic nerve injury, and damage to the femoral from its attachment to the femur or
head6. acetabulum.
Reluxation occurs in over 50% of cases after closed • Prosthetic capsule replacement9–11. Prosthetic
reduction7. If the joint remains unstable or reluxation capsule replacement is performed through a
occurs, open techniques or femoral head and neck craniolateral or dorsal approach to the hip
excision arthroplasty are indicated. joint8,9–12. If the joint capsule is damaged or
avulsed from the acetabulm, two bone screws
Open reduction and stabilization (2.0 mm or 2.7 mm screws with washers) are
Open methods of reduction allow exploration of joint, placed in the dorsal acetabular rim at
removal of soft tissue entrapped in the acetabulum, approximately the 10 o’clock and 1 o’clock
and internal stabilization. The success rate after open positions for the left hip (or 11 o’clock and
reduction and stabilization (approximately 85%) is 2 o’clock for the right hip). The screws serve as
significantly greater than after closed reduction7. anchor points for suture attachment. A hole is
A craniolateral approach to the joint is usually also drilled through the femoral neck to anchor
sufficient; however, a trochanteric ostectomy can be sutures. Monofilament suture material is ‘woven’
performed to improve exposure and provide stability between the screw heads and the femoral neck

155

155 Capsulorraphy for stabilization of coxofemoral


luxations. A craniolateral approach to the hip is performed
and the torn joint capsule is sutured with monofilament,
nonabsorbable sutures in a mattress or cruciate pattern.
Fractures and disorders of the hindlimb
187

to create a ‘web’ over the joint and prevent • Transposition of the greater trochanter.
reluxation (156). The sutures are tightened while Ostectomy of the greater trochanter improves
the limb is held in a weight-bearing position with exposure to the joint for capsulorraphy or
slight abduction and internal rotation. The limb prosthetic capsule placement12. When closing
may be placed in an Ehmer sling after surgery; the incision, the trochanter is simply transposed
however, the stability is generally adequate to approximately 1 cm distally and caudally. This
allow the cat to walk on the limb if needed. This transposition of the trochanter provides
technique has been very successful in maintaining ancillary stabilization by increasing the medial
joint reduction and has few complications when pull of the gluteal muscles and abducting and
performed properly. Complications may include internally rotating the femur. The trochanter is
damage to the articular cartilage by the suture, reattached with a tension band wire fixation or
reluxation through the ‘web’, and infection. a lag screw (157).

156 Prosthetic capsule replacement for stabilization of 156


coxofemoral luxations. A craniolateral or dorsal approach
to the hip joint is performed and two screws with washers
are inserted into the dorsal acetabular rim at approximately
the 10 o’clock and 1 o’clock positions for the left hip (or
11 o’clock and 2 o’clock for the right hip). A hole is
drilled through the femoral neck and monofilament suture
material is woven between the screw heads and the
femoral neck to prevent reluxation.

157 Transposition of the greater trochanter for 157


stabilization of coxofemoral luxations. The greater
trochanter is moved 1 cm distally and caudally and
re-attached with a tension band fixation or lag screw.
188

• Transarticular pinning. A small Steinmann pin or following pin removal. Complications of


Kirschner wire (1.6–2.0 mm diameter) is transarticular pinning include pin migration,
inserted through the femoral head and neck into perforation of the rectum, pin bending or
the acetabulum to provide joint stability (158)13. breakage, and osteoarthritis3,14.
Typically, the pin is inserted in a retrograde • Toggle rod fixation. This allows early use of the
fashion, starting at the fovea capitis and exiting limb after surgery, which may be necessary if
near the third trochanter. The joint is then injury to the opposite hindlimb is present15.
reduced and the limb is held in a weight-bearing A dorsal approach to the hip joint with
position with slight abduction while the pin is ostectomy of the greater trochanter is the
driven through the acetabular wall into the preferred approach. However, the technique
pelvic canal. An assistant evaluates pin depth by may also be performed through a craniolateral
rectal examination. The lateral portion of the approach to the hip. A hole is drilled through
pin is then bent over and cut short. Enough pin the femoral head and neck from the fovea capitis
length is left to allow later removal. A to the region of the third trochanter. A second
capsulorraphy is performed if possible and the hole is drilled in the center of the acetabular
incision is closed routinely. An Ehmer sling can fossa (penetrating the medial acetabular wall)
be applied after surgery but is not essential. The large enough to accommodate the toggle rod.
sling if applied is removed after 10 days and the (Securos Veterinary Orthopedics Inc.; IMEX
pin is removed after 2–3 weeks. The cat’s Veterinary Inc.) One or two strands of suture
activity is restricted for an additional 4 weeks material are then inserted through the hole in

158

A B

C D

158 Transarticular pinning for stabilization of coxofemoral luxations.


A A 1.6–2.0 mm diameter pin is inserted retrograde, starting at the fovea capitis and exiting near the third
trochanter. The pin is advanced until the tip is at the level of the femoral head.
B The joint is reduced and the limb is held in a weight-bearing position with slight abduction while the pin
is driven through the acetabular wall into the pelvic canal.
C The lateral end of the pin is bent over and cut short, leaving enough pin length to allow later removal.
D Ventrodorsal radiographic view of the hip joint in a cat. The craniodorsal hip luxation is stabilized with a
transarticular pin.
Fractures and disorders of the hindlimb
189

the center of the toggle rod. The suture may be performed and the greater trochanter is
attached to the toggle rod by inserting a loop of reattached using a tension band wire fixation.
suture through the hole in its center and then The suture material within the joint, which
placing the ends of the suture back through the maintains reduction until the periarticular soft
loop to lock the suture in place15. The toggle tissues are healed, eventually becomes
rod is then inserted through the hole drilled in encapsulated in the regenerating round
the acetabulum. By pulling on the ends of the ligament. A potential complication of toggle rod
sutures, the toggle rod is positioned against the fixation is premature suture breakage and joint
medial acetabular wall and cannot pass back reluxation.
through the hole. The free ends of the sutures • Fascia lata loop stabilization. This technique is
are then passed through the bone tunnel in the similar to toggle rod fixation in many ways,
femoral head and neck, exiting near the third except that the fasica lata is used rather than
trochanter. The sutures are secured to the femur suture material16. A caudolateral approach to
by drilling another hole through the lateral the hip joint is performed and a long strip of
femoral cortex. One end of the suture is passed facia lata (1 cm wide) is harvested. One end of
through the hole and the two ends are tied. the fascial strip is passed over the dorsal aspect
Alternatively, the suture can be tied to a sterile of the ilium and pulled into the acetabulum
button on the lateral aspect of the femur (159). (through a hole drilled in the acetabular fossa)
The sutures are tightened while the hip is held using a wire loop. Care is taken to protect the
in a reduced position. A capsulorraphy is sciatic nerve. The fascial strip is then passed

159

A B C

D E
159 Toggle rod fixation for stabilization of coxofemoral luxations.
A A hole is drilled through the femoral head and neck from the fovea capitis to the region of the third trochanter.
B A hole is drilled in the center of the acetabular fossa, penetrating the medial acetabular wall.
C Suture material is attached to the toggle rod and it is inserted through the hole in the acetabulum. The toggle rod is
positioned against the medial acetabular wall.
D The suture is then passed through the bone tunnel in the femoral head and neck, exiting near the third trochanter.
E The suture is secured on the lateral aspect of the femur either using a sterile button or by passing the suture through a
transverse hole drilled in the femoral cortex and tying the suture ends together.
190

through a tunnel drilled in the femoral head and A craniolateral approach to the hip joint is
neck starting at the fovea capitis and extending performed. Hematoma, remnants of the round
to the third trochanter. The luxation is reduced ligament, and other soft tissues are removed
and the two ends of the fascial strip are sutured from the acetabulum and the joint is reduced.
together near the trochanteric exit (160). A capsulorraphy is performed if possible. Using a
A capsulorraphy is performed and the incision is drill bit or Stenmann pin, a hole is drilled from
closed routinely. The cat’s activity is restricted lateral to medial in the ilium just cranial to the
for 6 weeks after surgery. External coaptation is acetabulum. A second hole is drilled from caudal
not required. Good results have been reported to cranial through the femur just distal to the
in two cats using this technique16. insertion of the gluteal muscles at the base of
• Extraarticular iliofemoral suture. Suturing the greater trochanter. A strand of large,
techniques have been described for stabilization monofilament suture material (0 polypropylene;
of hip luxations in cats (161 A)17,18. Prolene, Ethicon) is passed from lateral to medial

160 160 Fascia lata loop stabilization of coxofemoral


luxations. A strip of fascia lata is harvested and passed
over the dorsal aspect of the ilium, into the acetabulum
through a hole drilled in the acetabular fossa, and
through a tunnel in the femoral head and neck. The
luxation is reduced and the ends of the fascial strip are
sutured together over the lateral aspect of the femur.

161

B C
161 Coxofemoral luxation.
A Extraarticular iliofemoral suturing technique for stabilization of coxofemoral luxations. Holes are drilled from lateral to
medial in the ilium just cranial to the acetabulum and caudal to cranial through the femur at the base of the greater
trochanter. A strand of large, monofilament suture material is passed from lateral to medial through the hole in the ilium
and from cranial to caudal through the hole in the femur. The suture is then passed beneath the insertion of the gluteal
muscles on the trochanter and the ends are tied, with the hip joint internally rotated and abducted.
B Lateral radiograph of the pelvis of a cat with coxofemoral luxation and concomitant fracture of the femoral head.
C Postoperative lateral radiograph of the same patient showing total hip replacement using the BioMedtrix CFXTM Micro
hip system.
Fractures and disorders of the hindlimb
191

