Mandibular Fracture in a cat

Re: Mandibular Fracture in a cat

Iain McAllister — Wed, 06 Mar 2013 12:12:06 GMT

[quote user="Rob Davis"]

Thanks for that. What's the long term plan with the canine? Are they intending to do root canal work once the fracture has healed?

[/quote]

yes - that would be the choice as extraction would potentially destabilise the fracture

Re: Mandibular Fracture in a cat

Rob Davis — Wed, 06 Mar 2013 08:42:30 GMT

Thanks for that. What's the long term plan with the canine? Are they intending to do root canal work once the fracture has healed?

Re: Mandibular Fracture in a cat

Iain McAllister — Tue, 05 Mar 2013 20:03:42 GMT

Here is the referral photos - sorry scanned from a letter rather than original jpegs but thought people

would be interested - click pic to see full pic in another tab

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Wed, 27 Feb 2013 01:29:25 GMT

Yum.

Re: Mandibular Fracture in a cat

Iain McAllister — Tue, 26 Feb 2013 21:24:59 GMT

Here is the stabilisation - £700

The material goes round from 409 to 309 in case you can't see

He's eating well!

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Thu, 21 Feb 2013 19:22:32 GMT

[quote user="Virginia Campbell"]

I'm interested in this discussion as we have a cat in at the moment post RTA. His mandibular symphysis luxation was wired with a figure of 8 and he had a longitudinal hard palate split. The mucosa was closed as best we could but he was still uncomfortable as the split seemed unstable, so I went back in, extracted both of the little tiny upper first premolars then placed a pin (well a big K wire) across the hard palate. He seemed a lot more comfortable quickly (though we did leave an oesophagostomy tube in for a few days till he started eating some on his own - pulled it yesterday and he's eating well).

[/quote]

I don't know if I'm missing something but I can't see how a single pin across the palate would particularly help a split palate. The force you are trying to counter is distraction and the pin would not do that...... unless by luck the pin holds the bone by friction just for long enough. Or, maybe, though you weren't preventing distraction, there had been a bit of an angulating waggle between the bones which the pin did prevent.

Simple split hard palates heal very well with almost no treatment. Suturing the mucosa is usually a waste of time - unless it's very ragged or flappy it heals quickly with no sutures, and any sutures are generally removed by the cat's tongue in a couple of days.

However many (the majority of) split palates, when you radiograph them, turn out to be a split of much of the rostral part of the skull, right in the midline longitudinal plane. These do need compressing together. A wire across the palate does this perfectly and is well tolerated. A lot of faff, work loose? No, if you do it right. On no account let the resident orthopod get at it. .

As ever, if there is more than one fracture, always consider inter-jaw fixation to reinforce and generally stabilise everything, even if you have fixed the individual fractures. Thus you can ensure perfect occlusion.

[quote user="Virginia Campbell"]Why do the books go on at length about jaw fractures in the dog when cats get their faces smashed much more often?!! [/quote]

Twenty-five years ago, I asked the great Peter Emily a similar question although the exact subject was different. His reply: "Well, Evelyn, when an author doesn't say much about something, it's usually because he doesn't know anything about it"

Re: Mandibular Fracture in a cat

Virginia Campbell — Thu, 21 Feb 2013 18:54:15 GMT

[quote user="Evelyn Barbour-Hill"]The maxillary pin right through the nasal chambers and everything?[/quote]

What do you think of this for stabilising a hard palate split Evelyn? I mean sending the pin through just above where the first premolar was and through the bone of the hard palate? The trouble seems to be getting the aim right to avoid the teeth on the other side...unfortunately I missed where I was aiming for and when I met with a lot of resistance I took an Xray and sure enough, the pin was resting against the root of the canine. Hope I haven't stuffed up the canine. Do you think I would have been better off to measure the pin first and stop short of trying to get the pin to emerge from the other side and just accept a bit of bite into the hard palate at the other side for stabilisation?

The books talk about wiring across the palate anchoring round the teeth but I was worried that it would be a lot of faff, work loose and be a lot or annoying metal in the cat's mouth and not provide as strong stabilisation. I don't know which is better for occlusion.

Why do the books go on at length about jaw fractures in the dog when cats get their faces smashed much more often?!! OK apart from the ancient renal failure Yorkies whose mandibles just spontaneously fall apart around their disgusting first molars.

