What do we think? Salvageable, or not?

Re: What do we think? Salvageable, or not?

Miriam Lodewyks — Thu, 15 Aug 2013 18:11:10 GMT

UPDATE: wounds continue to granulate nicely and infection appears to be under control. We continue dressing to keep granulation beds moist (yup... manuka). The 2 central digits (now boneless) have become floppy and have granulated together into one mass of tissue. I suggested to the owner that amputating the distal portion would allow for speedier healing of the remaining granulation tissue, but the owner is adamant that we do not do this. He requests that we wait until wounds have healed and then assess functionality before committing to anything irreversible. Tibial fracture appears stable and callus forming nicely. Below the tarsus the entire limb remains swollen, floppy with only the slightest response to skin pinching in certain areas. With a firm dressing, the dog seems very comfortable and does weightbear. I am sceptical that this puppy will ever have normal functionality of this limb, but quietly more optimistic that we might be able to save something he can use to some extent. Thank hou for all your input and advice, all ideas and opinions (apart from JGW's) are appreciated.

Re: What do we think? Salvageable, or not?

Rob Loxley — Thu, 15 Aug 2013 16:37:55 GMT

[quote user="Arlo Guthrie"]So for this reason, I have deleted ALL the posts in this thread up to the point when things got silly[/quote]

Unfortunately we have lost some information/discussion about the wider state of the leg beyond the foot injury, particularly regarding the nerve function of the lower limb. We can all discuss wound management, but without knowing more the state of the whole limb & function, the big question of whether would managment and healing will be a futile endeavour?

Re: What do we think? Salvageable, or not?

Michael Woodhouse — Thu, 15 Aug 2013 15:46:14 GMT

[quote user="Evelyn Barbour-Hill"]I wonder if this leg might do even better if the paw was just kept in a plastic bag full of gel.[/quote]

There's moist and there's macerated! I think you'd get a soggy mess myself.

Re: What do we think? Salvageable, or not?

Evelyn Barbour-Hill — Thu, 15 Aug 2013 14:25:36 GMT

[quote user="Toby Birch"]Although dressings seem to become more diverse/complicated every day[/quote]

Indeed they do and I sometimes wonder if people are making something quite simple into something very difficult.

Somebody who ought to know, I can't remember who, engraved these words on my brain: "Granulation tissue is a healing tissue". As long as you have got the better of any deep infection, the granulating wound just needs to be kept moist so that the epithelial cells can slide in. There are all sorts of gels you can use to do that, or alginate.

I wonder if this leg might do even better if the paw was just kept in a plastic bag full of gel. Changed at suitable intervals of course .

I await the brickbats. If I'm hopelessly wrong I am prepared to be corrected.

Re: What do we think? Salvageable, or not?

Toby Birch — Thu, 15 Aug 2013 13:12:45 GMT

Honey (Manuka or otherwise) should help to keep the granulation tissue clean and aid epithelisation.

Although dressings seem to become more diverse/complicated every day you might want to try changing to silver dressings. I have used in a few cases and although the wound initially looks worse when you remove the dressing once cleaned looks great and we have found that (completely anedotally) the time to removing a bandage has been reduced when compared to those that we continued to use honey.

Re: What do we think? Salvageable, or not?

Arlo Guthrie — Thu, 15 Aug 2013 00:09:41 GMT

MULTIPLE POSTS DELETED

OK, now at my desk and wondering whether the title of this thread might apply as much to the thread as to the patient.

The first and most important thing to say is that this forum exists for professionals to share knowledge, experience, ideas and problems. Central to that is that we have a friendly, collegiate atmosphere.

The ability to work collaboratively is still a relatively new phenomenon, and some people have concerns about what it is OK and what it is not OK to discuss online.

I believe it is a matter of simple common sense. It is hard to imagine any right-minded individual, either a pet owner or another member of the profession, seeing wrong in discussing a case here for the benefit of the patient.

That said, we do live in a litigious world, and whilst I think the threat of a complaint for seeking the advice of your peers is a very remote one, of course you should not post case details or images which directly identify a patient or its owner without their permission. If you feel it prudent, you could consider asking clients to sign a consent stating: 'I agree that you may share case details and images relating to my animal with other veterinary surgeons in an online community set up for that purpose."

Coming back to the discussion so far. JGW diverted the thread from a case discussion into an attack on the motives for posting the case here combined with an attempt to scaremonger everyone into such a state of paranoia that they would probably feel it necessary to dye the black labrador platinum blonde before photographing it, adopt a pseudonym and put on a wig and a fake moustache before sitting down at the computer and posting details.

