Distal Tibia Fracture in a Cat - repair options please

Re: Distal Tibia Fracture in a Cat - repair options please

Malcolm Ness — Wed, 05 Nov 2014 16:11:25 GMT

[quote user="Anthony Todd"]So what happened to the dog with the tibial # which was, after all, where we started?[/quote]

We started with a cat, but we could always start a different thread about how we might manage the fracture if it were in a dog.

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Wed, 05 Nov 2014 16:03:38 GMT

So what happened to the dog with the tibial # which was, after all, where we started?

Re: Distal Tibia Fracture in a Cat - repair options please

Hannah Wynne Richards — Thu, 30 Oct 2014 09:44:34 GMT

I agree good old palpation (and actually looking at the patient) do seem under-taught skills these days.

Wynne

(Collander on head-yet again)

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Thu, 30 Oct 2014 09:41:04 GMT

[quote user="Hannah Wynne Richards"] If it's palpable, then there's no point in further tests. [/quote]

Hooray, but does that ever happen these days?

Of course if you can't feel the peach-stone then you do the tests [I should have made that clear]

Re: Distal Tibia Fracture in a Cat - repair options please

Hannah Wynne Richards — Thu, 30 Oct 2014 09:32:26 GMT

Anthony Yes and no. If it's palpable, then there's no point in further tests. If it's non-palpable (loop of intestine behind ribs, fat dog etc) you just have to test until you find the cause of the vomiting - otherwise you'll have unnecessary deaths.

Wynne

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Wed, 29 Oct 2014 13:42:35 GMT

[quote user="Anthony Todd"]The idea that a peach stone in the SI cannot be diagnosed and removed without a battery of tests, time and expense pervades, IMHO.[/quote]

Sorry, "can" should be "cannot"!!

Re: Distal Tibia Fracture in a Cat - repair options please

Evelyn Barbour-Hill — Tue, 28 Oct 2014 23:17:37 GMT

[quote user="Martin Atkinson"]

[quote user="Evelyn Barbour-Hill"]It's not supposed to be a substitute bone with the full strength of the original (and I think – I may be wrong about this – that it would be undesirable for it to be that, even if it could be achieved, as the bone itself would then demineralise and weaken).[/quote]I thought the idea of a plate, especially a compression plate, was to force the fractured ends together so they could heal by first intention with no disturbance from weight bearing so there is then a quicker healing process and no callus formation. Once the primary healing process has taken place then you want weight bearing through the bone to strengthen it and no weak points through the screw holes or pivot points at the ends of the plate which is why they took my tibial plate out.

[/quote]

The purpose of any plate (or any fixation device) (in a diaphyseal fracture, let's keep this simple) is to, in engineering terms, transmit the stress from one side to the other. In some situations it does it entirely by itself, as it were – a transverse fracture with little spikiness of the broken ends in the middle of a very straight bone, say – when you thus need a pretty stiff thick plate and plenty of screws so that the stress at any one screw is not too great. In other situations, say a curved bone where you can put a plate on the "tension side", the Sherman plate which is not very thick or stiff will do excellently (it can be thought of as providing tension on that side while muscles and tendons tense the other side). In all cases, even the thick stiff plate will break or pull its screws out if forces are applied which it is not designed to resist – or if it doesn't do that, being really too strong, it may break the bone. Any of which might happen if the dog jumps off the sea wall or the human trips over his doorstep.

Now, if 100% of the stress is transmitted through the plate, the bone thus relieved will actually weaken, as I understand it. I am not sure whether the actual bone healing process at the fracture site will be abolished by such stress relief.... I don't think so, but maybe Malcolm can tell us. I suspect, however, that the stress transmission is only a whole 100% through the plate for a short time, and as even the earliest phases of bone healing begin then some of the stress will be going through the bone again.

Compression plates, as I understand it, are but an extra refinement, having the additional function of compressing the broken ends together and achieving (by what I imagine are rather complicated physiological mechanisms) a more rapid healing with, ideally, no callus formation at all. I can't see at the moment that this would increase the bone-weakening effect of "stress relief" . Are compression plates always stiffer than other plates?

Re: Distal Tibia Fracture in a Cat - repair options please

Vet2Vet — Tue, 28 Oct 2014 20:26:37 GMT

That's right[quote user="Hannah Wynne Richards"]

Golden rule for casting - immobilise the joint above and beneath. It's really impossible to immobilise a stifle - so casting's out on this one.I'd say external fixator.