through the hole in the ilium. A curved Femoral head and neck excision arthroplasty
hemostat is placed under the ventral edge of the Surgical removal of the femoral head and neck is
ilial body to grasp the suture and bring it to the indicated for treatment of recurrent hip luxations,
lateral side of the ilium. The suture is then severe fractures of the acetabulum or femoral head
passed from cranial to caudal through the hole in and neck, and coxofemoral osteoarthritis19 (see
the femur. The suture is then passed from caudal Femoral head and neck excision arthroplasty
to cranial beneath the insertion of the gluteal for acetabular fractures). It may also be used as a
muscles on the trochanter using a hemostat or primary means of treating coxofemoral luxation in
straight needle. The joint is internally rotated cats. The procedure is completed through a
and abducted and the suture is tied18. To avoid craniolateral approach as previously described
drilling holes in the ilium and femur, an (144, 145). The prognosis after excision arthro-
alternative method of placing the suture has been plasty in the cat with coxofemoral luxation is
described17. Cranially, the suture is anchored in good20,21. Most cats will walk well within 5 weeks
the tendon of origin of the psoas minor muscle; and return to function within 5 months of
and caudally it is attached to the tendon of surgery1,21.
insertion of the middle gluteal muscle. After
manipulating the joint to ensure stability, the HIP DYSPLASIA
incision is closed. A nonweight-bearing sling is Hip dysplasia is much less common in cats than
applied for 7–10 days and the cat’s activity is in dogs, although the actual incidence is undeter-
restricted for 6 weeks. mined. The Orthopedic Foundation for Animals
reports that hip dysplasia is present in approximately
After open reduction and stabilization of a 18% of Maine coon cats. It is a congenital disease that
coxofemoral luxation, the limb can be placed in usually affects both hip joints and may lead to pain
a nonweight-bearing sling (Ehmer or figure-of-eight) and osteoarthritis. It occurs more commonly in female
for 7–14 days if tolerated by the cat. The sling must and purebred cats, though it has been reported in a
be monitored closely for complications. Many of the litter of domestic shorthair cats2,22–24.
internal stabilization techniques can be used without Some cats with hip dysplasia show no clinical signs.
external coaptation if early postoperative use of However, others present with hindlimb weakness,
the surgically treated joint is required. Exercise is reluctance to walk, or hip pain. The diagnosis of hip
restricted for 4–6 weeks after surgery. The prognosis dysplasia is based on radiographic findings of hip joint
after coxofemoral luxation is good if reduction and laxity, shallow acetabula, and mild remodeling of the
stability are achieved soon after injury. Osteoarthritis craniodorsal acetabular margin. Remodeling of the
is possible due to injury of the articular cartilage at the femoral neck, often seen in dysplastic dogs, is
time of luxation or surgical repair. Total hip uncommon in cats22,23,25–28. Hip joint laxity
replacement or femoral head and neck excision should is associated with the development of osteoarthritis
be considered if closed and open techniques are and may be confirmed using distraction radiography
unsuccessful, or if severe femoral head damage is or measurement of the Norberg angle from the hip-
present. These procedures may also be used as the extended ventrodorsal radiographic view. The mean
primary treatment method for hip luxations in cats. Norberg angle in normal cats is 92.4°28.
In most cases, cats with clinical signs of hip
Total hip replacement dysplasia are treated with cage rest for 2–3 weeks.
Total hip replacement can now be performed on most Long-term medical management with the non-
cats greater than 4 kg body weight as an alternative to steroidal antiinflammatory drug (NSAID),
femoral head and neck ostectomy, using a modular meloxicam, can be used but is rarely indicated. Total
cemented prosthesis (BioMedtrix CFX™ Micro hip hip replacement or femoral head and neck excision
system) (161 B, C). Indications include coxofemoral arthroplasty can be performed if clinical signs persist
osteoarthritis, luxation that cannot be maintained after conservative therapy2.
using closed or open procedures, fractures of the
femoral head and neck that are not amenable to
surgical repair, and malunions.
192

PART 3: FEMORAL AND PATELLAR FRACTURES

Femoral fractures occur commonly in cats and are difficult since the bone fragments are usually very
readily diagnosed by palpation and radiography. In small and visualization of the fragment is impossible
almost all cases, surgical intervention is indicated to when the femoral head is placed into the acetabulum.
reduce the fracture properly and provide stability. Consequently, confirming proper reduction of the
fracture is difficult unless intraoperative imaging is
PROXIMAL FEMORAL FRACTURES available. It is important that the implants do not
FEMORAL HEAD FRACTURES penetrate the articular surface of the hip joint. This is
Cause and pathogenesis checked by carefully manipulating the joint and by
Fractures of the femoral head are typically avulsion palpating the joint surface with a smooth hemostat or
fractures. A fragment of bone attached to the ligament periosteal elevator.
of the head of the femur remains within the joint An alternative method involves excising the
space while the remaining portion of the femoral head fragment from its attachment on the round ligament
is luxated craniodorsally. and then anchoring it to the femoral head with
Kirschner wires or a 2.0 mm lag screw placed from
Treatment and prognosis the articular surface into the femoral neck. This
Treatment of femoral head fractures is achieved by method allows visualization of the fragment, assures
reattaching the fragment with Kirschner wires or proper reduction, and allows the implants to
a screw, by removing the bone fragment, or by be countersunk below the articular surface. When
femoral head and neck excision arthroplasty1. possible, the implants are placed in the fovea capitis
and countersunk to reduce damage to the cartilage.
Kirschner wire/screw fixation The femoral head is then reduced into the acetabulum
If the avulsed fragment of bone from the femoral head and the joint capsule sutured to provide stability.
is sufficiently large, it can be re-attached using Complications after internal fixation of femoral
Kirschner wires or a small screw placed in lag fashion head fractures can include implant migration into
(162). This may be accomplished by placing the the joint, implant migration leading to fixation
implants from just distal to the greater trochanter, failure, avascular necrosis of the femoral head,
through the femoral neck, and into the avulsed bone. recurrent coxofemoral luxation, and osteoarthritis of
Unfortunately, placing the implants in this manner is the joint.

162

A B C D

162 Stabilization of femoral head fractures.


A Avulsion fracture of the femoral head. The avulsed fragment typically remains in the acetabulum, attached to the
ligament of the head of the femur.
B The fragment is re-attached with Kirschner wires or a screw placed from just distal to the greater trochanter, through
the femoral neck, and into the avulsed bone.
C The fragment is attached with Kirschner wires inserted from the articular surface into the femoral neck. The wires are
placed in the fovea capitis and countersunk to reduce damage to the cartilage.
D If the fracture configuration permits, a 2.0 mm screw may be placed in lag fashion to compress the fracture.
Fractures and disorders of the hindlimb
193

Fragment excision 163


If the avulsed fragment is too small to allow fixation,
it is simply excised. The femoral head is then reduced
and stabilized. Since the fragment is small and
typically involves the region of cartilage surrounding
the fovea capitis, hip joint function is generally good,
although osteoarthritis may develop over time.

Femoral head and neck excision arthroplasty


Femoral head and neck excision arthroplasty is
performed if damage to the femoral head is severe
(see 145). The prognosis after femoral head and neck
excision arthroplasty is very good and it is often
recommended as the procedure of choice for fractures
of the femoral head in cats.

SEPARATIONOF THE PROXIMAL FEMORAL


GROWTH PLATE
Cause and pathogenesis
Separation of the proximal femoral growth plate
occurs uncommonly in immature cats, usually as
a result of trauma. Most are Salter–Harris type
I fractures in which the separation occurs along the
physeal line (163)2. This injury is also referred to as a
capital fracture or a slipped capital epiphysis. 163 Ventrodorsal radiographic view of a separation
Spontaneous femoral capital physeal fractures have (Salter–Harris type I fracture) of the proximal
also been described in adult cats, typically in heavier, femoral growth plate. This injury is also referred to
neutered males with delayed physeal closure3. as a capital fracture or a slipped capital epiphysis.

Diagnosis
In most cases of proximal femoral growth plate
separation, the epiphysis (femoral capitis) remains within osteoarthritis may develop over time. If the epiphysis
the joint space while the femoral neck is displaced becomes more displaced or limb function is not
craniodorsally. Occasionally, displacement at the physis is satisfactory, internal fixation or excision arthroplasty
minimal and careful examination of the radiographs or is indicated.
additional frog-limb and extended views, is required to
confirm the fracture. The ligament of the head of the Total hip replacement
femur is purported to provide significant blood supply Total hip replacement is indicated for femoral head
to the femoral capital epiphysis4. fractures that are not amenable to surgical repair. The
prognosis is likely to be excellent.
Treatment and prognosis
Treatment of proximal femoral growth plate fractures Femoral head and neck excision arthroplasty
is by conservative therapy, femoral head and neck Removal of the femoral head and neck is commonly
excision arthroplasty, or internal fixation using performed for separation of the proximal femoral
multiple Kirschner wires1,4,5. growth plate (see 145). The prognosis is fair to good
and complications are few.
Conservative therapy
Some cats will return to adequate function without Kirschner wire/screw fixation
surgical treatment, particularly when displacement of If surgical stabilization is elected, it may be achieved
the epiphysis is minimal. Activity is restricted and the using three Kirschner wires1,5,6. A craniolateral
fracture is monitored radiographically. The hip may approach to the hip joint is performed to visualize the
function normally if the epiphysis heals in an fracture site. The Kirschner wires are inserted from just
anatomic or near-anatomic position, although distal to the greater trochanter and advanced through
194

the femoral neck until they are visualized at the physis femoral neck. The Kirschner wires are then advanced
(164). Alternatively, they may be placed in a retrograde into the epiphysis to provide stability. The joint is
fashion starting at the physis and exiting the lateral manipulated through a range of motion and the
femoral cortex distal to the greater trochanter. The articular surface is palpated with a smooth periosteal
Kirschner wires may be positioned such that they are elevator to ensure the wires do not penetrate the
divergent or parallel to each other. The fracture is then cartilage of the epiphysis. The Kirschner wires are bent
reduced by manipulation of the femur, ensuring that against the lateral femoral cortex to reduce soft tissue
the epiphysis is properly positioned relative to the trauma and prevent migration.

