FRACTURE MANAGEMENT IN BIRDS Jurnal Orto 3

Fracture Management in Birds
Author(s): R. Avery Bennett and Alan B. Kuzma

Source: Journal of Zoo and Wildlife Medicine , Mar., 1992, Vol. 23, No. 1 (Mar., 1992),
pp. 5-38
Published by: American Association of Zoo Veterinarians
Stable URL: http://www.jstor.com/stable/20460265
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Journal of Zoo and Wildlife Medicine 23(1): 5-38, 1992
Copyright 1992 by American Association of Zoo Veterinarians
REVIEW ARTICLE
FRACTURE MANAGEMENT IN BIRDS

R. Avery Bennett, D.V.M., M.S., and Alan B. Kuzma, D.V.M., D.V.Sc.
Abstract: Fracture repair in birds often presents a significant challenge to the veterinary surgeon.
Bird bones have been described as brittle with thin cortices that do not hold implants well. The
joints of birds appear to be particularly susceptible to ankylosis as a result of implant associated
trauma. Avian fractures are often open and frequently comminuted, especially in wild birds and
zoo specimens. In many cases, nearly perfect return to function is required for the patient to be
released or displayed. Many times the bones are small and the patient is fractious and prone to self
trauma.
External coaptation (slings, bandages, and splints) has long been a part of avian fracture man
agement. Intramedullary pins are commonly used in avian orthopedics. Newer intramedullary
techniques include the use of polypropylene rods and polymethylmethacrylate with or without
reinforcement with a polymer rod. Bone plating techniques with or without intramedullary poly
methylmethacrylate have recently been used in avian patients. Many modifications of the traditional
external skeletal fixation splints (such as Kirschner-Ehmer splints) have been developed, making
their application practical even in very small patients.
Key words: Avian, orthopedics, external coaptation, intramedullary pins, bone plates, external
skeletal fixation.
INTRODUCTION of their high calcium content. 0 19 38'58,62 The

Over the past 10 yr, great advances have avian humerus and femur are pneumatic,
been made in techniques for repairing frac which helps decrease body weight to aid
tures in birds. Not long ago, external coap flight and aids respiration and humidifica
tation was essentially the only method of tion of air. However, they have a large med
fracture stabilization routinely recommend ullary canal.'5 Bird bones tend to fragment
ed for avian patients.19'61 With recent tech or shatter upon impact, and many of the
nical advances, surgeons are now attempt bones of the distal extremities of birds have
ing to repair more challenging and difficult little soft tissue support and are covered only
avian fractures and have a more predictably by tendons and skin. Fragments can become
successful outcome. Classically, avian bones detached from their soft tissues and blood
have been described as brittle with thin cor supply.36'57 These factors contribute to a high
tices that do not hold implants well and with incidence of open, comminuted fractures
large medullary canals that are difficult to and make iatrogenic fracture during repair
fill without adding excessive weight to the attempts a significant concern.
affected bone. 9,15,19,36,38,39,41,62,80 Yet, there are
In discussing fracture treatment, it is im
many reports of successful treatment of avi portant to use accepted terminology.2'24'28
an fractures with nearly every type of fixa External coaptation refers to stabilizing a
tion used in mammals. fracture with a sling, splint, or other type of
Avian bones are thin and brittle because bandage. Internal fixation refers to the sur
gical implantation of stabilization devices
such as intramedullary (IM) pins, cerclage
From the Veterinary Medical and Surgical Group of
Ventura, 1195 South Wells Road, Ventura, California wires, and bone plates. External skeletal fix
93004, USA (Bennett); and 17-1278 Emery Place, North ation (ESF) refers to the use of fixation pins
Vancouver, British Columbia V7J 1 R3, Canada (Kuz that are inserted transversely into the bone
ma). Present address (Bennett): San Francisco Zoolog
ical Gardens, 1 Zoo Road, San Francisco, California percutaneously and are then connected by
94132, USA. some type of bar external to the body.
5

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6 JOURNAL OF ZOO AND WILDLIFE MEDICINE
an indication of dehydration, and fluid ther

PERIOPERATIVE MANAGEMENT
apy should be instituted.3" Blood transfu
Most avian patients are undersions severe
are best stress
made from donors of the same
after a fracture occurs both species; because ofheterologous
however, the transfusions
initial trauma and the additional with chicken
stressor pigeon
of blood appear to be
safe and efficacious.31
restraint and handling.15'18519733541857,58,80 Frac
ture assessment and repair should Serum uricbe acid
post of >30 mg/dl is an in
poned until the patient is stable dication
andofalldehydration
life (prerenal) or renal
threatening problems have been disease.4' The PCV and TS can help deter
addressed.
The initial examination should be as or
mine whether atrau
not primary renal disease
matic as possible and should include
is a factor. Surgery heshould be postponed un
mostasis, shock therapy, and temporary
til the patient is adequately hydrated. Pa
support for any fractures. Dexamethasone tients with a TS of <2 mg/dl are usually
sodium phosphate at 0.5-1.0 mg/kg i.v. and
severely debilitated, and a poor prognosis
a balanced electrolyte solution for at recovery
60-90shouldml/be offered.4'
kg during the first hr have been Respiratoryrecom
recovery time is the time it
mended for treatment of shock.'5"16"18"19'57 takes a bird to return
The to a prestressed re
bird should be maintained in aspiratory warm, ratedark,
following restraint and 2 min
quiet environment. Surgery may of handling.3'
need to A return
be to normal respira
delayed for several days while tionthe
in 3-5patient
min indicates respiratory sta
stabilizes. bility sufficient for most anesthetic and sur
Once the bird has recovered from shock, gical procedures.
all limbs should be evaluated for neurologic Serum AST, LDH, and cholesterol may
dysfunction, fractures, and luxations. be helpful in evaluating preoperative status.
Wounds associated with open fractures Of 54 birds used in a study of various an
should be cleaned, and necrotic soft tissue esthetic agents, three deaths occurred of
and bone should be debrided.63 5'67'69'80 Os which two were birds with preanesthetic se
teomyelitis is probably the most significant rum AST levels >650 IU/L, LDH >600
threat to fracture healing.67'69 Broad spec IU/L, and cholesterol > 700 mg/dl.3 32 Oth
trum therapeutic antibiotics should be in er birds had this level or higher of serum
stituted pending results of culture and sen AST and LDH but not in combination with
sitivity. Amoxicillin at 50 mg/kg b.i.d. or a high cholesterol level.
gentamicin at 8 mg/kg b.i.d. have been rec The bird's nitrogen balance should also
ommended. 16,63,64,80 Enrofloxacin at 10 mg/ be addressed, especially in wild birds that
kg b.i.d. may provide a better spectrum of may not have eaten for several days prior
activity than amoxicillin or gentamicin. to presentation.'5'57,67'77'80 Changes in body
Preoperative whole body radiographs weight can be used to monitor nutritional
should be made to assess any fractures and status.80 In a properly hydrated patient, if
luxations, as well as to evaluate the lungs, body weight increases, it is a good indica
air sacs, and other internal structures. Packed tion that the nutritional status of the patient
cell volume (PCV), total serum solids (TS), is appropriate.
blood glucose, serum aspartate transami Birds have relatively little glycogen stores
nase (AST), lactic dehydrogenase (LDH), in the liver, and small birds may deplete
cholesterol, and uric acid levels should be them in 12-24 hr whereas stores in larger
evaluated.3 33'4' Patients with blood glucose birds may last 24-48 hr.3' Vomiting and
of <200 mg/dl should receive 5% dextrose regurgitation may occur if the patient is not
i.v.31'41 If the PCV is <30%, surgery should fasted and can result in aspiration pneu
be delayed or a whole blood transfusion monia. A short fast of 1-3 hr will help de
should be considered.31'4' A PCV >60% is crease the probability of aspiration pneu

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BENNETT AND KUZMA-FRACTURE MANAGEMENT IN BIRDS 7
monia and will have minimal effectsNewon Brunswick, New Jersey 08903, USA)
blood glucose intraoperatively. Addition
make it easier to assess fracture alignment,
which
ally, 5% dextrose may be administered i.v. is especially important when align
intraoperatively to help maintain the
mentpa cannot be determined by direct vi
tient's blood glucose. sualization of fragment interdigitation as
withbehighly comminuted fractures or chron
Intraoperative i.v. fluid therapy should
provided using a balanced electrolyte so
ic fractures with callus covering the fracture
ends. The patient's anesthetic status is also
lution or 5% dextrose at 10 ml/kg/hr.3'39'40'77
Perioperative antibiotics, such as ampicillin
easier to monitor when respiratory move
at 80 mg/kg i.v., should be administeredmentsif can be observed under a clear drape.
the patient is not already on therapeuticCaseous
an material should be debrided from
tibiotics.31139'65'66 High-potency very chronic,
broad infected fractures before any at
spectrum antibiotics should not be usedtemptfor to stabilize the fracture is made; this
prophylactic perioperative therapy unlesspurulent material can interfere with healing
specifically indicated.3' and predispose the fracture to a non
Because of the devastating consequencesunion.67,69,80 The tissues must be handled
of osteomyelitis, standard aseptic patient
gently because excess tissue manipulation
preparation is essential. Also, loss ofwillbodydamage the blood supply and increase
heat must be minimized during anesthe the incidence of adhesion formation and os
sia.'5'31'33 Patient preparation with excessive
teomyelitis or nonunion. 15,57,80
amounts of water or alcohol can predispose Postoperatively, wounds should be
dressed, external fixation devices padded,
the patient to hypothermia. Feathers should
be plucked to a distance of 2-3 cm around antibiotics given as indicated, and the pa
the surgical site and around the entry andreturned to its warm, dark, quiet en
tient
exit sites for any pins. 1663-65'77 Plucked vironment.
feath Recovery from anesthesia may
ers are replaced quickly in undamaged be fol
aided by intermittently turning the pa
licles. Plucking flight feathers should beand administering i.v. fluid therapy to
tient
avoided, as this can damage the follicle promote
re the renal excretion of some in
sulting in the growth of malformed feath jectable anesthetic agents.3' The nutrition
and hydration status should be closely mon
ers.33'69 If feathers are cut, they are replaced
only during the normal molt cycle. Many itored and supported using i.v. fluid therapy
birds only molt once a year, so cut feathers
and force feeding as necessary.'5"194' Activ
may take a very long time to be replaced. ity can be limited by confining the patient
Flight feathers are molted one at a time toand
a small cage and adjusting the photope
require the support of the two adjacent riod. Radiographs should be made every 2
4 wk to assess bone healing.33'4"6365 Once
feathers for proper growth. If the adjacent
flight feathers have been cut, the pulpyfracture
blood healing has begun, active and pas
feather is exposed and susceptible tosive traurange of motion activity should be
ma. The skin of birds is very fragile gradually
and increased. The assistance of
tears easily. In areas where the skin hastrained
been rehabilitators is very useful when
damaged or torn, the feathers may be working
cut with birds that must recover the
ability to fly.
to avoid further injury to the skin.65 Water
soluble gel, masking tape, and stockinette
may be used to keep down and contour BONE HEALING
feathers under control. Bone healing in birds is not well under
The affected limb may be draped with a Limited information is available, and
stood.
no controlled studies on bone healing under
sterile stockinette or a sterile clear plastic
conditions of rigid stabilization have been
adhesive drape.33'77'80 Transparent drapes
reported. The rate of fracture healing ap
(Incise, Johnson & Johnson Products, Inc.,

