Humeral condylar fracture springer still lame

RE: Humeral condylar fracture springer still lame

Malcolm Ness — Fri, 19 Jun 2020 13:29:54 GMT

As Jo points out, many/most/almost all of these fractures are associated with IOHC, especially in this breed. Although many do well following good reduction and appropriate fixation (as is the case here) not all of them do. There is nothing obvious and unequivocal here to my eye as a cause of the ongoing lameness but here are number of candidates:

1. The fracture is fine and the seat of lameness is elsewhere.

2. There is evidence of OA in the form of osteophytosis and perhaps some sclerosis of the medial humeral condyle. Coronoid process disease is frequently seen in spaniels with IOHC so this might be a progression of that syndrome. Likewise, there may be some imperfection of the reduction that is driving a secondary OA and finally, the aetiology of IOHC is poorly understood but an underlying joint incongruity has been implicated - certainly, the 'fissure' seen in IOHC is of varying width between patients so when we compress the condyle with a lag screw we might be making the joint even more incongruent.

3. These repairs are associated with a surprisingly high rate of infection - the glide hole here looks rather wider and less distinct than I would expect so I think infection is a real possibility here.

4. While the surgery is pretty good, the implant placement is not perfect and there may be some discomfort associated with the ends of the screw or the pin.

5. It is not unusual to have the screw fracture in line with the fissure - this is related to IOHC, the incongruity and the fact that there remains a complex pattern of loading and potential instability even after screw placement. The broken screw is not always apparent.

As to what to do - first, I would examine the dog very carefully including a detailed palpation of the implants. If the lameness can be tolerated, I would let some more time pass and put the dog on a lengthy course of NSAIDs and normal, unrestricted activity. That may see the dog resolving back to normal, or at least near normal. If that doesn't happen then the next step is more surgery and that will inevitably be somewhat speculative. I would start by removing the implants. If that can be done without the need for further surgery that is a very good thing and I would be optimistic of seeing some further improvement. If the screw is broken of if the fracture is grossly unstable without the implants, then I would place a larger screw (5.5 or 6.5mm) and warn the owner that while the dog should improve, that improvement is likely to be incomplete.

Managing the client's expectations is often difficult in these cases - the surgery is technically straight forward providing proper attention is given to detail, but many clients come to consider this a "simple" fracture that should lead on to a predictably good outcome. While that is often the case, some perfectly well-managed cases have disappointing outcomes.

RE: Humeral condylar fracture springer still lame

Beats — Fri, 19 Jun 2020 12:28:31 GMT

Thanks Jo.

xrays taken today and I don't have any examination findings to report yet beyond normal range of motion of joint and not obviously painful (examined sedated I suspect) or swollen at ends of screw or showing external signs of implant infection (I thought probably no signs to say infected implants on xray either, but happy to be corrected on that one).

I spoke to the owner only briefly earlier in week, but sounded like a significant enough limp to me after walking on leash that I was concerned to book for xrays (we still have a list of non-urgent procedures waiting patiently, and I was concerned enough to have this one jump the queue). Having said that I don't think has collected any metacam since surgery at start of February and I perhaps over-reacted.

Sorry the details are a bit scarce, but thought worth posting the xrays anyway for now.

RE: Humeral condylar fracture springer still lame

Jo Dyer — Fri, 19 Jun 2020 12:17:22 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/29167/humeral-condylar-fracture-springer-still-lame"]there seems to be a fracture line still visible in humeral condyle at level of the 5th screw thread from screw head if that makes sense.[/quote]

I am no orthopod but these fractures are secondary to IOHC so I assume there will never be ossification here?

How long post op are the radiographs and how was the dog on examination?

You say the lameness is reported, is that by reported by the owner or observed by a vet? If the former, really silly question but thinking laterally, is it lame on the same leg? The condition is often bilateral so could be the contralateral one??