164

A B C

D E F

164 Stabilization of proximal femoral growth plate separations (slipped capital epiphysis).
A Salter–Harris type I fracture of the proximal femoral growth plate. The fracture occurs along the physis.
B Repair using Kirschner wires. Three Kirschner wires are inserted from the greater trochanter and through the femoral
neck to the physis.
C The fracture is reduced and the Kirschner wires are advanced into the epiphysis. Care is taken to ensure they do not
penetrate the articular surface.
D A screw and single Kirschner wire inserted through the femoral neck into the epiphysis.
E Small screws inserted through the articular surface into the femoral neck. The screw heads are countersunk to reduce
joint trauma.
F Craniocaudal radiographic view of a proximal femoral growth plate separation stabilized with three Kirschner wires.
(Radiograph courtesy of Dr. Mark Rochet.)
Fractures and disorders of the hindlimb
195

Alternatively, a screw may be inserted rather than should be obtained with the femur in several positions
Kirschner wires. A single Kirschner wire is placed to determine if the fracture site is stable before selecting
parallel to the screw to prevent rotation. Implantation conservative treatment. Hip-extended views and ‘frog-
of screws from the articular surface into the femoral limbed’ views are useful. If the fracture becomes
neck has also been described. The screw heads must displaced or fails to heal, internal fixation or femoral
be countersunk below the cartilage surface to reduce head and neck excision arthroplasty is indicated.
joint trauma. After fixation, the joint capsule is
sutured with 3-0 or 4-0 monofilament suture material Total hip replacement
and the incision is closed routinely. Postoperative care Total hip replacement is indicated for femoral neck
should include restricted activity for 3–4 weeks. fractures that are not amenable to surgical repair. The
prognosis is likely to be excellent.
FEMORAL NECK FRACTURES
Cause and pathogenesis Femoral head and neck excision arthroplasty
Fractures of the femoral neck are often the result of Femoral head and neck excision arthroplasty is often
trauma and may occur alone or in conjunction performed for unstable fractures of the femoral neck
with other fractures in the cat7. Pathologic femoral (see 145). It is considered by many to be the
neck fractures may occur secondary to metaphyseal treatment of choice for these fractures in the cat.
osteopathy or feline capital physeal dysplasia
(see Chapter 13)8–10. Kirschner wire or screw fixation
A craniolateral approach to the hip joint is performed.
Treatment and prognosis Reduction is achieved by manipulating the greater
Treatment of pathologic fractures is by total hip trochanter with a bone clamp until the fractured
replacement or femoral head and neck excision femoral neck is aligned. A Kirschner wire is then
arthroplasty. Treatment of traumatic femoral neck inserted across the fracture line to maintain reduction
fractures may be by conservative therapy, total hip while the remaining implants are placed. Multiple
replacement, femoral head and neck excision arthroplasty, Kirschner wires are inserted normograde across the
or internal fixation using Kirschner wires or screws. fracture starting from the lateral femoral cortex distal
to the greater trochanter (165)5. The wires are
Conservative therapy inserted into the femoral head without penetrating
Incomplete and nondisplaced fractures of the femoral the articular surface. They are cut and bent over
neck may be treated by immobilization of the limb and against the lateral cortex of the femur to reduce
restriction of activity for 4 weeks. Radiographs of the hip muscle trauma and prevent migration.

165 Radiographs of a femoral neck fracture. 165


A Ventrodorsal view of a right femoral neck
fracture.
B Postoperative ventrodorsal view showing
stabilization of the femoral neck fracture with
multiple Kirschner wires.

A B
196

Alternatively, a 2.7 mm cortical bone screw can be should not penetrate the articular surface of the
placed in lag fashion through the femoral neck and femoral head. The hole is measured and tapped and
into the femoral head. This is achieved by first drilling the proper length screw is inserted. Care is taken not
a glide hole (2.7 mm) from the base of the greater to overtighten the screw. A Kirschner wire is inserted
trochanter to the fracture line. A drill sleeve is across the fracture parallel to the screw to prevent
inserted into the glide hole to allow drilling of a rotation (166). Postoperatively, the limb is placed in
thread hole (2.0 mm) in the center of the femoral a nonweight-bearing sling for 7–10 days and the cat’s
head proximal to the fracture line. The drill bit activity is restricted for 4 weeks.

166

A B C D

166 Stabilization of femoral neck fractures.


A Multiple Kirschner wires are inserted normograde across the fracture starting from the lateral femoral cortex distal to
the greater trochanter. The wires are inserted into the femoral head without penetrating the articular surface and are bent
over to reduce muscle trauma and prevent migration.
B A 2.7 mm cortical bone screw is placed in lag fashion through the femoral neck and into the femoral head. First,
a 2.7 mm glide hole is drilled from the base of the greater trochanter to the fracture line.
C The fracture is reduced and a Kirschner wire is placed to maintain reduction. A drill sleeve is inserted into the glide hole
and a 2.0 mm thread hole is drilled proximal to the fracture line.
D A screw is inserted to compress the fracture line. The Kirschner wire prevents rotation around the screw.

167 167 Radiographs of a fracture of the


greater trochanter.
A Lateral view of the proximal femur.
The greater trochanter is fractured and
displaced. The coxofemoral joint is luxated.
B Postoperative ventrodorsal view. The
coxofemoral joint was reduced. The
displaced greater trochanter was reduced
and stabilized with two divergent
Kirschner wires.

A B
Fractures and disorders of the hindlimb
197

GREATER TROCHANTERIC FRACTURES cortex of the femur. A second screw or Kirschner wire
Cause and pathogenesis is placed to prevent rotation around the screw.
Avulsion fracture of the greater trochanter may occur
with or without luxation of the coxofemoral joint or Tension band wire fixation
separation of the proximal femoral physis. Two parallel Kirschner wires (1–1.6 mm) are inserted
from proximal to distal across the fracture line and
Treatment and prognosis into the medullary cavity of the femur. Compression
Open reduction and internal stabilization are the is achieved by placing a figure-of-eight orthopedic
preferred treatment (167, 168). The fracture is wire around the proximal portion of the Kirschner
reduced through a lateral surgical approach over the wires and through a hole drilled transversely across the
trochanter. The hip joint is not exposed unless an femur distal to the trochanter. The wire is twisted
open reduction of a coxofemoral luxation or repair of until tight and the proximal tips of the Kirschner wires
a slipped capital epiphysis is required. The greater are bent over and cut short.
trochanter is reduced and temporarily stabilized with
reduction forceps. Permanent fixation is achieved by Kirschner wire fixation
inserting a screw in lag fashion, tension band wire With the trochanter reduced, two or three Kirschner
fixation, or multiple Kirschner wires. wires (1.1–1.6 mm) are inserted from proximal to
distal through the trochanter and into the femur.
Lag screw fixation The wires should be placed at various angles rather
A 2.7 mm bone screw is placed in lag fashion from the than parallel to each other. They should engage the
trochanter to the femoral shaft. The glide hole medial femoral cortex, although care is taken not to
(2.7 mm) is placed in the trochanter and the thread penetrate the cortex excessively and traumatize tissue
hole (2.0mm) is placed in the femoral metaphysis. The on the medial aspect of the femur. The proximal
screw should be sufficiently long to engage the medial ends of the wires are bent over and cut short.

168

A B C D
168 Stabilization of greater trochanteric fractures.
A Avulsion fracture of the greater trochanter.
B Lag screw fixation. A 2.7 mm lag screw is inserted from the trochanter to
the femoral shaft. A 2.7 mm glide hole is drilled in the trochanter and a
2.0 mm thread hole is drilled in the femoral metaphysis. A Kirschner wire
is placed to prevent rotation around the screw.
C Tension band wire fixation. Two Kirschner wires are inserted across the
fracture line and into the medullary cavity of the femur. A figure-of-eight
wire is placed around the exposed ends of the Kirschner wires and through
a hole drilled transversely across the femur. The Kirschner wires are bent
over and cut short.
D Kirschner wire fixation. Two or three Kirschner wires are inserted at
divergent angles through the trochanter and into the femur, engaging the
medial femoral cortex. The ends of the wires are bent over and cut short.
198

INTERTROCHANTERIC FRACTURES ineffective since it is extremely difficult adequately to


Intertrochanteric fractures of the proximal femur immobilize the femur with casts or splints. Femoral
are typically stabilized with a combination of fractures treated with external coaptation alone may
intramedullary pinning and tension band wire fail to heal or heal in a malunion (170).
fixation (169). The fracture is reduced and two The femoral diaphysis is visualized through a lateral
Steinmann pins are inserted normograde through the surgical approach (171)11. An incision is made through
greater trochanter into the femoral medullary cavity. the skin and subcutaneous tissue over the craniolateral
The pins may be placed parallel to each other or as border of the femur from the greater trochanter to the
dynamic intramedullary cross-pins (Rush pins). A patella. The fascia lata is incised along the cranial edges
tension band wire is then placed around the exposed of the biceps femoris muscle and the biceps is retracted
proximal ends of the intramedullary pins and through caudally to expose the femur. The aponeurotic septum
a hole drilled transversely across the femur distal to on the lateral surface of the femur is incised to allow
the fracture site. cranial retraction of the vastus lateralis muscle. The
sartorius muscle is undivided in the cat (unlike the dog)
DIAPHYSEAL FEMORAL and may be encountered when performing a lateral
FRACTURES approach to the femur. Care is taken to preserve the soft
TREATMENT AND PROGNOSIS tissue attachments to the femur and bone fragments
Repair of fractures of the femoral diaphysis with open wherever possible during reduction.
or closed reduction and rigid stabilization is preferred Intramedullary pins and cerclage wires, external
in most cases. External coaptation is generally fixators, bone plates and screws, interlocking nails, or

169 170

A B
A B
169 Stabilization of intertrochanteric 170 Radiographs of a femoral malunion. Mild femoral shortening
fractures of the proximal femur. occurred as a result of the malunion.
A Two intramedullary pins are inserted A Lateral view.
normograde through the greater B Craniocaudal view.
trochanter into the femoral medullary
cavity. A tension band wire is placed.
B Alternatively, the pins may be placed
as dynamic intramedullary cross-pins
(Rush pins).
Fractures and disorders of the hindlimb
199

combinations of these methods can be applied with distally across the fracture and into the distal femur.
great success in stabilizing femoral diaphyseal fractures The pin is seated in the distal fragment without
in cats. entering the stifle joint. A second pin of identical
length can be used to measure how far distally the pin
Intramedullary pins and cerclage wires has been inserted. Radiographs are also used to
Placement of an intramedullary Steinmann pin confirm pin placement. The stifle joint is manipulated
is a very common method of stabilizing femoral through a range of motion to ensure the pin has not
fractures in cats12–14. The pin should be of a diameter penetrated the joint. Closed insertion of an
to fill 60–70% of the medullary cavity. Normograde intramedullary pin is possible if the fracture is
pin insertion is preferred because it allows proper minimally displaced or if adequate reduction of the
placement of the pin in the trochanteric fossa, may fragments can be achieved by palpation alone.
reduce the possibility of injury to the femoral head Excellent results can be achieved with closed pin
and sciatic nerve, and allows the pin to be cut short to insertion, particularly in young cats when the fracture
reduce trauma to the gluteal muscles and subsequent is repaired within 1–3 days15. However, swelling of
seroma formation (172). For normograde insertion, the soft tissues surrounding the femur and interpo-
the fracture is reduced and stabilized with bone sition of muscle between the fragments may prevent
clamps or cerclage wires (if they are to be used). The closed reduction in some cases.
pin is started at the medial aspect of the greater For retrograde insertion, the intramedullary pin is
trochanter (in the trochanteric fossa) and driven directed proximally from the fracture site before final

171 172
Biceps femoris muscle

Vastus
lateralis
muscle

A B C

171 Lateral approach to the femoral diaphysis. An 172 Normograde intramedullary pinning of the femur.
incision is made over the craniolateral border of the A, B A pin large enough to fill 60–70% of the medullary
femur from the greater trochanter to the patella. The cavity is selected. The pin is inserted at the medial aspect
fascia lata is incised along the cranial edges of the of the greater trochanter in the trochanteric fossa.
biceps femoris muscle and the biceps is retracted C The pin is driven distally across the fracture and seated
caudally. The aponeurotic septum on the lateral into the distal femoral segment.
surface of the femur is incised to allow cranial
retraction of the vastus lateralis muscle.
200

reduction of the fracture (173). It should be inserted Intramedullary pins are rarely used alone as they
along the lateral surface of the medullary cavity to avoid do not eliminate rotational forces at the fracture site.
injury to the femoral head and neck as the pin emerges Ancillary fixation with full cerclage wires or an
proximally16. The pin should exit the medullary cavity external fixator is often used to prevent rotation
at the trochanteric fossa. The proximal femur is held in (174). Application of cerclage wires is not feasible if
adduction and in a normal standing angle (or slightly the fracture is stabilized in a closed manner, but is
extended) so that the pin does not damage the sciatic easily performed during open fracture repair. An
nerve as it exits the proximal femur. The fracture is then external fixator can be applied to prevent rotation if
reduced and stabilized with a bone clamp. Cerclage closed or open pinning is used (175, 176). Stack
wires can be applied at this time if needed. The pin is pinning (placing several pins into the medullary
driven distally and seated into the distal fragment as cavity) does not completely prevent rotation but it has
described for normograde insertion. been used with success in cats17–20.