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pears to depend on the amountpneumatic

of displaceand medullary avian bone
ment, the integrity of the bloodnot been the
supply, well documented. Blood supp
a boneof
presence of infection, and the degree ismo
apparently derived from the
tion at the fracture.28 osteal, medullary, metaphyseal, and e
Although studies documenting ysealthe oc vessels.57 The nutrient a
blood
currence of primary bone healing supplies the medullary and endosteal
in birds
are lacking, primary bone healing
sels, in mamare the primary blood suppl
which
mals occurs under conditions of rigid
the fixa The periosteal vessels rec
diaphysis.
tion and results in bony unioncontributions
through di from vessels of the surro
rect growth of Haversian systems ing musculature
across the and soft tissues. The
extensive
fracture with minimal or no external anastomosis between the e
callus
developing. Primary bone healing tealdoes
and not
periosteal vessels. Histologic
callus
occur if there is a gap or motion at the formation
frac appears to develop f
progenitor
ture site. In one study with birds, minimal cells of the endosteum, p
teum,
callus was produced in six of eight and surrounding connectiv
fractures
repaired with bone plates indicating possi
sues.19'58 Endosteal callus, even in the p
ble primary bone healing.39 matic humerus, contributes slightly mo
healing
When rigid immobilization and than does periosteal callus. In
excellent
anatomic reduction do not exist,estingly, the endosteum is not normally
bone heals
sualized
by secondary bone healing.3 Secondary between the bone and the ai
bone
healing is characterized by stages of induc
lining the humerus under light microsc
tion, inflammation, soft callusClinically,
formation, avian bones seem to heal fa
than mammalian
hard callus formation, and remodeling. Fac bones; well-aligned s
tors at the fracture site, including bone mor
fractures heal in about 3 wk.'6"9'57'58'78 In
study
phogenic protein, stimulate callus with 20 pigeons (Columba livia
produc
tion. Fibroblasts proliferate andvolving fractures of various bones tr
osteogenic
cells from the periosteum and endosteum
with different types of fixation, 18 wer
migrate to and proliferate at theically stable with radiographic eviden
fracture
site. Collagen and mucopolysaccharides
callus at 3 are
wk."8 By 6 wk, there was com
osseous
produced, and calcium is deposited in union
the radiographically. Fra
severity
callus. This soft callus is gradually affects the rate and course of
convert
ed to woven bone by enchondral healing.62
ossificaRadiographic evidence of
tion. Eventually, a trabecular healing
pattern may
de lag behind clinical fracture
velops and bone trabeculae may bebility, indicating that implants can ofte
observed
safely
crossing the fracture. In the stage removed before there is radiogra
of remod
evidence
eling, there is a slow change in the shapeof
ofcallus formation. 1958'61
the bone due to an acceleration Boneof thehealing
nor was studied in pigeon
which fractures
mal process of deposition and resorption of were manually creat
bone. During this stage, function and or antebrachium and no
the humerus
of stabilization
strength are restored to the fractured bone. was provided.'9'58 The
The method of callus formation mally radiolucent
and the medullary canal of
pneumatic
contribution of endosteal and periosteal cal humerus became more den
diographically
lus in birds appears similar to that in mam over time, first becau
hemorrhage
mals.19'58 Endosteal callus is responsible for then because of connectiv
sue and
the rapid rigid support in well-aligned endosteal callus. By 9 wk pos
stable
ture,
fractures, whereas periosteal callus both endosteal and periosteal c
provides
were evident
secondary support and is not extensive un radiographically and his
ically. Callus
less there is motion at the fracture.16 The consisted of cancellous b
periosteal and endosteal blood supply and
cartilage, of fibrous connective tissue.

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
ther the ulna only or into both the radius

lus formation was better developed in ulna
fractures than humerus fractures either and be
ulna. No external coaptation was used.
In those birds where only the ulna was
cause the humerus is pneumatic or because
there is a greater degree of instabilitypinned,
and osteotomy healing was similar to
displacement with humerus fractures. Some
that in the first group, which had received
researchers have indicated there is a differ
only an osteotomy of the radius. After 3 wk,
the wings were palpably stable; however,
ence in the healing rate between pneumatic
and marrow-containing bones;58 however,
based on histologic evaluation, the radius
appropriate controlled studies are lacking.
had healed but the ulna had not. After 4 wk,
After 16 and 21 days, the amount ofthere canwas callus at the ulna osteotomies, and
cellous bone in the callus increased and
by 5car
wk both radius and ulna were healed
tilage and connective tissue decreased. This radiographically. When both the radius and
process of callus maturation appearedulna to were
be pinned, the healing of the radius
slower in humerus than in ulna fractures, was faster than when treated either with ex
lagging approximately 10 days. At 6 and ternal
12 coaptation or with the ulna only
wk postfracture, the callus of well-aligned pinned. However, healing of the ulna was
fractures continued to mature and began similar
to to that when the radius was not
develop the components of normal bone, pinned. Functionally, these birds did not fly
whereas unstable, poorly aligned fractures as well as those treated with external coap
appeared to change little between 4 and 12The study did not detail the methods
tation.
wk. of pin insertion but indicated the pins were
In another study on bone healing, three placed through the soft tissue around the
groups of pigeons were evaluated.61 Oste joints, which is likely to have affected flight.
otomies of the radius only or the radius and Vascular and avascular segmental frac
ulna were stabilized using external coapta tures of the radius were created and stabi
tion in one group. Healing progressed rap lized with an IM pin of unspecified diameter
idly with good alignment in those birds with in the third group of pigeons. Vascular seg
only an osteotomy of the radius. At week mental fractures healed similarly to the oth
3, motion was no longer palpable at the os er radius fractures described. Where a seg
teotomy site and endosteal callus was first ment of devitalized radius was created, callus
observed histologically. However, radio bridged around the segment by week 4. The
graphically the osteotomies did not appear segment then lost density and became in
healed. At 5 wk postosteotomy, there was corporated into the callus. Remodeling con
evidence of complete healing radiographi tinued beyond 18 wk.
cally and histologically. In birds with both This study confirmed that fracture heal
radius and ulna osteotomies, motion at the ing in birds proceeds more rapidly and with
fracture site persisted until 5 wk postosteot less callus if the fracture is more rigidly sta
omy, when there was also radiographic ev ble. The difference in the rate of healing
idence of callus formation. The callus was between the radius, ulna, and humerus was
composed of cancellous bone and was easily attributed to the varying degrees of dis
broken by torsion or bending force. After 8 placement and instability. Segmental frac
wk, the osteotomies were more stable and tures that have a viable blood supply should
there was histologic and radiographic evi heal as rapidly as a simple fracture. There
dence of callus remodeling. Birds in this fore, vascular attachments must be pre
group were able to fly 4-6 wk after removal served when repairing comminuted frac
of the coaptation. tures. However, devitalized segments should
In the second group, osteotomies of the still be incorporated into the repair to pro
radius and ulna were stabilized with an IM vide structural support. Union may be de
pin of unspecified diameter inserted into ei layed, but the fragments will be incorpo

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rated into the callus unlesseach

infection
bone fragmentis has healed, although
present. not to its other end. Treatment consists of
Disruption of the air sac as occurs with a establishing rigid fixation with compres
fracture of a pneumatic bone and leakage of sion, to shorten the fracture gap if possible,
air into the fracture site should be consid and bone grafting. Rigid and stable fixation
ered contamination. However, this does not is the most important aspect of treatment.
appear to predispose fractures of pneumatic Any infection present must also be treated.
bone to the development of osteomyeli Constant direct electrical current has been
tis.l9,58 The minimal amount of emphysema used to treat a nonunion fracture in a rough
occurring after the fracture of a pneumatic legged hawk (Buteo lagopus).50 Approxi
bone resolves within 24 hr. Osteomyelitis mately 6 mo after sustaining a fracture of
does not appear to cause systemic illness in the mid-diaphyseal radius and the distal ulna,
birds.6180 When infection is present at a there was no evidence of bone healing based
fracture, the site becomes filled with caseous on a radioisotope scan. A direct current bone
material and the bone ends become necrotic stimulator (Osteostim, Division of Telec
and sclerotic.6' In many instances, the callus tronics Proprietary, Ltd., 8515 East Or
may bridge around the caseous debris and chard Road, Englewood, Colorado 801 1 1,
unite the fracture. However, if the caseous USA) was implanted s.c. over the pectoral
plug is large enough, it will prevent fracture muscles with the cathode tunneled to the
union. A similar phenomenon occurs with site of the distal ulna fracture and threaded
sequestra.61,80 Frequently, the callus will through the fracture. The unit was designed
bridge the sequestrum and unite the frac to deliver 0.83 volts at 20 ,A. After 21 days,
ture. If this occurs, the area can be surgically there was evidence of callus formation both
opened, debrided, and curetted to allow radiographically and on bone scan. At 84
complete healing. days, the fracture was determined to be
Fracture nonunion can be classified as vi healed, as evidenced by the smooth bridging
able or nonviable.7 A viable nonunion frac callus, and the device was removed. These
ture may be hypertrophic, slightly hyper devices are expensive but may be beneficial
trophic, or oligotrophic. An oligotrophic in the treatment of nonviable nonunion
viable nonunion shows no evidence of cal fractures in birds.
lus but is biologically capable of healing.
The fragments are hypervascularized and BONE GRAFTS
with time the fracture ends become rounded The cellular events and benefits of can
and decalcified. Hypertrophic nonunions cellous, cortical, and corticocancellous bone
have abundant callus and blood vessels but grafting have been well established in mam
the fracture gap is filled with fibrocartilage. mals.74 They probably function similarly in
Inadequate stabilization and premature avian fractures. Bone grafts promote frac
weight bearing are the primary causes of this ture healing by three mechanisms. Osteo
type of nonunion. Nonviable nonunion genesis refers to the production of new bone.
fractures differ in that the blood supply is Surface cells that survive the transfer are
inadequate to allow fracture healing. The able to produce new bone. Cancellous bone
older terminology of vascular and avascular has a much larger surface area than does
nonunions is inappropriate because most cortical bone, thus providing more viable
nonunions formerly classed as avascular cells for new bone production. In studies
were actually oligotrophic viable nonunions with rat autogenous cortical grafts, 50% of
with an adequate blood supply. new bone production was from endosteal
All types of nonunions occur in birds.69 cells, 30% from periosteal cells, and only
With nonunion, the bone fragments will not 10% from osteocytes.30
unite without surgical intervention because Osteoinduction refers to the recruitment

