Greenstick fracture? Management?

RE: Greenstick fracture? Management?

Liz Barton — Thu, 28 Mar 2019 09:58:03 GMT

[quote user="Evelyn Barbour-Hill"]– the NHS is obsessed with casting, plaster casting at that[/quote]

When I was 4 years old I broke my femur, tibia and fibula. I had various casts on for about 9 months, with the first being from my hip to my toes. I remember my toes FREEZING in winter (lots of snow and only a sock limply hanging off the end of the cast for protection). My skin sloughed in layers like a snake. It was so itchy and utterly miserable. Fast forward to summer and it was all sweats and smell.

My leg healed fine, but it wasn't pleasant. I someone had offered me internal fixation and an 8 week recovery period I'd not have lost nearly a year of being a kid.

*That said I have cast animals - mainly calves, but also occasionally smalls when appropriate and cost has made alternatives prohibitive. I've had good success, but that's through careful case selection, and in the case of the calves their incredible ability to heal!*

RE: Greenstick fracture? Management?

Evelyn Barbour-Hill — Wed, 27 Mar 2019 23:19:39 GMT

Casting is mechanically unsound unless a) the reduced fracture is stable, and b)there is to be no requirement for stress transfer from one side of the fracture to the other.

Back in the day, back again a bit, veterinary surgeons would "cast" fractured femurs (though they used pitch bandages, not plaster) and no doubt they swore they worked and never gave any trouble.

A few points that spring to mind about all those young people we supposedly see going about with casts on their forearms:

– many of them will have Colles' fractures or other fractures of the wrist (not specially common in dogs except maybe greyhounds), not mid-radius

– often they keep them in slings

– many of them will have had some internal fixation, the cast is just in addition

– the NHS is obsessed with casting, plaster casting at that, because the plaster technicians jealously guard their trade (and plaster for all its disadvantages is much cheaper than the lightweight materials)(and I once had to remove a cast from myself, one applied by an expert NHS technician to my forearm, because my hand was turning blue)

RE: Greenstick fracture? Management?

Alistair Graham-Evans — Wed, 27 Mar 2019 22:32:51 GMT

I'll be interested in the outcome. I do use casts and gutter splints but I would only cast this if finances precluded internal fixation. Good luck - I hope it goes well.

PS Human casts don't often have to withstand chewing, going in muddy puddles, sprinting from a standing start when postmen appear, full weightbearing without the aid of crutches or slings etc, etc. We give written information and dire warnings if adequate cast or bandage care is not maintained rigorously.

RE: Greenstick fracture? Management?

Beats — Wed, 27 Mar 2019 19:23:05 GMT

[quote user="James Dunne"]humans do not wish to take nearly 60% of their weight through the arm immediately once it is stabilised[/quote]

...until they turn over in bed at night as an emminent hand surgeon once pointed out to me.

RE: Greenstick fracture? Management?

James Dunne — Wed, 27 Mar 2019 18:55:36 GMT

It's in a peer-reviewed paper published back in 2011. Meeson, Davidson and Arthurs: VCOT 2011;24(2):126-3: Soft tissue injuries associated with cast application for distal limb orthopaedic conditions. A retrospective study of sixty dogs and cats.

I've seen plenty of pretty bad cast complications as second opinions, sometimes multiple ones over the years from the same individual and the comment that follows is always the same: 'That never happened me before'. While I have nothing against casts whatsoever and use them for appropriate fractures, it is particularly concerning when infected non-unions of the tibia or radius are brought in where casts were used inappropriately and the owner was given no other treatment option at the start.

I do agree having said all of that, that the art of cast placement is dying.

RE: Greenstick fracture? Management?

Lucy Fleming — Wed, 27 Mar 2019 17:22:21 GMT

To flip it on its head, Anthony, what would be your argument of the benefits of plastering over surgical fixation?

RE: Greenstick fracture? Management?

Anthony Todd — Wed, 27 Mar 2019 16:25:06 GMT

[quote user="James Dunne"]complication rate of 63% with cast repair[/quote]

I have never heard of anything like that!!

Can you give me the reference for the 63% because my guess is whoever it was hadn't done many and/or there must have been other factors.

I just don't know how dinovets managed to get such good results using such cheap quick methods, now so decried, with 63%????

Mind you, as I said, it takes practice [just watch a busy human plaster clinic!]

RE: Greenstick fracture? Management?

Lucy Fleming — Wed, 27 Mar 2019 15:34:07 GMT

[quote user="Arlo Guthrie"]Please keep this discussion STRICTLY about the OP's case[/quote]

Sorry Arlo.

