dog ulnar and radial growth plate fracture

Re: dog ulnar and radial growth plate fracture

Anthony Dennison — Thu, 08 Jan 2015 09:06:56 GMT

[quote user="Anthony Todd"]

[quote user="David Mills"]the owners refused to neuter the dog [/quote]

PS They may have been wise. It appears that bone healing with testosterone present is a good idea. [loads of references if you like]

Sometimes one has to bend the rules to suit the situation.

[/quote]

This is true Anthony, but in a charity situation where they are trying to promote neutering and prevent further unwanted animals, sometimes these are the only opportunities to get people to neuter their pets.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Wed, 07 Jan 2015 16:30:16 GMT

[quote user="David Mills"]the owners refused to neuter the dog [/quote]

PS They may have been wise. It appears that bone healing with testosterone present is a good idea. [loads of references if you like]

Sometimes one has to bend the rules to suit the situation.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Wed, 07 Jan 2015 11:07:51 GMT

[quote user="David Mills"]Removed the RJB 5d ago and there was significant carpal instability, though no swelling, and the dog had been using the leg. [/quote]

A RJ loses it's support very quickly so no wonder there was no improvement, particularly given that lack of immobility.

I would be very very surprised if a correctly applied cast, particularly with modern materials and Soffban, applied once on first GA and X-ray, dog on lead, kept dry [old drip bag over foot etc., strapped on with plaster or tied,] left for 6 weeks, checked weekly, wouldn't have given an excellent result.

Hopefully the dog ended up with a dinovet who does the above.....

I can't believe any injury like this would have an amputation offered as a treatment option!

Re: dog ulnar and radial growth plate fracture

David Mills — Wed, 07 Jan 2015 01:42:36 GMT

An update on this - only back to work recently, and a colleague saw in the interim.

Removed the RJB 5d ago and there was significant carpal instability, though no swelling, and the dog had been using the leg.

A repeat X-ray showed a vertical fissure opening of the radial growth plate and some mild callus around the ulnar fracture. At this point, we advised could only offer amputation or referral (owners couldn't afford the latter). However, the owners refused to neuter the dog (a prerequisite of using our service); they have subsequently gone to another vet's for a second opinion, so we will await word from this.

Thanks for the useful input.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Sat, 03 Jan 2015 20:41:40 GMT

[quote user="Hannah Wynne Richards"]

Hope the dog's getting on well - whatever you've done with it.

Wynne

[/quote]

+1 again, be nice to know.

Re: dog ulnar and radial growth plate fracture

Hannah Wynne Richards — Tue, 23 Dec 2014 18:02:39 GMT

Hope the dog's getting on well - whatever you've done with it.

Wynne

Re: dog ulnar and radial growth plate fracture

Evelyn Barbour-Hill — Tue, 23 Dec 2014 17:10:57 GMT

I'd just like to confirm that my previous post was a genuine question about biomechanics and an endeavour to follow interesting points following on from the original post.

Perhaps a bit boring for the season.

Re: dog ulnar and radial growth plate fracture

Arlo Guthrie — Sun, 21 Dec 2014 17:47:35 GMT

Sod's law that open warfare should break out at precisely the time that Chateau Guthrie opened its doors for the annual Christmas shindig (as a result of which I'm feeling a bit worse for wear today).

Anyway, this discussion does highlight a limitation of the medium; one which I need to find a way of addressing.

I've read the thread a couple of times, and I really didn't read any malice (not quite the right word, but you know what I mean) in Tony's questions.

I read it simply as coming from someone who has strongly held opinions based on years of being in practise. I make no comment either way on the quality or validity of those opinions (I'm not a vet, so how could I?). My point is that I genuinely don't think he meant to cause offence. He just has a counter opinion and being an enquiring sort of a chap (a tenacious one at that), keeps questioning.

Nothing wrong in that. In fact, questioning the facts is really what this site is all about.

That said, there is the very real risk that repeatedly questioning / disagreeing with people who are acknowledged experts in their field might seem at best a bit annoying and at worst downright disrespectful!

As Gillian said, we have to remember that the specialists give a huge amount to this forum. We don't want to lose that. So although specialists should not be above being challenged (after all, they often have a different take on things working in referral practice or academia), I think challenging posts should be respectful of their achievements and qualifications and try not to persist with the same point unduly (unless there is some substantive new piece of information to add to the discussion).

[quote user="Anthony Todd"]If Arlo agrees that I'm a pain in the butt[/quote]

Well, occasionally - but you and me both, so I'm not going to censure you for that!

