Fracture of the week - cat humerus supracondylar (for discussion)

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Neil Wheadon — Mon, 03 Feb 2020 18:30:49 GMT

Just spent 2 weeks with 5 doctors and the subject of fracture repair came up

In people there is much debate about overstabalizing a fracture. In this respect if you get no movement at the fracture site then non union occurs. Maybe we're overthinking this as with an external fixator used and 2 pieces either side you're not going to get a lot of movement. Perhaps that's why a single pin works so well?

Neil

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Arlo Guthrie — Thu, 23 Jan 2020 18:00:09 GMT

I failed with the 13mb file, so we're trying to get to the bottom of why the larger files don't upload.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Beats — Thu, 23 Jan 2020 14:08:00 GMT

Still Arlo, not Beats. Lets see whether we can upload an image that is twice as big. This one is Le Sommeil (circa 1889-1894), and it must be one of the most someiffic sculptures I've ever seen ...

Anyway, it seems to have uploaded OK. It's a 3.1MB file. So finally, I'll try and upload a 10mb file (I think anything much more than that is probably too large).

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Arlo Guthrie — Thu, 23 Jan 2020 13:53:13 GMT

I could not upload a very large file myself, either using your account or my admin account, Beats. So now testing whether admin can upload smaller images. To make it bit more interesting, here's some culture for all you philistines. A sculpture called Le Secret (1909), by Rodin, which I took in October last year.

.. which seems to have worked. So now I'll try a bigger one under your account.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Arlo Guthrie — Thu, 23 Jan 2020 13:41:42 GMT

Beats Hmm - sorry for delay - I'm working on this!

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Beats — Thu, 16 Jan 2020 20:53:36 GMT

back to original fracture (sorry for multiple posts), here are post-op xrays from the actual case prior to cutting pin.

[[mention:39e7cd0660f34b9299b6d6ba21b12cdf:e9ed411860ed4f2ba0265705b8793d05] used same work around of doing post with pictures, copying (CONTROL "C" after highlighting text), then hitting reply, getting error, then hitting reply on a previous post to open new post attempt and pasting (CONTROL "V") and then typing this additional explanatory text before hitting "Reply" again and it worked with pictures.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Beats — Thu, 16 Jan 2020 20:47:13 GMT

still getting error message Arlo Guthrie when try to post picture - has long file name and might be just this particular file is a problem, so I'll try to post a random photo in this post to see. Letting you know just in case this is a more general problem for folks with posting photos that might impact on forum use.

picture inserts fine, type around it etc, then click reply and get error and doesn't post.

[Edit: copy whole post before posting, hit reply and get error, try again and simply do paste and has worked - hope that helps]

RE: Fracture of the week - cat humerus supracondylar (for discussion)

David Mills — Thu, 16 Jan 2020 09:52:00 GMT

Never discount conservative management of humeral fractures in cats, rest and analgesia. Many will heal without intervention with sufficient rest. They may not look too pretty on xrays but they often lead to a functional non-painful leg. There is quite a lot of supportive muscle in cats around that area.

Malcolm Ness used to consider this as a viable option.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Beats — Wed, 15 Jan 2020 21:05:50 GMT

This time on trying to post xray I got this message flash up on uploading one xray jpeg and clicking "reply"

"An error occurred. Please try again or contact your administrator."

Might be a temporary glitch, so I'll try again later.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Beats — Wed, 15 Jan 2020 21:03:20 GMT

Really good thoughts - thanks everyone - I've learned a lot!

Here's what I did with it:

2.4mm IM pin normograde from proximal, limited open reduction, driven into distal fragment to just proximal to epicondylar fossa.

1.6mm interface threaded pins (IMEX) for ESF - with full pin through humeral condyle.

Connected up with IMEX carbon mini connecting bars and IMEX clamps with straight lateral bar and bent bar from medial condyle pin to pin in proximal segment laterally. Lateral connecting bar tied into IM pin.

[xrays won't post - system complains of large file size - I'll try in 2 separate posts]

Xrayed after 9 weeks was basically healed - removed 3 of ESF pins and left IM pin connected to one ESF pin in proximal fragment for an additional 4 weeks, then pulled remaining metalwork and let outside again.

