Surgery or not - fractured metacarpal

RE: Surgery or not - fractured metacarpal

Beats — Wed, 26 Jun 2024 11:02:01 GMT

Personally, I'm more likely than not to put a fabello tibial suture of 50lb nylon leader line on cat with torn cranial cruciate. I find most of these have other traumatic injuries to eg medial collateral lig also, but generally just stabilise the cruciate and leave at that. I don't see many cases myself.

RE: Surgery or not - fractured metacarpal

Stigen — Wed, 26 Jun 2024 06:46:44 GMT

My opinon in all this is that I would rather choose the conservative option if that has a chance of working. I want to do the best for the animal without thinking of what makes the most money. I felt in this case that a surgical intervention and pinning could cause more trauma and risks of complications compared to leaving it to heal. And both strategies has the risk of future pain and arthrosis. The other veterinarian who did the surgery has a reputition locally for operating on "everything".
Also I did not appreciate him putting it to the owner that since the conservative option had been attempted the cat was basically at risk of loosing its whole leg, and he indicated to them that the callus formation in the most recent x-ray was basically unwanted "junk"-tissue that needed to be surgically removed (as the owner told us by telephone).

I have a second questions if any of you have the time to reply; Cruciate rupture in cat - operate or not ? yesterday I had one of those, and I know the opinions vary. This was a 4 year old cat,not overweight, that had been 7/10 lame for 1 day. Nothing on x-rays, but obvious cranial drawer on right hindleg.
I told them Nsaids and 6 weeks cage rest, but am also willing to refer it to an orthopedic surgeon if indicated.

RE: Surgery or not - fractured metacarpal

David Mills — Wed, 19 Jun 2024 08:08:01 GMT

So one option, after the tenets of EBVM, would be if the info doesn't exist it creates a knowledge requirement - so we either look for literature (doesn't exist) or synthesise it ourselves. Which is going to be difficult if not impossible in cats with this kind of injury - it's an uncommon presentation (location, localisation, degree of displacement) and long-term outcomes will be difficult to follow through. Then you will have different skills of surgeons with tis type of injury, and difficult compliance with post-op management.

So as what normally happens it comes down to experience of previous injuries, anecdote, opinion. In this arena, specialists for the most part will have opinions that would be based on more experience and training, as they would be expected in the main to have seen more of these cases with the proviso that they aren't part of the increasingly common graduate-intern-resident route with minimal exposure to 1st opinion practice tranche.

[quote userid="3513" url="~/f/clinical-questions/30978/surgery-or-not---fractured-metacarpal/244926#244926"]We do know however that a malaligned joint (which is what will happen if this bone heals with a significant malunion) can result in osteoarthritis and joint pain.[/quote]

Malaligned and malunion I always think are value-laden words to an extent - very few fractures are truly not in some way 'malaligned' if we apply the strict definition. 'Malunion' suggests inherently suboptimal but that ignores entirely the outcome the patient is probably most interested in - pain free function of the bone that returns it to or as close to pre-injury levels of activity and QoL. Now it may be that pain is a feature in the future but we can quantify that to an extent - this is one digit in a cat with highly flexible locomotion and 3 other functional digits in the same paw. I would say any intermittent pain in the future is likely to be minimal, and likely positively responsive to analgesia should any be required.

It is incontrovertible that surgical fixation, competently performed, is most likely to improve long-term success and minimise complications. But not 100%. To add to the considerations, intermittent pain in healed bones in people with no obviously significant malunion is reported. So we have duality of possible pain in either scenario.

[quote userid="3513" url="~/f/clinical-questions/30978/surgery-or-not---fractured-metacarpal/244926#244926"]In my previous answer I was not meaning to imply that this injury should be treated surgically, just that there is a valid reason for considering surgery even if we know that the bone is likely to heal without surgery.[/quote]

I think the issue Arlo Guthrie is getting at is that where opinion is all we have, as in this case, then there is significant and recognised risk of bias entering the decision-making process - and this is NOT directed at you Andy Moores but a general observation. So one clinic, as Stigen has experienced would not contemplate no surgery - which is wholly and utterly wrong both for the patient, client and profession. It is the exploitation of an owner's worry and the informational advantage the vet holds. It IS happening more and more as clinics invest in 'kit' and surgical offerings - these things have to pay for themselves and a £4k surgery pays off far more than a £15 bottle of metacam and the outcomes are probably the same. It matters because it cuts directly to the profession drift we are seeing.

