Association of Avian Veterinarians

Two Surgical Approaches to Fracture Malunion Repair

Author(s): Sheila C. Rahal, Carlos R. Teixeira, Oduvaldo C. M. Pereira-Junior, Luiz C. Vulcano,
Antonio J. A. Aguiar and Fabrício B. Rassy
Source: Journal of Avian Medicine and Surgery, Vol. 22, No. 4 (Dec., 2008), pp. 323-330
Published by: Association of Avian Veterinarians
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 Journalof Avian Medicineand Surgery 22(4):323-330, 2008
c 2008 by the Association of Avian Veterinarians

Two Surgical Approaches to Fracture Malunion Repair

Sheila C. Rahal, PhD, Carlos R. Teixeira, PhD, Oduvaldo C. M. Pereira-Junior, MS,
Luiz C. Vulcano, PhD, Antonio J. A. Aguiar, PhD, and Fabricio B. Rassy, DVM

Abstract. Two birds were presented with malunion fractures. The first was a young toco
toucan (Ramphastostoco) with malunion of the tarsometatarsusthat was treated by an opening-
wedge corrective osteotomy and an acrylic-pin external skeletal fixator (type II) to stabilize the
osteotomy. The second bird was an adult southern caracara (Caracaraplancus) with radial and
ulnar malunion that was treated by closing-wedge osteotomies. Stabilization of the osteotomy
sites was accomplished through a bone plate fixed cranially on the ulna with 6 cortical screws
and an interfragmentarysingle wire in radius. In both cases, the malunion was corrected,but the
manus of the southern caracara was amputated because of carpal joint luxation that induced
malposition of the feathers.
Key words. malunion, fracture, surgery, osteotomy, avian, toco toucan, Ramphastos toco,
southern caracara, Caracara plancus

Malunion fractures can produce bone shorten-
ing, angulation of the distal fragment, rotation of
the proximal or distal fragment, development of
joint pain, or cosmetic deformity."2 A malunion
may be functional, with minor axial deviation and
no severe impairment of adjacent joint function, or
it may be nonfunctional with severe axial deviation
and impairment of adjacent joint function.3
Treatment of malunion fractures may require
refracture with wedge osteotomy, rotational
osteotomy, or bone-lengthening procedures.' Sev-
eral techniques of corrective osteotomies are
described that should be used according to
deformity, including transverse-opening wedge;
closing wedge; reverse wedge; oblique, stairstep,
transverse derotational; and dome.2-5 In general,
closing and opening wedge osteotomies are
performed to correct axial deformities, step
osteotomies to increase limb length; dome oste-
otomy to correct angulation, bowing, and rota-
tion; and oblique osteotomies to correct all
components of the deformity.2'3 Realigning joint
surfaces, maintaining or gaining length, and
From the Departments of Veterinary Surgery and
Anesthesiology (Rahal, Teixeira, Pereira-Junior, Aguiar) and
Animal Reproduction and Radiology (Vulcano), School of
Veterinary Medicine and Animal Science, So Paulo State
University (UNESP), Botucatu (SP), 18618-000, Brazil; and
Quinzinho de Barros Zoo (Rassy), Sorocaba (SP), Brazil.
derotating the bone constitute the aim of the
osteotomy procedures.2 The osteotomy level may
be performed at the deformity or in a virgin area.6
Different types of methods may be used to fixate
the fracture or osteotomy site, such as external
coaptation, external skeletal fixation, intramedul-
lary pin alone or tie-in, intramedullary rod, circu-
lar ring fixators, bone plates, interlocking nail.3'7-15
However, in selecting a mode of treatment for
birds, care must be taken with regard to device
weight; fracture and/or osteotomy location; the
absence of soft tissue support; pneumatic long
bones, with large intramedullary spaces; cortical
bone, which is typically brittle and thin; and level
of function expected after treatment.9,1"0 Although
repair of avian malunion fractures have been
the treatment is always challenging
reported,7'8c13,15
and each case should be evaluated individually.
The purpose of this report is to describe 2 surgical
approaches used to treat nonfunctional malunions
and the evolution of the treatments.
Clinical Report
Case 1
A young, captive, 0.5-kg toco toucan (Ram-
phastos toco) of unknown sex was examined
because a valgus deformity in the frontal plane
and caudal bowing in the sagittal plane of the

