broken bones – from triage to bony union - … · broken bones – from triage to bony union...

$: Broken Bones – From Triage to Bony Union - … · Broken Bones – From Triage to Bony Union Steven G. Baker, DVM, ... External skeletal fixator ... Distal radius/ulna fracture$
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Broken Bones –From Triage to

Bony UnionSteven G. Baker, DVM, MS, Diplomate ACVS-SA

Staff Surgeon

[email protected]

Grayslake | Chicago | Crestwood | PremierVets.net

Emergency Management

Most fractures are traumatic in nature

Vehicular or similar collision

Stabilization (systemic)

Cover wound if present

History and physical exam (prioritized)


Diagnostics Pulse oximetry

Blood pressure, ECG

Blood work

Thoracic radiographs

Abdominal radiographs +/- contrast

Neurologic assessment

Orthopedic assessment


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Blood pressure, ECG

Blood work






Bladder rupture


cvm.umn.edu

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Blood pressure, ECG

Blood work







Blood pressure, ECG

Blood work







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Diagnostics Finally, radiographs of fracture

Include entire bone(s)

Proximal and distal joints for alignment


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Therapy Fluids

Analgesia

Systemic

Epidural / spinal

Local / regional blocks

Wound care

Temporary stabilization

Appendicular skeleton

Potential spinal fracture


Describing fractures What bone(s)

Portion of bone

Diaphysis, metaphysis, epiphysis, articular surface

Physeal – Salter-Harris classification

Morphology

Complete v incomplete

Simple v comminuted

Transverse, short v long oblique, spiral, segmental

Displacement

Open v closed

Chronicity


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Open Fractures

Unique combination of orthopedic and soft tissue injury

Infection

Delayed Union

Non-Union

Veterinary Surgery Small Animal. 2012 Saunders


Open Fractures - Ultimate Goals

Prevent infection and further soft tissue damage

Address/treat soft tissue

damage

Promote bony union

Restore function

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Open Fracture Classification

Type I: An open fracture with a wound smaller than 1 cm

Surrounding soft tissues are mildly/moderately contused. Frequently the external wound is created from the inside out by sharp bone fragments

Type II: An open fracture with a wound larger than 1 cm without extensive soft tissue damage, flaps, or avulsions

The external wound typically is created from the outside in by high energy forces

Open Fracture Classification

Type III: An open fracture with extensive soft tissue damage. Soft tissue avulsion, de-gloving injury, and bone loss are frequently noted. These include fractures with accompanying neurovascular injury requiring repair, gunshot injuries, and traumatic partial amputations IIIA: Adequate soft tissue coverage despite extensive soft tissue

laceration or flaps

IIIB: Extensive soft tissue loss, periosteal stripping and bone exposure

IIIC: Associated arterial injury requiring repair

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Wound Management

Confirm patient stable

Classify wound

Copious K-Y (sterile)

Clip wide

Clean surrounding skin

Copious wound lavage

Cut (debride necrotic tissue)

+/- Culture

Cover (bandage) wounds

Rigid external support


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Initial Surgical Debridement

Appropriate debridement irrigation and rapid stabilization (temporary)

No supportive literature on difference in infection rates comparing initial surgical debridement < 6 hours or > 6 hours

Treatment and prognosis of open fractures should not be based on a time interval alone

Soft tissue damage, viability, contamination, infection


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Open Fractures: ANTIBIOTICS

Required component of successful outcome

Timing: < 3 hours after injury significantly lower infection rate compared to 4 hours or greater

Coverage

Type I or II: First generation cephalosporin

Type III: Broader coverage, cephalosporin and fluoroquinolone

Nosocomial Infections (82%)


Open Fractures – Soft tissue treatment

Restoration of a soft tissue envelope

Pedicle muscle transfers

Microvascular free muscle transfers

Local skin/transposition flaps

Axial pattern flaps

Free skin grafts

Vacuum-assisted therapy


Open Fracture Treatment

Bone plates, plate rod, interlocking nail and external skeletal fixators

Type I fractures often treated similar to closed

External coaptation not recommended for definitive fixation

Type III/severely contaminated

External skeletal fixator


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Fracture forces Compression

Distraction / tension

Bending

Rotation

Shear

Fragment apposition


Bone Healing - physiology

Primary bone healing

Direct osteon formation across fracture site

Cutting cones

Contact v gap healing

Requirements

Rigid immobilization

Anatomic reduction

No callus formation

Slower than secondary


vet.upenn.edu

Bone Healing - physiology

Secondary bone healing

Phases

Inflammatory

Soft callus

Hard callus

remodeling

Requirements

Immobilization

Vascular supply

Faster than primary


aovet.org

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Fixation options

External

Coaptation

PROS: no destruction of blood supply, less cost, less anesthetic risk, less invasive