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
humerus
of mesenchymal cells to differentiate into fractures,5' and healing was eval
chondroblasts and osteoblasts. This uated
process for 168 days. Grafts neither contrib
uted to nor inhibited bone healing. Frac
is modulated by a hydrophobic non-spe
cies-specific glycoprotein called bone mor
tures supported by a graft appeared to heal
phogenic protein (BMP). This protein does callus, primarily because the graft
with less
not require viable donor cells, andmaintained
its ac fracture apposition and align
ment.
tivity has been demonstrated in grafts Although there was no significant dif
that
have been prepared by methods that kill in bone healing, there was a signif
ference
icant increase in incisional dehiscence,
cells but do not destroy proteins. Freezing,
freeze-drying, and decalcifying do sequestrum
not de formation, and foreign body re
stroy BMP, however autoclaving does. action compared with nongrafted fractures,
Osteoconduction describes the three-di
regardless of whether a xenograft or an al
mensional process of capillary, perivascular
lograft was used. Although grafts often se
questered,
tissue, and osteoblast ingrowth from the host segments of the graft were able
into the structure of the graft. The graft,
to take part in the fracture repair process,
therefore, provides structural and mechan
and the graft was incorporated into fracture
ical support. Osteoconduction is not ran by appositional new bone growth
healing
dom but follows an ordered spatial and pattern
graft resorption. Cortical bone grafts are
called creeping substitution. probably best used for fracture stabilization
Autogenous bone grafts have been andbenshould not be expected to make a major
eficial in avian fracture repair.62'69'73 In
contribution to bone healing.
working with mammals, sources of cancel More commonly, corticocancellous grafts
lous bone are abundant. In birds, the arelarger
used in birds. The sternum is the most
long bones (femur and humerus) are pneu available source of corticocancellous
readily
matic and do not contain significant bone.49'53 The graft is harvested after ele
amounts of cancellous bone. The more vating disthe pectoral muscles bilaterally. The
tal bones of birds are often very narrowcentral
and portion of the carina sterni is re
not good sources of cancellous bone. How leaving a bucket-handle remnant to
moved,
which
ever, in large birds and terrestrial birds, thethe pectoral muscles are reattached.
An alternate source of corticocancellous
proximal tibiotarsus may provide adequate
bone is the last one or two ribs.69 When
quantities of cancellous bone for grafting.40
Cortical grafts are especially valuable in
harvesting rib grafts, the inner periosteum
providing structural support where must large
be preserved to avoid invading the air
cortical defects exist and have been used
sac, which can result in subcutaneous em
physema. Corticocancellous bone may be
successfully in birds.' 161 Avascular cortical
bone contributes to the formation ofused bridgfor onlay grafting or cut into fragments
with rongeurs to be used around the fracture
ing callus after osteotomy of the radius.61
When working with highly comminuted site and for packing cortical defects.
fractures, small fragments that cannot be
incorporated into the repair may be placed
FRACTURE MANAGEMENT
around the fracture to function as autoge The principles of fracture treatment in
nous cortical grafts.39 Unfortunately, birds
there are similar to those established for
is no ready source of autogenous cortical
mammals and include rigid stabilization and
bone in birds. anatomic alignment with minimal distur
This lack prompted a study of stored bance
cor of callus formation and soft tissue
tical allografts (same species, different in
dissection.'6'28'57'78'80 Infection must be pre
vented. Any apparatus used must be well
dividual) and xenografts (different species)
in pigeons.5' Cortical allografts and xeno by the patient, and early return to
tolerated
grafts were applied in an onlay fashion function to is critical to prevent ankylosis.

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
fractures
When normal function is imperative, as with left unstabilized may traumat
wild birds intended for release, or mutilate themselves.
fractures
In a comparison of cage confinement wit
must be repaired so that the bone maintains
external
normal length, rotation, and angular oricoaptation and ESF of experime
tally
entation.67 Practical considerations in created
frac fractures of the femur, tibi
ture management include the cost tarsus, humerus, radius, and ulna, all fr
of the
materials, ease of application, level tures treated with cage confinement healed
of return
of function required, availability However,
of equipthe functional outcome was po
ment, and the surgeon's level ofHealing was slow with excessive callus f
expertise
with various fixation devices.78mation.
The tem Significant malalignment a
perament of the patient must also be con of the limb from fracture ove
shortening
sidered. A fractious bird may require occurred.
riding ad
Fractures
ditional stabilization compared with a calm of the pelvic and pectoral (co
patient. Some birds may be prone acoid, clavicle, and scapula) girdles gene
to self
allyisheal
mutilation if any external coaptation without support.41'67'80 However
used.
Compression, rotation, bending, displaced
and shearcoracoid fractures should be trea
forces are exerted on the fractureed with
and mustinternal fixation in birds that requ
be neutralized to promote fracturenormal flight.63646680 Minimally displa
healing.57
Transverse fractures are subject toand greenstick fractures also heal well b
rotation
restricting
and bending forces. Oblique and spiral frac the bird's activity using cage co
tures experience shear, rotation,finement.18'41'52'80
and bend With fractures of the
ing forces. Comminuted fractures diusareor sus
ulna where one of the two bones
intact, treatment with cage rest will ofte
ceptible to compression, rotation, bending,
and shear forces.57 The fixation yield an acceptable outcome.65 This type
device,
fracture
whether it involves external or internal sta management is best reserved f
stable
bilization, should neutralize the inherent minimally displaced fractures or fr
forces acting on the fracture to preventin
tures mo calm, small birds where impair
limb function
tion at the fracture site. Even forces that do is acceptable.
not cause gross movement can inhibit heal
ing; slight, undetectable motion can impede
EXTERNAL COAPTATION
Many
the growth of small capillary buds fractures in birds are amenable
across
the fracture. The more forces thatrepair
must using
be external coaptation, which ha
been well
neutralized by the fixation, the higher the described and illustra
ed. 4148'4953'64'66'6980 External coaptation
incidence of complications and failure.57
most appropriate if the bird is too small f
CAGE REST internal fixation, if there is minimal fract
displacement, if there are factors that ma
Some fractures in birds heal adequately
anesthesia
with no form of fixation. The bird should and surgery especially risky,
be maintained in a small cage andif kept
the fracture
as is highly comminuted, ma
ingmay
quiet as possible. The photoperiod primary
be repair impractical.36'44849 E
ternal The
adjusted to keep the patient inactive. coaptation protects the fractured lim
and is more
cage should be small enough to prevent ex comfortable for the patien
compared
cessive motion such as wing flapping or with cage rest without coapt
tion. Because
walking around. Cage rest as a method of of the manner in which t
wing and
fracture management is inexpensive andleg fold up close to the body, fr
ture
easily accomplished. The joints of thealignment
af may be reasonable with
ternal coaptation.48'49'66
fected limb are unrestricted so ankylosis re It is an inexpensiv
sulting from joint immobilization simple method for immobilizing fracture
is unlike
requiring
ly to occur. However, excitable birds with little time and a short anesthe

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
with less risk of infection if treatingnum

closed
rods, light-weight casting material or
fractures. However, the outcome is otherusuallysubstances that will add bending sta
acceptable only if good limb functionbility
is notto the coaptation. Orthoplast (John
required. son & Johnson Products, Inc., New Bruns
wick,
Birds with fractures treated with external New Jersey 08903, USA) and
Hexcelite (Hexcel Medical, 6700 Sierra
coaptation heal but with little functional
improvement over those treated withLane, Dublin, California 94566, USA) are
cage
rest only.78 Overriding of fracture segments
especially useful. Orthoplast is a solid sheet
is a problem particularly with humerusandandHexcelite is a mesh which is available
as apull
femur fractures probably because of the sheet or a roll of various widths. Both
of the pectoral muscles and the gastrocne
materials are firm at room temperature but
mius, respectively.41'78 Malalignment, jointheated in hot water become malleable.
when
ankylosis, limb shortening, and tendonBecause
con they can be molded to conform
tractures or entrapment within excessive
closely to the shape of the limb, they make
callus frequently occur with external verycoap
effective and comfortable splints.
tation and result in poor limb func
External coaptation should immobilize
the joints
proximal and distal to the frac
tion. 15,16,19,23,28,36,38,39,41,44,52,58,62,69,80 These
clinical conditions have collectively been 52'61'69 With all slings and splints, avoid
ture.41
termed fracture disease. The resultant
obstructing
de the vent and compressing the
sternum, which interferes with respira
crease in joint function may be acceptable
for pet birds and zoo animals but birds in
tion. 15,28,62,67,69 All forms of external coap
tended for release require nearly perfect tation
limb should be monitored very closely for
function to have the best chance for any signs of vascular compromise, soiling,
surviv
al.'6'44'47'63 Fracture disease is second slippage,
only to or other problems that may re
osteomyelitis as the cause of failure in quire
aviansplint replacement.
orthopedics where a functional outcomeExternal
is coaptation of the humerus is
generally
required.67 To minimize the effects of frac ineffective in supporting open,
ture disease, the coaptation shouldcomminuted
be re fractures.62'66 The muscle pull
moved as early as possible. External coap
generally results in severe overriding of the
tation frequently requires long-termfragments, which then heal in malunion.
Proximal humerus fractures are amenable
convalescence, which can lead to secondary
complications such as bumble foot and
to treatment with external coaptation as the
stress-related death.18'44 surrounding muscle mass may provide ad
equate
Slings, bandages, and splints should not stability and prevent displace
ment.6346
be made with adhesive tape because the glue With fractures of the humerus,
the entire wing should be wrapped to the
is very sticky and may damage the feathers
and skin. When the adhesive tape is re
body. This can be accomplished using a fig
ure-8 type bandage which crosses over the
moved, some glue remains in the feathers
back and encircles both carpi cranially and
attracting soil and interfering with normal
both
preening.48'49'69 Masking tape, drafting elbows caudally.48'49 This bandage may
tape,
paper tape, and self-adhesive tape are more
incorporate only one wing, leaving the other
wing
appropriate materials. Soft, conforming free to be used for balancing. Alter
cast
padding and conforming gauze work well the wings may be bandaged to the
natively,
for padding and as a base wrap for body slings,
using two encircling wraps, one at the
bandages, and splints. The color redshoulders
should to engage the carpi and one at the
be avoided with raptors as they may be at These wraps are then connected by
elbows.
a single tape band along the dorsal mid
tracted to and pick at the bandage. External
coaptation may be reinforced with wood ap
line.48'49 A third method involves placing a
plicator sticks, tongue depressors, figure-8
alumi bandage to the wing as described

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
below, then wrapping the wing to the body.

