Greenstick fractures... best treatment?

RE: Greenstick fractures... best treatment?

Clare Tapsfield-Wright — Sun, 30 Sep 2018 18:51:32 GMT

[quote user="Sam"]

I am not sure about the pups diet. The client has left us I believe.

I am not sure there was really a right way or a wrong way to treat this pup. Another vet has now reviewed the x-rays for me and having seen them is not in disagreement about the possible benefits of some form of support.

As for the robert jones bandage. I really wanted to support the limb very short term for travel as I had tried to arrange referral for surgery but I believe the estimate for the surgery being recommended was extremely off putting for the non insured "breeder" client.

All in all I do think that as a sole practitioner faced with this as an emergency late on a Friday night I did my best...... but never do I believe I am perfect... and I was also open with the client at the time that I am no orthopeadic specialist.... so maybe they just lost faith in me anyway.

Any way thanks for the replies and I have thanked people properly too Arlo

[/quote] Sam , you were there on the spot and you did what you thought was right. You sound like a very caring, reasonable, conscientious vet to me and I’d be happy to bring my dog to you and believe me that’s saying something cos I love my dog . You can’t please every owner or fix every case but you did your best. Good on you, onwards and upwards and like every vet and most good cheeses and wines you get even better with age.

RE: Greenstick fractures... best treatment?

Martin Atkinson — Sat, 29 Sep 2018 11:18:53 GMT

[quote user="Sam"]All in all I do think that as a sole practitioner faced with this as an emergency late on a Friday night I did my best...... but never do I believe I am perfect... and I was also open with the client at the time that I am no orthopeadic specialist.... so maybe they just lost faith in me anyway.[/quote]Sorry if I sounded over-critical I was not trying to be, especially once you explained more fully. As said I wouldn't have put on an RJ bandage as I've bad experiences in the past but its not a wrong decision.

Clients are still losing faith in me 43 years after qualifying so I wouldn't worry about that. Whatever you do some people will be dissatisfied if things do not meet their expectations which in many cases are unreasonable. The main reason people lose faith in me is because I don't bullshit or charm them, they are told the truth whether this hurts or not and I can do without clients who want a good bedside manner rather than that. I don't suffer fools gladly and that usually shows.

You can never do anymore than the best under the circumstances if you believe that was the right decision at the time then it was whatever anyone else tells you - we're all wiser with hindsight so don't lose faith in yourself.

RE: Greenstick fractures... best treatment?

Sam — Sat, 29 Sep 2018 11:02:52 GMT

I am not sure about the pups diet. The client has left us I believe.

Any way thanks for the replies and I have thanked people properly too Arlo

RE: Greenstick fractures... best treatment?

Martin Atkinson — Thu, 27 Sep 2018 13:01:46 GMT

[quote user="vetbl.locum"]

PS was repaired successfully but jumped from sofa today and re fractured leg :-(

And no I have not applied a bandage

[/quote]Fair enough for the rest of your comments.

After a discussion with the owner we discovered the kitten I started the OP with was being fed on an inadequate diet and a review of the radiographs showed suspect osteopaenia. I wonder if your pup has a similar issue and that is why it is fracturing easily?

RE: Greenstick fractures... best treatment?

Lucy Fleming — Thu, 27 Sep 2018 12:39:44 GMT

[quote user="Bob Russell"]Should I be doing anything other than resting her?[/quote]

Some analgesia? But no, I probably wouldn't. Risk of bandage complications probably much higher than any benefit of attempting to stabilize I would have thought (how would you even stabilise/ splint it into the natural position anyway?)

RE: Greenstick fractures... best treatment?

Bob Russell — Thu, 27 Sep 2018 11:30:52 GMT

Yet another change of direction for thread!

8 yr old dog fracture distal 5th phalanx, very mild medial displacement of toe. No more than 2/10ths lame. Should I be doing anything other than resting her?

RE: Greenstick fractures... best treatment?