CONS: owner compliance, pet tolerance, frequent changes, muscle atrophy / contracture, soft tissue wounds

FORCES: partially counteracts bending and rotation, not shear

TYPES: many


Definitive Stabilization (External Coaptation)

Distal to elbow/stifle

Incomplete fractures

Simple minimal/non-displaced

Young

Financial constraints

Cost of bandage changes or

complications



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Reduce further injury:

Soft tissue (neurovascular)

Musculoskeletal

Attenuate painful stimulus

Prevention of open fracture

Temporary Fracture Stabilization

Bandage Anatomy

Tape stirrups

Primary Layer (if wound)

Adherent

Non-adherent

Secondary Layer (absorb and support)

Cast Padding

Kling

Tertiary Layer (support and protect)

VetWrapRIGID SUPPORT


Bandage Anatomy

Open v closed toe

Advantages of open

Swelling

Slippage

Temperature

Ease of stirrups

Advantages of closed

Less digit mobility


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Types of Rigid Support


www.3M.com

anicareas.com

alfavet.bg

Cast v splint

Preformed

Metal

Plastic

Custom

Fiberglass

Orthoplast

GUIDE TO THE DISSECTION OF THE DOG, SEVENTH EDITION, 2010 Saunders Elsevier

Temporary Fracture Stabilization

Humerus

Spica or nothing

Radius/Ulna (or distal)

Modified Robert Jones

Femur

Spica or nothing

Tibia/Fibula (or distal)

Modified Robert Jones


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Splints

Applications

Temporary support

Destabilization after casting

Support for partial immobilization

Primary fixation for certain

fractures


Bandage Complications

Moist dermatitis

Muscle atrophy

Skin necrosis / gangrene

Valgus deformity of the forelimb

Amputation of limb or digits

Death

Closely monitor bandages and digits

Swelling, warmth, odor, moisture


63% developed soft tissue injury

60% mild, 20% moderate, 20% severe

Can occur at any time frame, no association with duration of cast/splint

Cost of treatment 4-121% cost of original orthopedic procedure


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External Coaptation

Toy breed

Distal radius/ulna fracture

High risk of malunion or nonunion

Why?

High interfragmentary strain

Poor apposition

Decreased intraosseous blood supply


Fixation options

External

External skeletal fixator (ESF)

FORCES STABILIZED: potentially all 5

PROS: fracture site not disturbed, implants easily removed, dynamization, adaptable to 3D anatomy

CONS: patient / owner compliance, pin tract drainage, implant loosening or breakage, soft tissue damage

TYPES: Ia, Ib, II, III, circular, Ilizarov, ring, hybrid, tie-in, transarticular, acrylic, etc.

Typically secondary bone healing



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ESF adaptability



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Fixation options

Internal

Intramedullary pin

FORCES: partial bending; not rotation, shear, or apposition

Rarely used effectively alone

Pin + wire

FORCES:

Only used in very specific fracture configurations

Long oblique diaphyseal

Not radius

Rush pins

Cross pins


Fixation options

Internal

Cerclage wire

PROS: fragment apposition

CONS: minimal counteraction of bending forces

Must be combined with other fixation

Can produce shear forces

Must perfectly reconstruct cylinder


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Fixation options

Internal

Bone plates

FORCES COUNTERACTED : all

PROS: early return to function (usually), excellent fragment apposition, massive variety of types, locking technology

CONS: cost, invasiveness, potential for stress protection

Can add IM pin or cerclage wire for additional stabilization

Option of application in neutralization, compression or buttress fashions

Potential for minimally invasive plate osteosynthesis


Fixation options

Internal

Interlocking nail

FORCES COUNTERACTED: all

PROS: minimal disturbance of fracture site, faster healing, potential for dynamization

CONS: cost, implant removal exceedingly difficult, technical problems

Only amenable to specific fracture configurations in certain bones

Secondary bone healing

New system (I-LOC by Biomedtrix) is promising


biomedtrix.com


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broken bones – from triage to bony union - … · broken bones – from triage to bony union...

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