How long has this been broken?

Re: How long has this been broken?

Malcolm Ness — Sat, 26 Apr 2014 17:09:04 GMT

Thank you.

Happy to help.

Re: How long has this been broken?

Anthony Dennison — Fri, 25 Apr 2014 22:31:05 GMT

Dear Malcom,

You are my hero! Thank you so much for such an excellent post, I will pass it on to the case vet (not on vetsurgeon, so I offered to get extra opinions). The owners may be happy to hear this.

Incidentally, the cause of the injury was her running up a tree (?!) and landing awkwardly so this would fit.

Re: How long has this been broken?

John Flynn — Fri, 25 Apr 2014 21:24:43 GMT

[quote user="Malcolm Ness"]

...

In summary, Plan A for me would be pain control and passage of time. Only if that fails would I consider surgery and then I would go for SOP locking plate or a well-applied Ex Fix.

[/quote]

It's excellent contributions such as this (the whole post, not just the quoted part!) that make this forum such a useful clinical resource.

So on behalf of all those who read this and learned something new and useful, many thanks to Malcolm once again for taking the time to share his knowledge on a case for all our benefit

Re: How long has this been broken?

Tim Browning — Fri, 25 Apr 2014 17:21:44 GMT

Phew ! I am glad a proper vet said all that , with an intact fibula I would agree with a conservative approach first but would expect the younger vets here to be suspicious of this.

Re: How long has this been broken?

Malcolm Ness — Fri, 25 Apr 2014 15:54:53 GMT

This looks like a fresh fracture. The fibula is intact and that along with the long spiral shape of the fracture indicates that torsion around the long axis of the tibia was the cause. This is a reasonably common fracture pattern in dogs of this age and type and often caused by them bouncing up on their back legs and landing in an uncoordinated fashion. There is minimal evidence of local soft tissue swelling and that too is consistent with the likely aetiology. It is likely that the soft tissue envelope including periosteum remains intact or only minimally damaged.

Many of these cases can be managed to excellent effect without anything other than medical pain control and a degree of confinement/controlled exercise.If the stifle and hock are both pointing North, then conservatism would be my first choice. See the dog back every week or so to confirm that things remain the right shape and look to re-radiograph after four weeks or so.

Even a properly applied R-J will do little to control the torsional instability that is the feature of this case and, as you have discovered, the extra distally anchored weight and the dog's inability to control the heavily dressed limb will likely make things considerably worse. Co-aptation with a cast has the same limitations and any cast needs to extend proximal to the stifle - casts in general and high casts in puppies in particular are very prone to complications.

If necessary, surgical stabilisation can be considered. Ex fix is a good choice - bilateral frame with at least one full pin and one (preferably two) half pins proximally and distally. All pins should be positive profile threaded pins and placed after pre-drilling. The ex fix should be placed without exposing/opening the fracture. Lag screws plus a neutralisation plate could be made to work but it is massive over-kill and turns a closed, simple fracture of a bone looking to heal into an open fracture of a bone dissected free of much of its blood supply. Either way, implants (plates, screws and ex fix pins must stick within the diaphysis and not encroach the growth plates. Pin and wire would be a poor choice - it is difficult to normograde pin an immature tibia and retrograde pinning will involve invasion of several structures that were, until the time of surgery, normal - the stifle joint, the prox and distal physes and the metaphyses. Furthermore, the one thing that pins are really very poor at doing is controlling torsion and torsion is what this fracture is about. The final surgical option would be to apply medially a SOP locking plate - that has the advantage of being applied without the need to dissect down to the bone with disruption of blood supply and soft tissue envelope and provides excellent stability against all the forces likely to act across this healing fracture.

In summary, Plan A for me would be pain control and passage of time. Only if that fails would I consider surgery and then I would go for SOP locking plate or a well-applied Ex Fix.

Re: How long has this been broken?

Martin Atkinson — Fri, 25 Apr 2014 14:29:42 GMT

[quote user="Utlendigur"]I always understood (happy to be corrected) that radiographs were the property of the practice and the clients were paying for the vet's time and expertise in interpreting them, rather than the actual xray film itself - so they are entitled to have a copy of it but not the actual radiograph itself. [/quote] No need to be corrected this is the fact.

Re: How long has this been broken?

Utlendigur — Fri, 25 Apr 2014 14:26:56 GMT

I always understood (happy to be corrected) that radiographs were the property of the practice and the clients were paying for the vet's time and expertise in interpreting them, rather than the actual xray film itself - so they are entitled to have a copy of it but not the actual radiograph itself.

Ditto contacting prof-con and vds with a view to reporting to the RSPCA. The last owner-applied splint I saw was a staffie with a fractured femur whose owner applied a piece of wood, wrapped in insulating tape to its tibia and nearly destroyed its lower leg.

Re: How long has this been broken?

Anthony Dennison — Fri, 25 Apr 2014 12:07:01 GMT

Hit the nail on the head Martin, which is why we went for dressing only (which they are arguing about as the dressing had to be taken off). It's got 'bad debt' written all over it!

Re: How long has this been broken?