Julie Innes — Thu, 27 Sep 2018 11:18:18 GMT

[quote user="vetbl.locum"]PS was repaired successfully but jumped from sofa today and re fractured leg :-([/quote]

RE: Greenstick fractures... best treatment?

vetbl.locum — Thu, 27 Sep 2018 01:52:48 GMT

[quote user="Anthony Todd"]A simple condyle fracture with a DIY condyle clamp is so easy and just basic carpentry, even I have done it.[/quote]

And so have I albeit several years ago

RE: Greenstick fractures... best treatment?

vetbl.locum — Thu, 27 Sep 2018 01:50:15 GMT

[quote user="Robin Grimmer"]Could you not have done the x rays and dressing if required under sedation?[/quote]

I could have but decided against on cost/ risk / benefit grounds

RE: Greenstick fractures... best treatment?

vetbl.locum — Thu, 27 Sep 2018 01:46:56 GMT

[quote user="Gillian Mostyn"]I would have just given NSAIDS +opioids and no RJ bandage and it would be seen at referral within 24hrs[/quote]

That was my plan also :-)

RE: Greenstick fractures... best treatment?

vetbl.locum — Thu, 27 Sep 2018 01:44:39 GMT

[quote user="Martin Atkinson"]Maybe I'm missing something here but I am a slight loss as to how you made a diagnosis of a condylar fracture without an X-ray or could make the decision to refer without that knowledge.[/quote]

Basis for Diagnosis - History of fall Acute 10/10 lameness Severe pain crepitus when palpating elbow I thought was good enough grounds for provisional diagnosis.

Sedation would not yield good images IMO

Surgeon is going to take more anyway Surely cost to client is reduced as is risk to pup.

Rgds

PS was repaired successfully but jumped from sofa today and re fractured leg :-(

And no I have not applied a bandage

RE: Greenstick fractures... best treatment?

Gillian Mostyn — Wed, 26 Sep 2018 13:01:26 GMT

[quote user="vetbl.locum"]My colleague thought that I had neglected case :-( and should have done the imaging at presentation.[/quote]

Have they worked out yet that what they did changed nothing? ie your diagnosis and plan was spot on?

RE: Greenstick fractures... best treatment?

Gillian Mostyn — Wed, 26 Sep 2018 12:59:12 GMT

If there was a strong suspicion of a fracture in the elbow (and crepitus can be little else at this age) then I would have referred immediately and let the next vet take the pictures. But, then, I don't do ortho any more and luckily have a brilliant ortho practice down the road.

I would have just given NSAIDS +opioids and no RJ bandage and it would be seen at referral within 24hrs.

RE: Greenstick fractures... best treatment?

Beats — Wed, 26 Sep 2018 10:08:04 GMT

[quote user="Martin Atkinson"]Maybe I'm missing something here but I am a slight loss as to how you made a diagnosis of a condylar fracture without an X-ray[/quote]

The epicondyles will be assymetrical, with crepitus and the relevant history.

I would have the vet doing the surgery take the xrays personally unless an xray is required to know that it will need surgery not to be undertaken by the xrayer (if that makes sense).

Fixing these asap is easiest in my opinion. I did one in an adult springer 3 weeks after it fractured once and was nightmare to get reduced, in a pup that would have been a malunion by then...

RE: Greenstick fractures... best treatment?

Anthony Todd — Wed, 26 Sep 2018 10:00:14 GMT

[quote user="Martin Atkinson"]However I don't agree with the RJ dressing for the same reasons already given in this thread so analgesia and cage rest was appropriate.[/quote]

Almost certainly anyone is going to want really good X-rays and several views before diving into surgery in case of surprises, so sedate, bandage as described below and surgery, schedule, do, or refer.

A RJ will give as much support and benefit as a bucket of cold [sorry urine-soaked] bandage swinging from the lower leg and may displace any fracture, and will be agony.

Easy to give good support and prevent pre-surgery swelling with stretchy bandages round the chest and elbow joint.

A simple condyle fracture with a DIY condyle clamp is so easy and just basic carpentry, even I have done it.

RE: Greenstick fractures... best treatment?

Martin Atkinson — Wed, 26 Sep 2018 09:03:18 GMT

Maybe I'm missing something here but I am a slight loss as to how you made a diagnosis of a condylar fracture without an X-ray or could make the decision to refer without that knowledge. I know you used the word 'suspected' but suspicion is not IMO enough of a reason to refer without some attempt at a definitive diagnosis.

I would have sedated and X-rayed on day of presentation unless it was totally impractical at the time so I can understand your colleague's reaction albeit negligence is a bit of a strong word. However I don't agree with the RJ dressing for the same reasons already given in this thread so analgesia and cage rest was appropriate.

RE: Greenstick fractures... best treatment?

Robin Grimmer — Wed, 26 Sep 2018 08:33:41 GMT

[quote user="vetbl.locum"]

Slight tangent:

15wo staff pup with suspected lateral condyle fracture left fore , I administered analgesia and cage rest while awaiting referral

Next day pup was given GA, imaged & RJ applied to 'supported leg' then another day passes before referral and another GA and repair

I thought why RJ as cannot support elbow and did we really need 2 GAs ?

