difficult fracture repair

RE: difficult fracture repair

Hannah Wynne Richards — Thu, 12 May 2016 08:54:57 GMT

There's a horizontal line of denser bone at the proximal end of the distal fragment, so it looks to me as though it's healed across as a malunion, forming a false joint.

A cast might have worked initially, but now you'll have to go in, freshen up this edge, and get rid of any necrotic bone, before you'll have a chance.

Wynne

RE: difficult fracture repair

Michael Woodhouse — Thu, 12 May 2016 02:08:05 GMT

You can use a different means of internal fixation. A cast hasn't worked.

RE: difficult fracture repair

Anthony Todd — Thu, 12 May 2016 02:05:10 GMT

[quote user="Michael Woodhouse"]You mean because it has ALREADY HAD A CAST and still has a broken leg?!?!?!?[/quote]

So you cannot repeat a CAST but can repeat a COMPLICATED INTERNAL FIXATION?

RE: difficult fracture repair

Michael Woodhouse — Thu, 12 May 2016 01:40:52 GMT

[quote user="Anthony Todd"]Unfortunately we don't need much more info in this case and it really isn't one to mention plaster disasters after a glance at these X-rays and a read of the thread....[/quote]

You mean because it has ALREADY HAD A CAST and still has a broken leg?!?!?!?

Did you read the OP?

[quote user="Ruta"]then he repeated operation and put cast on[/quote]

RE: difficult fracture repair

Anthony Todd — Thu, 12 May 2016 01:35:51 GMT

[quote user="grumpyoldman"]

[quote user="Anthony Todd"]Despite what others will opine you can get adequate fixation in a low tibial # with a cast.[/quote]

On the one hand nothing else has worked to date. On the other something vague about joint above and joint below not moving springs to mind . Seen a few post plaster of paris disasters in the past ,but to be fair we are speculating without all the relevant info at our disposal ,so 101 opinions is fine. [/quote]

Unfortunately we don't need much more info in this case and it really isn't one to mention plaster disasters after a glance at these X-rays and a read of the thread....

I keep seeing all these A&E programs with elderly folk and children having their wrists in casts, and below the elbow joint too, but what would human orthopods know?

Silly me, forgot "insurance", which now almost always seems to be a diagnosis or treatment.

RE: difficult fracture repair

grumpyoldman — Wed, 11 May 2016 22:02:28 GMT

[quote user="Anthony Todd"]Despite what others will opine you can get adequate fixation in a low tibial # with a cast.[/quote]

RE: difficult fracture repair

Utlendigur — Wed, 11 May 2016 16:30:48 GMT

What was the original repair? (IM pin alone, pin cerclage, pin/ESF combo, plate?). When you say the implants were rejected, do you mean they loosened or were infected?

I'm not an orthopod but I think if I was faced with that I'd try a very limited opening up the fracture site to swab, debride and place a cancellous bone graft, then a bilateral ESF (full pin proximal and distal, with a least one other half pin each side.

RE: difficult fracture repair

Will McMullan — Wed, 11 May 2016 15:49:10 GMT

Fractures will heal in the presence of infection, as long as the fracture site is stable. I'd be worried about putting a plate and screws in here because if you put implants into an already infected bone you run the risk of the infection not resolving until the implants are removed again, even if the fracture has healed. I would prefer external fixation and would probably think about grafting the fracture site. The medullary canal doesn't look to be fully closed over on the radiographs but debridement or ostectomising the fracture ends may be necessary. Amputation is of course an option but if the owners are sensible and prepared to put the time/money in over the next few months you may get this to heal to a functional union.

RE: difficult fracture repair

Anthony Todd — Wed, 11 May 2016 14:38:16 GMT

[quote user="robloxley"]When all you've got is a hammer...?[/quote]

Sometimes the temptation to use all the tools just because you can when the wood is rotten has to be resisted.

RE: difficult fracture repair

Neil Wheadon — Wed, 11 May 2016 13:36:25 GMT

[quote user="Ruta"]Thank you very much for your support, I decided don't get involved on this situation and refer case to University clinic. Maybe it is not best decision, but as far as I considered it is not my patient and probably too difficult to solve it by my own.[/quote]

Good call

Can you tell us what they did please?

Neil

RE: difficult fracture repair

Ruta — Wed, 11 May 2016 13:18:06 GMT

Dear, colleagues,

Thank you very much for your support, I decided don't get involved on this situation and refer case to University clinic. Maybe it is not best decision, but as far as I considered it is not my patient and probably too difficult to solve it by my own.

Regards,

Ruta

RE: difficult fracture repair

Neil Wheadon — Wed, 11 May 2016 12:52:44 GMT

Amputation has to be discussed

Sometimes you can't win them all. It's a small dog that's 8 years old and it's a long road to get this right even if you could.

Neil

RE: difficult fracture repair

Rob Loxley — Wed, 11 May 2016 12:47:33 GMT

[quote user="Anthony Todd"]Back in the day a cast would be my option[/quote]

When all you've got is a hammer...?

RE: difficult fracture repair

Anthony Todd — Wed, 11 May 2016 05:39:33 GMT

[quote user="grumpyoldman"]

biopsy culture and sensitivity , scrape it out , bone graft , anterior grade IM pin with a vetisco interlocking plate, or 2 stacked obliquely.

[/quote]

[Instead of a derogatory one star, which helps nobody!!]

I'm no orthopod or surgeon but even a carpenter would say that the bones [if they were wood] wouldn't hold screws and anything else in the bones would just weaken them further.

I would have thought a physical exam plus the de rigeur blood or the routine WCC would tell you whether there was infection or not.

Back in the day a cast [if no infection, and it's probably had all the A/Bs under the sun] would be my option.

Despite what others will opine you can get adequate fixation in a low tibial # with a cast.

Further surgery IMHO is a certain recipe for an eventual amputation, which is still available if a cast fails.

RE: difficult fracture repair

grumpyoldman — Tue, 10 May 2016 20:23:29 GMT

biopsy culture and sensitivity , scrape it out , bone graft , anterior grade IM pin with a vetisco interlocking plate, or 2 stacked obliquely.

RE: difficult fracture repair

Michael Woodhouse — Tue, 10 May 2016 20:13:51 GMT

Do you have the original radiographs?

(not something like a pathological fracture? it looks a mess.....)

Maybe biospy & culture as Mark says.

RE: difficult fracture repair

Mark Rowland — Tue, 10 May 2016 19:50:46 GMT

Haha Im sure the orthopods will shoot me down in flames but in the absence of a reply from them...

I would open this and swab it. you need to make sure there is no infection there preventing healing.

I think external fixation is your safest bet if you don't have swab results in your hand. I love my fessa kit

If its been a while and the dog is ok wish on the limb though I would swab first. If its infected, your implants will just act as a wick.

goodluck Mark