Will this fracture heal?

RE: Will this fracture heal?

Anthony Todd — Wed, 30 Sep 2015 15:40:01 GMT

[quote user="Malcolm Ness"]No, you won't.[/quote]

Yes. you are quite right, and so's Evelyn but most of us cast tibial # in cats back in the day and I don't remember too much distortion and almost always excellent results.

I think, though, that confinement is vital too, and we tried, and tried, not always successfully.

RE: Will this fracture heal?

Evelyn Barbour-Hill — Wed, 30 Sep 2015 15:26:38 GMT

[quote user="Anthony Todd"]Surprising, in a cat, how far "up" the femur the cast can go and how much upper joint immobility you can get.[/quote]

Speaking as a dinovet, I really really disagree.

Over the years there must have been millions of cats and dogs unnecessarily casted, the only beneficial functions of the cast being: a) to give the impression of doing something; b) to handicap the patient, thus making it more amenable to cofinement and rest.

RE: Will this fracture heal?

Martin Atkinson — Wed, 30 Sep 2015 15:26:02 GMT

Thanks for the continuing input guys. The Robert Jones dressing had already started to slip so providing little or no support above the stifle and was soaked in piss as the cat couldn't get into its tray. Now removed, cat a lot happier hopping on 3, fracture still stable, we're going to loan a collapsible cage, review in 2 weeks probably. The only other realistic option was euthanasia and a slightly wonky leg is probably preferable to that fingers crossed.

RE: Will this fracture heal?

Malcolm Ness — Wed, 30 Sep 2015 15:10:05 GMT

[quote user="Anthony Todd"]and if you flex the lower joints in the cast you can prevent most of the rotational forces. [/quote]

No, you won't. To control the torsional forces on the tibia you need to fix both the hock and the stifle. Fixing the hock is easy enough to achieve by casting it in flexion. To fix the stifle similarly is impossible and to restrict it even to a limited extent involves placing the stifle in flexion and casting up above the mid-point of the femur.That is neither practical nor necessary.

[quote user="Anthony Todd"]Such good apposition already[/quote]

[quote user="Anthony Todd"] but some sort of immobilisation will prevent the fracture widening.[/quote]

On the contrary, the bones are not apposed at all but in any case, that is of secondary importance - functional outcome depends upon reasonable maintenance of limb length and excellent maintenance of joint alignment. A cast would make things worse in this case by making the distal limb heavier and unwieldy while still allowing the cat to twist its proximal limb thereby rotationally distracting the fracture ends.

RE: Will this fracture heal?

Anthony Todd — Wed, 30 Sep 2015 14:57:18 GMT

[quote user="Kate Richardson"]I wouldn't be happy about casting such a fracture- I think including the stifle joint is asking for trouble,[/quote]

Why, and what sort of trouble? Assuming the cat is really really in a cage and not jumping off the sofa or in the garden, which is many dino-owners understanding of "confine".

Wouldn't sitting in a cage with the fracture un-immobilised possibly lead to separation of the bone pieces?

RE: Will this fracture heal?

Kate Richardson — Wed, 30 Sep 2015 12:21:56 GMT

I wouldn't be happy about casting such a fracture- I think including the stifle joint is asking for trouble, so its really good to know that you advise no support dressing/cast at all in this case Malcolm

RE: Will this fracture heal?

Anthony Todd — Wed, 30 Sep 2015 10:09:12 GMT

[quote user="Hannah Wynne Richards"]

The golden rule with a cast is stabilise the joint above and beneath the fracture. As it's in the lower limb, this is possible, so should heal fine. Just make sure you warn the owners that pressure sores may occur beneath, so tell them to smell the cast daily,and check it yourself weekly.

Wynne

[/quote]

+1, and if you flex the lower joints in the cast you can prevent most of the rotational forces. Another golden rule with cat fractures, even with a cast, is to confine the cat, certainly in the house and preferably in a cage.

Owner compliance with "keep in" is usually non-existent!

Surprising, in a cat, how far "up" the femur the cast can go and how much upper joint immobility you can get.

Such good apposition already I can't see any reason for anything more, but some sort of immobilisation will prevent the fracture widening.

RE: Will this fracture heal?

Martin Atkinson — Wed, 30 Sep 2015 10:00:58 GMT

[quote user="Malcolm Ness"]This case will probably do well with conservative management and that would be my first choice. [/quote]Thanks Malcolm I'm sure that is what the owner wants to hear.

[quote user="Malcolm Ness"] The shape of the fracture lines indicates that this is a torsion injury. [/quote] I know it looks just like my fractured tibia from a skiing accident when i twisted out of the binding but it didn't release quickly enough!

