Fractures

Classification

Causative factors
 Direct violence
 Indirect
 Disease
 Repeated stress
External wound
 Closed
 Open
Location- bone wise
Morphology-proximal, shaft, distal
severity- simple, wedge, complex
 Specific nomenclature

 Articular, partial articular, complete articular,

extraarticular,
 Incomplete, complete

 Multifragmental, comminuted

 Impacted, avulsion

 Stable, unstable
Salter Harris Fractures in immature dogs
Classification
 SH I, II, III, IV, V
SH I -- physis fracture or separation
SH II----Physis and metaphysis fracture
SH III ---- physis and epiphysis fracture
SH IV -- Physis, metaphysis and epiphysis fracture
SH V --- Compression fracture at physis level
Fracture healing
STAGES OF FRACTURE HEALING
 Stage 1: Inflammation
 Bleeding from the fractured bone and surrounding
tissue causes the fractured area to swell. This
stage begins the day you fracture the bone and
lasts about 2 to 3 weeks.
Stage 2: Soft callus
 Between 2 and 3 weeks after the injury, the pain
and swelling will decrease. At this point, the site of
the fracture stiffens and new bone begins to form
(see figure). The new bone cannot be seen on x-
rays. This stage usually lasts until 4 to 8 weeks
after the injury.
Stage 3: Hard callus
 Between 4 and 8 weeks, the new bone begins to
bridge the fracture. This bony bridge can be seen
on xrays. By 8 to 12 weeks after the injury, new
bone has filled the fracture.
Stage 4: Bone remodeling
 Beginning about 8 to 1 2 weeks after the injury, the
fracture site remodels itself, correcting any
deformities that may remain as a result of the injury.
This final stage of fracture healing can last up to
several years.
 The rate of healing and the ability to remodel a
fractured bone vary tremendously for each
patient and depend on age, your health, the kind
of fracture, and the bone involved. For example,
young animals are able to heal and remodel their
fractures much faster than adults.
Factors affecting fracture healing

 Energy transfer of the injury

 The tissue response
 Two bone ends in apposition or compressed
 Micro-movement or no movement
 Blood supply
 No infection
 The patient
 The method of treatment
Orthopaedic surgery
 Management of fractures in Small animals
 The primary aim of every fracture treatment is to
restore the anatomical shape of the fractured bone
and full function of the traumatized osseous and
associated soft tissues.
 A group of Swiss orthopedic and general surgeons
joined together (AO/ASIF) to study the methods of
internal fixation which were being used for human
surgery. They concluded that absolutely rigid fixation
of the fragments and early mobilization of the
traumatized limb was of primary importance for
successful fracture healing.
• State of the art of internal fixation techniques and
implants were produced for maximal stability of the
fracture by rigid fixation, with minimal adverse bone
reaction to the implant.
• Emphasis was placed on treatment of the whole
traumatized limb, including the fracture, adjacent joints,
and associated soft tissues, thus facilitating return of
normal vascularity, nourishment of joint cartilage through
pain-free movement, prevention of fracture disease, and
early return of full limb function.
Fracture
Reduction

and

Coaptation
Reduction of Fractures

 = Replacing fracture
segments in original
anatomic position
 Non-surgical (= closed)
 Temporary (until surgical
repair)
 Permanent (supported by
cast or splint)
 Surgical (= open) Courtesy of Dr. Kerwin
Closed Fracture Reduction

 Get bone ends in contact (= apposition)

 Line up fracture ends (= alignment)
 Alignment + apposition = reduction

 Avoid additional trauma

 Further fracture may result with excessive force
 Damage to soft tissue potentially
 Causes infection
 Delays healing
Methods of Closed Reduction

2
1

1 = Traction
2 = Counter traction Gordon extender
3 = Manipulation
Methods of Closed Reduction

Using the animal’s weight as counter-traction

Methods of Open Reduction

Levering with instruments

Methods of Open Reduction

Bone reduction forceps

 Successful Fracture Reduction

1. At least 50% contact between fracture

cortices
2. Check for rotation of the distal segment
3. Always get a post-reduction radiograph
4. Do under general anaesthesia or
sedation
Courtesy of Dr. Kerwin
 Goals of Fracture
Stabilization
1. Minimize time needed for
 compression
bone healing
 tension
2. Neutralize stresses
 bending
acting on fracture
 torsion
3. Allow early painfree  shear
ambulation and weight-
bearing
4. Allow return to complete
function
Stabilization Method chosen
depends on:
 Type and location of fracture
 Single or multiple fractures
 Signalment of animal
 Concurrent soft tissue damage
 Temperament and use of animal
 Expertise and resources of veterinarian
 Financial resources of client
Methods of Fracture Immobilization