Wynne

[/quote]

Re: Distal Tibia Fracture in a Cat - repair options please

Martin Atkinson — Tue, 28 Oct 2014 19:41:17 GMT

Re: Distal Tibia Fracture in a Cat - repair options please

Evelyn Barbour-Hill — Tue, 28 Oct 2014 15:00:17 GMT

[quote user="Martin Atkinson"][quote user="Evelyn Barbour-Hill"]Is that what a plate is supposed to do?[/quote]Surely the idea is that as well as stabilising and dynamically compressing the fracture it bridges it and transfers weight from above to below,[/quote]

Absolutely, it transfers stress from one distant end of the bone to the other distant end thus prevents even the slightest movement at the fracture site (something that a cast can never do.... but I digress). It's not supposed to be a substitute bone with the full strength of the original (and I think – I may be wrong about this – that it would be undesirable for it to be that, even if it could be achieved, as the bone itself would then demineralise and weaken).

Re: Distal Tibia Fracture in a Cat - repair options please

Martin Atkinson — Tue, 28 Oct 2014 12:25:55 GMT

[quote user="Evelyn Barbour-Hill"]Is that what a plate is supposed to do?[/quote]Surely the idea is that as well as stabilising and dynamically compressing the fracture it bridges it and transfers weight from above to below, maybe not designed to take falling on to it which probably put forces greater than body weight through it but clearly it worked. If we plate an animal's leg we can't give it crutches, it will weight bear once the pain of surgery has resolved. Its probably just best that it doesn't chase rabbits for a few weeks.

Re: Distal Tibia Fracture in a Cat - repair options please

Evelyn Barbour-Hill — Tue, 28 Oct 2014 11:21:17 GMT

[quote user="Martin Atkinson"]I would say the plate did what it was supposed to do - support my weight and allow full limb function[/quote]

Is that what a plate is supposed to do?

Re: Distal Tibia Fracture in a Cat - repair options please

Martin Atkinson — Tue, 28 Oct 2014 11:16:42 GMT

[quote user="Anthony Todd"]Or some could say, including your surgeon, that you were very, very, lucky that it didn't turn into a reop or a disaster...[/quote]No, I would say the plate did what it was supposed to do - support my weight and allow full limb function (although it possibly helps that I only weigh 63kg)!

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Mon, 27 Oct 2014 19:08:16 GMT

[quote user="Martin Atkinson"]but it illustrates the point.[/quote]

Or some could say, including your surgeon, that you were very, very, lucky that it didn't turn into a reop or a disaster...

Anywaaaay, what was done to the OP cat and how has it turned out?

Re: Distal Tibia Fracture in a Cat - repair options please

Martin Atkinson — Mon, 27 Oct 2014 16:12:52 GMT

[quote user="Anthony Todd"]

[quote user="Linda Filshie"]Hmm, yes, like the dog we splinted with a couple of # metatarsals that escaped from the house, jumped a 6 foot fence and went for a lovely long run through Ashdown Forest after rabbits...and then the owners waited three days with the splint cracked, filthy and soaking wet to bring the dog in. You can imagine the happy outcome of that little escapade.[/quote]

Mmm, yes with external fixation,pins or plates it would have been fine.....

[/quote]Actually Anthony it would. I made brief reference to a similar fracture I sustained. It was on day one a ski trip and spent the rest of the week in traction, The Austrian doctor refused to do surgery and would have kept me there for 6 weeks but at least he didn't put me in a cast and send me off on a wing and a prayer. The insurers refused to pay for that I was repatriated back to the UK on an air ambulance after a week now just with a cast! The first thing I did was contact an orthopaedic surgeon and he put in a compression plate with a few lag screws. I was discharged after 2 days and as I entered my home on crutches I tripped on the door step and fell forward. Instinctively I put the plated leg out first to support myself with all my weight on it. The plate took al the force with no problem and I felt no pain. I was back at work the next day. Compare that to 6 weeks in traction or longer in a cast because it would never have healed. I skied with the plate in the next year and it was removed after 18 months. Result perfect union, perfectly straight, same length leg.

CF the dog in the OP and Linda's case. Maybe we don't need to achieve such perfection in pets but it illustrates the point.

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Mon, 27 Oct 2014 08:46:34 GMT

[quote user="Gillian Mostyn"]although you now concede that some modern methods are a vast improvement, your general attitude contradicts that.[/quote]

No, you've got me all wrong, or rather, I haven't got it across! I only rail against what I perceive as the prevailing attitude that:

The old methods, only because of their antiquity and not because of their alleged effectiveness, are wrong and [politely??] dinosaureal.

This extends to the idea that nothing can be treated until it is diagnosed and nothing is diagnosed unless it is, or at least, suggested, by an expensive, often equivocal test, usually tests.....and bloods, of course.

The idea that a peach stone in the SI cannot be diagnosed and removed without a battery of tests, time and expense pervades, IMHO.