RE: Will this fracture heal?

Malcolm Ness — Wed, 30 Sep 2015 09:03:55 GMT

This case will probably do well with conservative management and that would be my first choice. By conservatism, I mean confinement and medical pain control - no bandages, casts or splints. Clinical monitoring every week or so (check limb length and alignment and look of signs of tentative weight-bearing during the first ten days then gradual improvement thereafter).

The shape of the fracture lines indicates that this is a torsion injury - the bone has fractured due to excessive torsional load applied to the tibia. The displacement is limited and will tend to be controlled by the shape of the fragments and the soft tissues. The patient is probably young because most long bone fractures in cats are in young patients - ageing a cat on the basis of open phases is a very inexact science.

Casting this fracture would be problematic - as wyn points out, a necessity is immobilisation of joints above and above the fracture and that is always challenging in a cat. While a cast is good at controlling bending forces, it is less good at resisting axial loads and very poor at controlling torsional deformity. Given that axial shortening and torsional deformity are the specific problems in this case, the benefits of a cast will be minimal while the disadvantages of a cast will remain. Not a good choice.

A single IM pin has all the same limitations - it will effectively control bending (but that is not likely to be a cause of failure in this case) but almost useless in controlling torsional deformity. An IM pin offers little that conservative management is likely to achieve.

Any surgery needs to control all the potentially damaging forces and offer a faster, more certain return to function than conservative management if the cost and morbidity is to be offset. (NB - ref the title of this thread - almost every fracture will HEAL if left alone - the aim of fracture management is not to get the bone to heal, but rather to restore full function)

If surgery is contemplated here, plates and screws would be best; Ex fix (properly applied!) would be good; pin and multiple cerclage wires would be acceptable (but a poor third and difficult to justify in this case as the cat is likely to do well if left alone).

RE: Will this fracture heal?

Martin Atkinson — Wed, 30 Sep 2015 08:55:03 GMT

[quote user="John Flynn"]Happy to talk you through step-by-step how I would personally do this if it helps.[/quote]Thanks for the offer, I'm quite happy with the surgery the issue is what the owner can afford. As said she probably can't afford what I've already done so this comes down to how philanthropic I'm feeling.

RE: Will this fracture heal?

Hannah Wynne Richards — Wed, 30 Sep 2015 08:38:29 GMT

Wynne

RE: Will this fracture heal?

Dagmar Steele — Wed, 30 Sep 2015 08:32:00 GMT

I must say John, this is a very kind offer! If it was my patient I'd love to try it with your guidance.

RE: Will this fracture heal?

John Flynn — Wed, 30 Sep 2015 08:09:35 GMT

For me, this would be a pin (normograde or retrograde, whichever you're more comfortable with) and cerclage wire and cage rest 4 weeks (age-dependent) then re-xray.

Your implant costs are <£20 and, assuming you have something suitable to hold a pin in and drive it and cut it with afterwards (or premeasure and cut before with hacksaw if going normograde), then the cost really comes down to what you value your time/effort at.

I would consider this no more time-consuming on the whole than a cast, personally, but I think 10mins is rather overoptimistic for either procedure - you've probably spent 10 mins just composing and reading these posts already!

If you send the xrays around other local clinics, you may well find someone who will do this for a price the owner can afford. But of course in the time you spend doing this you might have been able to just do it yourself and learn something in the process...

Happy to talk you through step-by-step how I would personally do this if it helps.

RE: Will this fracture heal?

David Mills — Tue, 29 Sep 2015 20:36:33 GMT

Why not just stick a pin in it normograde through the stifle? Would take all of 10 minutes.The rapid fibrous bulid up around the fracture will quickly nullify any rotational instability and I would wager this would give a more predictable outcome.

RE: Will this fracture heal?

Robin Grimmer — Tue, 29 Sep 2015 20:11:32 GMT

It will heal. It's a young cat, right - Looking at the tibial crest?. It's interesting that the distal tibia is fractured, and the proximal fib. As far as I can tell the distal fib looks ok so should act as a splint. I reckon this would probably heal with just cage rest, which of course costs nowt.

RE: Will this fracture heal?

Kate Richardson — Tue, 29 Sep 2015 20:03:33 GMT

I would say yes, but I'm no orthopod, as a medic if I can avoid surgery then I will!

RE: Will this fracture heal?

Dagmar Steele — Tue, 29 Sep 2015 19:43:55 GMT

It's a cat, of course it will heal! Honestly, I'm sure it will.