Re: Mandibular Fracture in a cat

mariette asselbergs — Thu, 21 Feb 2013 18:16:01 GMT

"Well, most clients would prefer a very reasonably priced proper solution to a cheap poor one. Why do we have this assumption that fixing a cat's jaw properly must be terribly sophisticated and awfully expensive? "

Agree Evelyn, just live with lots of clients who will not do any costly stuff for cats. In our practice the cut off point for clients is often about £100, if its more then its PTS and a new cat. This is not my assumption but what we live with.

Mariette

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Thu, 21 Feb 2013 18:00:09 GMT

[quote user="mariette asselbergs"]

Or perhaps – I've just thought of this - remove the involved canine teeth and any associated bits and bobs of bone, suture the soft tissues up firmly, and give semi-liquid or soft food (and heaps of pain relief of course). It might heal good and solid, or it might heal with a fibrous union, or it might heal with still quite a hinge at the site: in all these cases the function might be quite good. (Evelyn)

Isn't this just what MIchael said as a first (practical as always) reaction on this case?

[/quote]

I thought someone would say that. No, it isn't just what Michael said - for a start, he didn't mention any surgery, just inaction and pain relief. For another, he suggested that the fracture could be relied upon to knit solid and as I say above that is not necessarily so. In the sort of case described by Mr. Mills, to which I was referring, "see and wait and keep pain and infection free" would certainly not be an option. Secondly, my suggestion was for a way out of the rather special problem faced by Mr. Mills because of the nature of his clinic, certainly not for the case in the original post.

[quote user="mariette asselbergs"]PS I found it interesting to read all that is possible to do, but can imagine that a lopt of our sort of clients would prefer the cheap and less perfect solution which so often works in cats: See and wait and keep pain and infection free.[/quote]

Well, most clients would prefer a very reasonably priced proper solution to a cheap poor one. Why do we have this assumption that fixing a cat's jaw properly must be terribly sophisticated and awfully expensive?

Re: Mandibular Fracture in a cat

mariette asselbergs — Thu, 21 Feb 2013 16:35:51 GMT

Isn't this just what MIchael said as a first (practical as always) reaction on this case?

Mariette

PS I found it interesting to read all that is possible to do, but can imagine that a lopt of our sort of clients would prefer the cheap and less perfect solution which so often works in cats: See and wait and keep pain and infection free.

Re: Mandibular Fracture in a cat

Gerry Henry — Thu, 21 Feb 2013 09:16:29 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Gerry Henry"]Not many people know that.[/quote]

Where can I read more? Any books you'd recommend?

[/quote]

http://www.chandlerhousebooks.com/index.php?page_id=272

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Thu, 21 Feb 2013 00:57:01 GMT

Re: Mandibular Fracture in a cat

David Mills — Thu, 21 Feb 2013 00:53:50 GMT

[quote user="Evelyn Barbour-Hill"]but I'd guess the oral "amputee" might need a bit more adaptation and a bit more owner care. That's just how I see it , I'm only speculating[/quote]

Yes, fair enough. It's not something we actually do at the moment, but it came up as a possibility in a case the other day. I guess it's one of those things that we'll only see if it works by trying it, though that has an air of the experimental about it. Although we have done mandibulectomies and they have done well, so this may be no different, and a few days in hospital is not an issue. Food for thought (mind the pun).

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Thu, 21 Feb 2013 00:49:42 GMT

[quote user="David Mills"]A few reasons really. One is lack of expertise and familiarity with ex-fixing mandibles. Another is time - both in terms of surgery time, and recovery time. Even with limbs we have to be very careful with fixing fractures - this goes for owned and strays equally. We do a lot of amputations because they give, in our hands at least, predictable results in a quick time (surgery and recovery) which do not heavily rely on owner compliance for success; if they are strays then it means a long stay in hospital/rehoming centre that could be filled 5-6 times over by other animals. If we were to fix every fractured area we see our hospital/rehoming centre would be bottlenecked with recovering animals. This also means that we don't have that much kit to carry out a wide range of repairs. Whilst fixing would obviously be preferable, I'm wondering if amputation would give acceptable outcome for the cat's ongoing welfare, even if it isn't ideal. [/quote]

Hum. Yes. The only objection I can see is that perhaps the cat after amputation would still need a bit of a hospital stay to be sure it adapted to a new way of eating. And I'm not sure that the cat would be able to just go home and resume what might be an, er, should we say semi-neglected lifestyle? I appreciate your limb amputees may do well, but I'd guess the oral "amputee" might need a bit more adaptation and a bit more owner care. That's just how I see it , I'm only speculating.