It is important to bind the wing to the body
or adequate immobilization of the humerus
will not be achieved (Fig. 1).66
External coaptation is commonly used to
treat nondisplaced fractures of the pectoral
girdle. The three methods described above
for immobilization of the humerus may be
used to treat such fractures. Preventing NXIMA~~~~~~~~~~~~~~~~
movement of the wing will minimize move
ment at the fracture site and allow healing
to progress.
Radius, ulna, and carpometacarpus frac
tures may be stabilized by a figure-8 band
age that uses the primary flight feathers as
a splint. The tape should cross on the lateral
surface of the wing and encircle the carpus
cranially and the elbow and flight feathers
caudally (Fig. 2a). 48'49'64'86 The wing may then
be bound to the body. However, it is not a b
necessary to immobilize the wing against
Figure 1. a
the body because the elbow and carpus will
by wrappin
already be immobolized. With proximal ra one at the
dius and ulna fractures, this type of bandage the elbows.
may result in cranial overriding that can tape dorsall
force the distal segments into the basilic ar figure-8 b
both elbow
tery and vein and the radial nerve, resulting
a fractured
in vascular and neurologic compromise.48'49
With fractures of either the radius or ulna,
but not both, external coaptation generally nal coapt
results in good fracture healing with a func used in b
tional outcome.41'6667'80 cluding
A braile sling may also be used to treat 3).41,52,66
fractures of the radius, ulna, and carpo padded,
metacarpus.41'49 It consists of a strip of gauze, to curve
cloth, or soft leather with a longitudinal slit to the lev
at the midpoint. The slit is placed over the tarsus wi
folded carpus and the strips are then either gle. It is
crossed or tied medial to the humerus then splint is
wrapped around the elbow and flight feath anatomic
ers and tied again (Fig. 2b). The sling may it does n
be modified to prevent injury to the carpus, ing from
which may occur if the wing hits the walls it is a us
of the cage. A pouch of leather or padded femur.69
cloth may be attached to the slit to cover the reco
the flexed carpus.66 portant i
As with humerus fractures, it is difficult By exten
to adequately immobilize femur fractures to the t
with good anatomic alignment using exter mobilize

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
b
Figure 2. a. A figure-8 bandage applied to stabilize a fracture of the radius and ulna should encircle the carpus
cranially and the elbow caudally and should cross on the lateral surface of the wing. b. A braille sling may also
be used to immobilize a fractured radius and ulna. A long strip of cloth or leather with a slit at the midpoint
is placed with the slit over the carpus and then tied medial to the distal humerus, wrapped around the elbow,
and tied again.
tibiotarsus is easier to anatomically reduce

body with the tape lateral to the leg, over
because there is less muscle pull, and thethe synsacrum, and around the abdomen.69
spica will immobilize the joints proximal Schroeder-Thomas (ST) splints may be
and distal to the fracture. used to treat fractures of the tibiotarsus or
Femur fractures may also be treated usingtarsometatarsus. They may also be used as
an encircling bandage. The tape should pass
an adjunct to internal fixation of the tibio
over the dorsum at the synsacrum lateral totarsus by preventing rotation and allowing
the flexed leg and over the open foot, then
weight bearing to minimize the incidence of
across the abdomen and around.48 Because
bumble foot in the contralateral limb. The
of the potential for femur fractures to overconstruction and application of ST splints
ride, this technique works best if there is in birds has been illustrated.6466 The ST
minimal displacement or as an adjunct tosplint is a traction splint modified by ad
IM pinning. justing the configuration to conform to the
A modified Ehmer sling can be used toshape of the limb and the location of the
immobilize nondisplaced fractures of the fracture.2 Thus, the configuration of the ST
tibiotarsus and tarsometatarsus.41,69 Thesplint will vary with the location of the frac
tibiotarsus and tarsometatarsus are bandture. It should not be applied to maintain
all joints in hyperextension and traction,
aged together using one to support a fracture
which will predispose the limb to severe
of the other. The leg is then wrapped to the

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
a / b /
Figure 4. A Sch
formed with the
Traction is achiev
proximal and dist
to the femur (a),
bar, applying tens
of the tibiotarsus
bar and the tarsom
applying tension t
the correct d
fragments t
(Fig. 4).
For foot and tarsometatarsus fractures, a
ball bandage may be used or a syringe case
cut in half may be used as a spoon splint.41'48
For small patients, a soda straw may be cut
in half to be used as a spoon splint. Tar
sometatarsus fractures can be stabilized with
a small Steinmann pin or Kirschner wire
molded to conform to the plantar surface
of the tarsometatarsus and one of the digits,
then taped in place (Fig. 5). Light-weight
casting material can be used in larger birds.
Phalanx fractures can be immobilized by
bandaging the digit to a tennis ball or pad
Figure 3. A spica splint may be used toded dowel.48 Alternatively, a ball bandage
immobilize
fractures of the femur or tibiotarsus. The can
splint should
be used.67'69 A large ball of gauze is placed
extend to the dorsal midline and be bandaged around
in the grasp of the bird's foot. The toes are
the abdomen to immobilize the coxofemoral joint.
bound over the surface of the ball with con
forming gauze and tape. The bird can then
bear weight on the ball but the fractured
fracture disease. It should be applied with
digit is immobilized.66
the limb in a functional position Another
with ten type of digit splint is made by
cutting
sions applied to separate the joints at an x-shaped piece of flat material
each
end of the fractured bone. Proper such applica
as plastic or X-ray film.69 The splint is
placed on
tion of the ST splint requires tension on the
theplantar surface of the foot,
padded, andin
joints proximal and distal to the fracture taped to the foot. This splint

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
plants and equipment that may be very so

phisticated and expensive. Closed fractures
are much less likely than open fractures to
develop osteomyelitis. However, when in
ternal fixation is used to stabilize a closed
fracture, an open fracture is created with an
accompanying increased risk of developing
osteomyelitis or a compromise to the blood
supply to the fracture.'6'47 In avian ortho
pedics, internal fixation is often combined
with external coaptation; however, this
combination should be avoided as the neg
ative aspects of both types of repair may be
manifested.39,44
The surgical approaches to long bones of
birds have been described.48 49'53'67 Dis
placed fractures of the coracoid bone are
frequently treated with an IM pin, and the
approach to the coracoid has also been de
scribed.48'63-5 When closing the surgical
wound, the muscles may be loosely apposed
to cover the fractured bone especially if there
is question
Figure 5. A fracture of the tarsometatarsus was regarding the viability of the
bone.64'67
treated in this budgerigar (Melopsittacus undulatus) us When there is concern that sutur
ing a wire splint taped to the tibiotarsus, the
ingtarso
the muscles may contribute to joint im
metatarsus, and the digit.
mobility it is only necessary to close the
skin.53
Intramedullary
is flatter than a ball bandage but allows early pins
The application of IM pins is familiar to
return to function after the splint is removed
because the foot is maintained in a flatter,
most veterinarians. They are relatively in
standing position. The flexor muscles are provide axial alignment and
expensive,
stronger than the extensors allowing them
bending strength, and require minimal tis
to more easily overcome the stiffness cre for insertion.27'41'45'47'69'80 In
sue exposure
ated while in the bandages. most cases, their insertion requires general
anesthesia and a surgical approach to the
INTERNAL FIXATION fracture.
The best chance of anatomic fracturePins provide bending stability and align
healing and normal limb functionmentoccurs
but are not stable against rotation and
with internal fixation. Internal fixation
shear forces.'5"6"8,39,41,47,61,62,65,69,70,80 Rota
should provide rigid immobilization, ana
tional alignment is especially critical with
tomic reduction and alignment, and early
wing fractures to preserve the aerodynamics
return to function with minimal fracture
of the wing aerofoil.22'39'80 Some overriding
may occur
disease. '6'38'69 However, internal fixation re with oblique fractures due to
quires general anesthesia, which may shearbe
forces.20 Fractures that are not stable
prolonged for difficult fractures. Theoften
degree
develop excess callus, which may pre
of surgical expertise required depends on
vent normal function. External coaptation
the method of internal fixation proposed.
is often used in conjunction with IM pin
All forms of internal fixation require
ning im
to stabilize the fracture against rota

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
enough
tion and shear forces. 28,39,65,67,69,70,80 scar tissue to inhibit normal jo
How
ever, this combination frequentlyfunction.
results inIn birds not requiring return t
the development of seriousnormal complica
degree of function, some loss of
tions. 16'20,28'36'39 More appropriately, cer be acceptable. To prevent pe
bility may
clage or hemicerclage wires or ESFticular
mayfibrosis,
be pins should be inserted
they do
used to counter shear and rotation forces. not enter or exit through or nea
joint. If
A stack pinning technique using two to four an IM pin must be placed thro
pins will help prevent rotation especially
or near a joint, it should be removed as s
as it
with humerus and femur fractures.28'635 is feasible to decrease the degree
damage.
Because avian bones are relatively defiFor example, when treating a
cient in metaphyseal cancellousverely
bone andcomminuted fracture of the rad
the cortices are thin, they may andnotulna,
pro an IM pin may be inserted i
vide adequate purchase for theIM pin
ulna to maintain alignment. The w
ning;'5"16'28'39,48,49,77 however,may then be placed in a coaptation slin
controlled
Usually
studies are lacking. Partially threaded within 2 wk, the pin can be
pins
moved
may provide better purchase.63'64'70 and the wing stabilized with exter
Partially
coaptation
threaded pins do not increase resistance toalone for the remainder of
healing period.
pin pull out34 and have been recommended
It was once felt that the IM pins sho
for the treatment of humerus fractures.635
The pin should be inserted suchbethat the enough diameter to fill the m
of large
threaded portion exits the medialullary
distal canal
hu as completely as possible to p
merus, thus engaging cortical bone. vide more stability and counter shear f
Inserted
in this fashion, partially threaded es.'5',6,77
pins areHowever, filling the medullary c
may interfere with endosteal callus for
susceptible to fracture at the threaded-non
tion by
threaded junction because of the stress compromising endosteal blood
riser
ply and
effect.24'26 Further, if the goal of IM pinning may make the affected limb ex
is to counter bending force and provide ax
sively heavy. 15,16,20,28,77 In an osprey (Pand
haliaetus),
ial alignment, the pin will accomplish its avascular necrosis of the
merus distal
goal regardless of the purchase at the entry to the point of entry of
principal
and exit sites. If the pin is expected to counnutrient artery was attribute
ter shear or compression forces, occlusion
threads enof the artery by a large IM pin
gaging only one cortex would be Although
of littlethe necrosis was confirmed
value as the bone can easily slide tologically,
along the significant doubt regarding t
nonthreaded end of the pin, resulting causein
ofcol
the bone necrosis existed and
lapse at the fracture site. It is best, therefore, the cause to pin occlusion of
tributing
to use IM pins to counter bending nutrient
force and artery was speculation. An ex
sivelywires
rely on other methods such as cerclage large pin may split the bone or ca
or ESF to stabilize the fracture other iatrogenic
against ro fractures, especially if th
tation and shear forces.4' are preexisting fissure fractures.284762 C
clage using
The most significant concern when wires should be used to prevent
IM pins in the management of progression
avian frac of fissure fractures.62 Curren
it is recommended
tures is possible damage to the articular and that the IM pin fill 1/
2/3 Of the
periarticular structures.28,41,47-49,61,62,69,80 medullary canal.27,6365
This
damage can be especially seriousWhen
when describing
IM the direction of ins
pinning is combined with externaltion coapta
for IM pinning, normograde refer
tion. Pins penetrating articularstarting the pin from an external landm
cartilage
and advancing
cause damage to the articular surface and it toward the fracture
retrograde
predispose the joint to ankylosis. Even pinsrefers to inserting the pin throu
the fracture,
placed near a joint can cause deposition of the medullary canal, the cor