Martin Atkinson — Fri, 25 Apr 2014 11:47:49 GMT

[quote user="Anthony Dennison"]what with it being a bank holiday weekend, the owner umming and aaah-ing about whether they could afford the op[/quote] What proportion of owners who walk in with an 'emergency' without calling first, especially under suspicious circumstances wont'/can't pay? - the majority in my experience.. I would be very careful about doing anything other than basic support until I knew there was some money on the table!

Re: How long has this been broken?

John Flynn — Fri, 25 Apr 2014 11:43:36 GMT

[quote user="Anthony Dennison"]Pin and wire was the plan, but what with it being a bank holiday weekend, the owner umming and aaah-ing about whether they could afford the op, it being a stable fracture and the vet that does ortho ops away until after the weekend, we thought a Robert Jones would be sufficient for a few days. The reaction that the dog gave to the RJ dressing made us hesitant to put a cast on.[/quote]

Understood. I've never personally enjoyed pinning dog tibias like this, but i can see how that's a perfectly reasonable plan especially given reluctance to apply external coaptation.

Re: How long has this been broken?

Anthony Dennison — Fri, 25 Apr 2014 10:55:25 GMT

[quote user="John Flynn"]

Just me, but I would cast this and crate restrict for 3 weeks and re-xray.

What implants needed ordered? If operating, I'd consider either pin+wire or ESF as cheapest options with minimal inventory requirements. As a plate +/- lag screws would be fine also, there seem so many options to fix this fracture that I can't see the need to leave it for 5 days and then operate on it.

[quote user="Anthony Dennison"]Turns out the owner has applied his own cast and thinks that will do[/quote]

It might if they don't cause soft tissue injuries and keep adequately restricted? Were they offered a vet-applied cast initially?

[/quote]

Pin and wire was the plan, but what with it being a bank holiday weekend, the owner umming and aaah-ing about whether they could afford the op, it being a stable fracture and the vet that does ortho ops away until after the weekend, we thought a Robert Jones would be sufficient for a few days. The reaction that the dog gave to the RJ dressing made us hesitant to put a cast on.

Re: How long has this been broken?

John Flynn — Fri, 25 Apr 2014 10:40:58 GMT

Just me, but I would cast this and crate restrict for 3 weeks and re-xray.

[quote user="Anthony Dennison"]Turns out the owner has applied his own cast and thinks that will do[/quote]

It might if they don't cause soft tissue injuries and keep adequately restricted? Were they offered a vet-applied cast initially?

Re: How long has this been broken?

katja wagner — Fri, 25 Apr 2014 10:32:24 GMT

I would seek advice from the RCVS and VDS about reporting this client as it seems the dog will not receive any necessary veterinary care.

katja

Re: How long has this been broken?

Anthony Dennison — Fri, 25 Apr 2014 10:26:03 GMT

The reason why I ask is I thought that the break may have occurred about 24-48hrs before presentation, rather than the owners claim that it happened the night before (though this is in question as there were 2 people in the consult, when my colleague was told it happened the previous night one turned to the other and said 'I though it happened this morning...'). Probably my orthopaedic inexperience, but I thought that the ends of the fracture wouldn't look as rounded.

Dog presented last Thursday, as it seemed a stable fracture a Robert Jones dressing for over the weekend whilst the correct consumables were ordered in for the following Tuesday and so the vet doing the op could plan her approach. When it was time for the dog to be discharged, it wouldn't get up and starting screaming, biting at the bandage. We had to take it off and apply a lighter one, and told the owners that we would be in contact about booking the procedure in. They wanted to see the radiographs as they didn't believe it was broken, unfortunately we had already sent them over to the main site to be looked at by the vet that would do the procedure.

My colleague then couldn't get in touch with them despite multiple left messages on answerphones and with family members until yesterday. Turns out the owner has applied his own cast and thinks that will do. They want the radiographs rather than sending them direct to a different vet, to which they were told we would send them direct if a vet requested them.

Just a dodgy situation. There is a dog that has had a fractured leg for at least 1 week that needs veterinary treatment and isn't getting it. We have had no history requests from any other vets. I saw the dog for it's 1st vaccination and he had already been walking it, didn't really listen to anything I told him and never came back for the 2nd jab. Last week was the first time we saw it back since then.

Re: How long has this been broken?

Robin Grimmer — Thu, 24 Apr 2014 21:33:01 GMT

Looks recent. How stable is it? It doesn't look very displaced. If it is stable, you might be able to use a cast or splint.

Re: How long has this been broken?

ChrisBVSc — Thu, 24 Apr 2014 20:22:43 GMT

Not an ortho expert but I also agree it looks pretty recent. Out of interest what makes you think it's not?

Re: How long has this been broken?

Linda Filshie — Thu, 24 Apr 2014 19:00:42 GMT

Looks recent to me too.

Re: How long has this been broken?

Richard Carter — Thu, 24 Apr 2014 18:43:14 GMT

looks pretty recent to me - I cannot see any periosteal remodelling yet? Don't quite follow why you think there should be loss of bone edge sharpness. I have seen greenstick fractures come apart a few days after the initial injury that can also look like this and be surprisingly non-painful.