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Thu, 21 Feb 2013 00:40:50 GMT

Re: Mandibular Fracture in a cat

David Mills — Wed, 20 Feb 2013 22:53:25 GMT

[quote user="Evelyn Barbour-Hill"]

Similar injuries but bilateral, you mean? That would certainly be tricky. Or a fracture like this case, but maybe a symphyseal separation, or a fracture close to the symphysis? I've treated smashed chins by simply removing all the small fragments and bits of dubious viability, and wiring the symphysis. If there's enough bone left to make a symphysis of sorts (without creating malocclusion) they do fine.

[/quote]

Yes we've had a couple bilateral similar areas in the last few weeks with symphysis intact (no rhyme or reason), with lower canines apices appearing compromised.

[quote user="Evelyn Barbour-Hill"]owever, if the fracture were, as in this case, through the level of the apex of the canine (as it often is, due to mechanics), I can't really see why you would go for amputation. External fixation could be done cheaply. Is there some other reason why it wouldn't be acceptable in your situation? Genuinely interested.[/quote]

A few reasons really. One is lack of expertise and familiarity with ex-fixing mandibles. Another is time - both in terms of surgery time, and recovery time. Even with limbs we have to be very careful with fixing fractures - this goes for owned and strays equally. We do a lot of amputations because they give, in our hands at least, predictable results in a quick time (surgery and recovery) which do not heavily rely on owner compliance for success; if they are strays then it means a long stay in hospital/rehoming centre that could be filled 5-6 times over by other animals. If we were to fix every fractured area we see our hospital/rehoming centre would be bottlenecked with recovering animals. This also means that we don't have that much kit to carry out a wide range of repairs. Whilst fixing would obviously be preferable, I'm wondering if amputation would give acceptable outcome for the cat's ongoing welfare, even if it isn't ideal.

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Wed, 20 Feb 2013 22:31:26 GMT

[quote user="Gerry Henry"]Not many people know that.[/quote]

Where can I read more? Any books you'd recommend?

Re: Mandibular Fracture in a cat

Gerry Henry — Wed, 20 Feb 2013 20:07:26 GMT

The father of cranio-maxillary surgery, Dr. Varaztad H. Kazanjian, fled oppression in Turkish Armenia aged 16, emigrated to america where he combined night school with a day job in a wire mill in Worcester, Mass, attended Harvard Dental School, volunteered for the RAMC in WWI where he 'invented' cranio-maxillary reconstruction (using his knowledge of anatomy, dentistry and metallurgy) together with many of the modern plastic surgery procedures we use today (McIndoe rated him very highly). King George V knighted him after the war, a truly remarkable man.

Not many people know that.

Re: Mandibular Fracture in a cat

Martin Atkinson — Wed, 20 Feb 2013 19:27:45 GMT

[quote user="Evelyn Barbour-Hill"]The maxillary pin right through the nasal chambers and everything? I don't mean to criticise, I'm sure it worked and it was the only thing to do in that case at that time. But on the whole I wouldn't let an orthopod anywhere near the s[/quote] Yes. I was equally horrified at the thought of it at the time and expected a blood bath but it went OK with no complications at the time or subsequently.

Incidentally, on the question of amputation I've seen 2 dogs with bilateral fractured mandibles behind the canines both from dogs that bit on a gate: one was a police dog which did the damage chasing a villain, we amputated that one as it was complete mess and it did very well (as a pet - it wasn't much good as police dog after that!) and one (a Golden Retriever) that did it in the clinic when it got its lower jaw stuck in the bars of the Shorline kennel gate trying to bite its way out (eek!), I got to that one very soon after the injury, wired it back in place and it did very well. I've also had a Retriever that gave itself a fracture/evulsion of an upper canine doing the same trick (are they all mental?!) I popped that one back in and it healed as well. Retrievers are now on suicide watch when kennelled!

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Wed, 20 Feb 2013 17:33:41 GMT

[quote user="Iain McAllister"]

Have referred it to a local veterinary dentist for intra oral wiring/splinting - I think the removal of the fragment would have been a good second option though in a patient where funds were even more limited - I'll try and get pics of the result - thanks for the help

[/quote]

Jolly good.

Not sure what you mean by " the fragment". Sorry if it seems I'm labouring the point, but I can only see one fracture on your radiograph, albeit somewhat comminuted, so what is it you would remove?

[quote user="Martin Atkinson"]No one pin straight through both (I mean one through both sides of the mandible and one straight through the maxilla - I think I might have put external fixaters on rather than a wire loop now I come to think of it)), this was a technique an orthopod told me about (sorry can't remember who) it amazed me at the time that I didn't hit anything vital but it was a desperate measure after I failed to align the fracture with a plate because there was no-where to put the screws.[/quote]

The maxillary pin right through the nasal chambers and everything? I don't mean to criticise, I'm sure it worked and it was the only thing to do in that case at that time. But on the whole I wouldn't let an orthopod anywhere near the skull.

