Approach to Fractures for the General Practice
Initial Stabilization of the Patient and Fracture
Typically a fracture alone does not need emergency surgery. Oftentimes, patients present with a fracture after experiencing some form of blunt force, like a vehicular trauma or fall from a height. Frequently, more emergent conditions arise from this experience, like pulmonary contusions, arrhythmias, or diaphragmatic hernias, that should be addressed first.
A pet may present with signs of shock and be non-ambulatory. It is imperative to assess the patient’s ability to ambulate as well as their neurologic status once they have received appropriate resuscitation, and preferably prior to administering analgesics. Additionally, be sure to evaluate all four limbs. It is not uncommon for a second, less obvious, fracture to be overlooked (i.e. a scapular fracture) when a more noticeable fracture is present (i.e. a tibia fracture).
For fractures below the elbow and stifle, external coaptation stabilizing the joints proximal and distal to the fracture should be applied prior to transportation or if surgery is delayed. This will increase patient comfort and prevent the fracture from further displacing or becoming an open fracture. It is not recommended to bandage fractures of the humerus or femur.
Timing of Surgical Repair
Certain fractures may be more emergent than others, but overall, fractures should be fixed as soon as is safe for the patient. Articular fractures (like humeral condylar fractures that are common in young French bulldogs and spaniels) should be repaired within the first few days after the injury.
Salter-Harris fractures should also be repaired as early as is safe for the patient to try and preserve normal limb growth and alignment. Granulation tissue and bony callus begin to form within the first week following a fracture in young patients, making repair more challenging with a greater potential for damage to the blood supply.
The Open Fracture
The importance of prompt initiation of IV antibiotics is well documented in people with open fractures. A significant decrease in the infection rate occurred when antibiotics were administered within three hours of injury compared to four or more hours after injury. Preventing further contamination and soft tissue trauma is critical.
The wound should be thoroughly lavaged with sterile saline or tap water. Sterile water-soluble lubricant should be placed in the wound, and the surrounding hair clipped. Bordering skin can be cleaned with 4% chlorhexidine gluconate, but the wound bed should be avoided. Alternatively, a 0.05% chlorhexidine solution can be used to lavage the wound and provide antibacterial activity without causing tissue reaction. A sterile dressing and bandage should be applied to prevent additional contamination and trauma.
Types of Fixation
The days of fracture fixation using an IM pin and cerclage are in the past. Many factors are involved when selecting a method of fixation, including the fracture location, configuration, and age of the patient. An understanding of the forces sustained by the bone and implants is imperative to achieving successful repair. The majority of fractures are repaired with plate and screw fixation.
With the introduction of locking plates and the use of fluoroscopy, minimally invasive plate osteosynthesis (MIPO) has become more popular. This allows fracture fixation without disruption of the blood supply at the fracture site, and therefore the potential for more rapid healing and return to function. External skeletal fixation is also an excellent option for preserving the fracture hematoma, especially for an open fracture.
Pre-op, immediate post-op, and four week recheck radiographs of a French bulldog puppy with a fracture of the lateral humeral condyle. This fracture was successfully repaired with fluoroscopic assistance, and the patient went on to have excellent limb function.
When to Refer
Complications of fracture repair can arise, including malunion, which can lead to angular limb deformities and decreased limb use long term, and osteomyelitis, which can weaken the bone and necessitate implant removal. This is why we encourage the referring community to always alert owners of the option to have their pet’s fracture repaired by an orthopedic surgeon.
We have successfully repaired many fractures and have all the equipment and resources needed on site to address any fracture injury, including those that exhibit a propensity for complications. The experienced surgeons at VETMED are always available for case discussion, recommendations, second opinions, and general cost estimates for repair.
Always feel free to call and ask for Dr. Owen directly should you wish to consult with her on a case or garner a second opinion.
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