This kind of paranoia is completely unwarranted, and threatens the collaborative atmosphere I've worked so hard to create here. So for this reason, I have deleted ALL the posts in this thread up to the point when things got silly. I don't do this lightly. I am not trying to stifle debate about discussing cases online. The point is that that is a discussion for a different thread.

I have also suspended JGW from posting in this forum for the rest of this month. Both for casting nasturtiums, and for scaremongering. Not for the first time.

My sincere apologies to Groovejet and Heidi for not stepping in a little earlier.

I do hope normal service can resume now, and we can pick up where we left off ...

If you want to post anything that does not directly relate to the clinical aspects of this case, please do it in a new thread.

Re: What do we think? Salvageable, or not?

Heidi W. — Wed, 14 Aug 2013 15:47:29 GMT

1.The owner is declining amputation at this time.

2.The owner is aware that photos have been taken.

3.They are also aware that it has been discussed on an online forum.

(Originally posted in reply to a now deleted post)

Re: What do we think? Salvageable, or not?

Michael Woodhouse — Wed, 14 Aug 2013 00:53:57 GMT

[quote user="GrooveJet"] Still not convinced this leg will be functional, but we're focussing on getting the wounds to heal.[/quote]

Why? A numb leg will just get chewed by the dog once you stop bandaging.

Chop the leg off. Cured in 14 days with stitches out.

Re: What do we think? Salvageable, or not?

David Mills — Tue, 13 Aug 2013 22:54:50 GMT

Despite what Kruuse tell you, if the wound is granulated, the effect of manuka is negligible. It is only really of use before granulation tissue. Companies will tell you it keeps the surface of the granulation tissue clean, which is a load of, well, crap.

Re: What do we think? Salvageable, or not?

Miriam Lodewyks — Tue, 13 Aug 2013 22:27:35 GMT

FYI: we had nothing to do with the initial treatment of this case. It was presented to us as seen on photo no. 1. We're now re-dressing daily with Allevyn and Manuka. Granulation tissue looks OK but middle phalangeal bones falling off and toes are disconcertingly floppy. Still not convinced this leg will be functional, but we're focussing on getting the wounds to heal.

Re: What do we think? Salvageable, or not?

Sammy82 — Mon, 12 Aug 2013 19:15:23 GMT

Agree on likely cause. It looks quite clean now, so I think healing will mainly require a lot of patience now. We had good experience with Manuka honey (if cost is an issue, I think normal honey will work just as well). I think the necrotic/ exposed bone will need removal to allow healing, maybe an x ray will help you to determine which bones are still vital, and which are showing signs of lysis.

Re: What do we think? Salvageable, or not?

Hannah Wynne Richards — Mon, 12 Aug 2013 10:39:26 GMT

I thinkthe same as Gillian. I bet VDS are groaning about this one!!!!!!!!!!!!!!!

Wynne

Re: What do we think? Salvageable, or not?

Gillian Mostyn — Sat, 10 Aug 2013 14:01:49 GMT

I'm guessing the initial bandaging was a fair bit too snug.......

Re: What do we think? Salvageable, or not?

Heidi W. — Sat, 10 Aug 2013 13:46:00 GMT

Unfortunately we do know how the paw got in this state and apologies for being cryptic but we are unable to post these details.

Re: What do we think? Salvageable, or not?

Linda Filshie — Sat, 10 Aug 2013 11:12:37 GMT

As per my post above, I would suspect it's the lack of sensation that is responsible for this state of affairs in the first place...

Re: What do we think? Salvageable, or not?

Miriam Lodewyks — Sat, 10 Aug 2013 11:08:36 GMT

Regarding the recent photo: as my colleague already mentioned, one of the phalangeal bones came off with a recent dressing and the other exposed bones do not look viable either. More worryingly (for us, perhaps not the pup) is the lack of sensation below the hock.

We continue to dress with Allevyn and Honey, and are hopeful that the owner will allow us to treat this until it reaches it's conclusion.

Re: What do we think? Salvageable, or not?

Miriam Lodewyks — Sat, 10 Aug 2013 11:04:15 GMT

Re: What do we think? Salvageable, or not?

Linda Filshie — Fri, 09 Aug 2013 21:52:38 GMT

[quote user="Heidi Whieldon"]

Update on this case:

We have been changing the dressings daily and applying manuka honey + allevyn. The smell is now much more tolerable! The owner is declining amputation at this stage. Today we found what is presumably PIII digit 4 just loose in the dressing. Below the hock there is no cutaneous sensation, which is, in an abstract way, at this moment, a saving grace for this pup, as he seems completely oblivious to dressing changes and remains BAR. There is no withdrawl or deep pain response below the hock however there is still some warmth to the distal limb.