173 173 Retrograde intramedullary pinning of the femur.


A A pin large enough to fill 60–70% of the medullary cavity is selected. The
pin is inserted proximally from the fracture site and exits the medullary cavity
at the trochanteric fossa.
B The fracture is reduced and the pin is driven distally and seated into the
distal femur.

A B

174 174 Ancillary fixation with


intramedullary pins.
A Full cerclage wires.
B A type Ia acrylic fixator is
applied to prevent rotation
around the pin.
C A type Ia external fixator is
placed to prevent rotation and
collapse at the fracture site.
D A type Ia external fixator and
full cerclage wires for stabilization
of a comminuted femoral
fracture.
E Multiple intramedullary pins
A B C D E (stack pinning).
Fractures and disorders of the hindlimb
201

Bone plates and screws (tension surface) of the femur through a lateral
Bone plates are commonly used to stabilize femoral approach. DCPs and cuttable plates with 2.7 mm
fractures in cats and, when properly applied, are able cortical screws are commonly used. Limited-contact
to counteract all of the forces acting at the fracture dynamic compression plates (LC-DCP) with 2.4 mm
site20,21. They are easily applied to the lateral surface screws are also used for repair of femoral fractures.

175

A B C
175 Radiographs of a transverse, mid-diaphyseal femoral fracture stabilized with an intramedullary pin and type Ia
acrylic external fixator.
A Preoperative lateral view.
B Postoperative lateral view.
C Postoperative craniocaudal view.

176

A B C D
176 Radiographs of an oblique, distal diaphyseal femoral fracture stabilized with an intramedullary pin, full cerclage
wires, and a type I acrylic external fixator in a tie-in configuration.
A Preoperative lateral view.
B Preoperative craniocaudal view.
C 6-week postoperative lateral view.
D 6-week postoperative craniocaudal view. Fracture union is complete.
202

The screws should engage a minimum of five cortices Oblique fractures


on each side of the fracture line. Bone plates may The fracture is reduced. The plate may be applied
be applied to the femur to stabilize most fracture as described for transverse fractures but without
configurations (177). compression. Alternatively, a lag screw or cerclage
wires can be placed to compress the fracture line and
Transverse fractures maintain reduction while the plate is applied. If the
The fracture is reduced, ensuring proper angular and orientation of the oblique fracture line permits, one of
rotational alignment of the proximal and distal fracture the plate screws can be placed in lag fashion across the
segments. The linea aspera located along the caudal fracture line (177).
border of the femur is an excellent landmark for
ensuring proper rotational alignment. The plate is Comminuted fractures
properly contoured and applied to the lateral femoral A bone plate can be applied in several ways to stabilize
cortex. In most diaphyseal fractures, sufficient room comminuted femoral fractures (179). When the area
exists proximally and distally to place a minimum of of comminution is small, the primary fragments
three screws on each side of the fracture line. A 2.7 mm are apposed as in a transverse fracture and the
DCP or 2.4 mm LC-DCP is commonly used. The oval comminuted fragments are used as autogenous graft.
holes in DCP plates allow the fracture line to be This results in only minor shortening of the femur and
compressed to enhance stability and promote healing. clinical function is normal.
Cuttable plates and tubular plates may also be used If the area of comminution is too large to permit
(178). Reconstruction plates (2.7 mm) may be useful shortening of the bone, the fragments may be
for stabilization of more distal diaphyseal fractures. reconstructed using cerclage wires or lag screws. The

177

A B C D E
177 Bone plate stabilization of transverse and oblique femoral fractures.
A A transverse fracture stabilized with a DCP to achieve compression across the fracture line. A minimum of three screws
is placed on each side of the fracture line.
B A 2.7 mm reconstruction plate is easily contoured to the curvature of the distal femur to stabilize distal diaphyseal
fractures.
C An oblique fracture stabilized with a lag screw and bone plate.
D An oblique fracture stabilized with full cerclage wires and a bone plate.
E An oblique fracture stabilized with a bone plate. The plate screw crossing the fracture line is placed in lag fashion.
Fractures and disorders of the hindlimb
203

178 Bone plate stabilization of a transverse 178


femoral fracture.
A Craniocaudal radiographic view of a transverse
femoral fracture.
B Postoperative craniocaudal view. The fracture
was stabilized with stacked cuttable plates. Two
full cerclage wires were placed on the distal
segment to compress a fissure fracture.

A B

179

A B C D E

179 Bone plate stabilization of comminuted femoral fractures.


A Comminuted diaphyseal femoral fracture.
B Stabilization with full cerclage wires and a neutralization plate.
C Stabilization with lag screws and a neutralization plate.
D Stabilization with a bridging (buttress) plate. Autogenous cancellous bone graft is placed in the defect.
E Stabilization with plate-rod fixation. An intramedullary pin is placed normograde in the medullary cavity to maintain
bone length and alignment. A plate is contoured and applied in buttress fashion on the lateral aspect of the femur. The
proximal and distal screws are bicortical. The remaining screws are monocortical. Suture material may be used gently to
move fragments into the fracture site if necessary.
204

plate is then applied in a neutralization function The plate can alternatively be applied in bridging
(180). This method provides anatomic reduction and (buttress) fashion to span the area of comminution
ensures load sharing between the plate and bone. (181). The proximal and distal fragments are
However, it requires manipulation of the fragments stabilized, leaving the comminuted fragments
and there may be interference with soft tissue undisturbed within the fracture gap. This preserves
attachments and blood supply.

180

A B

C D
180 Comminuted femoral fracture repaired with lag screws and stacked cuttable plates
applied in neutralization function.
A Preoperative craniocaudal view.
B Preoperative lateral view.
C Postoperative craniocaudal view.
D Postoperative lateral view.
Fractures and disorders of the hindlimb
205

soft tissue attachments and blood supply, but cancellous bone graft is placed in the defect to
also requires the plate to bear additional load until promote healing23.
healing occurs. The fracture heals by callus forma- Another option for stabilization of comminuted
tion. When applying a plate in bridging fashion, diaphyseal fractures is plate–rod fixation (179)24. An
plate failure can occur through empty screw holes intramedullary pin is placed in normograde fashion to
and the cat’s activity must be restricted postopera- maintain length and alignment of the bone while the
tively. DCPs and cuttable plates applied in buttress bone plate is applied. The pin should fill approximately
fashion have been used with success in comminuted 35–40% of the medullary cavity. The plate is contoured
femoral fractures in cats22. Steel 2.4 mm LC-DCPs and applied in buttress fashion on the lateral aspect of
may be applied in buttress fashion to comminuted the femur. The most proximal and distal screws engage
femoral fractures; however, titanium LC-DCPs are both femoral cortices (bicortical). The remaining
not recommended for use in buttress fashion. screws engage only the near cortex (monocortical). A
Stacking two cuttable plates increases their strength minimum of three monocortical screws and one
and is helpful when applying cuttable plates bicortical screw are placed on each side of the fracture.
to comminuted fractures. Lengthening (Synthes Comminuted fragments and the fracture hematoma in
Inc.) and biological healing plates (Veterinary the fracture site are not disturbed. However, suture
Instrumentation) are devoid of screw holes centrally material may be used gently to move distant fragments
and are ideal for use in buttress fashion. Autogenous into the fracture site if necessary.

181

A B C D
181 Comminuted femoral fracture repaired with a cuttable plate applied in bridging (buttress) fashion.
Autgenous cancellous graft was placed at the fracture site.
A Immediate postoperative craniocaudal view.
B Immediate postoperative lateral view.
C 1-month postoperative craniocaudal view.
D 1-month postoperative lateral view.
206

External fixators pin–bone interface and reduce the incidence of


A type Ia external fixator applied to the lateral aspect of premature pin loosening. In some cases, the external
the femur will provide adequate stability for most fixator is placed in conjunction with an intramedullary
fractures in cats (182)25. They may be applied in a pin to prevent rotation around the pin and increase the
closed manner if the fragments can be reduced by resistance of the frame to bending forces (185). A
palpation or if intraoperative imaging is available to slightly smaller intramedullary pin may be used
help ensure adequate alignment. They may also be to allow placement of the transfixation pins. The
applied after open reduction (183). A minimum of external fixator frame can also be attached to the
two (and preferably three or four) transfixation pins are proximal portion of the intramedullary pin (tie-in
placed on each side of the fracture line if the fixator configuration) using a connecting bar to increase
is the primary means of fracture stabilization (184). stability further26. Acrylic or traditional connecting
Positive profile pins improve holding power at the bars may be used.

182

A B C D

182 Stabilization of femoral diaphyseal fractures with external fixators.


A A type Ia external fixator applied to the lateral aspect of the femur. A minimum of two transfixation pins are placed on
each side of the fracture line. The fixator may be applied closed or after open reduction.
B A type Ia external fixator and full cerclage wires.
C An acrylic type Ia external fixator and an intramedullary pin.
D Tie-in configuration. The external fixator and intramedullary pin are attached proximally with a connecting bar.

183 183 A type Ia external fixator applied to the


femur after open reduction of the fracture.
The external fixator provides additional support
to the fracture repair and is easily removed when
healing is complete.
Fractures and disorders of the hindlimb
207
184

A B
184 A type Ia acrylic external fixator applied to a transverse femoral fracture.
A Craniocaudal view.
B Lateral view.