323

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324 JOURNALOF AVIANMEDICINEAND SURGERY

To perform surgical correction, the bird was

i premedicated with diazepam (0.5 mg/kg IM), and
Figure1. A toco toucan (case 1) with tarsometatarsus
malunion of the right pelvic limb. Observe the
inadequate position of the right foot.
right pelvic limb of unknown cause (Figs 1 and
2). The bird was in excellent body condition. No
lesions were present on the weight-bearing
surface, and all toes showed sensation and ability
to flex during examination. However, the defor-
mity induced functional limitation because the
bird was unable to adequately use the right foot
for perching (Fig 1). Craniocaudal and lateral
radiographs of both pelvic limbs demonstrated a
mid-diaphyseal malunion of the right tarsometa-
tarsus, with 260 valgus (Fig 3a) and recurvatum.
The bone length of the right tarsometatarsus was
approximately 7% less than that of the left
tarsometatarsus, and the articular space of the
right hock joint was widened in the lateral
compartment. No abnormality was observed in
other joints or in the left pelvic limb.
anesthesia was induced with ketamine (10 mg/kg
IM) and diazepam (0.2 mg/kg IM). General
anesthesia was maintained with isoflurane admin-
istered through a noncuffed endotracheal tube (9-
cm long, 2-mm internal diameter). End-tidal CO2
and respiratory rate were monitored with a
capnograph (POET TE End Tidal CO2 monitor;
Criticare Systems, Waukesha, WI, USA), with a
sensor attached to the endotracheal tube. Butor-
phanol tartrate (0.2 mg/kg IM; Torbugesic; Fort
Dodge, Campinas, Brazil) was administered
intraoperatively and 4 hours after the surgical
procedure. An intravenous catheter was placed in
the brachial vein, and a balanced crystalloid
solution (lactated Ringer's solution) was admin-
istered at a rate of 10 ml/kg per hour throughout
the surgical procedure. The bird was placed in
dorsal recumbency, and its body temperature was
maintained by using a heating pad. The area from
the distal end of the tibiotarsus to the digits was
surgically prepared with a chlorhexidine acetate
solution and was isolated with sterile field drapes.
Through a simple longitudinal skin incision
(approximately 1 cm) over the medial aspect of
the middle third of the tarsometatarsus, an
opening-wedge osteotomy was performed with
an osteotome and a hammer at the point of
maximal diaphyseal deviation. The malalignment
was corrected until the proximal and distal joint
surfaces were parallel. The osteotomy site was
stabilized by placing 2 transfixion Kirschner
wires (Biomecfnica, Jau, Brazil) percutaneously
through each bone fragment and connecting them
with acrylic bars (type II single-plane external

;-I-

Figure 2. Pelvic limbs of a toco toucan with right tarsometatarsal malunion. (a) Note the valgus deformity in the
frontal plane and caudal bowing in the sagittal plane of the right leg; (b) lateral view of the right tarsometatarsus
before the surgical procedure, and (c) the alignment of the right limb after the surgical correction.

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 RAHAL ET AL- TWO SURGICAL APPROACHES TO FRACTURE MALUNION REPAIR 325

mlJ-
I

Figure 3. Craniocaudalradiographicviews of the pelvic limbs of the toco toucan described in Figure 1: (a) before
surgery,showing mid-diaphysealmalunion of the right (R) tarsometatarsuswith 26c valgus compared with the left
(L) tarsometatarsus;(b) 15 days after surgery;(c) 62 days after surgery;(d) immediatelyafter fixator removal;and (e)
5 months after fixator removal.