 External
 Casts  Internal Fixation
 Splints  Intramedullary pins and
 Slings interlocking nails
 Kirschner wires (pins)
 Internal/External  Cerclage wires
 External Skeletal  Plates
Fixators  Screws
Indications for External Coaptation
( = Bandages, Casts and Splints)

Stabilize the limb (“Limb-splint”)

 Prevent full weight-bearing
 Render joints which they span immobile
 Support temporarily prior to surgery
 Provide additional support after surgery
 As an alternative to surgery for certain injuries
Mechanics of External Coaptation

 Neutralized
Bending

 Torsion  Neutralized (Important: always

include joints above and below
fracture)

 Compression
 NOT neutralized
 Distraction
 NOT neutralized
 Rigid stabilization
 NO
(Up to 20 degrees motion at
fracture site and joints)
Courtesy of Dr. Kerwin
 General Principles of External
Fracture Coaptation

1. Immobilize the joints above and below

2. Provide adequate padding under the cast/splint
3. Work from distal to proximal
Always start at the toes
Keep pressure even
4. Leave access to tips of toenails to monitor for swelling
5. Sedation can make a difference
6. Position leg in neutral standing position
7. Always get a post-cast radiographs (2 views!)
8. Don’t underestimate time and cost required
Common Splints, Bandages and
Casts
 Limb splints
 Tongue depressor splints
 Mason metasplints ( “spoon” splints”)
 Gutter splints with POP or PVC
 Spica splint
 Traction splints
 Schroeder-Thomas splints (Thomas or T-splint)
 Casts
 Padded limb bandages
 Robert Jones bandage
 Modified Robert Jones bandage
 Reinforced Robert Jones bandage
Common Slings, Bandages and
Splints
 Slings
 Ehmer sling
 90-90 flexion sling
 Robinson sling
 Carpal flexion sling
 Velpeau sling
 Hobbles
Disadvantages of Casts and
Splints

 Persisting motion at fracture site

 Limited limb function
 Constant monitoring and frequent changing
 Joint immobilization
“Prolonged immobilization results in fracture
disease: healed bone but non-functional limb”
 General Application Features

1. Anchore tape strips (=“Stirrups”) at toes

2. Apply primary bandage layer over open
wounds
3. Apply good padding over primary layer and
under cast or splint (= secondary layer)
4. Outer protective layer (= tertiary layer)
Distal Limb Splints

 Indicated to protect
wounds or fractures
below the tarsus or
carpus

Courtesy of Dr. Kerwin

Mason Metasplint or Spoon
Splint

Courtesy of Dr. Kerwin

 Splint Application: Primary
layer

Open carpal injury Materials that can directly contact wound

Courtesy of Dr. Kerwin
Splint Application: Secondary
layer

Rolling on cast padding

Courtesy of Dr. Kerwin

 Securing the Padding with
Gauze

Different widths of Gauze Note open, stretchy weave

Courtesy of Dr. Kerwin

 Putting on the Splint

Make sure splint fits snugly Tightly wrap splint with

more gauze

Courtesy of Dr. Kerwin

 Attaching the Stirrups

Tape strips are separated and twisted 180 degrees so that sticky
side of tape attaches to splint
Courtesy of Dr. Kerwin
Putting on the Tertiary Layer
for Protection

Don’t get this layer too tight!!

Courtesy of Dr. Kerwin

 Spica Splint

 For temporary stabilization of:

 Humeral/femoral fractures
 Elbow and stifle luxations

 Spica cast applied body torso

and roll the dog around the cast,

 Stabilize fore limb in slight

forward and hind limb in slight
backward position

Courtesy of Dr. Kerwin

Schroeder-Thomas Splint

 Aluminum rod splint

 Properly designed,
can maintain traction
on distal limb
fractures
 DO NOT USE for
fractures...
 Above stifle
 Above elbow

Courtesy of Dr. Kerwin

Schroeder Thomas splint

Courtesy of Dr. Kerwin

Schroeder Thomas Splint

Courtesy of Dr. Kerwin

Casts for fractures below the
elbow/stifle

Main indications:
 Permanent stabilization:
 Stable load-sharing fractures
 Younger healthy animals
 Temporary stabilization:
 Before surgery (always with strict
rest)
 All animals
 All fractures below stifle/elbow