185

A B
185 A type Ia external fixator and intramedullary pin applied to a comminuted femoral fracture.
A Craniocaudal view. Three transfixation pins are inserted on each side of the fracture line. Positive profile pins
are used to enhance the pin–bone interface and reduce pin loosening.
B Lateral view.
208
186 186 ILN fixation of femoral
fractures.
A Diagram of a comminuted
diaphyseal femoral fracture
stabilized with an ILN placed in
buttress fashion.
B, C Craniocaudal and lateral
radiographic views of a femoral
fracture stabilized with a 4.0 mm
ILN. The ILN is inserted
normograde into the femoral
medullary canal and attached to
the extension rod and drill-
aiming guide to allow insertion
of 2.0 mm screws through the
bone and ILN. One or two
screws may be placed on each
side of the fracture line.
(Radiographs courtesy of Dr.
A Mark Rochet.)
B C

Some cats will be reluctant to use the limb for usually placed to provide a buttress function and
a time after application of an external fixator to the the fracture fragments are minimally disturbed.
femur, presumably because of the pins penetrating Autogenous cancellous bone graft is placed at the
large muscles. The cat’s activity is restricted during the fracture site if desired, or small fracture fragments can
healing period, although weight bearing and joint be morselized and packed around the fracture.
motion are encouraged. Fracture healing is monitored Alternatively, the fragments can be anatomically
radiographically and the fixator is removed when reduced with cerclage wires. The ILN then provides
healing is complete. External fixators can generally be a neutralization function. In most cases, however,
removed with the cat under sedation or short-term cerclage wires are not placed unless they contribute
anesthesia. significantly to the repair. The implants are generally
not removed unless complications occur.
Interlocking nails (ILNs)
4.7 mm and 4.0 mm diameter ILNs may be used to DISTAL FEMORAL FRACTURES
stabilize simple and comminuted fractures of the Distal femoral fractures in cats include fractures of the
femur in cats (Small Interlocking Nail System, distal femoral growth plate, supracondylar fractures,
Innovative Animal Products LLC.) 27,28. The trochlear fractures, and condylar fractures. Clinical
fracture is exposed via a limited surgical approach. signs include swelling, crepitus, and pain in the distal
The appropriate length ILN (68–134 mm) is femur. Most cats are initially nonweight-bearing,
selected based on radiographs and is inserted into though some will begin to place weight on the limb
the medullary cavity in a normograde fashion. If if the injury is several days old. The diagnosis is based
necessary, the proximal cortex and medullary cavity on palpation and radiography of the femur.
can be opened using the ILN or a Steinmann pin in External coaptation is ineffective in stabilizing
a retrograde fashion, though this is more disruptive most distal femoral fractures because the epiphysis
to the fracture site. An insertion guide is then used is displaced by its muscular attachments. Internal
to place screws through the bone and the nail to fixation allows better anatomic reduction and implant
provide axial and rotational stability. 2.0 mm screws placement stabilizes the fracture site.
are used for these small nails. The distal screw is With distal femoral fractures, the cruciate and
usually placed first. One or two screws are placed on collateral ligaments (and other soft tissue support
each side of the fracture line and should be at least structures of the joint) may be damaged as well,
1–2 cm from the fracture site (186). requiring additional treatment to re-establish joint
When stabilizing comminuted fractures, the ILN is function. In fractures involving the articular surface of
Fractures and disorders of the hindlimb
209
187 188

A B
187 Radiographs of a Salter–Harris type I fracture of the
distal femoral growth plate. A B C
A Lateral view.
B Craniocaudal view.

the femur, anatomic reduction, rigid fixation, and


early joint motion are essential for return of normal
joint function29,30. Inadequate treatment of intra-
articular fractures can lead to delayed or nonunion,
poor joint function, and progression of
osteoarthritis31. If an articular fracture is irreparable
or severe complications develop, limb amputation or D E F
stifle arthrodesis may be indicated.
188 Repair of Salter–Harris type I and II fractures of the
FRACTURESOF THE DISTAL FEMORAL distal femur. A Salter–Harris type I fracture of the distal
GROWTH PLATE femoral growth plate. B Repair using a single
Cause and pathogenesis intramedullary pin placed normograde from the distal
Fractures involving the distal femoral growth plate femoral epiphysis. The pin is inserted just cranial to the
occur commonly in immature cats and are usually origin of the caudal cruciate ligament. The pin is advanced
Salter–Harris type I or II fractures (187)2,32,33. They to the proximal femur and countersunk below the articular
also occur with some frequency in young adult cats surface at the intercondylar notch of the stifle joint.
and may result from late closure of the growth plate C Cross-pin fixation. Kirschner wires are inserted through
after early neutering34. The epiphyseal segment is the nonweight-bearing cartilage lateral and medial to the
usually displaced caudally and proximally. trochlear ridges. The wires cross and exit the cranial cortex
of the femur approximately 2 cm proximal to the fracture
Treatment and prognosis line. D Parallel Kirschner wire fixation. E Lateral view
Surgical stabilization of distal femoral growth plate showing the proper angulation of the pins. F Dymanic
fractures is achieved through a parapatellar approach to intramedullary cross-pinning (Rush pinning).
the stifle joint and distal femur. The epiphyseal
segment is pulled distally to achieve reduction. Smooth
pins are inserted across the growth plate to provide after fracture fixation39. Proper surgical technique is
stability yet allow continued growth35. Studies have essential since postoperative epiphyseal alignment is an
found that mild growth disturbance is common after important factor influencing the outcome after surgical
repair of Salter–Harris type I and II fractures of the repair36,37. Repair of Salter–Harris type I and II
distal femur36–38. Fortunately, lameness is uncommon fractures is usually achieved using one of several
and cats adapt well to minor changes in limb length described pinning methods (188).
210

Single intramedullary pin the long digital extensor tendon. A second Kirschner
A lateral parapatellar approach is made to the stifle wire is inserted at a corresponding point just medial
joint and distal femur. The patella is reflected to the medial trochlear ridge. They are both directed
medially to visualize the fracture site and the to exit the cranial cortex of the femur approximately
intercondylar notch. A Steinmann pin (50–70% of 2 cm proximal to the fracture line (189)1,40–42. The
the diameter of the medullary cavity) is inserted Kirschner wires may be placed either parallel to each
normograde into the distal femoral epiphysis other or in a crossed-pin fashion. Once the wires are
immediately cranial to the origin of the caudal positioned, they are cut and countersunk below the
cruciate ligament39,40. The fracture is reduced and cartilage surface using a nail-set. The joint is lavaged
the pin is advanced across the fracture line and into and closed routinely. The prognosis after internal
the medullary cavity of the metaphysis. The pin is fixation of distal femoral growth plate fractures in cats
advanced until it engages the cancellous bone at the using two Kirschner wires is excellent, although
proximal femur. It is then cut and countersunk complications such as malalignment, implant failure,
below the articular surface at the intercondylar notch nonunion, and patellar luxation have been
of the stifle joint. The joint is lavaged and closed reported37.
routinely. Complications with this technique are
uncommon but may include instability, infection, Dynamic intramedullary cross-pinning
pin migration into the joint, and iatrogenic fracture Two Kirschner wires (1.1–1.6 mm) are positioned in
of the femoral epiphysis39. a similar manner as described above for the cross-
pinning technique 40,43. However, rather than
Crossed or parallel Kirschner wires penetrating the cranial femoral cortex proximal to
A lateral parapatellar approach is used to access the the fracture line, the wires glance off the inner
fracture site and stifle joint. The fracture is reduced cortical wall and continue up the medullary cavity.
and temporarily stabilized with pointed-reduction With this technique, the pins are often described as
forceps. A Kirschner wire (1.1–1.6 mm) is inserted having been inserted in ‘Rush fashion’. This is
through the nonweight-bearing cartilage lateral to achieved by first inserting the medial and lateral
the trochlear ridge and 3 mm cranial to the origin of Kirschner wires into the epiphyseal segment to the
level of the fracture line. The wires are inserted at a
10–15° angle to the median plane of the femur. The
fracture is reduced and the wires are alternately
pushed up the femoral shaft, directing them toward
the greater trochanter. During insertion, the
189 hand-chuck is only minimally rotated to prevent the
wires from penetrating the cranial femoral cortex. If
desired, the wires can be alternately tapped into
place with a small mallet rather than inserted with
the hand-chuck. Another means of assuring the wires
pass up the medullary cavity and do not penetrate
the femoral cortex is to blunt the tips of the wires
prior to insertion. This requires that the wire tracts
in the epiphyseal segment be predrilled using a small
drill bit. The wires are seated into the proximal
femoral metaphysis. A Kirschner wire of similar
length is used as a measuring-pin to ensure the wires
are adequately inserted. Kirschner wires inserted in
the dynamic intramedullary cross-pinning technique
achieve three-point fixation that provides rotational
and axial stability43.
A B
189 Repair of a Salter–Harris type I fracture of the distal Single Rush pin
femur using cross-pin fixation. A modification of the single intramedullary pinning
A Craniocaudal view. technique involves the insertion of a 2.4 mm Rush pin
B Lateral view. into the medullary cavity44. A 2.4 mm hole is drilled
Fractures and disorders of the hindlimb
211

into the distal femoral epiphysis immediately cranial to External fixators


the origin of the caudal cruciate ligament. The hole is External fixation may be used to stabilize simple or
directed to the center of the growth plate. A second comminuted supracondylar fractures if adequate
2.4 mm hole is drilled in the metaphyseal surface of bone exists distal to the fracture site to place the
the growth plate to open the medullary canal. The transfixation pins. External fixators may be applied in
fracture is reduced and the Rush pin is inserted a closed fashion if acceptable reduction can be
normograde into the drill hole and advanced across achieved. If open reduction is indicated, a lateral
the fracture line. The pin is advanced until it engages approach to the femur is combined with a para-
the cancellous bone at the proximal femur. The hook patellar approach to the stifle. The fracture is reduced
on the end of the Rush pin is positioned in the and transfixation pins are placed through the femur in
intercondylar notch. a lateral to medial direction. A minimum of two pins
are placed proximally and distally to the fracture site.
SUPRACONDYLAR FRACTURES The transfixation pins are then attached using acrylic.
Cause and pathogenesis Acrylic connecting bars are easily contoured
Supracondylar fractures in adult cats are typically to accommodate the curved distal femur, are
transverse or short oblique and do not involve the lightweight, and eliminate the need to ensure all
articular surface. transfixation pins are inserted in the same plane. They
also allow different sized transfixation pins to be used
Treatment and prognosis in a single frame. A type I external fixator is suffi-
Repair is achieved using the pinning techniques ciently strong to stabilize distal femoral fractures in
described for Salter–Harris fractures, external fixators, cats, particularly if the fracture is well reduced. An
or bone plates and screws (190). intramedullary pin may be inserted to augment the
Pinning techniques described for repair of distal stability, although this is rarely necessary. A hybrid
femoral growth plate fractures may be used to stabilize type I–II external fixator frame may be used for more
supracondylar fractures in adult cats45. distal fractures where two transfixation pins cannot be