[quote user="Anthony Todd"]block me easily[/quote]

Certainly not! I wouldn't block anyone for asking questions. And who knows, maybe tomorrow you'll have the cure for cancer.

[quote user="Anthony Todd"]but I wonder whether the denigration of the Canadian Vet Journal and its vet journo isn't more worthy of censure?[/quote]

No, I don't believe so. Malcolm was putting forward a relevant opinion, you can take it or leave it. Personally, I'd take it!

In summary, I do not believe that Tony really deserved the blasting he got in this thread. Equally, I can see how his persistence has raised a few hackles, and my one suggestion is: Tony, perhaps be a shade less persistent in the future. In other words, do continue to make your point - but try to make it once!

I hope that reads in the spirit it was intended.

And now for something completely difference.

I just loved the remark from some wag on seeing Tony and Cherie's Christmas Card (scroll down):

"It's amazing how his teeth just follow you round the room"

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Sun, 21 Dec 2014 11:47:21 GMT

[quote user="David Mills"]Ah well, problem is old chum, you - and chums - ain't recognised experts are you? [/quote]

No I'm not .

What continues to surprise me is the intransigence of the forum to respond to a contrary suggestion or opinion when it comes from someone who isn't a recognised expert ,or young, but can offer an opinion or suggestions from some experience .

Contra argument or explanation I welcome but just blanking it because it's from a dinovet even if he has done it ,or used it, isn't as edifying as the forum believes.

I never used a RJ, as I have said, nor did I ever have any bad results from using orthopaedic padding and either a stretchy crepe bandage or stretchy sticking plaster.

I'll bet few on the forum have ever tried it even once, let alone had a problem with it, but universal condemnation with actually no evidence let alone experience because an undoubted expert, who hasn't tried it either, says it's rubbish.

Logical? Scientific? Ill-researched?

If Arlo agrees that I'm a pain in the butt he can block me easily but I wonder whether the denigration of the Canadian Vet Journal and its vet journo isn't more worthy of censure?

Re: dog ulnar and radial growth plate fracture

David Mills — Sun, 21 Dec 2014 01:54:15 GMT

[quote user="Anthony Todd"]This other way seemed to work well in my and all other hands whereas I have seen RJs , although probably badly executed, which have had problems and don't do what they're supposed to do.[/quote]

Ah well, problem is old chum, you - and chums - ain't recognised experts are you? Therefore, as Ben Goldacre says, you present, in this instance, background noise rather than a scientifically significant opinion. Best to leave this thread to people who have a current, vested, interest in it don't you think? Given that a) you'll never see the dog; b) as the OP, sorry, but I value an expert's incredibly kind free advice on the subject than some ill-reseacrched googlised cherry picking. As the OP, can I kindly request that you don't reply to this thread again? Arlo?

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Sat, 20 Dec 2014 22:52:12 GMT

[quote user="Evelyn Barbour-Hill"] I have not the slightest doubt that Robert-Jones splints work and that Malcolm knows what he is talking about.[/quote]

I agree with all of the above but only when Malcolm does it.

All I am suggesting , without any personal remarks or claims of personal superiority, is, that after 100 odd years, with all the advantages in materials and knowledge , there may be better ways of reducing swelling, haemorrhage, and providing temporary better immobilisation thus providing a better prelude for fracture or joint repair.

I gently suggested [I believe] another way which is easier and quicker to apply, less restrictive for the animal, applies longer, if not permanent, pressure, and does not cause as many problems if it gets wet, which can happen with a RJ.

This other way seemed to work well in my and all other hands whereas I have seen RJs , although probably badly executed, which have had problems and don't do what they're supposed to do.

Furthermore a literature search, although in humans and not involving fractures, seems to suggest that, although a RJ, or modified RJ, works well other materials seem to work just as well, but are better tolerated and cheaper, which I guess also means easier to apply.

There just might be a better way which I think is worthy of consideration.

Re: dog ulnar and radial growth plate fracture

Evelyn Barbour-Hill — Sat, 20 Dec 2014 22:12:25 GMT

This forum having the character it does, I had better make it plain first of all that I am not criticising or anything like it, and I would have no right to do so when limb orthopaedics is not my field. I have not the slightest doubt that Robert-Jones splints work and that Malcolm knows what he is talking about.

But I am genuinely a little puzzled, and possibly confused, and would like to be enlightened. A Robert-Jones splint, like a cast or any other immobilising device, has the purpose of transmitting stress from one side of the fracture to the other, with the minimum of stress being transmitted through the fracture site; otherwise it would not immobilise it. In the case of the radius and ulna, for instance, transmitting all forces from carpus to elbow (or, at any rate, from distal extremity of radius to proximal extremity of radius. Thus there must be forces between the living tissues and the splint material. Therefore there must be pressures.