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
Figure 6. This long, oblique humerus fracture in a bird was treated with cerclage wires but not s
against bending force. Refracture occurred at the distal wire due to the stress riser effect.
three-point
and out the skin.24 These terms do not relate fixation Rush-type pin. When
to proximal and distal. properly applied, these pins will counter
Cross pin and Rush pin techniques majorarefracture forces. A Rush pin is spe
used exclusively to stabilize metaphyseal
cially designed to perform in this manner.
They
fractures. With the cross pin technique, are expensive and require special in
pins
are usually inserted at an acute angle nor
strumentation for insertion. However, the
same biomechanical stability can be
mograde from the medial and lateral aspect
achieved using Steinmann pins or Kirsch
of the end of the bone such that the articular
ner the
surface is spared. The lateral pin crosses wires with the Rush technique. These
fracture and exits the medial cortex pins should be cut very short to minimize
proxi
mal to the fracture and the medial pinperiarticular
cross injury.
es the fracture and exits the lateral Orthopedic
cortex wires (cerclage, hemicerclage,
and interfragmentary) are frequently used
similarly. The Rush pin technique achieves
a three-point fixation.24 The pins in areavian
in fracture management as an adjunct
to IM
serted as cross pins but do not penetrate the pin stabilization. The principles of
their
opposite cortex. Rather, they glance off theapplication have been described.45 Full
opposite cortex, bend and lodge againstcerclage
the wires should not be used as the sole
near cortex. The pins should be inserted
method at of fracture stabilization as they are
notbone
a 300 angle to the axial plane of the stable against bending force (Fig. 6).
for optimal results. The shape of the bone
They are most applicable for stabilizing long
in relationship to the pin determinesoblique
whethand spiral fractures with a length of
- 2 x the diameter of the bone. They may
er the pin acts as an IM pin or as a dynamic

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
Figure 7. A fracture of the distal humerus in a red-tailed hawk (Buteojamaicensis) was tre
type pins. This bird achieved full flight and was released after the pins were removed.
also be used to stabilize fissure fractures and

or normograde insertion from the lateral
medial epicondyle of the humerus have bee
to hold butterfly fragments in apposition.69
Hemicerclage and interfragmentaryrecommended.80
wires However, these tec
are used to neutralize rotation and shear
niques may result in severe periarticular f
forces on transverse or short oblique
brosis frac
and limited wing function. For dist
tures.69 They are also used primarily with
fractures of the humerus, a cross pin or Ru
IM pin fixation. A hemicerclage pin
wiretechnique
only is applicable, with a pin
prevents rotation in one direction serted
while annormograde from the lateral and m
dial epicondyle
interfragmentary figure-8 wire prevents ro of the humerus (Fig. 7).8
Thisimpor
tation in either direction.69 It is not technique may also be used for fr
tant for the wire to encircle the pin.
turesWith
of the proximal humerus.48'49'79
In the
all orthopedic wires used in birds, great ulna, the IM pin should be plac
care
must be taken to prevent iatrogenic frac from a point distal to the elb
normograde
tures.48 In small birds, absorbable suture
(Fig. 8).36,41,53,61,67,80 The pin should be
material can be used as orthopedic wire.69
serted approximately between the seco
Generally, the humerus should and
be pinned
third primary feather follicles distal
in a retrograde manner exiting the deltoid
the elbow. The pin is started perpendicula
to the
crest of the proximal humerus.41'67'80 bone then the angle is changed t
Nor
mograde insertion from the deltoid crest angle such that the pin will foll
very acute
distad may be performed, especially whenof the ulna. This angle shift is f
the shaft
a closed pinning technique is used.4' Ret by the gentle caudal curve of t
cilitated
rograde placement out the distalulna.
humerus
The distal ulna and carpus must n

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
area must be meticulous as the blood supply

to the distal wing is tenuous. A single artery
and vein located between the major and mi
nor metacarpal bones supply the distal wing
and feather follicles.69 If the blood supply is
damaged, necrosis of the distal wing will
result.
Retrograde insertion out the trochanteric
fossa of the femur is recommended.4152'6569
However, normograde insertion from the
trochanteric fossa distad is easily accom
plished. Normograde insertion is indicated
for closed pinning techniques52 and may be
less likely to cause entrapment of the sciatic
nerve. For distal femur fractures, a cross pin
or Rush pin technique is best.4'80 Pins are
inserted normograde from both the medial
and lateral epicondyles of the femur.
The tibiotarsus is also difficult to pin
without invading a joint surface. Normo
Figure 8. This ulna fracture in a ferruginous hawk
(Buteo regalis) was treated with an intramedullarygrade
pin pin placement from the craniomedial
proximal aspect,63-7 retrograde pin place
inserted normograde from between the second and third
primary feathers distal to the elbow to avoid ment
pene out the stifle,6>7 and retrograde pin
trating the joint surface. Note the sequestrum atplacement
the out the tarsus66'69 have been rec
fracture site.
ommended. When birds perch or fly, the
stifle is maintained in a hyperflexed posi
be penetrated. When pins are placed ret
tion.67 Because of this, a pin through the
rograde out the elbow, periarticular fibrosis
craniomedial aspect of the proximal tibia is
results in loss of range of motion.67 If a usually
pin well tolerated both while in place
is placed in the ulna retrograde, the pin must
and after pin removal. A Rush-type pin may
be directed out the caudal aspect of the ulna
be inserted entering the cortex near the end
as far distal to the elbow as possible to avoid
of the bone at either joint, thereby avoiding
injury to the articular cartilage.52'69 How
periarticular injury.67'77 It is difficult to enter
the radius without damaging a joint, butever,
in this insertion is technically difficult as
most cases, when the ulna is reduced Rush-type
the pins do not readily bounce off
radius comes into alignment. A Rush-type the cortex but, rather, tend to penetrate.
Proximal and distal fractures of the tibio
pin can be inserted into the radius through
the cranial cortex at the distal end.69 Alter
tarsus may be treated using a cross pin or
natively, an interfragmentary wire or a Rush
shut pin technique.41'80
tle pin can be inserted into fractures of the
Fractures of the tarsometatarsus and pha
radius if stabilization of the radius is langes
nec are best treated using other methods.
essary.63-65,67 There are no good points of entry for pin
Metacarpus fractures can be stabilized
insertion, and most of these fractures heal
with an IM pin.69 The pin can be inserted
readily with external coaptation. The ten
normograde from the carpus or retrogradeuous blood supply to the distal extremities
out the carpus. Normograde insertion of further
the increases the potential for compli
pin through the extensor process is morecations.
difficult, but the carpal joint will be dam
The weight of steel IM pins generally rep
aged if this is not done. Dissection in this
resents a much higher percentage of body

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
a b
Figure 9. Polyprop
through the cente
ends of the wire ar
weight IM
in poly
birds
if not wk
remove
than
flight. In mos
stainless
can be on
removed
the e
After insertio
length.
enough nique,
to dimi
th
damage but
tion lo
or
tissues.
trieval. In man
under Polypropylene
local rods provide little rota an
in the tionalskin.
stability when used alone. Rotational If
locatedstability canor be provided by inserting
if a a
was Kirschner wire or hypodermic
used, needle
gene
approach
through the near cortex,maythrough the poly b
mer rod, and out the far cortex on each side
Intramedullary
of the fracture.47-9 Unfortunately, this con p
High density
centrates stresses at the transverse pins, pre
dine disposing the bone to fracture through the
fluoride,
North pin hole.41 Rotational stability may also be
Americ
vania provided 19103,
by adding an ESF device,48,49,63,64
welding rod
external coaptation, or IM PMM. These rods (
are not as rigid as steel and may allow
companies) mi
hav
or cromotion at theIM
with fracture site, which could
pol
in thedelay healing.4'
treatme
These rods
Polymer rods are inserted using a shuttleare
13% the
technique, which can be weigh
technically difficult
available, easi
(Fig. 9).475364 Once inserted, they cannot
easily be removed. The length of rod that
sive.41,47-49 T
not need to
can be placed using the shuttle technique is be
has limited to the length of the longer
healed, 41,44fracture
a studyfragment.47-9 If one segment is short, the
with ra

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
a~~~~~~~~
Figure 10. This mid-diaphyseal fracture was treated using a

methylmethacrylate. The postoperative view shows good align
rod can only be inserted tive period.

into Birds used thei
that fragment
a short distance, which may compromise
immediately after surgery a
ercise
stability.48'49 Because the rodthe wings 7-10
reinforces onlydays la
a section of the bone,werethe stress
able to concentra
fly 14-21 days p
When used
tion and diaphyseal fulcrum as the
produced bysole m
zation,
strong motion can result this technique
in additional frac is be
aphyseal
tures at the ends of the rod.47 fractures with m
nation
In a study involving 10 and comminution.47
fractures treated
with IM polymer rodssizes
withof polypropylene
Kirschner wire rod
transfixation,47 there technique
was minimal is not applicable
fibrous
ing <75the
connective tissue surrounding g.23 Using
rods and the
no macrophages and giant cells. Evidence
nique,48,49,53 an appropriat
of infection was present in two
pylene rod fractures,
is cut to the leng
one of which went on to heal,
into the and
longer theofother
the two ma
resulted in a nonunion.mentsNo (Fig.
external
10). Acoap
hole is d
tation was used in this lystudy.
through the
In all rod near t
cases,
one or both of the transfixation
length of suture pinsmaterial
mi is
grated out of the bone as hole.
the a result
Theof pincyclic
is inserted
motion. This probably fragment andclinical
was of little the fracture
significance because it occurred
two ends ofafter the
the suture are
fracture was stabilized the
with fibrous
rod is forcedcallus.
into the o
Malalignment resulted shuttling
in those it fractures
into place. Th
where excessive activity caused
shuttled fracture
into the otherof frag
one cortex allowing the rod to
center holecome
is atout
theoffractur
that segment. an equal length of rod is pre
This technique provided good
fracture wing mo Because
fragment.
bility and function inforthesecondary fractures to
early postopera