The original MRCVS had not taken xrays which is why we could not post details regarding this. We radiographed yesterday, which revealed a complete, non displaced oblique mid shaft fracture of the tibia which is showing good signs of healing. As far as we can ascertain there was no original injury to the paw and that is all I shall say on that matter!

[/quote] So sounds like peroneal neuropathy (2ry to trauma I guess). Given that you're seeing radiographic signs of healing this injury happened at least 3 weeks ago. I would think the lack of deep pain response is a poor prognostic indicator for return of sensation to this limb, and I am guessing the trauma to the paw is secondary either to dragging of the foot/inability to determine noxious stimuli and therefore remove foot from harm's way or self mutilation. I'm sure the ortho/neuro guys will have good advice, but I would be recommending amputation at this stage.

Re: What do we think? Salvageable, or not?

Heidi W. — Fri, 09 Aug 2013 21:15:05 GMT

Update on this case:

The original MRCVS who saw this case (came to us for 2nd opinion) had not taken xrays which is why we could not post details regarding this. We radiographed yesterday, which revealed a complete, non displaced oblique mid shaft fracture of the tibia which is showing good signs of healing. As far as we can ascertain there was no original injury to the paw and that is all I can say on that matter without getting into trouble!

Re: What do we think? Salvageable, or not?

Malcolm Ness — Fri, 09 Aug 2013 08:54:34 GMT

[quote user="Clive Ansell"] regular ga's or sedations, debridements, dressings, ab's C&S. It may be cheaper and bring quicker resolution to amputate, which may well be the same outcome anyway.[/quote]

There is granulation tissue here which is inherently resistant to infection so the ongoing need for antibiotics in this case is small. The bones may or may not be biologically viable - they certainly won't ever form a usefully functional joint so a decision is needed as to whether to leave them to incorporate into the healing/granulating paw or to remove them surgically while leaving the remaining soft tissues to progress. If the bone is dead it will need to be removed, if not it can be left in situ - drilling multiple small holes will encourage further "nests" of granulation to form. I do not see any need here for extensive or repeated debridement or multiple GAs. The key is to use a light dressing that keeps the wound physiologically moist.

That said, the key information remains the extent and prognosis of the hock injury and we don't have that.

Re: What do we think? Salvageable, or not?

Clive Ansell — Fri, 09 Aug 2013 07:29:41 GMT

It may heal if infection can be controlled, along with regular debridement and dressing changes. In any event there is always the option of amputation.

From a cost point of view, it could be a long haul with regular ga's or sedations, debridements, dressings, ab's C&S. It may be cheaper and bring quicker resolution to amputate, which may well be the same outcome anyway.

Re: What do we think? Salvageable, or not?

mariette asselbergs — Fri, 09 Aug 2013 07:11:29 GMT

I had a cat much worse and we had to amputate the other leg so this one needed to be salvaged to survive. It took time but it healed with an ankylosed tarsus and the wound healed over and it is still running (yes, running, up and down the stairs) around 6 years later. The owners can probably learn how to change bandages. Manuka honey and/or intrasite are wonderful stuff for these. As others have said, how painful is the dog, and does it leave the paw alone? And money....

Best of luck and show us results in time?

Mariette

Re: What do we think? Salvageable, or not?

Nicola Lawlor — Thu, 08 Aug 2013 20:50:39 GMT

I would use wet-dry dressings to debride further here, culture and sensitivity testing meanwhile and once debridement done something like activon honey dressings. No harm in trying if the owner is committed to trying knowing it may not do well and the costs are not a primary issue. See what you can salvage and you may well be surprised. Keep the limb well dressed to support the fracture and it has a chance to heal - I am assuming it is not badly displaced saying that.

Re: What do we think? Salvageable, or not?

Allie Woodward — Thu, 08 Aug 2013 00:48:05 GMT

I would consider removal it if owner insists I have had amazing results with veterinary biosist dressing once infection is under control. Allevyn, flush daily to decontaminate. And redress. How bad is the tarsal fracture?

Re: What do we think? Salvageable, or not?

Suzanne Kelly — Wed, 07 Aug 2013 21:17:07 GMT

If owners can afford it sedate dog every 1-2 days and dress with honey and a baby's nappy. Sounds mad, but I had a rottie that had it's leg pretty much torn apart by a pit bull. Leg a rotten stinking mess. Os wanted to try so we did and dog aok now. You've nothing to lose.