190

A B C D E F

190 Repair of supracondylar femoral fractures.


A Cross-pin fixation.
B Dynamic intramedullary cross-pin fixation (Rush pinning).
C A type Ia acrylic external fixator. A minimum of two pins are placed proximally and distally to the fracture site.
D A hybrid type I–II external fixator and intramedullary pin for stabilization of a comminuted supracondylar fracture.
E Bone plate fixation with a reconstruction plate.
F Bone plate fixation with a mini L plate.
212

inserted into the epiphyseal segment. They are parapatellar incision is used and can be extended into
also useful to buttress comminuted supracondylar a lateral approach to the femur to improve exposure
fractures. Rarely, a transarticular fixator is placed of the supracondylar region. An arthrotomy allows
across the stifle joint to support internal fixation of visualization of the intraarticular fractures.
a supracondylar fracture. If possible, screws (2.0 mm or 2.7 mm) placed
in lag fashion are used to stabilize the fractures.
Bone plates and screws Alternatively, Kirschner wires are used to hold
Bone plates may be used to stabilize supracondylar fragments in reduction, but they do not create
fractures if the epiphyeal segment is large interfragmentary compression. Good anatomic
enough46,47. Cuttable plates, DCPs, and recon- alignment is essential and gaps or steps in the articular
struction plates have been used for repair of distal surface should be avoided.
femoral fractures in cats 21,47 . Reconstruction
plates (2.7 mm) are more easily contoured to fit Unicondylar fractures
the curved distal femur than standard bone plates Unicondylar fractures are repaired using inter-
and can be positioned more distally on the femur fragmentary compression when possible. In a study of
without interfering with the patella. Proper experimentally induced unicondylar fractures, lack of
contouring permits the insertion of three screws in interfragmentary compression lead to instability and
the small epiphyseal fragment of most fractures. caused delayed union, osteophyte formation, and
Mini plates can also be used to repair distal femoral cartilage erosion31. A parapatellar approach to the
fractures in cats46. Various shapes are available stifle joint is used and may be combined with a partial
(straight, T plates, L plates) to ensure adequate horizontal capsulotomy to reduce the caudally
fixation of the distal fracture segment. Mini plates displaced condylar fragment. Once reduced, the
also allow the insertion of small 2.0 mm screws fragment is temporarily fixed with Kirschner wires or
into the epiphyseal fragment. bone forceps. Stabilization is achieved by placing a
lag screw from the femoral metaphysis into the
CONDYLAR AND TROCHLEAR FRACTURES fractured condyle (191). Alternatively, the lag screw
Cause and pathogenesis may be started in the condyle and placed into the
Condylar and trochlear fractures involve the articular femoral metaphysis, with care taken to avoid
surface of the distal femur. Fractures involving a single damaging the articular cartilage. Ideally, the lag screw
condyle are termed unicondylar. The medial condyle is inserted perpendicular to the fracture line. Rotation
is most commonly fractured, becoming separated around the lag screw is prevented by the addition of
from both the femoral shaft and the lateral condyle. In a Kirschner wire across the fracture line or the
most instances, the caudal cruciate and medial placement of two screws in larger fragments. If
collateral ligaments remain attached to the fractured necessary, the lag screw may be placed transversely
medial condyle. Bicondylar fractures occur when the into the other condyle to achieve fixation48.
medial and lateral condyles separate, and each is
fractured from the femoral shaft. They are often Bicondylar fractures
termed ‘Y’ or ‘T’ fractures. Concurrent damage to the Surgical treatment of bicondylar fractures requires
cruciate ligaments or menisci is not uncommon repair of both the intercondylar fracture and
with bicondylar fractures. Trochlear fractures of the the supracondylar portion of the femur (192).
distal femur may occur in conjunction with condylar A parapatellar approach to the stifle joint is used.
fractures and are usually transverse or oblique. The two condyles are reduced and held in position
with Kirschner wires or bone-holding forceps. An
Diagnosis intercondylar lag screw is placed to create compression
Lateral, craniocaudal, and, occasionally, oblique between the condyles. Two screws provide better
radiographic views are helpful to confirm the presence rotational stability, but there is often insufficient room
of articular fractures and plan implant placement prior for placement of two screws. Fortunately, rotation
to surgery. around the lag screw is prevented when the
supracondylar portion of the fracture is stabilized.
Treatment and prognosis Once the joint surface has been reconstructed, the
Intraarticular fractures involving the femoral trochlea remaining supracondylar fracture is repaired using
or condyles require internal fixation to realign the crossed pins, crossed lag screws, a Steinmann pin, or
articular surface and preserve joint function. A dynamic intramedullary cross-pins (Rush pinning). If
Fractures and disorders of the hindlimb
213
191

A B C D E
191 Stabilization of unicondylar fractures of
the distal femur.
A A lag screw is placed from the metaphysis
into the fractured condyle. A Kirschner wire
is inserted to prevent rotation around the
screw (craniocaudal view).
B Lateral view.
C A lag screw and Kirschner wire are placed
from the nonarticular portion of the
condyle into the femoral metaphysis or the
intact condyle.
D Lateral radiographic view of a medial
condylar fracture of the distal femur.
E Craniocaudal radiographic view.
F Postoperative radiographic view (lateral)
of a medial condylar fracture repaired with a F G
lag screw and Kirschner wire.
G Craniocaudal postoperative view.

192 Stabilization of bicondylar fractures of 192


the distal femur.
A Fixation with an intercondylar lag screw
and dynamic intramedullary cross-pinning
(craniocaudal and lateral views).
B Fixation with a bone plate. One of the
distal plate screws is inserted in lag fashion
to compress the intercondylar fracture
(craniocaudal and lateral views).
C Fixation with an intercondylar lag screw
and a type Ia acrylic external fixator
(craniocaudal view).

A B C
214

the supracondylar portion of the fracture is small osteochondral fragments to the underlying
comminuted, an external fixator or bone plate applied subchondral bone. The wires are countersunk below
in buttress fashion may be applied. External fixators the articular surface with a nail-set. Those fragments
may also be used as the primary means of fracture too small to stabilize are discarded. Stability is then
stabilization, particularly in open or comminuted provided by the application of small bone plates and
supracondylar fractures, but these do not create screws (2.0 mm or 2.7 mm) to the lateral aspect of
interfragmentary compression between the condyles. the distal femur. Mini plates (Synthes) are
A transarticular fixator may be used but is rarely particularly useful and come in various shapes to
needed for additional support after internal fixation49. allow insertion of two screws in the distal segment.
Mini L plates and T plates are used commonly. In
Trochlear fractures cases where plate fixation is impractical, crossed lag
Fractures involving the femoral trochlea may be screws or multiple Kirschner wires may be applied.
simple (often transverse or oblique) or comminuted. Autogenous cancellous bone graft is placed in any
Internal fixation is required to realign and stabilize defects. Postoperatively, passive range-of-motion
the articular fragments (193)46. A lateral para- exercises are used to restore joint mobility. If
patellar surgical approach is used. The fragments are external support is necessary after fixation, a
reduced to avoid gaps or steps in the articular nonweight-bearing sling may be applied. Therapy is
surface. Kirschner wires can be inserted to attach initiated when the sling is removed. In a study of
seven cats operated on for repair of trochlear
fractures, 85% had good functional recovery46.

Comminuted articular fractures


Comminuted fractures of the distal femoral articular
193 surface are repaired using Kirschner wires or lag screws
(193). Osteochondral fragments are reduced and
stabilized using Kirschner wires placed through the
fragment into the subchondral bone. Lag screws can be
used to stabilize larger fragments50,51. The Kirschner
wires and screw heads are countersunk below the
articular surface to minimize cartilage damage during
joint motion50,51. Fragments which cannot be stabilized
are discarded51. Larger articular fragments may also be
A B stabilized using Herbert bone screws (Zimmer Inc.)52.
They have threads at both ends and no head, enabling
them to be implanted completely beneath the cartilage
surface. The threads at either end of the screw have a
different pitch so that, as the screw is tightened, the
pitch differential between the screw ends compresses
the bone fragments together. Herbert bone screws are
available in 16–30mm lengths, have a shank diameter of
C D 1.85 mm, and a thread diameter of 3 mm or 4 mm.
Bioabsorbable implants have also been used to reattach
193 Repair of femoral trochlear and articular osteochondral fragments53. Pins made of polydioxanone
fractures. (PDS, Ethicon) and composites of polyglycolide or
A Kirschner wires are inserted and countersunk polylactide (BIOFIX VET-rods, Bioscience Ltd.) are
to reattach small osteochondral fragments. inserted through the osteochondral fragment into
A mini L plate is applied to the lateral aspect of the underlying subchondral bone53,54.
the distal femur.
B, C Articular fractures are stabilized with
Kirschner wires inserted and countersunk below
the cartilage surface.
D A lag screw is inserted and countersunk
below the articular cartilage.
Fractures and disorders of the hindlimb
215

POSTOPERATIVE CARE OF PATELLAR FRACTURES


FEMORAL FRACTURES CAUSE AND PATHOGENESIS
The cat’s activity is restricted after surgery to prevent Patellar fractures are uncommon and occur as a result
disruption of the repair. Early passive motion and of direct trauma to the patella or, in some cases, from
controlled exercise are encouraged after repair of extreme traction applied by the quadriceps mechanism
articular fractures to maintain range of motion and when the stifle joint is extended to break a fall. Patellar
improve joint function. In cases where a transarticular fractures are typically closed and usually involve
external fixator was applied to augment stabilization, the articular surface of the patella. Comminuted,
the fixator is removed as soon as the fracture site is longitudinal, and transverse fractures of the patella can
stable to allow initiation of physical therapy. Fracture occur, and some are minimally displaced58. Transverse
healing is monitored radiographically until complete. fractures are the most common type.
Implants are typically not removed unless compli-
cations develop. CLINICAL SIGNS
Cats with patellar fractures are acutely nonweight-
COMPLICATIONS OF FEMORAL bearing and may have a history of a fall or
FRACTURES other trauma. The cat will eventually begin to bear
Complications of femoral fracture repair include weight on the limb but will usually remain lame.
malunion, delayed union, infection, implant failure, Many are unable to extend the stifle fully or to
stifle or hip joint stiffness, quadriceps contracture, support weight with the stifle in extension59. Pain,
and sciatic nerve injury 55. The application of swelling, and crepitus in the stifle joint are common
a 90–90 flexion splint has been recommended for clinical signs.
1–2 weeks after surgery in young cats and cats with
severe trauma that are at risk for joint stiffness and DIAGNOSIS
quadriceps contracture (194)56. Hindlimb ampu- The diagnosis of patellar fractures is confirmed
tation is often required if quadriceps contracture radiographically. Mediolateral, craniocaudal, and
develops after fracture fixation, although successful tangential views are used to determine the type of
treatment with a dynamic flexion apparatus in a cat fracture and the presence of comminution.
has been reported57. Osteoarthritis may develop
after surgical repair of articular fractures, although it TREATMENT AND PROGNOSIS
is rarely severe in cats and is minimized by good Patellar fractures are repaired to preserve the
surgical technique, anatomic reduction, rigid quadriceps extensor mechanism, reestablish continuity
fixation, and early postoperative joint motion. of the articular cartilage surface to minimize the
development of degenerative joint disease, and to
provide fixation sufficient to allow bone healing.