I'd be another one to suggest to the OP that some sort of stabilisation is required. You may be right that there's minimal pain when the fracture is not moved (though I would expect there must be some pain), but how likely is it that it is going to get bumped or knocked, or the dog try to stand on it etc at some point in the healing process. If you've heard back from the referral centre, I'd be interested to hear what technique they used.

RE: Greenstick fracture? Management?

James Dunne — Wed, 27 Mar 2019 15:22:28 GMT

Anthony, be fair: BITD many vets fixed these fractures with casts because they didn't have the materials or training or facilities to offer more appropriate fixation. I am very comfortable applying casts even in situations when it is not ideal, but I would not lie about the realities of cast-associated complications. A recent-ish publication indicated a complication rate of 63% with cast repair; internal fixation has a vastly reduced complication rate compared to that. As for comparing human radius fractures to dogs - humans do not wish to take nearly 60% of their weight through the arm immediately once it is stabilised; it is usually supported non-weight bearing in an off-the-shelf moulded apparatus. It's not comparing like with like.

RE: Greenstick fracture? Management?

Arlo Guthrie — Wed, 27 Mar 2019 15:19:03 GMT

**** BWARP BWARP BWARP **** OFF TOPIC ALERT

Please can we have some consideration for the OP and not turn this into yet another thread where the discussion becomes tangential to the OPs request.

Anthony Todd START A TANGENT! THAT IS WHAT IT IS FOR.

Please keep this discussion STRICTLY about the OP's case.

RE: Greenstick fracture? Management?

Joyce Whitehead — Wed, 27 Mar 2019 15:07:58 GMT

I’m going to respond to this Anthony, as I am a dinovet, and have also done quite a few casts in the olden days, and I would definitely say they were not without issues. I can remember a couple where toes were irrevocably damaged by a too tight cast, and one memorable one put on by a locum which lost most of the skin with the cast, it required amputation. Add in to this non unions, very slow recovery limb deformity etc. Yes some did fine, but not all. Yes they were not correctly applied, or were too tight, or not checked often enough, but we need to accept that without the rose tinted spectacles, things were not always perfect BITD and things didn’t always just get better. If my dog had a fractured radius I’d get an orthopod to fix it, as I don’t like orthopaedic surgery.

Things have changed Anthony, and in my opinion generally for the better. And owners are much better educated as to what we can and can’t do. I don’t get the relevance of your last post...

RE: Greenstick fracture? Management?

Anthony Todd — Wed, 27 Mar 2019 13:26:29 GMT

[quote user="Lucy Fleming"]I think dogs and cats are less likely to hare around with undone shoelaces, on a skateboard/ roller skates, or use a trampoline...[/quote]

I'm going to turbo just to stick to the facts below:

Tibial fracture in dogs and cats represented 21.5% and 10% while humoralfractures were 7.9% and 14% in dogs and cats respectively. Humoral condylerfractures were most commonly seen in puppies aged 4 to 6 months.Fractured radius-ulna incidence was 19% and 14% in dogs and cats respectively.

not my BOLD

Incidence, Occurrence, Classification and Outcome of Small ... - waset

https://waset.org/publications/.../incidence-occurrence-classification-and-outcome-of-sm...

J Trauma. 2011 Jan;70(1):154-8. doi: 10.1097/TA.0b013e3181d32252.

The distal radius, the most frequent fracture localization in humans: a histomorphometric analysis of the microarchitecture of 60 human distal radii and its changes in aging.

RE: Greenstick fracture? Management?

Anthony Todd — Wed, 27 Mar 2019 13:09:56 GMT

[quote user="Niall Taylor"]... and they can tell you when it hurts when a stoical dog wouldn't. Not every complication from casting will cause distal swelling.[/quote]

No wonder few, if any, dinovets venture onto the forum!

They've all cast loads of these #s with no trouble and have all managed to deduce that dogs and cats seem to limp more, or lick, or carry or moan, when something hurts and, fortunately the foot gave early warning as well.

I don't think I have any foot NOT swell if there was a problem, and they did usually at the slightest increase in intra-cast pressure.

Is internal fixation totally free of [serious!] complications and can they all be fixed so easily?

RE: Greenstick fracture? Management?

Lucy Fleming — Wed, 27 Mar 2019 12:58:45 GMT

[quote user="Anthony Todd"]It's a wonder the # is so common then?[/quote]

I think dogs and cats are less likely to hare around with undone shoelaces, on a skateboard/ roller skates, or use a trampoline...

RE: Greenstick fracture? Management?

Niall Taylor — Wed, 27 Mar 2019 12:56:01 GMT

[quote user="Lucy Fleming"]

[quote user="Anthony Todd"]I wonder why I see so many young people with their forearms in a cast if it is so fraught?[/quote]

They don't walk on all fours? [/quote]

... and they can tell you when it hurts when a stoical dog wouldn't. Not every complication from casting will cause distal swelling.