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
convalescent period, external coaptation

cement bond by both cohesion and
sion.42'56'62
should be applied, especially with active pa These bioadhesives hav
tighter bonding
tients, severely comminuted fractures, or than PMM, are slow
polymerize, and have a lower heat o
fractures with a short fragment.47
lymerization. They have not been u
Intramedullary polymethylmethacrylate
avian fracture treatment.
Polymethylmethacrylate (Surgical Sim
Polymethylmethacrylate has been
plex-P, Howmedica, Inc., Rutherford, New
alone or in combination with other me
Jersey 07070, USA; LVC Bone Cement,
of fracture fixation in birds. It may b
Zimmer, P.O. Box 708, Warsaw, Indiana or marrow-containing
in pneumatic
46580, USA) is a nontoxic bone and
cement
maythat
also be used to incorporate fr
produces a cohesive, mechanical frictioninto the repair of comm
fragments
fractures.44'62'75
bond with the interstices of the bone. 10'36'38'62 It is light weight, rel
It is not a sticky adhesive. It is inexpensive,
packaged as fairly easy to apply, r
a liquid monomer (20 ml per stable, package)
andand
allows early return to fu
without
a powdered polymer (40 g per package) interfering
with with joint
barium sulfate incorporated in the powder
tion.9,10,38,44
Endosteal
to provide radiopacity. Because of the small callus formation and end
quantity needed when working with avianto the fracture may be
blood supply
ited by IMdi
bones, the package should be aseptically PMM, although no contr
vided into 10 sterile alloquots of 1have
studies ml been conducted. Clini
fracture The
monomer and 2 ml polymer.9 10'39'43'44 healing is not apparently a
powder contains a peroxide catalyst and the Similarly, the heat of pol
ed. 23'38'3941
liquid contains a tertiary amine, which
ization can to cause tissue necrosis and
gether speed the rate of reaction.1 62 Once
blast death but does not significantly
mixed, the reaction of polymerization is
the rate of callus formation. 1'38'62
exothermic, producing temperatures In a studyof of fracture healing,62 hum
> 1 00?C. 1,36,39,62 These high temperatures
fractures were re created and treated by
sult in osteocyte death andnal bone necro
coaptation (group 1), external co
sis. 1,36,38,62 Irrigation with cool
tionfluid is rec
after surgical implantation of a "
ommended to help dissipateof thePMMheatin of the soft tissues (group 2)
PMM
polymerization.38 39'43'44'62 During for
the internal fixation of the fr
curing
process, the PMM expands its (group volume 3%,
3). Tissue necrosis occurred t
anchoring itself firmly.69 Curing eral time
depth is of
ap 10 Am as a result of the
proximately 10 min, although of it is influ
polymerization in both groups 2
enced by many factors such as Because of this, more tissue necrosi
temperature,
continued mixing, and the observed presence histologically
of in groups 2
blood.21'3962 If the components are the
during cooled first 10 days. However, aft
to 30C, the mixture will remain daysmalleable
there was more tissue necrosis in
longer and have a slight increase 1 and in2shear
because of excessive motion
strength.4'62 Pulsating water lavage
fractureof can
when compared with group 3
cellous bone interfaces enhancesthe theIMcement
PMM maintained fracture stab
bonding, as does the addition of In aboth
solublegroups 2 and 3, the PMM
nontoxic filler such as sucrose or tricalcium
cause a tissue reaction. The PMM wa
phosphate.29 59'60'62 These fillers also by
capsulated de thick fibrous tissue, and
crease the temperature attained cellduring
foreignpo body reactions were comm
lymerization and decrease the release of freeconnective tissue-bone c
the fibrous
monomer, which can cause hypertension
interface. The thickness of this reacti
and cardiac arrest.462 Other typescreased of with
bone time. Caseation and gr

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
ma formation did not occur, and normal

reported, after the fragment was removed
hematopoietic tissue was often observed
the fistula healed without further compli
cations.
very close to the PMM. In one bird, bac
terial colonies were observed within theusing IM PMM, patient selection
When
PMM; however, no overt signs of infection
is critical. Fractures that may be treated with
were noted in any birds. No cementIM loos
PMM include corrective osteotomies,
ening was observed during the 75 days of
closed fractures, and open fractures with
the study.62 minimal contamination and no exposed ne
Bone healing in this study seemed to be
crotic bone.23'38'39 Severely contaminated
delayed when IM PMM was used.62 Thewith necrotic exposed bone should
fractures
not receive
death of osteogenic cells or interference of IM PMM. The PMM is brittle
and if used alone is most appropriate for
the PMM with callus bridging the fracture
patients weighing <500 g.44
site were proposed as possible mechanisms.
Histologically, in some locations, there was
There are two methods used to stabilize
PMM between the fracture fragments. Frac with IM PMM.9,"0'62 In one meth
fractures
ture healing resulted when the callus od,
bridged
the PMM is mixed until it is a doughy
around the interfering PMM. A collar of It is pressed into the medullary
consistency.
PMM between the fracture ends can prevent
canal of the two fragments, the fracture is
union.35,62 Therefore, PMM shouldreduced
not be and the PMM is allowed to cure.
allowed to escape from the medullaryItcanal.
is important to implant the PMM as a
Infection within the bone cement can have
single mass or lamination will occur and the
cement may fracture through this weak
devastating consequences. Once infected, the
area.62
bone cement will act as a chronic focus for
infection.38'39 Tissue necrosis and theAlternatively,
pres holes may be drilled prox
ence of a foreign body predispose tissues todistal to the fracture and the liquid
imal and
mixture injected into the medullary canal
the development of infection.62 To prevent
infection within the cement, resulting
whileinthea fracture is held in reduction.'0'62
septic foreign body reaction, various anti
This technique avoids the potential for lam
biotics have been added during the ination
mixing of the cement. It is important to
process.9'62 However, the addition place
of anti
several holes so the air can escape from
the medullary canal and be displaced by the
biotics causes a slight decrease in the strength
of the cement.62 Because of the heatbone cement.
of po
lymerization, the antibiotic used must be
heat stable. Cephalothin, gentamicin,Polymer
androds with IM PMM
Polymer rods may be used with IM
potassium penicillin have been used.38'3944
Cephalothin is most commonly used PMM.23,43,44
at 1 When IM polypropylene rods
g/packet or 100 mg/aliquot.39'44,54 areIn
used
huin conjunction with IM PMM, ro
mans, infection may occur several years
tationalafstability is achieved (Fig. 10).44
ter implantation of PMM,9 but it has Therebeen
is minimal soft tissue damage, nor
shown that the bacteriostatic effectsmal
ofjoint
thefunction, minimal callus forma
antibiotics added to the PMM last up tion,to
and5 early return of function with min
yr. 62,72,76 imal fracture disease.44 When working with
In a red-tailed hawk (Buteojamaicensis), fractures near a joint, 1-2 cm of medullary
the addition of cephalothin to the PMM did canal is necessary to achieve adequate pur
not prevent sequestrum formation with a chase with this technique.23 The disadvan
Streptococcus sp. infection.38'39 In a pigeon, tages of using this technique are the same
12 wk after fracture repair, a small fragment as those associated with the use of IM PMM
of bone cement was retrieved from a drain alone. Timing and coordination are critical.
ing tract. 10 Although culture results were not It is not recommended for use in open, con

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
taminated fractures because of cortices of avian bones were thought un

the serious
able toPMM.
consequences resulting from infected provide adequate screw pur
When this method was used to stabilize
chase.1617,28'47,69,80 However, there are no
fractures in 12 raptors, six werestudies
able on
tothefly
screw-holding strength of avi
an bones. Plates
between 2 and 6 wk postoperatively.23 Allwere successfully used for
fracture
six originally had closed fractures. Twomanagement
open and corrective oste
fractures required longer to healotomies
(flying in large
at birds whose bones had sub
10-12 wk), one nonunion (also an stantial
open cortical
frac thickness, such as the legs
ture) occurred, one bird died of unrelated
of ratites.5 i1740,6979 Bone plates provide the
complications, and two other closed
advantagesfrac
of rigid internal fixation and an
tures were in the immediate postoperative
atomic alignment without interfering with
joint
period and doing well at the time thefunction,
report allowing early return to func
was published. tion. 2833'38'39,4162,69 If external coaptation is
The technique has been well described used in conjunction with bone plates, these
and illustrated.23,43"44 The rod should fill ap benefits are diminished because of fracture
proximately 1/2-3/4 of the medullary canal to disease.33 Excessive callus formation in birds
allow room for the PMM. Because the PMM can interfere with limb function by imping
forms a cohesive bond, barbs are cut into ing on soft tissues.38'39'61'62 Fractures re
the rod by slicing the polypropylene with a paired using bone plates may heal by pri
scalpel blade at an acute angle such that the mary bone healing with minimal or no
barbs point toward the ends of the bone and callus.
away from the fracture and the center of the Bone plate fixation, however, is techni
rod. This increases the strength of the bond cally difficult to perform and requires spe
by creating an irregular surface for the ce cialized training. The equipment is expen
ment to fill. The medullary canal is cleaned, sive, the surgical exposure and tissue
lavaged, then dried with sterile cotton tipped dissection is extensive, and the surgery time
applicators. The PMM is mixed and in is prolonged.'6"17,28,33,36'38,40'41'62,6979 In a study
jected into the medullary canal of each seg that evaluated average anesthesia time for
ment of the fracture using a syringe and 16 bone plating,33 a mean of 2.5 hr (range: 1.5
gauge needle for birds weighing < 1 kg or 3.75 hr), including patient preparation and
using a polyvinyl chloride i.v. tube attached pre- and postoperative radiography, was re
to a syringe to backfill the medullary canal. quired. The operative period was 50-130
The polypropylene rod is then inserted us min with a mean of 90 min. Two of the 10
ing the shuttle technique previously de birds died at the end of surgery and a third
scribed. Careful planning is required be died 12 hr postoperatively. Two other birds
cause of the limited time for curing of the died 7 and 16 days postoperatively, but the
PMM. Care must be taken to avoid getting role that the prolonged anesthesia played in
PMM between the fracture ends which could these deaths can only be speculated.
delay healing. External coaptation is rec Recently, bone plates have been used in
ommended for 7-10 days, after which the birds with36-39 or without33 IM PMM. Bone
bird may be confined to a small cage for 4 plates are applied using standard American
7 wk. With proper patient selection, this is Society for Internal Fixation (ASIF) tech
an excellent technique for repair of simple niques.'2 These techniques are very specific,
closed or minimally contaminated fractures and bone plate application should not be
of the diaphyseal region of long bones. attempted without prior training. Semitu
bular plates, dynamic compression plates
Bone plates (DCP), and veterinary cuttable plates have
Plate fixation of fractures in birds has his been used successfully in birds. Semitubular
torically been discouraged because the thin plates conform to the round avian bones

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
better than do DCP's. Semitubular should

plates be cleaned well between screws. The
screws
are thinner, which makes closure over the must be inserted delicately to pre
vent
plate easier and creates less interference with iatrogenic fractures and stripped
soft tissues. However, they are not as threads.
strong
as DCP's. The strength of the semitubular If a screw strips the threads in the bone,
a nut
plate is a function of its transverse can be made from a polypropylene
curva
ture.'2 If the plate is bent in conforming
syringeit
case.69 A small piece of polypropyl
to the bone, the curvature may be enelost,
is cut and a hole drilled, then tapped.
weakening the plate. The nut is then placed on the far cortex to
The ASIF 30-cm 50-hole veterinary cutthe screw as it exits and hold the
engage
table plate (Synthes 243.99 or 242.99;
screw1690
securely in place.
Russell Road, Paoli, Pennsylvania 19301,
In a study of 10 fractures treated with
USA) is ideal for the treatment of boneavian
plates, the bones appeared to have ad
equate
fractures.33'36'38 These plates can be used withscrew holding strength.33 Both semi
either 1.5-mm or 2.0-mm screws (243.99
tubular plates and DCP's were used in this
plate) and 2.0-mm or 2.7-mm study.
screws Of the 10 fractures, three experienced
implant failure, and in several other frac
(242.99 plate). They are small, light weight,
and strong, have closely-placed screwtures,
holes,
threads stripped during screw im
and can be cut to an appropriate length.
plantation. In one bird with a metacarpus
When an entire long bone must be spanned
fracture, the threads stripped, allowing the
plate to
by the plate, only every other hole need bebecome displaced. Two semitubular
filled and they can be stacked forplates
addedapplied to the tibiotarsus bent within
strength. 14,33,39 72 hr postoperatively. Failure was probably
Because of the thin, brittle corticesdue
oftoavithe lever arm created by the rela
an bone, special care must be takentionship
during between the insertions of muscles
several steps of bone plate application.33 The
relative to the joints generating significantly
fracture should be examined closely more
for evleverage than is typical in dogs and
idence of fissure fractures. Cerclage wires
cats.33 These two plates did not have unfilled
may be used under or over the plate holes
as needbut did have cortical defects at the
ed to stabilize fissures or pull comminutions
fracture site. When the bent plates were re
into the repair. The drill bit must be sharp
moved, all screws were tight except the screw
and straight with no wobble. A dullthrough
bit rewhich the plate bent. Five of the
quires excessive pressure, which could re used had unfilled holes, which cre
1 1 plates
atewob
sult in iatrogenic fractures. If the bit weak points in the plate. These holes
bles, the hole may be slightly larger were
thanoften
the left unfilled because of cortical
defects,
screw core diameter, which, with a thin cor which further weakened the bone
tex, may significantly decrease screw plate
holdsystem at a location where the most
ing power. Proper drill guides must bestrength
used was needed.
Increasing the plate length will increase
so that the screws are placed in the correct
location within the screw hole of thethe plate.
flexural strength of the system; there
fore,
If not properly placed, the threads may it may be beneficial to span the entire
crack
and strip or an iatrogenic fracture maylength
occur of the bone with the plate. Plates
shouldare
as the screw is tightened. As the threads be applied to the tension surface of
tapped, the tap should be advanced one the turn
bone.'2 The tension and compression
surfaces of avian bones have not been de
clockwise followed by /2 turn counterclock
wise. The counterclockwise turns clear theand may be different from those
termined
of to
tap flutes making it easier for the tap mammalian
cut bones. This lack of knowl
threads as it advances into the cortex with
edge may contribute to implant failure. If a
the next clockwise turn. The drill plate
and istap
applied to the tension surface and