194 Photograph of a 90–90 flexion splint applied to 194


the hindlimb of a cat. The stifle and hock joints are
maintained at 90° of flexion to prevent quadriceps
contracture and minimize joint stiffness after femoral
fracture repair.
216

Conservative treatment Tension band fixation


External coaptation may be used in some nondis- A tension band device can be used to repair transverse
placed fractures, maintaining the stifle in extension to and comminuted patellar fractures since it will
prevent movement of the fragments caused by counteract the distracting forces created by the
contraction of the quadriceps muscles. A bandage quadriceps muscles60. The fragments are reduced
should remain in place for 4–6 weeks. Physical therapy and a Kirschner wire is inserted normograde or
is then needed to reestablish quadriceps muscle retrograde through the patella to realign the
strength and joint mobility. fragments prior to placement of the tension band
wire. Predrilling with a 1.1 mm drill bit may be
Surgical treatment necessary to place the Kirschner wires in the
In most cases, the tension created by the quadriceps extremely hard bone of the patella. The Kirschner
muscles necessitates internal stabilization of patellar wire must not penetrate the caudal articular surface of
fractures. Internal fixation provides increased stability, the patella, but should protrude from the patella
allows proper alignment of the articular surface to proximally and distally59,60. A single Kirschner wire is
minimize the development of osteoarthritis, and usually adequate, although double Kirschner wires
allows earlier return of stifle function, thereby minimize rotational forces between fragments. They
decreasing muscle atrophy and loss of joint range may be crossed or placed parallel as dictated by the
of motion that can occur with prolonged fracture lines. A cerclage wire is then placed encir-
immobilization37,58,60. A lateral or medial stifle cling the protruding ends of the Kirschner wire in
arthrotomy is performed to visualize the articular either a mattress or figure-of-eight fashion. The
surface of the patella. Accurate reduction of the cerclage wire is tightened and the pins are cut short
articular surface is important to reestablish joint to minimize soft tissue trauma.
congruity. The stifle is held in extension while
reduction forceps are used to realign the fracture Postoperative care
fragments. Small chondral or osteochondral fragments Postoperatively, the cat’s activity is restricted until
are discarded if they cannot be incorporated into the clinical union is achieved. If necessary, the stifle can be
repair (partial patellectomy)61. The tendon ends immobilized in a padded bandage for 1–2 weeks to
are sutured to preserve the quadriceps mechanism if protect the incision site and prevent flexion of
a partial patellectomy is necessary. Complete the joint early in the healing process. However,
patellectomy has been reported in the cat but is not the bandage should be removed as soon as possible
recommended and may lead to pain, decreased stifle to allow joint movement and rehabilitation of
function, ligament instability, osteoarthritis, and the quadriceps muscles. Mild, passive flexion and
muscle atrophy59,62. extension of the stifle may be started as early as 5 days
Cerclage wiring or tension band fixation is used for after surgery in most cases. Activity is gradually
stabilization of patellar fractures (195). increased starting 2 weeks after surgery. The implants
are removed once the fracture has healed if pin
Cerclage wire migration or irritation of the surrounding soft tissues
A cerclage wire may be used to stabilize nondis- occurs.
placed fractures of the patella. A large-bore
hypodermic needle is used to pass a cerclage wire Complications and prognosis
(0.8 mm [20 AWG]) through the quadriceps tendon Seroma formation, implant migration, and osteoarthritis
(proximally) and the straight patellar tendon are possible complications of surgical repair of patellar
(distally) to encircle the patella completely. The fractures. Limb function is usually good if accurate
tension band wire is positioned on the cranial surface reduction and rigid stability are achieved59.
of the patella (tension side) to prevent displacement
of the fracture line during weight bearing.
Tightening the wire until the fracture is slightly
overreduced will create compression at the fracture
when the stifle is flexed60.
Fractures and disorders of the hindlimb
217

195

A B

195 Stabilization of patellar fractures.


A Cerclage wire is placed encircling the patella. A hypodermic needle may be
used to pass a cerclage wire through the quadriceps tendon proximally and the
straight patellar tendon distally. The wire is positioned on the cranial surface of
the patella to prevent displacement of the fracture line during weight bearing
(craniocaudal and lateral views).
B Tension band fixation of a patellar fracture. A Kirschner wire is inserted
normograde or retrograde through the patella to realign the fragments. A
cerclage wire is placed (mattress or figure-of-eight pattern) encircling the
protruding ends of the Kirschner wire.
218

PART 4: STIFLE DISORDERS is usually unilateral. Patellar luxation affects both male
and female cats2. Most affected cats are less than
3 years of age, and, in one report, 66% were less
The stifle joint is comprised of the femorotibal and than 1 year of age2,7. Patellar luxation may also occur
femoropatellar joints, their common joint capsule, secondary to femoral fracture repair, surgical
and ligamentous support structures (196). The treatment of other stifle injuries, or congenital defects
cruciate ligaments (cranial and caudal) and collateral affecting the femur or tibia7.
ligaments (medial and lateral) provide stability to the
stifle joint. Traumatic disruption of these ligaments CLINICAL SIGNS
and luxation of the patella (traumatic or congenital) Mild patellar laxity is normal in cats. Slight subluxation
are common causes of stifle pain and lameness in cats. of the patella is often elicited during palpation and
rarely causes clinical signs unless aggravated by trauma8.
PATELLAR LUXATION In many cats, patellar luxation causes no clinical signs
CAUSE AND PATHOGENESIS and is detected incidentally during physical
Congenital medial patellar luxations occur in Devon examination. In other cats, however, patellar luxation
Rex, Abyssinian, and domestic shorthair cats1–4. Most causes gait abnormalities, pain, acute lameness, locking
are bilateral and may be associated with a shallow of the limb in extension, or a crouching stance.
trochlear groove, slight medial deviation of the tibial A review of 21 cats with patellar luxation reported
tuberosity, and an underdeveloped medial femoral that 66% were markedly lame or had noticeable gait
condyle5. Coxa vara, lateral bowing of the distal abnormalites7. The lameness is intermittent in
femur, and tibial torsion are not typically seen in cats some cats. Cranial cruciate ligament (CrCL) rupture
with patellar luxation6,7. A weak association between secondary to patellar luxation is rarely described in cats.
medial patellar luxation and hip dysplasia is described
in cats8. DIAGNOSIS
Patellar luxations may also occur as a result of The diagnosis of patellar luxation is made by palpation
trauma, although the trauma is often unobserved9. of the joint and evaluation of patellar stability.
Minor trauma may produce clinical signs in cats with A grading system is used to describe the clinical
previously subclinical patellar laxity. Medial luxation severity of the patellar luxation:
is most common and may occur unilaterally or • Grade I: the patella is manually luxated using
bilaterally. Lateral luxation occurs less frequently and digital pressure, but reduces spontaneously when
pressure is released. Cats with grade I luxation
rarely show clinical signs.
196 • Grade II: the patella is manually luxated using
digital pressure or with rotation of the tibia. The
patella can be reduced easily and will remain in
place until the limb is manipulated. Not all cats
with grade II luxation show clinical signs.
• Grade III: the patella is luxated at the time of the
examination. It may be positioned into the
trochlear groove using digital manipulation, but
spontaneously reluxates. The degree of lameness
is variable with grade III luxations, but is often
persistent.
• Grade IV: the patella is permanently luxated and
cannot be reduced with digital manipulation or
rotation of the tibia. Grade IV luxations are
uncommon in cats.
Patellar luxation may also be identified on cranio-caudal
radiographic views of the stifle joint. The position of the
A B tibial tuberosity and development of the medial femoral
196 Feline stifle joint. condyle are assessed on lateral and craniocaudal
A Lateral view. B Craniocaudal view. (Photographs radiographs. A ‘skyline’ radiographic view may be used
courtesy of Tom Thompson.) to assess the depth of the femoral trochlea.
Fractures and disorders of the hindlimb
219

TREATMENT AND PROGNOSIS Retinacular imbrication


Conservative or surgical treatment may be used to Monofilament, nonabsorbable suture material (2–0)
treat patellar luxation in cats. Conservative therapy is is placed in the retinacular fascia (Lembert or mat-
recommended for treatment of cats without clinical tress pattern) to achieve imbrication (197 A)9.
signs or if signs are mild or infrequent. Confinement Alternatively, a narrow strip of the retinacular fascia is
and limited activity is encouraged during bouts of excised and the resultant edges are sutured. The
intermittent, mild lameness. lateral retinaculum is imbricated to stabilize medial
Surgical treatment is recommended for cats with patellar luxations; the medial retinaculum is imbri-
more severe luxation and those with persistent clinical cated to stabilize lateral patellar luxations. The region
signs2,7,10. A lateral parapatellar approach is made to the of imbrication should begin at the distal aspect of the
stifle joint. Depending on the severity of the luxation, stifle joint and continue proximal to the patella.
soft tissue procedures and bony reconstructive proce-
dures are used alone or in combination to restore Fabellar–tibial antirotational suture
normal anatomy, prevent patellar luxation, and improve An antirotational suture is used to prevent internal
stifle joint function. rotation of the tibia and maintain proper alignment of
the quadriceps mechanism. A suture is placed around
Soft tissue procedures the lateral fabella and through a hole drilled
In cats with grade II luxation, soft tissue procedures in the tibial tuberosity (197 B). Monofilament,
alone are often adequate to maintain patellar reduction. nonabsorbable suture material (2-0 to 0) is often
used. An antirotational suture may also be used to
Capsular imbrication stabilize joints with concurrent CrCL rupture.
A portion of the joint capsule is excised and the edges
are sutured to increase tension10. Monofilament, Fabellar–patellar suture
absorbable suture material (3–0) is often used. The A suture is passed in a figure-of-eight pattern from
lateral joint capsule is imbricated to stabilize medial the fabella to the patella (197 C). The suture can
patellar luxations; the medial joint capsule is be passed around the patella or placed through the
imbricated to stabilize lateral patellar luxations. patellar tendon. The suture is tightened just enough
to stabilize the patella.