All I can think of is that the RJ distributes the forces so widely that there are no peaks of pressure sufficient to damage the soft tissue below.

Secondly, I find it hard to believe that any such device – acting upon the bones by transmitting forces through soft tissue – can truly immobilise a fracture. Maybe the answer is that it does not, but that it comes near enough to immobilisation (i.e. transmits across the site a sufficiently great proprtion of the stresses) for healing to proceed as fast as it can. Or maybe it's a bit more complex, in that the presence of the partially immobilising splint will act upon the proprioceptors (as with those "elastic supports" people put on their knees) to limit the contraction of the significant muscles that would distract the fracture.

Or maybe I've got it all wrong.

Re: dog ulnar and radial growth plate fracture

Gillian Mostyn — Sat, 20 Dec 2014 19:10:25 GMT

OMG Anthony. Are you serious?

Malcolm is an RCVS specialist in orthopaedics. His expertise and experience are invaluable on this forum and it is immensely kind that he gives his time and opinions ( for which I expect he, quite rightly, charges a lot of money for at work) FOC here. He never criticises other people's posts and is diplomatic when offering alternative options, while being open to ideas.

He would be the last one to say it so I will... Sometimes a person deserves respect simply due to their professional status. It isn't that you shouldn't query their opinion.. Nobody is above that...but you don't accuse them of simply being wrong and cite papers to prove it! That is rude.

The specialists who offer advice on this forum are kind and generous... I would hate to see the 'dinovets' of this world make them think the hassle simply isn't worth it.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Sat, 20 Dec 2014 18:54:29 GMT

[quote user="Malcolm Ness"]Are you the same Anthony Todd who earlier in this thread said that you had never used an R-J.[/quote]

One and the same.

I'm also the same as the Anthony Todd who thought your description of the method was first class.

But, apart from your use, in very many cases, all successfully apparently, and your exposure to considerable scrutiny by your peers and the claim of which there is no doubt that you have done a bit of orthopaedics you don't answer what I think are reasonable points.

Sarcasm really doesn't help your argument either, and you may well have placed more casts than I , totally ignoring my question regarding the step from a 2 week maximum RJ or a 2 day maximun from that denigrated veterinary journo, so we still don't know what the next step is!

I assume there is one, or does it just progress to a cast because, as you say, you've done so many more than me.

You then go on to rubbish someone, who I don't know, who may be a total idiot, but makes some statements which seem to make some sense at least to me.

Surely this is a discussion forum not a forum for the aggrandisement of one's personal reputation nor the denigration of others but for others perhaps to gain some tips or tricks?

I was just asking, with the benefit of my small, inadequate, experience in general and small animal practice some questions about the RJ and trying to see if there may be a better way.

I don't think there has been any sneering at all from me, just some questions which I think are reasonable, considering the method and materials are about 100 years old ,and materials, at least , have improved.

I've put on a few pressure bandages using soffban etc. no where near as many as the astronomical numbers in your experience but they've all done rather well in my limited and rose-tinted view so I think it's reasonable to ask, on a forum like, this whether, after over 100 years there are better materials and methods now available.

Arrogance is a subjective opinion but have had the chance to meet and discuss materials and methods with some of the world's most eminent authorities and it is their humility that has always struck me and their ability to listen to other points of view and offer reasoned responses which are freely forthcoming. They also accept that some things raised by others way down the food chain may have, just occasionally, some merit.

I would suggest that members read the reference posted as they may note the points of relevance even if it has been dismissed so completely.

It may not be such a waste of time.

Re: dog ulnar and radial growth plate fracture

Malcolm Ness — Sat, 20 Dec 2014 17:09:54 GMT

Are you the same Anthony Todd who earlier in this thread said that you had never used an R-J.

If so we come from wildly different points of view. I write as someone who has used them repeatedly an successfully in very many cases over very many years. Admittedly, I don't have the unique experience that comes from provincial general practice but I have done a bit of orthopaedics in my time and, furthermore, I have had my expertise in that subject exposed to considerable scrutiny by my peers. Again, admittedly relatively few of them can boast your unique experience and expertise of just about everything. As an aside, I strongly suspect that over the years. I have placed more casts than you.

You may find it surprising, but I do know of Greg Harasen - he is general practitioner with an "interest" in orthopaedics. The plethora of papers, I suspect is due to the fact that he works for the Canadian Vet Journal and most of his offerings are editorials or opinionated review-type articles. He has published remarkably little other than occasional case reports in reputable peer-reviewed journals and he has not progressed beyond an "interest" in orthopaedics. The `Canadian Vet Journal has a low impact factor and has no reputation as a surgical or orthopaedic publication.