skeletal fixator) (Fig 2c). The wires were placed
by using a manual hand drill in a medial-to-lateral
direction, initiating with the most proximal and
most distal to the fracture site and not through
the primary incision. The wire diameter (1 mm)
did not exceed 20% of the bone diameter. The
wire ends were bent over to improve the bond
between the pins and the cement (Jet acrilico,
Artigos Odontol6gicos Classico Ltda, S5o Paulo,
Brazil), and a saline solution drip was used on the
fixation wires to dissipate heat generated during
acrylic polymerization. The skin incision was
closed with nylon monofilament 4-0 suture in a
simple interrupted pattern. Enrofloxacin (20 mg/
kg IM; Flotril; Schering-Plough, Cotia, Brazil)
was administered after anesthetic induction and
continued orally for 4 days.
The bird presented full-weight bearing on the
right foot approximately 24 hours after surgery.
Fifteen days after surgery, additional survey
radiographs were taken (Fig 3b). The bone
alignment was maintained, and little evidence of
periosteal callus formation at the fracture site was
observed. The articular space of the right hock
joint was similar in both compartments. The bird
struck the external fixator on the ground fre-
quently, and, 62 days after surgery, the fixator
was removed. The external fixator had displace-
ment close to the medial surface skin, but limb use
had not been affected, and no evidence of
drainage from wire-tract sites was observed.
Radiographs showed the healing of the osteotomy
site, with the presence of a lucent area in the
medial cortex (Fig 3c and d). After removal of the
fixator, the bird showed full functional use of
the limb, and all joints had full range of joint
motion.
Radiographic and computed tomographic (CT)
studies were performed 5 months after fixator
removal by using the same anesthetic protocol
previously described. Sequential transverse imag-
es of the pelvic limbs were done on a helical
scanner (Shimadzu SCT-7800CT, Kyoto, Japan),
with the bird placed in dorsal recumbency. The
scanning parameters were 120 kVp, 110 mA, 1.0-
mm-thick slices, pitch 2.0, and 1 s/rotation. The
images were reconstructed with Voxar 3D soft-
ware (Voxar, Framingham, MA, USA). The bone
alignment had not changed, but the lucent area
was still visible in the medial cortex of the
osteotomy site on the craniocaudal radiographic
view (Fig 3e). The CT imaging showed that this
area was correlated with a depression of the
contour of the cortical surface of the bone, but
the cortical bone was intact (Fig 4). The wire
tracts were not seen in either the radiographic or
the CT examination.
Case 2
A free-ranging adult, 0.9-kg, unknown sex,
southern caracara (Caracara plancus) was exam-
ined because of a severe deformity of the right
wing. According to a zoo veterinarian, the bird
had been captured from the wild a few months
before because it was unable to fly. In spite of the
disability, the body condition was very good. For
physical examination and to take radiographs, the
bird was anesthetized with ketamine (22.5 mg/kg
IM) and midazolam (0.15 mg/kg IM). A varus
deformity of the right radius and ulna, with no
evidence of crepitus and luxation of the carpal
joint, was detected on palpation. Results of whole-
body ventrodorsal radiographs revealed malunion

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326 JOURNALOF AVIANMEDICINEAND SURGERY

a b c
Figure 4. Tridimensionalcomputed tomography views of the right (R) and left (L) pelvic limbs of a toco toucan 5
months after fixator removal. Observe a depression of the contour of the cortical surface of the bone in the
osteotomy site (arrow) but with an intact bone cortex.