197
Fabella
Fascia lata

Patella

Patella
Patellar Fabella
ligament Patella
Patellar
ligament

Tibial
Tibial tubercle
tubercle
A B C

197 Soft tissue re-constructive procedures for stabilization of patellar luxations.


A Retinacular imbrication. Suture material (mattress or Lembert pattern) is placed in the retinacular fascia from proximal to
the patella to the distal aspect of the stifle. B Fabellar–tibial antirotational suture. A suture is placed around the lateral fabella
and through a hole drilled in the tibial tuberosity. C Fabellar–patellar suture. A suture is passed in a figure-of-eight pattern
from the fabella to the patella. The suture may be passed around the patella or through the patellar tendon beside the patella.
220

Releasing incision removed with a file, bone rasp, or rongeur (198).


A releasing incision is made through the fascia on the The procedure is easily performed and adequately
side opposite the luxation to relieve tension on deepens the trochlea, but destroys the articular
the tissues that may lead to postoperative reluxation. cartilage11. Techniques which preserve the
In some cases, the releasing incision is made as part articular cartilage are preferred.
of the surgical approach to the joint. The synovial • Trochlear wedge recession12,13: a small saw is used
membrane is sutured to reduce leakage of to excise a wedge-shaped osteochondral fragment
synovial fluid from the joint, but the fibrous joint from the trochlea, preserving the articular surface
capsule and retinacular fascia are left open. (199). A small amount of bone is removed from
the resultant femoral defect and from the apex of
Bony reconstructive procedures the excised wedge of bone using a saw, scalpel
Trochleoplasty blade, or rongeur. The osteochondral fragment is
Trochleoplasty techniques are used to deepen the then positioned back into the defect. The replaced
trochlear sulcus and improve patellar stability. Several wedge is thus recessed, creating a deeper trochlear
techniques have been described, although techniques sulcus. Fixation of the wedge is not necessary. The
that preserve the articular cartilage are preferred. proximal aspect of the trochlear sulcus may not be
• Sulcoplasty: the articular cartilage and altered with the technique, and may need to be
subchondral bone of the trochlear sulcus are widened or deepened with a small file.

198 199

Caudal
cruciate
ligament
Patella
Bone
cartilage
wedge
A B
198 Femoral sulcoplasty for stabilization of patellar
luxations. A The articular cartilage and subchondral bone
of the trochlear sulcus are removed with a file.
B Completed sulcoplasty. The procedure adequately
deepens the trochlea, but destroys the articular cartilage. A B

199 Trochlear wedge recession.


A A saw is used to excise a wedge-shaped osteochondral
fragment from the trochlea, preserving the articular surface.
B Bone is removed from the wedge and the femoral defect
and the osteochondral fragment is replaced (recessed),
deepening the trochlear sulcus.
Fractures and disorders of the hindlimb
221

• Block recession trochleoplasty14,15: a small saw articular surface than wedge recession. Care must
and osteotome are used to remove a rectangular be taken to avoid damaging the cartilage,
osteochondral fragment from the trochlear sulcus, especially in smaller cats.
preserving the articular surface of the trochlea
(200). A small section of bone is removed from Tibial tuberosity transposition
the resultant femoral defect (and from the base of Transposition of the tibial tuberosity is rarely required
the excised ostechondral block) with a rongeur in cats. However, in cases of severe or recurrent
prior to replacing the fragment. Block recession luxation, transposing the insertion of the straight
trochleoplasty increases the depth of the proximal patellar ligament will align the quadriceps mechanism
sulcus and recesses a larger percentage of the (and thus the patella) over the trochlear groove to

200

A D
B C

E F G
200 Block recession trochleoplasty.
A A saw and small osteotome are used to remove a rectangular osteochondral fragment from the trochlear
sulcus (preserving the articular surface).
B, C Diagrams depicting the proper cuts performed in the trochlear sulcus.
D Photograph showing the excised osteochondral block and resultant defect in the trochlear sulcus.
E Bone is removed from the defect in the trochlear sulcus and from the base of the excised osteochondral
block with a rongeur (shaded areas).
F The osteochondral block is replaced in the defect.
G Completed block recession trochleoplasty. Block recession trochleoplasty increases the depth of the
proximal sulcus and recesses a larger percentage of the articular surface than trochlear wedge recession.
222

improve patellar stability. The tibial tuberosity is cut resent bandages and immobilization is not necessary
with a small osteotome, beginning just caudal to the for a satisfactory outcome. Exercise is restricted for
insertion of the straight patellar ligament (201). The 4 weeks to allow healing.
osteotome is directed distally to free the tuberosity.
Alternatively, the tuberosity can be cut with a small CRUCIATE LIGAMENT INJURIES
bone cutter. It is preferred to leave the fascial CRANIAL CRUCIATE LIGAMENT INJURY
attachments at the distal aspect of the tuberosity Cause and pathogenesis
intact. The tuberosity is then displaced laterally to The CrCL in the cat prevents stifle hyperextension,
correct medial patellar luxation (or medially to correct excessive internal rotation of the tibia, and cranial
lateral patellar luxation). Alignment is confirmed translation of the tibia (cranial draw motion)16.
by viewing the limb from its cranial aspect. The Rupture of the ligament causes joint instability lead-
tuberosity is moved until the hip joint, femoral ing to pain, effusion, and osteoarthritis. Complete
trochlea, and tibial tuberosity are in a straight line. In rupture of the CrCL occurs relatively infrequently in
most cases, the tuberosity is only displaced a few cats, perhaps because the CrCL is relatively larger than
millimeters to achieve proper alignment. It is then the caudal cruciate ligament in the cat (unlike dogs
reattached using two small Kirschner wires driven and humans)17. Partial tears of the CrCL are also
through the tuberosity and into the underlying tibia. reported infrequently in cats, perhaps because cats
Care is taken not to place the Kirschner wires into the develop few clinical signs with partial tears or recover
stifle joint or into the soft tissues on the caudal aspect quickly when they occur. Trauma is thought to be the
of the tibia. With the tuberosity transposed, the tibia most common cause of CrCL rupture in the cat.
is internally and externally rotated to confirm patellar The exact mechanism of rupture is unknown, but
stability. severe internal tibial rotation, stifle hyperextension, or
supraphysiologic loading of the ligament may cause
Prognosis rupture. The influence of hormones, genetics, joint
The prognosis after surgical repair of patellar luxation inflammation, and conformation on CrCL rupture in
in cats is good to excellent6,7. The limb may be cats has not been evaluated. However, cats with CrCL
bandaged for 1 week after surgery, although many cats rupture are often overweight9.

201 201 Tibial tuberosity


transposition. A The tibial
tuberosity is removed with an
osteotome, beginning just caudal
to the insertion of the straight
patellar tendon. The osteotome is
directed distally to free the
tuberosity (dashed line), leaving
the distal fascial attachments intact.
B, C The tuberosity is moved
laterally (to correct medial patellar
luxation) and reattached with two
Kirschner wires inserted through
the tuberosity and into the
proximal tibia. Placing the
Kirschner wires into the stifle joint
or the soft tissues caudal to the
tibia should be avoided. The hip,
femoral trochlea, and tibial
tuberosity should be in alignment
A B C when the limb is viewed from its
cranial aspect.
Fractures and disorders of the hindlimb
223

Clinical signs Conservative therapy


Signs of acute CrCL rupture include a sudden Conservative therapy is the treatment of choice for
onset lameness (may be nonweight-bearing), stifle pain, most cats with CrCL rupture. The cat is confined
and joint effusion. The lameness usually improves to limit activity and, if necessary, placed on a diet to
with rest, but may worsen after exercise. reduce weight. Normal limb function and pain-free
range of motion usually return within 4–5 weeks20.
Diagnosis However, many cats treated conservatively will have
The diagnosis of CrCL rupture is based primarily on persistent joint laxity, mild muscle atrophy, thickening
clinical signs, physical examination findings, and of the joint capsule, and mild osteoarthritis20.
radiographs. Physical examination reveals a positive
cranial draw sign, positive tibial compression test, Surgical stabilization
joint pain, and stifle joint effusion (202). With Stabilization of the stifle after CrCL rupture is
more chronic ruptures, crepitus and periarticular recommended only in cats with persistent lameness
thickening may be noted on palpation of the joint. unresponsive to conservative therapy. Obese cats may
Joint laxity usually persists even in chronic cases of be reluctant to ambulate during conservative therapy
CrCL rupture. A ‘click’ may be noted during and may benefit from early surgery. The presence of
palpation and is indicative of a meniscal tear. meniscal calcification alone does not warrant surgical
Radiography of the stifle may reveal joint effusion or intervention, since some cats with this condition
signs of osteoarthritis. Calcification or ossification of have no clinical signs20. However, removal of the
the medial or lateral meniscus is reported in cats mineralized meniscus is beneficial if pain and lameness
with CrCL rupture and can be observed persist after conservative therapy18. Cats should
radiographically18,19. be evaluated for cardiomyopathy before being
anesthetized for surgery21. Intracapsular and
Treatment and prognosis extracapsular surgical techniques have been used for
Treatment of CrCL rupture in the cat is either repair of CrCL deficient stifles in the cat; however,
conservative therapy or surgical stabilization. extracapsular stabilization is simple to perform, is less
invasive, and provides good results9,16,22.

202 Diagnosis of 202


CrCL ruptures.
A Cranial draw
sign.
B Positive tibial
compression test.

A B
224

Extracapsular stabilization imbricates the lateral bony tunnel. One end of the suture is then passed
joint tissues to prevent cranial draw motion and from lateral to medial, caudal to the patellar tendon,
minimize internal rotation of the tibia. The limb is and back through the bone tunnel to the lateral
shaved and prepared from the hip to the metatarsus. side. The suture should be placed in a mattress
A hanging-limb preparation is used to allow fashion such that the free ends are positioned
manipulation of the stifle joint during surgery. A caudally, thus allowing the knot to be buried
lateral parapatellar arthrotomy is performed. A small beneath the biceps fascia.
Hohmann retractor or mosquito hemostat is placed Once the suture is properly placed through the tibial
in the intercondylar notch and over the tibial plateau crest and around the lateral fabella, it is tightened and
to displace the tibia cranially during joint exploration. secured. The stifle joint is placed in a weight-bearing
Torn remnants of the CrCL and damaged portions of position with the tibia externally rotated. The suture is
the menisci are excised. The joint is then lavaged and tightened until no draw motion can be elicited before
the joint capsule is sutured with absorbable suture the suture is secured. A pointed reduction forceps