You clearly have little respect for my experience and expertise in surgery or orthopaedics and that is your prerogative. I am thick-skinned and can shrug off the sneering of people more arrogant and more unpleasant than you. However, I am finding it rather tedious to offer an opinion on a case, frequently at the request of others, to then find myself under pressure to respond to the harvest of your seemingly random, and usually ill-informed Googling.

To prevent others wasting time, the pubmed link provided above is to a paper about human total knee arthroplasty. Between the dressing described, which bears no resemblance to a veterinary R-J, the cases which are studied - knee joint arthroplasty - and the end-points measured, this paper has absolutely no relevance whatsoever to a discussion on the veterinary use of R-Js in the distal limb of a skeletally immature dog.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Sat, 20 Dec 2014 11:46:02 GMT

[quote user="Malcolm Ness"]there is no pressure at all under a well applied cast.[/quote]

Couldn't agree more.

The advantages, and indeed the reason for a RJ ,was to provide an even constant pressure to prevent or reduce swelling and/or haemorrhage but, particularly with today's modern materials, this can be achieved without a cumbersome RJ and, in my limited anecdotal experience a well applied cast, better now with light weight materials, does this well.

The RJ was used before the availability of stretchy bandages and, as I understand it, relied on the "stretchy" even compression of the cotton wool under the non-stretchy outer covering viz:

And don't forget it should sound like a ripe watermelon when tapped if it has been applied correctly.

So no compression from the rigid outer layer then....

All the "compression" comes from the cotton wool, which will lose this, as the nonsensical quote says, "after one or two days". let alone when it gets wet!

My guess is there would be at least 2.5cm of cotton wool all around the top and bottom of the RJ, so significant movement is therefore present; not ideal for fracture or joint repair.

It stands to reason that if the RJ is left for two weeks there will be some significant attempts at union. Because the top and bottom of even a well applied RJ has some movement union may be delayed or compromised.

Greg Harasen seems to have published an awful lot of orthopaedic papers [77 by one count, Google him!] and he seems to me to be not the sort of chap to write "nonsense" and as everyone these days wants papers, and not experience, saying this quote is "nonsense" seems a bit harsh and unjustiried.

There are papers which even suggest that some support of Greg may not be nonsense either, eg:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613516/

Re: dog ulnar and radial growth plate fracture

Malcolm Ness — Sat, 20 Dec 2014 08:25:10 GMT

[quote user="Anthony Todd"]That makes the Robert Jones bandage wholly inappropriate for any use beyond a day or two.[/quote]

That is nonsense!

A well-applied RJ provides effective support in appropriate cases for as long as 2 weeks. A major feature of the dressing is that it provides adequate support without excessive pressure on soft tissues. The pressure transducer information is a red herring - there is no pressure at all under a well applied cast.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Fri, 19 Dec 2014 23:21:27 GMT

This from:

Can Vet J. Jun 2012; 53(6): 679–680.

PMCID: PMC3354833

Orthopedic therapy under wraps: The pros and cons of external coaptation Greg Harasen

The support bandage in most common use in small animal orthopedics is the Robert Jones bandage named after 19th century British surgeon Sir Robert Jones. Jones was a pioneer in orthopedic surgery and radiography. He also described a common 5th metatarsal fracture that he sustained himself on the dance floor! The bandage for which he is best known is seldom mentioned in his writings (). It consists of a roll or rolls of heavy cotton covered with layers of tightly applied bandaging material to provide uniform compression to the skin surface of the limb. In veterinary orthopedics the Robert Jones bandage may be the best example we have of the misuse of external coaptation, again not because of a deficiency in the technique but because of inappropriate case selection. The Robert Jones bandage is applicable for very short-term reduction and prevention of soft tissue inflammation, and the temporary stabilization of non-displaced, stable fractures distal to the stifle or elbow (1,5). The elastic qualities of the bandaging material provide the compression to the surface of the limb that can minimize inflammation and provide some stability to underlying fractures, but that same elasticity means that the compression is very temporary. Pressure transducers under these bandages have demonstrated that compression lasts for as little as 2 to 5 minutes in some applications but likely no more than 24 to 48 hours in the extreme (,). That makes the Robert Jones bandage wholly inappropriate for any use beyond a day or two.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Thu, 18 Dec 2014 19:01:28 GMT

[quote user="Gillian Mostyn"]

Anthony.. The RJ Malcolm describes is taught extensively at college when I was there. It is also part of the nurse training syllabus and is one of the stations in the practical exam. Another reason having RVNs is important....!!!