There was radial nerve paralysis present on initial presentation, a limited open approach was taken to visualise anatomy and avoid radial nerve with half-pin (ESF one) in distal fragment laterally. Function predictably returned in few weeks.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

James Dunne — Tue, 14 Jan 2020 12:24:16 GMT

The idea that all cat fractures heal if the bone ends are in nearby vicinities needs to be binned. I have seen a number of cat non-unions secondary to poor fracture reduction, just like in dogs. As has been mentioned already, cats tend to exert tremendous forces on any repair performed, so it should be robust. This fracture could be repaired a number of ways, depending on owner's capabilities postop, cat's temperament, finances, etc. The simplest option with the lowest cost inventory, as already mentioned, is an IM pin and external fixator. The IM pin will want to be 25-40% of the intramedullary canal diameter to effectively resist bending. It will significantly strengthen an ESF frame if it is 'tied in' to the frame. It will also protect a plate from bending. Other options are plate-rod [likely 2.4mm plate], orthogonal plates, ESF on its own, interlocking nailing. Since the cat is 9 years old, it may be worth grafting the fracture; depending on surgeon experience and the amount of tissue dissection this could have a significant influence on whether it will heal and how long the fracture will take to heal. A pin can be inserted normograde either distal to proximal or vice versa. 4 weeks crate confinement; utility room is fine after that. We usually radiograph at 6 weeks and assess using the the 'AAAAA' system - Alignment [normal limb alignment, no rotation], Angulation [any varus/valgus], Apparatus [are the implants okay/displaced/broken, any peri-prosthetic lucency], Apposition [is there contact between fracture ends] and Activity [callus formation/ bone lysis]. Rightly or wrongly I tend to confine cats until union is very well progressed radiographically. Hope that is of some use!

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Neil Wheadon — Tue, 14 Jan 2020 10:53:39 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/28796/fracture-of-the-week---cat-humerus-supracondylar-for-discussion/218783"]Really in cats if you get the bone ends somewhere close they will heal. I've seen a number done as a student retrograde with no other fixings and I think they all did fine. I remember one guy pinning a cat's femur in less time than most of us would spay a cat. It was fast and cheap and seemed to work.[/quote]

I used to do a lot of these and sort of agree with Michael, however I like Dinu's addition of something to stop rotation. In this case there isn't a lot to stop rotation, but of all the ones I did I don't recall post op rotation being an issue and i wasn't plating them, just an IM pin and circlage wire if there were fragments

Post op 6 weeks rest. In a bedroom, maybe leave the bed in, but take chest of drawers etc out, litter tray, but window sills are an issue

Neil

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Michael Woodhouse — Tue, 14 Jan 2020 09:55:02 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/28796/fracture-of-the-week---cat-humerus-supracondylar-for-discussion/218774"]normograde or retrograde?[/quote]

Retrograde as I find it vastly easier!

Doesn't need to be massive in a cat, but I would likely go bigger and not as far

Open. I like to eyeball it.

Really in cats if you get the bone ends somewhere close they will heal. I've seen a number done as a student retrograde with no other fixings and I think they all did fine. I remember one guy pinning a cat's femur in less time than most of us would spay a cat. It was fast and cheap and seemed to work.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Anthony Dennison — Tue, 14 Jan 2020 09:32:29 GMT

I would cage confine for a decent period of time. Cat's are really good at climbing the walls if restricted to a small room where they can still jump and potentially damage the metal work. At least 4 weeks, and I wouldn't let outside until post op radiographs at about 6-8 weeks shows good healing.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Beats — Tue, 14 Jan 2020 00:20:37 GMT

[quote userid="9239" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/28796/fracture-of-the-week---cat-humerus-supracondylar-for-discussion/218775"]Was the fracture open or closed?[/quote]

Closed.

And aftercare:

Cage confinement? If so, how many weeks estimate? Single room confinement with some ability to jump up? Whole house confinement? Estimate of time until can go outside again?

[again, those questions aren't all for you, Dinu! Just trying to prompt considerations of what constitutes adequate or appropriate confinement after repair]

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Dinu Catilina — Tue, 14 Jan 2020 00:10:43 GMT

What I would do:

Adult cat, there are a couple of butterfly fragment and possibly a fissure in the proximal fragment. For me this is a rod-plate construct. IM pain normograde, not more than one third of the diameter of the humerus at the most narrow point. I would not attempt to sit it in the medial epicondile. Locking plate 2 or 2.4 mm depending on the size of the cat on the cranio-lateral aspect, 2 screws in each fragment. I use Evolox (the kit I have), SOP would be a nice option as well.

Was the fracture open or closed?

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Beats — Mon, 13 Jan 2020 22:57:17 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/28796/fracture-of-the-week---cat-humerus-supracondylar-for-discussion/218773"]IM pin.[/quote]

normograde or retrograde?

Big IM pin down to top of epicondylar fossa, or thin one all way down into medial condyle?

Beginning proximal or distal?

Open or closed reduction?

[you don't have to answer all those questions, Michael! Throwing them out for anyone wanting to think through their approach to case]

PS - also I'm not sure how to edit title, but distal diaphyseal humeral fracture probably better description than supracondylar for this one.

RE: Fracture of the week - cat humerus supracondylar (for discussion)

Michael Woodhouse — Mon, 13 Jan 2020 22:22:57 GMT

IM pin. I'd probably place a small 2 pin ex-fix to prevent rotation for 4 weeks.

Same # in a dog I'd plate but the smallest I have is 2.7mm and I think that would be too much metal for a cat.