orthopaedic opinion please?

Re: orthopaedic opinion please?

Martin Atkinson — Mon, 01 Oct 2012 08:54:15 GMT

[quote user="Malcolm Ness"]See comments from others about poor disappointing results with conservative treatment - I suspect that at least some of those cases are due to immobilisation in a cast or support dressing.[/quote] It was not so much I had disappointing results due to poor return to function following immobilisation but that most of the distal tibial epiphyseal fractures I've seen have been too unstable to be considered for external support in the first place or attempts at external fixation have failed at an early stage and they've had to fixed surgically. I guess I've just been unlucky with case presentation.

Re: orthopaedic opinion please?

Nicola Lawlor — Sat, 29 Sep 2012 20:43:37 GMT

Thank you Malcom - that makes a lot of sense. We will review the case next week and make a plan either way. Hopefully a few days in a support dressing will have done the initial work and we can continue conservative care out of a dressing. If not will be getting the K wires out.

Re: orthopaedic opinion please?

Evelyn Barbour-Hill — Sat, 29 Sep 2012 12:38:11 GMT

[quote user="Gillian Mostyn"]as long as the majority vote honestly then the system would work. Obviously if only the numpties vote then the system fails....[/quote]

Ah, alas, 'twas ever the problem with democracy................

Re: orthopaedic opinion please?

Malcolm Ness — Sat, 29 Sep 2012 10:26:07 GMT

[quote user="Nicola Lawlor"]I am curious as to why this is better managed without a support dressing - just because it affects mobility and cat will cope better without that issue??[/quote]

If it is so unstable as to need support then (because it is a peri-articular fracture) it would benefit from surgical fixation. What's more, immobilising very young joints inevitably leads to some stiffness/loss of range and in many cases that is permanent. The aim of any fracture treatment should be the permanent restoration of full function and while it is easy to get bones to heal under a cast, in a young patient with a periarticular fracture, the restoration of full function is less predictable. See comments from others about poor disappointing results with conservative treatment - I suspect that at least some of those cases are due to immobilisation in a cast or support dressing.

wrt healing - a functional clinical union should be established within 4 weeks (by which time the kitten should appear very near normal). Radiographic union and remodelling will follow over the subsequent month or two. As with all immature physeal fractures there is a risk developing an angular deformity but that is quite uncommon with this particular fracture.

Re: orthopaedic opinion please?

Martin Atkinson — Sat, 29 Sep 2012 09:30:34 GMT

Thanks for the support JHL et al, I'm grateful but I'm a big boy so I can take criticism. Just to add to the controversy: I developed my own technique for this years ago whereby I drill a tunnel through the distal epiphysis and one through the distal tibial shaft from the medial side then and thread a simple wire loop through the tunnels, then twist tight - worked a treat. I would probably now use the method previously mentioned in this thread or a pin and wire tension band but I simply don't see the case load anymore - animals don't seem to fracture their legs as much as they used to. Why is this - is it down to cars having better brakes or what? (Cue 3 fracture distal tibial epiphyses in the next week)!

Re: orthopaedic opinion please?

Gillian Mostyn — Sat, 29 Sep 2012 09:18:06 GMT

[quote user="James Laidlaw"]I find it easier to haul your way through the commentary and opinion on this site by completely ignoring the star system.[/quote]

In contrast, I find it very useful to gauge weight of opinion. Afterall, as soon as you rank it yourself you can see the number of people who have voted. Red star + one vote = little notice paid. Red star + 30 votes = might need to change my methods/opinions!!!

You'll always get a few numpties who don't have the b******** to comment, but just rank people instead, but as long as the majority vote honestly then the system would work. Obviously if only the numpties vote then the system fails....

Re: orthopaedic opinion please?

James Laidlaw — Sat, 29 Sep 2012 08:26:02 GMT

[quote user="james herriot lied"]

Why are people red starring Martin? He's given a clinical opinion, which is hardly controversial. It may differ in certain aspects from Malcolm's (and mine, as though that would be useful anyway), but I don't get the criticism. It's all becoming a bit daft.

[/quote]

I find it easier to haul your way through the commentary and opinion on this site by completely ignoring the star system.

Re: orthopaedic opinion please?

Rob Loxley — Sat, 29 Sep 2012 00:04:50 GMT

[quote user="james herriot lied"] It's all becoming a bit daft.[/quote]

IMHO the star system became a bit daft quite some time ago. Going back to another thread, we're all professionals capable to assimilating information; do we need a star rating to do that??

Re: orthopaedic opinion please?

james herriot lied — Fri, 28 Sep 2012 21:29:48 GMT

Re: orthopaedic opinion please?

Nicola Lawlor — Fri, 28 Sep 2012 21:24:11 GMT

Sorry Malcom just re-read your post. Will re x-ray in a week yes. How long until you would expect full healing though after this?

Re: orthopaedic opinion please?

Nicola Lawlor — Fri, 28 Sep 2012 21:22:45 GMT

Thank you for the input - I am pretty sure the malleoli were aligned with the talus so sounds like conservative care will be acceptable. I will carefully review the x-rays on Monday just to be sure and call the owner if needs be. The leg did bend a little in strange ways when I was positioning for x-ray but I figured that was due to the fracture itself.

I am curious as to why this is better managed without a support dressing - just because it affects mobility and cat will cope better without that issue?? I can certainly take the dressing off at review this coming week anyway. How soon would you re x-ray this to check healing given the kitten is 16 weeks old now? I presume strict rest in a crate without a dressing is acceptable. How long for in this?

Many thanks

Re: orthopaedic opinion please?

james herriot lied — Fri, 28 Sep 2012 18:29:42 GMT

What Malcolm said: cat, young, in apposition and did I mention it's a cat? And young?

My experience has been the opposite of Martin's, but he's very, very old and will have seen a lot more of these . To be fair, we see a huge number more of proximal tibial SH fractures.

Either way, good outcome should be expected.

Re: orthopaedic opinion please?

Martin Atkinson — Fri, 28 Sep 2012 18:15:58 GMT

If it seems stable and non-displaced in the cast then I would leave it for now but re-xray in a week but IME these don't do well with conservative treatment so if it is unstable I would fix it with a pair of crossed arthrodesis wires - i.e.one through each malleolus. But then I'm not an orthopod!

Re: orthopaedic opinion please?

Malcolm Ness — Fri, 28 Sep 2012 17:54:07 GMT

The most important aspect of these fractures is the state of the medial malleolus of the tibia and the distal epiphysis of the tibia - these are the origins of the medial and lateral collateral ligaments respectively. If these are non-displaced relative to the tibial tarsal that is good but if they are displaced or unstable you can infer an instability of the hock joint that will need to be treated surgically (open reduction and fixation of the very small fiddly bits of ligament-attached bone using Kirschner wires). Fortunately, many of these distal tibial physeal fractures in younger kittens have the ligament/malleolus anatomy preserved - in effect the tibial physis has "slipped". In those cases conservative management is appropriate providing there is reasonable (2/3 or more) contact between the diaphysis and epiphysis and providing that limb alignment is good. Pain control (NSAIDs) and restricted activity are all that is needed - I would avoid casting or support dressings as much as possible and certainly for no more than a few days. Repeat rads after 5-7 days - if it hasn't moved then it will be fine, if it has moved then surgery (as described above) is indicated.

Prognosis for return to normal is excellent and it should be using the leg very confidently within 3 weeks.