[/quote]

Still think a well applied cast is better, certainly less cumbersome for the animal. and much more advantages [or fewer disadvantages] now with lightweight waterproof materials.

Usually I used this underneath:

Soffban Natural Padding Bandage

in appropriate widths, also good under a pressure bandage to reduce swelling and add some support, acts just like a RJ if applied under a crepe stretchy bandage, less bulky nd easy to get off without any sort of anaesthetic.

If both are applied correctly what is the advantage of an RJ over a cast, padded obviously with that padding bandage like a very thin roll of cotton wool.

Is it only because they are still taught?

What's the sequence nowadays; ie GA, Xray, RJ, for 2 weeks then what?

Do you ever apply a cast, if so when.? Taking the OP case as an example.

Re: dog ulnar and radial growth plate fracture

Andrew Mellor — Thu, 18 Dec 2014 17:56:06 GMT

And don't forget it should sound like a ripe watermelon when tapped if it has been applied correctly.

The only issue I have with adhesive strips as stirrups is that I have seen a few nasty reactions where the tape is applied but better and less painful than an unsupported fracture I guess.

Re: dog ulnar and radial growth plate fracture

Gillian Mostyn — Thu, 18 Dec 2014 15:04:22 GMT

Re: dog ulnar and radial growth plate fracture

David Mills — Thu, 18 Dec 2014 13:03:32 GMT

Thanks kindly for replies, esp Malcolm and John.

Yes, there is significant instability in the carpus in both cr/cau and med/lat directions with crepitus. It was acutely painful to slight touch, dog NWB on limb. There were other views but we're on film and they wouldn't photo well.

We have applied a Robert Jones today - interestingly, the dog is using the leg for the first time with this. We are reassessing between Christmas and New Year. Will post the rads up once we do. Thanks again.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Wed, 17 Dec 2014 16:32:07 GMT

[quote user="Malcolm Ness"]Advantages are good immobilisation and consequent pain control. No need to flex wrist (to stop a cast slipping off). No additional distal weight as you will get with a cast. Easy to place and easy to remove. Allows good weight-bearing.[/quote]

I should have said they weren't mine, as I never used them.

I reckon your comprehensive instructions should be taught [or applied....] better 'cos the ones I saw giving trouble were nothing like that......

They also get wet though......

Sometimes I, and others used a "rocker bar splint" with some aluminium rod on both sides keeping weight off the foot.

Is that ever done now; worked well when we did it?

I still reckon a cast, done well, in the case in question would do finel, held on by casting well above the elbow

Re: dog ulnar and radial growth plate fracture

Malcolm Ness — Wed, 17 Dec 2014 15:58:41 GMT

[quote user="Anthony Todd"]Far be it for me etc. etc. but I've never found RJs, although always recommended, very effective in that either they are too tight and the foot swells [particularly if involving the hock and the hind leg] or too loose and they fall down or off so I've never used them.[/quote]

I have never had an R-J slip off neither have I ever seen toes swell. I (very strongly) suspect that the "R-Js" you are referring to haven't been put on properly. We often receive referred cases with what the history describes as a Robert-Jones dressing but what I would call a light support dressing. If this was a greyhound pup at 4-5mths, the RJ would comprise a full roll of cotton wool placed in one layer (v.important) then compressed first with wide bandage as tight as possible then with Elastoplast/Tensoplast wrapped, again as tight as possible. Before the cotton will is applied, a pair of adhesive tape strips are placed on the leg and turned back to incorporate under the elastoplast to act as stirrups to stop slippage.

Advantages are good immobilisation and consequent pain control. No need to flex wrist (to stop a cast slipping off). No additional distal weight as you will get with a cast. Easy to place and easy to remove. Allows good weight-bearing.

Re: dog ulnar and radial growth plate fracture

Anthony Todd — Wed, 17 Dec 2014 14:42:27 GMT

[quote user="Malcolm Ness"]I would apply a Robert-Jones dressing [/quote]

Far be it for me etc. etc. but I've never found RJs, although always recommended, very effective in that either they are too tight and the foot swells [particularly if involving the hock and the hind leg] or too loose and they fall down or off so I've never used them.

What's the disadvantage of a cast [toes exposed of course]. You can X ray through the fibreglass or epoxy ones and you can see if it's too tight etc.?

I usually left them on for 6 weeks without a change unless necessary and I think most dinovets did the same. Check weekly with religious fervour though!!!

Why do you prefer a RJ?

[quote user="Malcolm Ness"]there is a significant chance that this case will go bad.[/quote]

Are you thinking of joint movement restriction?