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
there is a cortical defect on the compression

side, as with the two tibiotarsus fractures
jA
reported, implant failure is more likely.'2

Under these conditions, it would be better
to shorten the limb but create a buttress on
the compression side to make a more stable
system.
Intramedullary PMM may be used in
conjunction with a bone plate for increased
screw holding power (Fig. 1 l).36,38,39 Once
the fracture is converted to a two-piece frac
ture using cerclage wires to incorporate
comminutions and stabilize fissures, the :.4
medullary canal is lavaged with warm saline
and dried with cotton-tipped applicators.
Using a 6-ml syringe with a 4-cm segment
of polyvinyl chloride i.v. tubing, the med
ullary canal of each segment is filled with
PMM in the area where the plate will be
applied. It is important to back-fill the canal
by inserting the tube about 1 cm beyond the
end of the proposed location of the plate
then injecting the PMM while withdrawing
the tube. By filling the canal beyond the ends
of the plate the stress riser effect is avoided,
diminishing the chance of fracture at the Figure 11. A veterinary cuttable plate with intra
end of the plate. The PMM should not ex medullary polymethylmethacrylate was used to stabi
lize a comminuted fracture of the humerus in a red
tend beyond the ends of the fracture so as tailed hawk.
not to interfere with fracture reduction and
healing. Excess can be removed with bone
rongeurs. A veterinary cuttable plate is ap Cultures were obtained at the time of im
plied using standard ASIF technique in a plantation and plate removal, if performed.
neutral fashion on top of any cerclage wires. Only one positive culture was obtained, al
The IM PMM provides a substance to drill though six of the 13 fractures were open at
and tap for improved screw security.38 Frag presentation. One open fracture developed
ments may be pulled to the plate using the a sequestrum; however, the infection re
lag technique.'2'39 The limb is placed in ex solved after removal of the sequestrum and
ternal coaptation for 24 hr and passive range a 4-wk course of appropriate antibiotic ther
of motion therapy is initiated upon removal apy.
of the coaptation. The bird is maintained Plate removal is generally recommend
in a confined area for approximately 2 wk ed.33,38,39,79 However, when left in place, the
and controlled physical therapy is per additional weight of the plate and PMM
formed daily. Flight training is started ap does not cause clinically evident dysfunc
proximately 2 wk postoperatively. tion.38'39 In mammals, cold sensitivity may
Fractures repaired using this technique necessitate plate removal. In birds, cold sen
frequently heal with minimal callus.38'39 sitivity could produce pain and result in self
When used in 11 naturally occurring frac mutilation. However, in a Canada goose
tures and two corrective osteotomies, no (Branta canadensis) at temperatures of
implant failure nor loosening occurred.38'39 - 200C, self-mutilation and discomfort were

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
weight.
not observed.38'39 Stress protection refers to 1528'41'4749'62'65'80 Fixators allow early
loss of bone strength resulting from the return
de to function and free motion of ad
crease in stress applied to the bone when jacenta joints. 2841'5'64'65'71'78 Because they do
not inhibit joint function, they may be left
bone plate absorbs the force. Fractures may
in place for extended periods of time. Ex
result at the ends of the plate where the bone
ternal skeletal fixation is also very useful for
has been stress protected."139 Because of these
factors, plate removal prior to release of stabilizing
wild corrective osteotomies.5 Open,
birds is recommended.39 Plate removal re
comminuted fractures are ideally suited for
stabilization with ESF as the device can sta
quires general anesthesia and an extensive
bilize the fracture while the soft tissues are
surgical approach.33 In a study on anesthesia
treated.26'36'7' The device is also completely
time, the mean anesthetic period for plate
removal was 90 min (range: 45-120 min), removable, eliminating any nidus for resid
and the operative time was 20 min (range:ual infection. Minimal or no surgical ap
proach is required, which decreases the
10-30 min). In birds, the decision on when
to remove the plate is based on physical chances
and of compromising the blood supply
radiographic evaluation. Removal maytobe the fracture.15'36'48'49 Transarticular ESF
has been recommended for the treatment of
done as early as 8 wk or as long as 1 yr after
metaphyseal fractures.63'64 The fixation pins
surgery.39 In captive birds, it may be best
are placed in the two bones adjacent to the
to leave implants unless they cause prob
lems. joint. This technique immobilizes the joint
and the metaphyseal fracture.
EXTERNAL SKELETAL FIXATION Traditional ESF devices can be costly,
In 1897, the first use of ESF was described heavy, and difficult to align.63'64 Because the
in humans. Over the years, several similar connecting bar and clamps protrude from
devices have been used. In 1940, Ehmer the limb, they are subject to mechanical
modified a human design specifically for damage or may damage adjacent body
veterinary use. This device is currently structures.48 49'64'78 The thin cortices of avian
manufactured by the Kirschner Company bones do not provide the same degree of pin
(Timonium, Maryland 21093, USA). Thus, purchase for the fixation pins as do mam
the Kirschner-Ehmer splint is only one type malian bones, which may result in prema
of ESF. The biphase splint (Walter Lorenz ture loosening of the fixation pins or fracture
Surgical Instruments, Inc., Jacksonville, at the pin-bone interface.28'47'62'78 If the fix
Florida 32218, USA) uses acrylic cement as ation pins are not inserted carefully, iatro
the connecting bar and has been modified genic fractures may result.'6'62'80 Pin track
for use in small animals and birds using sepsis has been reported in humans but not
Kirschner wires or Steinmann pins as fix recognized clinically in birds. Some re
ation pins and PMM as the connecting bar.28 searchers have stated that removal of the
A variety of ESF devices have been suc fixator requires general anesthesia and risks
cessfully used to stabilize avian frac further tissue trauma and anesthetic com
tures. 16'1836,46,48'49'6244'69'78 These devices pro plications.62 However, external fixators are
vide good anatomic alignment and stability, easily removed without anesthesia. The fix
which promotes faster fracture healing with ation pins are generally loose by the time
minimal callus.48'49'78 When properly the fracture has healed and easily slip from
applied, they stabilize fractures against the thin avian cortices.
rotation, bending, and shear forces. The nomenclature of ESF has been based
External skeletal fixation does not damage on a combination of surgeons' and manu
the articular and periarticular structures, facturers' descriptions, resulting in great va
is easily removed once the fracture has riety and confusion. To standardize this no
healed, and, if properly constructed, is light menclature, three basic types of ESF designs

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
are described (Fig. 12).26 The type I or half

pin splint has fixation pins that penetrate
only one skin surface and both bone corti
ces. The connecting clamps and bar are only
on one side of the limb. Type II or full-pin
splints have fixation pins passing through
both skin surfaces and both cortices with
connecting clamps and bars on two sides of
the limb in a single plane. Type III splints
are a combination of full- and half-pin
splints, where the type I and type II splints
are placed 900 on the rotational axis to each
other and connected, creating a three-di
mensional frame. Other modifiers are used
to further describe the splint. These include
the type of clamp (single or double), the
number of connecting bars, and the number
of fixation pins.
There are specific principles for applica
tion of ESF to achieve optimal fracture sta
bilization. 13,28,48,49,68 These apply to avian
fractures as well. To minimize0m D
problems
with incision or wound management and
the potential for pin tract sepsis, pins should
be driven through small holes created in
intact skin and not through the primary in
cision or open wounds. Pin placement
should avoid large muscle masses, which
may cause premature pin loosening. Care
must be taken during pin insertion to avoid
wobbling, which can weaken purchase and
result in pin loosening. Both full and half
pins must be placed through both cortices
to achieve secure fixation. For type I splints,
pins should be inserted with an angle of 35
550 between the most proximal and most
distal pins so that the fixationFigure 12. a. Type Idoes
device fixator. b. Type II fixator. c, d.
Type III fixator.
not slide off or from side to side. Type II
splints are mechanically strongest if the fix
ation pins are parallel to each lower other
incidence ofand
fixation pin loosening.
perpendicular to the long axis Currently, three to four pins are recom
of the bone.
However, because the device maymended slide from
for each fragment.
side to side, most surgeons place In at
ESF,least
pin placement
one with relation to
pin in each fragment at antheangle. Tradi
fracture site and the ends of the bone
tionally a minimum of two affectspinsstability.
in eachPlacing the fixation pins at
fragment has been recommended. Howev
the proximal and distal ends of the bone is
er, by increasing the number of best for neutralizing
fixation pins, the forces exerted at
the stress on each is decreased and the
the fracture. de this decreases the
However,
vice maintains its stability longer with
strength of the a therefore pins should
fixator,

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
Vsv~~~~~~~~~~~~
Figure 14. Fixation pin purchase may be improved
by inserting an intramedullary polypropylene rod
through which the fixation pins pass. The fixation pins
may be bent over and incorporated into the cement of
a biphasic fixator.
Figure 13. Type I fixator with a double connecting

bar for increased strength.
the near cortex, penetrate the rod, and exit
the far cortex (Fig. 14).
Kirschner-Ehmer fixators
be placed over the entire length of the frag
ment for the best stability. Partially threadStandard Kirschner-Ehmer (KE) fixators
ed pins have been recommended, but havethe
been used in the treatment of fractures
in medium and large birds.'6 Their main
stress riser effect often results in pin break
age at the threaded-nonthreaded junction.6limitations are their size, weight, and ex
Threaded fixation pins are available pense.
with The connecting bar and clamps are
quite heavy and the size of the fixation pins,
only enough threads to engage the far cortex,
thus protecting the clamps, and connecting bars are only ap
threaded-nonthreaded
junction within the medullary canal (Ellisfor larger birds. As the number of
propriate
pin, Kirschner Co.). This type of fixation
connecting clamps and bars increases, the
pin is now available costand
in 0.035-, 0.045-, and weight also increase. Compared
0.062-inch sizes (IMEX Veterinary,with
Inc.,
other methods of fracture fixation, the
1227 Market Street, Longview, Texas
components of the KE fixator approach or
75604, USA). exceed the cost of bone plates and screws.
The distance between the connecting bar When applying the KE splint, it is best to
and the skin should be kept to a minimum. insert the most proximal and distal fixation
As this distance is increased, the strength of pins first. The total number of clamps to be
the device decreases. However, soft tissue used are placed on the connecting bar and
swelling must be taken into account. The the first and last clamps are fixed to the
stability of the ESF device varies with the proximal and distal pins. The remaining fix
configuration.25'48 49 Type III is stronger than ation pins are then passed through their re
type II, and type II is stronger than type I. spective clamp and then through soft tissues
With type I splints, adding a second con and bone. This placement technique will
necting bar (Fig. 13) increases its strength. keep all of the pins in line with the con
An IM polypropylene rod can be used in necting bar. If the fixation pins are placed
conjunction with ESF in birds to increase free hand and are not all in line, they will
the holding power of the fixation pins.36'63'64 not be able to be attached to the connecting
Using this technique, the fixation pins enter bar, which could result in iatrogenic frac

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
tures during attempts to force them to fit.