[quote user="Bob Russell"]Not at all surprising. We tend to fall over![/quote]

So a broken arm is more likely in a two legged human than in a four legged animal.

Niall

RE: Greenstick fracture? Management?

Bob Russell — Wed, 27 Mar 2019 12:45:00 GMT

Not at all surprising. We tend to fall over!

RE: Greenstick fracture? Management?

Anthony Todd — Wed, 27 Mar 2019 12:13:38 GMT

[quote user="Lucy Fleming"]They don't walk on all fours? [/quote]

It's a wonder the # is so common then?

RE: Greenstick fracture? Management?

Julian Earl — Wed, 27 Mar 2019 11:34:55 GMT

[quote user="Julie Innes"]

One of the most disturbing cases I had was a Sheltie with a similar fracture which we started to treat with a cast But the dog was lost to follow, up until it finally came in for treatment with another problem. It came into the consulting room carrying its forelimb - due to its non-union..... Owner was unconcerned, as he had confidence that it would 'heal with time'

Problem was he was an orthopaedic surgeon at the local hospital

[/quote]

The most disturbing one for me was also owned by a doctor, a GP, not a surgeon I believe

. He had a GSD aged 6 months with a mid-shaft femoral fracture presented after six weeks! His reason for the delay? "Well, it's only a dog!" No real concept of suffering and cruelty I think. This was early in my career and I cannot remember the outcome. Doctors??

RE: Greenstick fracture? Management?

Lucy Fleming — Wed, 27 Mar 2019 11:17:02 GMT

[quote user="Anthony Todd"]I wonder why I see so many young people with their forearms in a cast if it is so fraught?[/quote]

They don't walk on all fours?

RE: Greenstick fracture? Management?

Anthony Todd — Wed, 27 Mar 2019 10:37:52 GMT

[quote user="Alistair Graham-Evans"]We have careful notes and recommend twice weekly cast checks - I do not think long term casting is a benign procedure.[/quote]

Of course it isn't and nobody says it is! [apart from a mad human orthopod]

Fortunately regular inspection and reinforced advice can prevent most of them with inspection and/or foot swelling as a nice early warning sign, easily rectified if needed.

Casts are an art though, and take some practice.

I wonder why I see so many young people with their forearms in a cast if it is so fraught?

RE: Greenstick fracture? Management?

Julie Innes — Wed, 27 Mar 2019 09:02:54 GMT

[quote user="Chris Barker"]

Problem was he was an orthopaedic surgeon at the local hospital Part of the reason it is recommended that if you break your leg in Carlisle you crawl to Newcastle for treatment...

[/quote]

. That is scary!

RE: Greenstick fracture? Management?

Chris Barker — Wed, 27 Mar 2019 08:00:29 GMT

Problem was he was an orthopaedic surgeon at the local hospital Part of the reason it is recommended that if you break your leg in Carlisle you crawl to Newcastle for treatment...

RE: Greenstick fracture? Management?

Alistair Graham-Evans — Mon, 25 Mar 2019 22:03:32 GMT

[quote user="Anthony Todd"]

[quote user="Alistair Graham-Evans"]but repeat casting can be costly over an extended period.[/quote]

Why repeat cast, particularly with modern lightweight durable water insoluble materials?

Just check daily then weekly for X weeks. Make sure the foot is visible.

[/quote]Seen too many cast complications

But we have >30 degrees and high humidity for much of the year.

We have careful notes and recommend twice weekly cast checks - I do not think long term casting is a benign procedure.

RE: Greenstick fracture? Management?

Anthony Todd — Mon, 25 Mar 2019 16:55:10 GMT

[quote user="Lucy Fleming"]about her cat with fractured femur and followed the benign neglect route.[/quote]

Nobody of my acquaintance and probably a convenient paraphrase of what was advised.

Mind you there was a legendary vet in NZ who apparently could I/M pin a cat's femur closed.....

RE: Greenstick fracture? Management?

Lucy Fleming — Mon, 25 Mar 2019 16:40:33 GMT

[quote user="Julie Innes"]With cats my old boss used to say as long as both ends of the bone were in the same room they would heal![/quote]

I saw a cat a couple of years ago where the owner had "spoken to her uncle who is a vet" about her cat with fractured femur and followed the benign neglect route. I can't lie, the bone was healed, but the femur did have about a 75 degree bend in the middle (assessed by palpation, not radiographs!). I can't imagine the long term outcomes in cases like that are as good as they would be if the fracture is reconstructed more precisely...