Courtesy of Dr. Kerwin

 Casting Materials

Quick setting, wettable fiberglass cast materials

Applying a Cast
 Patient should be deeply
sedated or anesthetized
 First apply: (as for splint)
 stirrups,
 primary and
 secondary layers
 Get quickly to work
 Wear gloves
 Applying a Cast

Quickly soak material in

cool water, shake excess
Apply smoothly and evenly, no
thumbprints or pressure points
“Bivalving” a Cast

 Cut cast full length both

sides
 Allows cast to be
changed and re-applied
frequently
 Less time-consuming
 Weakens cast slightly

Courtesy of Dr. Kerwin

Finishing the Cast
 Finished Cast

Apply Tertiary
Layer
Be Creative! (Courtesy of Dr. Fitch)
Courtesy of Dr. Kerwin
 Robert Jones Bandage

 Indications:
 Temporary stabilization of fractures below the
humerus/femur
 Huge amounts of roll cotton

 Sounds like
a ripe watermelon
if done correctly!

Courtesy of Dr. Kerwin

 Putting on a Robert Jones

Put on lots of roll cotton Compress tightly with gauze

layer

Courtesy of Dr. Kerwin

 Putting on a Robert Jones

Completed gauze layer

Applying the tertiary layer
Courtesy of Dr. Kerwin
Modified Robert Jones bandage

 Frequently used post-operatively after

fracture repair of joint surgery
 Protects incision
 Reduce swelling
 Increase animal comfort
 Cast padding instead of cotton
 May supplement with a lateral splint
Ehmer Sling (Figure 8
sling)
 Closed or open
reduction of cranio-
dorsal hip luxations
 Abducts and
internally rotates hip
 Monitor very closely,
often cuts into skin

Courtesy of Dr. Kerwin

90-90 flexion sling

 Non-weight-bearing
rear limb sling
 For a few days after
repair of distal
femoral fractures
 Hip and stifle in
approximately 90
degrees of flexion
Prevention of
Quadriceps Contracture!
Courtesy of Dr. Kerwin
Carpal flexion sling

 Non-weight-bearing
forelimb sling
 May be used to
maintain joint motion
in elbow and shoulder
but prevent weight-
bearing after fracture
repair

Courtesy of Dr. Kerwin

Hobbles

 May be used to
prevent excessive
abduction
 after pelvic fractures,
ventral hip luxations or
inguinal soft tissue
surgery
 Monitor feet closely
for swelling

Courtesy of Dr. Kerwin

Velpeau sling

 Used as a non-
weight-bearing sling
after
 Scapular fractures
 Shoulder
luxations/instabilities

Courtesy of Dr. Kerwin

Monitoring the Cast or Bandage
 Strict cage rest until cast is removed,
but encourage controlled weight-bearing
 Plastic bag over cast when animal goes outside (remove
immediately when inside)
 Change cast within 12-24 hrs if:
1. Toes are swollen or reddened
2. Cast slips
3. Animal is chewing at cast
4. Cast is wet or smells
5. Animal is depressed or febrile, any unexpected problem!
 Change weekly if wound management needed
 Change every 2-3 weeks
Complications: Swollen Toes

Courtesy of Dr. Kerwin

Complications: Strike-Through

Courtesy of Dr. Kerwin

 Complications
Cast sore over olecranon

Foot sloughing from tight cast

(Two-finger test/Monitoring)
Use donuts to protect
protuberances Courtesy of Dr. Kerwin
Fracture fixation techniques in
Farm animals

 Metacarpus and metatarsus (approximately

50%), tibia (approximately 12%), radius and
ulna (approximately 7%), and humerus (<5%).
 Fractures of the femur and pelvis also occur,
but are uncommon. Fractures of the axial
skeleton (mandible, vertebra, ribs, pelvis) are
even less common.
 Decision-FPAS-fracture patient
assessment score
 consider the cost of the treatment
 the success rate of the treatment,
 the perceived or potential economic or
genetic value of the animal
 the location and type of fracture.
 Two splints or a cast
 Two pieces of a large polyvinyl
chloride (PVC) pipe cut in half and
placed 90° to each other
 Half-limb casts
 Full-limb casts
 metal rods within the cast-larger
patient
 fiberglass casting
 Thomas splint
fracture with PVC and pop
splint
Modified Thomas splint
Base of horn fracture
Mandible fracture