Once the KE device is applied, the clamps
and any sharp pin ends should be padded
and covered with tape.
Some authors have reported successful
treatment of fractures using a two-pin type
I fixator.'6,80 This system is not stable, as
the fracture segments can rotate around the
single pin in each segment resulting in an
angular deformity. However, when bending
is supported by an IM pin, a two-pin type
I fixator effectively prevents rotation and
collapse. Application of an ESF device in
conjunction with an IM pin will prevent
rotation and enhances the rigidity and
strength of the system.7'
Biphasic fixators
Biphasic ESF devices use various size
Kirschner wires, Ellis pins, or Steinmann
pins as fixation pins but the connecting bar
and clamps are replaced by acrylic polymer *s
or other stiff material. Non-sterile hoof re
pair PMM (Technovit, Jorgensen Labs,
Loveland, Colorado 80537, USA),78 5-mm
epoxy glue,46,48'49,5" Hexcelite cast Figure 15. This fracture of the radius and ulna was
materi
stabilized using a biphasic fixator with the fixation pins
al,6365'7' and dental acrylics have been used.36
bent over and incorporated into the acrylic connecting
With biphasic splints, if the fixation
system. pins
are not in exact alignment, they can still be
easily connected because the connecting
material is initially malleable.inforcing
Thesebars ma within the connecting system
(Fig. 15).
terials are significantly less expensive than
the traditional KE clamps and bars Alternatively,
and are flexible tubing such as a
very light weight, making them Penrose
usefuldrain
evencan be placed over the ends
for very small patients. Injectionofor
thespinal
fixation pins. The tubing must be
needles (22 or 25 gauge) may beflexible
usedenough
for to incorporate all of the fix
fixation pins in small birds." ation pins and to slide along the pins placed
at an
Nonsterile PMM can be used for angle. It can be very challenging to
biphasic
fixators in two ways.36 The PMM can
place the tubebeover six to eight pins that are
mixed until it has the consistencyallof
placed at different angles and to slide the
dough
tube downpins
and then molded around the fixation the pins close to the skin. Once
while the fracture is maintained the in
tubereduc
is in place, the fracture is held in
reduction and
tion. To create a better bond between thethe liquid PMM is injected
pins and the PMM, the pins may into the tube (Fig. 16).
be notched
with a pin cutter or bent over and Hexcelite
incor is a casting material that be
comes soft and
porated into the connecting system. Bypliable when immersed in
bending the fixation pins over, hotthe
water.
PMMIt can be molded when in this
form, as
cannot slip off and the pins function but reonce it cools it becomes quite

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
should be placed in a line with this tech

nique so that the v-trough can be placed
over the fixation pins. The epoxy is mixed
and placed in the trough. A pin may be laid
in the trough to reinforce the resin. Enough
space must be left between the resin bar and
the skin so that a pin cutter can be inserted
for removal of the fixator. Fracture reduc
tion must be maintained while the resin
cures, and the resin should not drip onto
the skin or into wounds. This type of ESF
device typically weighs <5 g.
A similar technique is used for very small
birds.46 Injection needles or spinal needles
are used as fixation pins. A Steinmann pin
serves as the connecting bar, and each of
the fixation pins is secured to the bar using
the epoxy resin. Cyanoacrylate glue can be
used to hold the fixation pins to the Stein
mann pin connecting bar while the epoxy
is mixed, applied, and allowed to cure.
Light-weight connecting bar fixators

Figure 16. Intravenous tubing filled with acrylic ce
ment using hypodermic needles as fixation pins was Recently, a new connecting bar has be
come available (Manuflex, Trade-Coop,
used to stabilize a fracture of the tibiotarsus in a black
headed caique (Pionites melanocephala). This fixationBudapest, Hungary) that is made of a soft
allows early return to function without damaging ad
jacent joints. The fracture has healed.
metal with numerous holes through which
the fixation pins are inserted (Fig. 17).36 The
connecting bar is then crimped on top of
the pins to secure them firmly. The system
rigid. It may be used repeatedly by reheating
is inexpensive, light weight, and suited for
the material. This casting material is easily
avian fracture repair.
cut to size with bandage scissors. Once the
fracture is reduced, the warmed casting ma
terial is wrapped around the ends of the pins
PROGNOSIS
using enough layers (usually three or four)Prognosis is somewhat dependent on the
intended use of the bird. Pet birds and zoo
to provide stability. Once the material cools,
the device is stable. To prevent injury to specimens
the may function without the ability
to fly with precision. However, with wild
patient's skin, the ends of the pins should
birds, hunting birds such as falcons (Falco
be covered with casting material, the device
should not touch the skin, and there should
spp.), and racing pigeons, anything less than
be no sharp edges exposed. The device 100%
can of normal function cannot be regard
be covered with a light bandage to protect
ed as successful.63646669 A slight malunion
adjacent body surfaces.64'7' or a few degrees of rotation can produce a
A technique applicable to birds weighing
severe loss of function.67 In terms of aero
<300 g uses an epoxy resin for the dynamic
con control, the distal wing is most
necting system.46 A v-shaped trough is con critical as birds with a few degrees of axial
structed from an index card to hold themalalignment
liq of the humerus fly well. How
ever, a similar malalignment at the distal
uid resin while it solidifies. The fixation pins

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
wing will preclude normal flight.67 Regain

ing the ability to fly does not guarantee the
ability to survive in the wild. In two raptors
with fractures of the coracoid that were
'P
treated nonsurgically, excessive callus for
mation prevented the passage of large pieces
of food along the esophagus.66 In one bird
the problem resolved after 2 yr. The other
bird was released, and its severely emaci
ated carcass was later recovered. In many
birds some decrease in leg function may be
acceptable; however, in raptors the legs are
important for obtaining food, and in ter
restrial species they are necessary for sur
vival. Malunion of fractures may result in
impaired flight and balance, which are also
important for courtship and copulation.'5
Fractures of the humerus are usually open
and severely displaced with significant over
riding because of the strong pull of the pec
toral muscles.'9'58,66 The rotational forces
applied by these muscles predispose frac
tures to heal with rotational deformity. A
Figure 17. A light-weight connecting bar fixator has
relatively small degree of rotational defor
been applied to the tibiotarsus of this turkey vulture
mity in the humerus can significantly
(Cathartes aura).impair
flight.38'4",62,64'66'80
There is normally a longitudinal sliding
motion between the radius and areulna.
often open, andSyn
healing may take several
mo to complete.66and
ostosis may develop between the radius
ulna if there is enough displacement so involving
In a study the376 raptors63,64 with
two bones heal together. This results in
fractures treated over a 2-yraperiod, 166 were
decreased ability to supinate and pronate
not repaired because of the severity of the
the distal extremity, which may limit
injuries or becausepre
the patient was severely
cision maneuvering flight.4",67'69 debilitated. Many birds died before fracture
Fractures near or through jointsrepair
are could belikely
attempted. External coap
to heal with a nonfunctional outcome
tation was used in 104be
birds, and surgical
cause of ankylosis resulting from repair was performed
callus im in 106 birds.
pingement and adhesion of tendonsOnlyand lig
18 of 51 surgically treated humerus
aments.4' Many fractures arefractures
open and
healed; only 12 of these achieved
comminuted with compromise of the
full flight. sup
The other six birds that healed
porting soft tissue and blood supply. This
could not be released because of secondary
type of fracture is likely to takeproblems
longer such as bumble
tofoot. The most
common cause of nonunion was the for
heal and has a higher risk of developing
osteomyelitis.4' mation of a large segmental sequestrum,
Fractures distal to the carpus and
probably duetarsus
to damage at the time of the
carry a guarded prognosis because ofOf the
original injury. the humerus fractures
treated with external coaptation, 13 of 18
tenuous blood supply to these regions. Any
additional dissection may further healed withcompro
a functional recovery. This im
mise the blood supply. Fractures in this area
proved prognosis using external coaptation

158.140.167.49 on Sun, 09 May 2021 07:04:38 UTC
is due to the reduced severity of these frac CONCLUSION

tures. In recent years, great advances have been
In the two-bone system of the antebrachi made in the treatment of fractures in birds.
um, only 22 of 74 birds had fractures of Modifications of ESF devices have allowed
both bones. When both radius and ulna were them to be used in even very small patients.
fractured, there was usually accompanying The development of techniques for bone
severe soft tissue injury. The success rate plate application has allowed an early return
with surgical management of ulna or radius to function, which is especially important
and ulna fractures was 25%, whereas 60%h for zoo and wildlife patients. In avian frac
of birds with antebrachial fractures treated ture management, basic orthopedic princi
with external coaptation were able to fly, ples must be applied. Fractures treated with
again because of the lesser degree of sever biomechanically sound fixation and proper
ity. attention to the soft tissues will be most
Fracture of the tibiotarsus was the most likely to heal with a functional outcome.
common leg fracture. These fractures al Much remains to be learned about avian
ways require stabilization. Of the 27 frac fracture management. Further studies on
tures, 18 were treated surgically. Those bone healing (especially during rigid fixa
treated nonsurgically were managed with tion), bone strength and implant holding
external coaptation because the fracture was ability, and implant stability are needed.
very close to a joint, highly comminuted, or Osteomyelitis, bone sequestration, and joint
chronic with significant callus formation or ankylosis continue to be major factors in
because the bird was severely debilitated. hibiting healing and functional outcome.
Only six healed, and four were released. The
ESF probably failed because of premature LITERATURE CITED
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FRACTURE MANAGEMENT IN BIRDS Jurnal Orto 3

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FRACTURE MANAGEMENT IN BIRDS Jurnal Orto 3

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Fracture Management in Birds

Author(s): R. Avery Bennett and Alan B. Kuzma

Stable URL: http://www.jstor.com/stable/20460265

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