My colleague thought that I had neglected case :-( and should have done the imaging at presentation.

What is reasonable care for this pup ? Any comments? Would you have done more?

rgds

[/quote]

Could you not have done the x rays and dressing if required under sedation?

RE: Greenstick fractures... best treatment?

vetbl.locum — Wed, 26 Sep 2018 08:21:41 GMT

Slight tangent:

15wo staff pup with suspected lateral condyle fracture left fore , I administered analgesia and cage rest while awaiting referral

Next day pup was given GA, imaged & RJ applied to 'supported leg' then another day passes before referral and another GA and repair

I thought why RJ as cannot support elbow and did we really need 2 GAs ?

My colleague thought that I had neglected case :-( and should have done the imaging at presentation.

What is reasonable care for this pup ? Any comments? Would you have done more?

rgds

RE: Greenstick fractures... best treatment?

Martin Atkinson — Tue, 25 Sep 2018 08:51:19 GMT

[quote user="David Mills"]I can't for the life of me think why someone would want to ex fix one in a cat though. [/quote]Because although it is stable in non-ortho parlance the leg is bent, the fibula is fractured so it is giving no support, so it will heal with a deformity of a laterally displaced foot if it is not corrected. The opinion is from an orthopod in whom I have great faith, who never performs surgery if it is not necessary.

RE: Greenstick fractures... best treatment?

Niall Taylor — Tue, 25 Sep 2018 08:18:22 GMT

[quote user="David Mills"]I can't for the life of me think why someone would want to ex fix one in a cat though. [/quote]

Because the sentiment "Don't do something, just stand there" doesn't come naturally to many vets. And, if I was being very cynical, I'd say maybe defensive medicine (or surgery in this case).

Niall

RE: Greenstick fractures... best treatment?

David Mills — Tue, 25 Sep 2018 00:30:32 GMT

[quote user="Christina Smith"]

This for me is the crux of the problem, one vet says this the other that. L4 or L2 ? Chlaymydia vacc or not ?Worm monthly or 3 monthly? Bandage or no bandage ? No wonder the wider public have no faith. Personally I would not have bandaged a high fracture but it is a case of the devil and deep blue sea. If it goes wrong then you would hope your fellow colleagues would support your treatment but you never know in this world of oneupmanship. Don't worry be happy. It was a dogue do bordeaux or is that judgemental ?

[/quote]

Problem as oft is is that the op only has the clients word for this. I would not comment on another vets treatment of a case based on a client's report, and I don't know a vet who would.

As to other things, a proper RJB properly applied can be very good. But we've been here before.

As to the case, I wouldn't have bandaged, but it would take quite a bit of owner compliance. Also improperly healed greensticks can cause issues further down the line.

I can't for the life of me think why someone would want to ex fix one in a cat though.

RE: Greenstick fractures... best treatment?

Clare Tapsfield-Wright — Mon, 24 Sep 2018 22:44:11 GMT

Hi Sam , three things to take from this .

You did what you thought was right at the time for that particular fracture in that pup and you cage rested it too so highly unlikely any harm done.

You came on here and enlisted the opinion of other vets and we have all learned or reflected (!) on the exchange and that’s what matters.

There are many ways of approaching a case and it’s the vet on the spot that makes the decision. The owners version of the other vets opinions may not always be accurate. Don’t worry too much or you’ll do your head in !

RE: Greenstick fractures... best treatment?

Gillian Mostyn — Mon, 24 Sep 2018 21:54:51 GMT

[quote user="Christina Smith"]you would hope your fellow colleagues would support your treatment but you never know in this world of oneupmanship.[/quote]

I know what you mean...the professionalism is sadly lacking in some quarters, but, in this case, the OP actually asked for opinions! None of us have been critical, just honest about what we would have done!

RE: Greenstick fractures... best treatment?

Christina Smith — Mon, 24 Sep 2018 20:40:55 GMT

RE: Greenstick fractures... best treatment?

Anthony Todd — Mon, 24 Sep 2018 19:28:23 GMT

Howls of derision from the intelligensia, I'm sure, but it's about time [60 years??] that Robert Jones bangages were confined to the history books with the advent of stretchy bandages and stretchy, very sticky, plaster!

In this case, padded with that lovely thin semi-cotton wool roll, and a suitably bent aluminium rod or strip for 4/6 weeks of on-the-lead exercise in the dry!!