at the junction of the proximal and middle thirds
of the radius and ulna, with deformity of
approximately 760 (Fig 5).
To surgically correct the fracture malunion, the
bird was premedicated with ketamine (22.5 mg/kg
IM) and midazolam (0.15 mg/kg IM). General
anesthesia was induced with isoflurane adminis-
tered by a face mask. Once anesthetized, the bird
was intubated with a noncuffed endotracheal tube
(11-cm long and 2-mm internal diameter) and was
maintained with isoflurane. Brachial plexus local
anesthesia was performed with lidocaine 2%
(10 mg/kg SC) plus bupivacaine 0.25% (1.25 mg/
kg SC). The heart rate was monitored with an
electrocardiogram monitor (SDM 2000, Dixtal,
Sto Paulo, Brazil). Lactated Ringer's solution
(10 ml/kg per hour IV) was administered through
a catheter placed in the left basilic vein through-
out the surgical procedure. The caracara was
positioned in left lateral recumbency on a heating
pad with the right wing extended. The feathers
were removed from the antebrachium, and the
surgical site was prepared routinely for sterile
surgery. A chlorhexidine acetate solution was
used for skin disinfection. A dorsal surgical
approach to the radius and ulna was made
according to the method described by Orosz et
al.'6 The skin was incised longitudinally on the
dorsal aspect of the right ulna in the deformed
area. The muscles and tendons of the extensor
metacarpi radialis and the extensor metacarpi
ulnaris and supinator and ectepicondyloulnaris
muscles were retracted, and secondary remiges
were removed to expose the bone diaphysis. A
closing-wedge osteotomy was performed at the
point of the greatest deformity of the ulna and
radius by means of an oscillatory bone saw
irrigated with 0.9% saline solution. The bone
wedge was stored in blood-soaked gauze. The
osteotomy sites were stabilized through a bone
plate (45-mm long, 5-mm wide, 2-mm thick, 6
round holes) (Cruz Alta Company, Fernand6po-
lis, SP, Brazil) fixed cranially on the ulna with 6
cortical screws (2.0-mm diameter) (Cruz Alta
Company), with 3 proximal and 3 distal to the
osteotomy site, and an interfragmentary single
wire was placed in the radius. Autogenous bone
graft obtained from the wedge of the ulna was
packed in the ulna osteotomy site. The muscles
were closed with a simple continuous suture, and
the skin incision was closed with a simple
interrupted pattern by using nylon monofilament
4-0 suture. Antibiotic therapy with enrofloxacin
(20 mg/kg IM) was begun immediately after
anesthetic induction and continued orally for
4 days. A figure-of-eight bandage was placed on
the right wing, and the wing was bandaged to the
body for 15 days.
Immediate postoperative radiographs showed
correction of bone malalignment (Fig 6a). A
lucent zone was apparent in the ulnar fracture
site 2 months after surgery, and loosening of 1
screw close to the fracture site was observed
(Fig 6b). At 5 months after surgery, the radius

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 RAHAL ET AL- TWO SURGICAL APPROACHES TO FRACTURE MALUNION REPAIR 327

Figure 5. Whole-body ventrodorsal radiographic view of a southern caracara, showing malunion fracture at the
junction of the proximal and middle thirds of the right radius and ulna.

t*1
Figure 6. Lateral radiographic views of the right radius and ulna of the southern caracara: (a) immediately after
surgery, showing the correction of bone malalignment; and (b) 2 months after surgery, showing a lucent zone at the
ulnar fracture site, and loosening of the 1 screw proximal to the fracture site.

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328 JOURNALOF AVIANMEDICINEAND SURGERY

Figure7. Whole-body ventrodorsalradiographicview of the southern caracarain Fig 5, showing fracturerepair of

the radius and ulna and the absence of the manus.

was healed, but a fracture line was still evident in
the ulna. The ulna fracture had healed by 8
months after the surgery. However, the bird was
not aesthetically acceptable for exposition, be-
cause the wing feathers remained malpositioned
because of luxation of the carpal joint detectable
only by palpation. To remove all primary remiges
(n = 10), the manus was amputated by disartic-
ulation between the radial carpal bone and
metacarpal bones, and between the ulna and
ulnar carpal bone (Fig 7). The surgical procedure
was performed with the bird under general
anesthesia by using the same protocol, as
previously described. At the final evaluation,
10.5 months (Fig 8) after the first surgery, the
bird showed a good cosmetic appearance, and it
was reintroduced into the exhibition area of the
zoo.
Discussion
In both cases, the malunion fractures induced
disability and required treatment. In case 1, a single
transverse osteotomy was performed, which al-
lowed rotational, angular, and lengthening correc-
tions.4 The cortex is opened on the concave surface
to correct the axial deformity and the resulting
wedge-shaped gap is usually filled with cancellous
bone graft.2,4,5This osteotomy is considered less
stable and requires longer to heal because of the
gap.3 Despite this, no bone graft was used in this
case because young patients usually have good
healing potential.2 However, a depression in the
contour of the medial cortical surface at the
osteotomy site was observed in the 3 dimensional
CT imaging 5 months after frame removal. The
bone healing probably was not sufficient to fill the
gap uniformly between the ends of the osteotomy.
The closing-wedge technique, as used in case 2,
removes a predetermined wedge of bone from the
point of maximal deformity.2,4,5 It is considered
relatively simple but results in some shortening of
the bone.2-4 The limb length was not a concern in
this case, given that the bird would not be
released into the wild, the contracture of the soft
tissue was significant, and closing-wedge osteot-
omy provides faster healing than an opening-
wedge osteotomy because of maximizing bone-to-

