How do you approach digit fractures?

RE: Digit fractures

Malcolm Ness — Thu, 07 May 2020 06:54:42 GMT

Hi,

Taking your questions in order:

1.1 I would typically bandage with thinner strips of Vetwrap or similar extending no further than mid MC/MT. Very limited 'padding' under the bandage - I prefer to use the thin specifically made Cast Padding rather than cotton wool here as the latter tends to 'ball-up'. If a stiffer bandage is needed, I use Elastoplast adhesive tape. Change as often as needed - typically every week or so. 1.2. I very rarely, if ever, use splints for toe fractures - they are ineffective unless you have placed a relatively large bandage and that is, I think, counter-productive in these cases. 1.3. Taping toes with as little interference to the rest of foot function is the aim. Less is more.

2. I have occasionally (in racing dogs) operated to place a lag screw to fix a saggital fracture of a joint surface. Whether this made any difference to outcome is a moot point. The mini-hook plates can be useful on MT and MC fractures but they are (very) rarely applicable in toe fractures.Some P1 s might just be long enough to accommodate these implants but most are not. There is simply not enough bone on a P2 fracture to make this a viable/useful/effective technique (that is not, of course, to say that someone will have tried!). Even on MT/MC fractures in racing dogs with relatively large bones (in this context!) these hook plates are rather difficult to make, of questionable functionality and terribly fiddly to apply. I think that most of them, in reality, function as a proximally fixed buttress/internal splint. Their utility in anything other than the specific and distinct MT/MC fractures of racing greyhounds is virtually non-existent.

Malcolm

RE: Digit fractures

Beats — Wed, 06 May 2020 20:27:00 GMT

Thanks, Malcolm - really appreciate the detail in your reply (particularly the insights into AO bias which I've never thought about before)!

I feel satisfied that in my inexperienced hands a less-is-more approach is probably best as a general rule, but I might be more inclined to xray in future, and the select case may get some form of bandaging or taping support (with regular checks etc).

Final questions:

Q1) Regarding bandaging (in select cases where have been xrayed and deem benefit outweighs risk), would you (generally-speaking) be more inclined to recommend for an average general practitioner to:

1) tape only (Allesandro recommended Chirofix or Hapla Band, or failing that VetWrap cut into thinner strips), and if so how far up would you extend this? [The advantage of this I could see is that the toes remain more visible and bandage-induced damage may be more readily appreciated perhaps?] With a protective boot placed over the top when going out on walks.

2) standard soft padded bandage with or without spoon splint, without taping toes.

3) taping toes and soft padded bandage +/- splint.

Q2) If xray and involves joint, does this mean you would be more likely to surgically reduce e.g. lag screw or mini 1.0mm customized hook plate?

Many thanks once again!

Dave

RE: Digit fractures

Malcolm Ness — Wed, 06 May 2020 19:30:25 GMT

Hi,

I think your approach is quite sensible and I wouldn't be in a hurry to make substantial changes. Most fractures of P 1 or 2 will heal adequately with 'benign neglect'. I will usually radiograph to confirm that there is no articular involvement (there usually isn't) and I will often consider bandaging to effectively splint the fractured toe against its neighbour. However, I have considerable experience with greyhounds and therefore familiar with the fine details of effective bandaging of these distal injuries. The potential to apply dangerous or ineffective bandages is significant. Bandage support is appropriate for 4-6 weeks and the close (over-close) cutting of the nail to minimise loading of the toe during the convalescent period is something I would always do.

With respect to surgical repair of toe fractures - this is something I have done relatively infrequently and nearly always in racing greyhounds or other canine athletes. I would not put too much weight in the AO stuff - bear in mind that AO was for many years maintained by the Synthes Corporation as a 'soft, fluffy' part of their otherwise forthright sales and marketing effort. In essence, they were looking for ways to pursue their dogma of open reduction and surgical fixation of fractures to support their aim of selling implants. Alex Piras is a very good, practiced surgeon with something of a reputation for operating on things that others would manage less aggressively. He is also very accomplished and experienced operating on greyhound injuries which are mainly in the smaller bones - wrist, hock, MCs, MTs and digits. These small-bone repairs are extremely technically challenging and few surgeons (even experienced Ortho Diplomates) will be able to duplicate Alex's operating. For toe fractures, we will occasionally make a 2mm diameter screw fit but much more often we are using 1.5mm diameter screws. Technique MUST be meticulous and patients need to be skeletally mature and ideally athletic. The bone in immature etc dogs is often simply not hard enough to hold the extremely fine thread of 1.5mm screws. Even then, the repair is fragile and must be supported/protected in much the same way that you would manage with bandages etc. MC and MT fractures are a separate subject.

One last thing - not all toes are equal - the centre two toes do most of the work meaning that first, they are a bit more of a challenge to manage either surgically of conservatively. Likewise, if you do have to amputate a digit, the outer toes (1,2 or 5) can be removed with relatively little impact on foot function but similarly if digit 3 or 4 is amputated the functional consequences will be greater.

In summary, your current strategies sound good and as far as (most) toe-fracture-surgery goes, 'just because you can, doesn't mean you should'!

I hope this is helpful - get back to me if you want more.