[quote user="Martin Atkinson"]And no it is actually difficult to align the mandible with perfect precision so your priority is to have the teeth aligned so the animal can eat and close its mouth once healed, the fracture will heal so long as it is reasonably opposed. [/quote]

Yes, that's right, I quite agree, but if the teeth are perfectly aligned then the mandibular fragments must be perfectly aligned even if they don't look as if they are. Get the occlusion correct and everything else will follow.

Re: Mandibular Fracture in a cat

Martin Atkinson — Wed, 20 Feb 2013 16:41:57 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Martin Atkinson"]'ve treated these in the past by putting a pin through the maxilla and one through the mandible[/quote]

Interesting. Do you mean one pin each side? Where did you put the pins in the maxilla?

[quote user="Martin Atkinson"]lined the jaw up so the mouth closes anatomically (the exact alignment of the fragments is secondary to this)[/quote]

That should be exactly the same thing, shouldn't it?

[/quote] No one pin straight through both (I mean one through both sides of the mandible and one straight through the maxilla - I think I might have put external fixaters on rather than a wire loop now I come to think of it)), this was a technique an orthopod told me about (sorry can't remember who) it amazed me at the time that I didn't hit anything vital but it was a desperate measure after I failed to align the fracture with a plate because there was no-where to put the screws. IIRC, I passed the pins between the canines and the 1st lower premolars in the mandible and between the 1st and 2nd upper premolars in the maxilla (that should give enough room on the fracture side of the mandible in the OP's case). And no it is actually difficult to align the mandible with perfect precision so your priority is to have the teeth aligned so the animal can eat and close its mouth once healed, the fracture will heal so long as it is reasonably opposed.

Re: Mandibular Fracture in a cat

Iain McAllister — Wed, 20 Feb 2013 15:30:54 GMT

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Wed, 20 Feb 2013 14:46:31 GMT

[quote user="David Mills"]

[quote user="Evelyn Barbour-Hill"]

[quote user="David Mills"]Another query. What would be the result of amputating the cranial fragment en masse? [/quote].

Well, I'm sure it would heal and leave a functional mouth of sorts, but why would you want to do that in this case?

[/quote]

Not this case. We've had strays coming in with similar injuries. We couldn't justify ex fix but if amputation left acceptable function then it would avoid PTS.

[/quote]

However, if the fracture were, as in this case, through the level of the apex of the canine (as it often is, due to mechanics), I can't really see why you would go for amputation. External fixation could be done cheaply. Is there some other reason why it wouldn't be acceptable in your situation? Genuinely interested.

Re: Mandibular Fracture in a cat

David Mills — Wed, 20 Feb 2013 14:28:41 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="David Mills"]Another query. What would be the result of amputating the cranial fragment en masse? [/quote].

Well, I'm sure it would heal and leave a functional mouth of sorts, but why would you want to do that in this case?

[/quote]

Not this case. We've had strays coming in with similar injuries. We couldn't justify ex fix but if amputation left acceptable function then it would avoid PTS.

Re: Mandibular Fracture in a cat

Evelyn Barbour-Hill — Wed, 20 Feb 2013 14:05:45 GMT

[quote user="Gerry Henry"]

Uneccessary complications.

Evelyn, yes I know about the artery and nerve but how critical is it if you damage either/both, would there be a loss of function?

[/quote]

Well, no, it would probably be OK. But you don't want a possibly contaminated pin stuck through an artery, you don't really want a lot of haemorrhage and you don't want to compromise (lovely word) the blood supply. Fouling up the nerve might induce a lot of continuing pain or it might lead to loss of sensation. In the human field if you permanently desensitise the chin you are in trouble and you might be looking at a "malpractice suit" (I know that's an American phrase, but it's so picturesque I love it); but of course it hardly matters to the cat or dog.

[quote user="David Mills"]Another query. What would be the result of amputating the cranial fragment en masse? [/quote].

Well, I'm sure it would heal and leave a functional mouth of sorts, but why would you want to do that in this case?

[quote user="Martin Atkinson"]'ve treated these in the past by putting a pin through the maxilla and one through the mandible[/quote]

Interesting. Do you mean one pin each side? Where did you put the pins in the maxilla?

[quote user="Martin Atkinson"]lined the jaw up so the mouth closes anatomically (the exact alignment of the fragments is secondary to this)[/quote]

That should be exactly the same thing, shouldn't it?