MANAGEMENT OF FRACTURES AJADI R ADETOLA DEPARTMENT OF VETERINARY MEDICINE & SURGERY

Aim of Fracture Management Restore bone back to normal anatomical alignment Restore function Alleviate or control pain Treat soft tissue damage Prevent infection

Emergency Treatment of Fractures: General Measures Ensure adequate ventilation Control haemorrhage Treat shock Prevent infection Repair wound

Splinting Aimed at preventing injury to soft tissue Reduce soft tissue injury Alleviate pain occasioned by bone movement Use Robert Jones dressing, Thomas splint, Plastic splint or Mason metal splint

Fracture: Causes of pain Movement of bones against each other Post-operative oedema or swelling Role of interleukins secondary

Fracture Management: Pain Relief Application of splint Use of tranquilizer Use of opioid analgesics Non-steroidal analgesics

Fracture and Shock Usually associated with severe trauma Psychogenic shock is common in toy breeds

Fracture: Management of shock Maintain patent air- passage way and ventilate the animal Maintain circulating blood volume Control pain Administer corticosteroid Administer tranquilizer

Bone Reduction: Definition The entire process of restoring close apposition and alignment of the fracture fragments

Close Reduction Non invasive method of restoring close apposition and alignment of fracture fragments

Close Reduction: Advantages Minimal risk of haemorrhage Minimal risk of infection Minimal requirement for anaesthesia Relatively cheap Required little instrumentation or expertise

Close Reduction: Disadvantages Increased risk of soft tissue damage Poor or inadequate bone reduction Interposition of soft tissue between fragment ends Does not allow the use of internal immobilization device Higher incidence of non-union or mal-union

Close Reduction: Techniques Manipulation: toggling or angulation Traction Counter-traction

Open Reduction: Definition Restoration of closed apposition of bone fragments through skin incision and muscle separation at the fracture site.

Open Reduction: Indications Recent fractures in which muscle spasm makes close reduction difficult Intracapscular fracture Delay or non-union fracture Application of internal fixation device Treatment of malalignment Removal of sequestra Removal of internal fixation

Open Reduction: Advantages Allows accurate reduction Allows use of internal fixation device to provide rigid immobilization Prevent injury to nerves and blood supply Prevents interposition of soft tissue between fracture ends Minise complications of fracture healing

Open Reduction: Disadvantages Increase risk of infection Interference at first stage of bone healing Increased risk of anaesthesia Increased instrumentation and expertise Stripping of muscle from periosteum may cause delayed union It is expensive

Signs of Adequate Bone Reduction Restoration of length not of paramount important in quadruped Re-alignment of bone and adjacent joints Correction of rotational displacement Apposition of fragments ends sufficient to ensure healing Radiographic verification of bone alignment

Fracture Immobilization: Definition Fixation of the fracture segment in the reduction position during the period of healing

Features of Ideal Fixation Method Should maintain apposition of the fracture fragments throughout the period of bone healing. Should allow movement of as many joints as compatible with the apposition Should not compromise blood or nerve supply to the bone or soft tissue Should be removable or completely inert in tissues for the life of the animal Be well tolerated by the animal and require minimum after care Be economically feasible for average client

External Immobilization Devices Plaster of Paris cast Plaster splint Mason metal splint Aire cast Thomas splint Modified Robert Jones Kirschner- Ehmer splint

Limitations to The Use of External Immobilization Device Stability of the fracture Location of the fracture Presence of infection Temperament of the animal Availability of material

Plaster of Paris Cast: Advantages Easy to apply Ready availability of materials Cast can be molded to maintain very definite position of the bones Allows for easy ambulation

Plaster of Paris Cast: Disadvantages Can easily be made too tick or heavy Provides inadequate immobilization of the femur or humerus May further impede circulation in cases of severe post- operative swelling Impairs treatment of open wound Does not allow for vaporization of wound exudates Requires general anaesthesia or tranquilization inorder for cast to set properly set

External immobilization device: Signs to monitor Change in temperament of the animal Unexplained soiling of the device Swelling proximal or distal to the device Inability of the animal to tolerate the device Displacement of the device from the site of application

Internal Fixation Devices: Advantages Early return to full function of limbs Accurate anatomic reduction Avoidance of fracture diseases Accessibility for treatment of soft tissue injuries Minimal care during convalescence

Internal Fixation Devices Intramedullary pins Bone plates Intrafragmentary compression devices

Intramedullary Pins Steinman pins Rush pins Kuentscher nail Jonas pins Kirschner wire

Bone Plates Finger or small fragment plates Compression plates Spinal plates

Intrafragmentary compression devices Cortical screw Lag screw Tension band wire Cerclage wire Hemi- cerclage wire Smille nail

Treatment of Fracture: First 6-8 hrs Debride the edges of the wound Protect wound with sterile gauze Apply traction to prevent bone movement and clip the hair Scrub the area and apply drape Trim the edges of the wound and enlarge if necessary Irrigate wound with copious amount of ringers solution Trim away all devitalized tissue and remove bone without soft tissue attachment Re-drape and prepare for aseptic surgery Reduce the fractured bone Apply a suitable fixation device

Treatment of open fracture: Wound closure Early wound closure turns open fracture into closed fracture thus preventing secondary infection and osteomyelitis Undermine skin edges to provide some relief of tension Close fascia loosely to prevent trapping of fluid Eliminate all dead space Apply local antibiotics

Contra-indications to primary wound closure Wound over 8- 10 hours Severe swelling Extensive skin necrosis When adequate debridement is not possible

Treatment of Fracture: After 8- 10 hrs Do not close the wound immediately as infection is likely to occur After debridement, pack the wound with sterile Vaseline gauze Immobilize area with Robert Jones dressing or plaster cast Administer systemic antibiotics and observe closely for sign of local or systemic infection Close wound 6-7 days after and institute definitive fracture treatment Bone plate is preferred in the presence of threatened infection as it leaves the medullary blood supply intact

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