That's all I have ever been on about, as far as diagnosis is concerned.

Re: Distal Tibia Fracture in a Cat - repair options please

Gillian Mostyn — Mon, 27 Oct 2014 08:20:39 GMT

Fair enough.. Maybe it was too basic to be sensible. I also do agree that some vets make things overly complicated and more expensive than necessary. However, although you now concede that some modern methods are a vast improvement, your general attitude contradicts that. If I have 'got you all wrong' then I apologise.

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Mon, 27 Oct 2014 08:05:01 GMT

[quote user="Gillian Mostyn"] Sometimes making things more expensive, complicated and skilled is in the best interests of the animal- although not always the GP vet.[/quote]

Oh dear, glad you started with "sometimes" instead of "always", which my insight on here seems to feel is the norm.

The "castrate in a welly" example doesn't do your argument, much credit either.

Re: Distal Tibia Fracture in a Cat - repair options please

Malcolm Ness — Mon, 27 Oct 2014 08:03:27 GMT

[quote user="Gillian Mostyn"]quick, easy, cheap and effective [/quote]

My problem with casting any fracture is that while it is widely available, it is rarely cheap (if charged properly), it is never spectacularly quick (either in vet time or in time to return to best function) and it is frequently less effective and more risky (in terms of complications) than other methods. Many tibial fractures lend themselves to casting but the fracture shown in the OP is not one of them.

Re: Distal Tibia Fracture in a Cat - repair options please

Gillian Mostyn — Mon, 27 Oct 2014 07:54:36 GMT

But, Anthony, just because something is quick, easy, cheap and effective doesn't mean it is the best method. Sometimes making things more expensive, complicated and skilled is in the best interests of the animal- although not always the GP vet.

At a basic level this is illustrated by the 'cat castrate in a welly' technique.

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Mon, 27 Oct 2014 07:42:50 GMT

[quote user="Linda Filshie"]Very droll, Anthony.[/quote]

Sorry, Linda, It seemed to suggest the incident as a disadvantage of casts.

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Mon, 27 Oct 2014 03:12:35 GMT

[quote user="Malcolm Ness"]Your apparent sneering disregard [/quote] etc.

Never. I never play the man, just the argument , and "dinosaur" is hardly a compliment, mate.

[quote user="Malcolm Ness"]I have managed to get rather old while working in clinical practice and while I think that that has provided me with some insight, that is all it has done.[/quote]

So have I, but sadly most of the insight has come lately from the "modern" "state-of -the-art" etc. etc. comments and suggestions here, many of which are a vast improvement on the methods used in my day but not all.

I don't think I can think of a single example where the new treatment is simpler and cheaper than the old and this really can't be the case in everything we did.

Experience of things that seemed to work was what I gained from clinical practice as well as the good advice from others more effective and experienced than me, which, although it may stagger most of you, I slavishly followed.

Re: Distal Tibia Fracture in a Cat - repair options please

Anthony Todd — Mon, 27 Oct 2014 03:03:01 GMT

[quote user="Martin Atkinson"]I wouldn't take him too seriously Malcolm, he is playing Devils Advocate half the time![/quote]

No I never do. no point, but I do find it's so odd and frustrating when things that have worked in [arguably but without any figures] my and other "dinovets" hands, are dismissed as being of the devil and more importantly ineffective.

This applies through the whole range of Vet Med and surgery, not in all cases, obviously, but in many.

I am sure that other methods of # tibia repair work and may give better results but casts did and would in the OP case too.

Re: Distal Tibia Fracture in a Cat - repair options please

Martin Atkinson — Thu, 23 Oct 2014 14:19:08 GMT

[quote user="Anthony Todd"]When I discuss my travails here with other dinovets they all just sigh, usually agree with me,[/quote]I'm a dinovet and I usually disagree with you Anthony.

PS Are we to believe the picture is you when you a mere baby dinovet.

[quote user="Malcolm Ness"] I always agree with you when I think that you are right. Sometimes, when I think that you are wrong, I will disagree. Your apparent sneering disregard for the experience, knowledge and opinions of others, I find a little wearing. [/quote] I wouldn't take him too seriously Malcolm, he is playing Devils Advocate half the time!

Re: Distal Tibia Fracture in a Cat - repair options please

Malcolm Ness — Thu, 23 Oct 2014 09:18:34 GMT

[quote user="Anthony Todd"]other dinovets they all just sigh, usually agree with me,[/quote]

I always agree with you when I think that you are right. Sometimes, when I think that you are wrong, I will disagree. Your apparent sneering disregard for the experience, knowledge and opinions of others, I find a little wearing. Like you, I have managed to get rather old while working in clinical practice and while I think that that has provided me with some insight, that is all it has done.