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 RAHALET AL-TWO SURGICALAPPROACHES
TO FRACTUREMALUNIONREPAIR
Figure 8. Final cosmetic appearance of the southern
caracara after treatment of the malunion fracture.
bone contact.4 For these reasons, the closing-
wedge method was considered the best option.
The external skeletal fixation was used to fixate
the osteotomy site in case 1 because the tarso-
metatarsus bone has little soft-tissue coverage,
requires minimal surgical exposure, and allows
early return to function. In addition, it does not
damage articular or periarticular structures, and
rotation and shear forces are countered.9 A type
1A hybrid external skeletal fixator was used
successfully to stabilize an opening-wedge osteot-
omy performed on an adult bald eagle with distal
tibiotarsal varus malunion.'" Although a type II
splint has disadvantages, such as increased weight
and the size of the apparatus, this configuration
offers rigidity and reduces torsional forces neces-
sary to maintain the bone alignment,'0 as
observed in case 1. The displacement of the
external fixator probably occurred because the
bird frequently touched it on the ground, which
stimulated loosening at the pin-bone interface. In
addition, some loosening should be expected
because of thin cortical bone, and Kirschner
wires are not threaded.9,10However, the implant
provided stability for bone union to occur by
indirect bone healing.
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329
In case 2, a bone plate and screws were used
because rigid stability, anatomical alignment, and
lack of interference with joint movement are
provided with the bone plates.2'9Despite difficulty
of screw purchase because of thin and brittle bone
cortices in birds, veterinary cuttable plates were
successfully used, with or without intramedullary
polymethylmethacrylate.8,14,"6 The plate used in
case 2 was lightweight, small in size, and has
closely arrayed screw holes like a cuttable plate.
Although autogenous bone graft from wedge
bone was used to stimulate fracture healing, a
lucent zone was apparent in the ulnar fracture site
2 months after surgery, and total healing was
observed only 8 months after surgery. Autoge-
nous callus was used in a red-tailed hawk with a
tie-in fixation for repair of a humeral cortical
defect that may have been assisted by woven bone
deposition.'2 Fracture stability, blood supply, and
the presence of infection are factors that may
affect bony union.9 No signs of infection were
observed in case 2. However, the blood supply
may have been compromised during elevation of
the muscles and osteotomy procedure, or from
original trauma. In addition, axial compression at
the fracture site was not achieved because of the
geometry of the round holes. In human patients,
corrective osteotomies performed in the diaphy-
seal area have a tendency to slow or delay
healing,6 and this may also occur in birds. The
loosening screw observed radiographically in case
2 was not identified on palpation, nor was the
plate. Because an extensive surgical approach
would be necessary, the plate was not removed. In
addition, cold conduction caused by the plate8'9
was not a concern because of the warm climate of
the region.
Because immobilizing the carpal joint luxation
did not maintain the reduction, the manus
amputation was considered the best option for
cosmetic appearance in case 2. An arthrodesis of
this joint could be another option to test whether
the bird could be released into the wild. Full flight
capacity was restored in 2 raptors with luxation
and fracture of the metacarpophalangeal joint
treated by arthrodesis supported by a type I
external skeletal fixator.'7 In conclusion, the
surgical methods adopted in these cases improved
limb function and enabled the ability to return to
activity in captivity.
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