RE: Surgery or not - fractured metacarpal

Arlo Guthrie — Wed, 19 Jun 2024 07:40:17 GMT

[quote userid="3513" url="~/f/clinical-questions/30978/surgery-or-not---fractured-metacarpal/244926#244926"]All valid questions Arlo and the answer to most if them is 'we don't know', that information simply does not exist. We do know however that a malaligned joint (which is what will happen if this bone heals with a significant malunion) can result in osteoarthritis and joint pain. Now it's only a digit you might say, which is of course true, and it might never be an issue, which is also true, but we do see patients with clinical issues due to pain in their digital joints and so I don't think it's wrong to take that into consideration in this particular case.[/quote]

I'm going to start a new discussion thread, because I really don't mean this to sound like I am having a dig at you specifically! I just do think it raises a really important question about veterinary care (and the costs).

I find it difficult get my head around the idea that surgery with unknown benefits should be even be offered as an option to a client when there isnt any data about what may happen if they do or do not proceed with surgery.

[quote userid="3513" url="~/f/clinical-questions/30978/surgery-or-not---fractured-metacarpal/244926#244926"]How you present that information to the owner is of course critical and it is of course important to be fully open and transparent with them about what we do and do not know.[/quote]

I just don't think there is ANY way of presenting that information in a way that allows owners to make a decision. All you can say is: "the cat may suffer pain in the future", which creates a FAR bigger compulsion to proceed with surgery than the actual evidence seems to demand.

[quote userid="3513" url="~/f/clinical-questions/30978/surgery-or-not---fractured-metacarpal/244926#244926"] just that there is a valid reason for considering surgery even if we know that the bone is likely to heal without surgery.[/quote]

But is there?? Sorry, Andy, I am nervous of challenging this because, well, you know what you are talking about, and I don't! And also because I don't want this to read as criticism, it is not. It's a really important philosophical point, which is whether or not 'the animal may suffer pain in the future' is a valid reason for considering surgery, or whether surgery should demand a better evidence base.

Lets not forget also the owners who are insured, and who are likely therefore to just wave it through on the basis that ANY risk of future pain is intolerable, thereby inflating insurance premiums.

I'm going to start this as a new discussion thread ...

RE: Surgery or not - fractured metacarpal

Andy Moores — Tue, 18 Jun 2024 20:11:42 GMT

All valid questions Arlo and the answer to most if them is 'we don't know', that information simply does not exist. We do know however that a malaligned joint (which is what will happen if this bone heals with a significant malunion) can result in osteoarthritis and joint pain. Now it's only a digit you might say, which is of course true, and it might never be an issue, which is also true, but we do see patients with clinical issues due to pain in their digital joints and so I don't think it's wrong to take that into consideration in this particular case. How you present that information to the owner is of course critical and it is of course important to be fully open and transparent with them about what we do and do not know. In my previous answer I was not meaning to imply that this injury should be treated surgically, just that there is a valid reason for considering surgery even if we know that the bone is likely to heal without surgery.

RE: Surgery or not - fractured metacarpal

Arlo Guthrie — Tue, 18 Jun 2024 12:48:09 GMT

[quote userid="3513" url="~/f/clinical-questions/30978/surgery-or-not---fractured-metacarpal/244921#244921"]You can make arguments either way for surgical/non-surgical management. The fracture is quite displaced. The fracture will no doubt heal without surgery but it will heal as a malunion. This is probably not going to have a significant effect on the cat in the short-medium term but malalignment of the metacarpophalangeal joint over the longer term could have consequences.[/quote]

Andy Moores - Andy, I am possibly going to sound a bit impertinent here, but I think in the current cost of living crisis, and CMA investigation and all that, it's really important for treatment decisions to be based on evidence (however slim!), because without it, unqualified statements like this:

[quote userid="3513" url="~/f/clinical-questions/30978/surgery-or-not---fractured-metacarpal/244921#244921"]but malalignment of the metacarpophalangeal joint over the longer term could have consequences.[/quote]

can lead to (expensive) treatment based more on the fear of something happening than the actual risk.

Your statement raised all sorts of questions in my head:

a) What are the possible consequences?

b) What percentage of cats suffer those unnecessary consequences?

c) At what age do they suffer those consequences (ie are they as likely to die before they get there!)

d) What are the costs of surgical intervention?

e) What percentage of surgical interventions eliminate further consequences

f) What percentage of surgical interventions cause further problems!

Without this info, I am not sure how someone could make a considered decision about whether to opt for surgery.

Sorry to raise this question, Andy, it's just that I genuinely think 'could have consequences' is something which, whether spoken or in a forum, does drive the costs of vet care upwards unless it is put into proper context.

RE: Surgery or not - fractured metacarpal

Stigen — Mon, 17 Jun 2024 07:18:53 GMT

Thank you so much Andy. The cat did`nt seem to me to be one to tolerate bandage, so I told them cage rest and nsaid for 5 weeks.

RE: Surgery or not - fractured metacarpal

Stigen — Mon, 17 Jun 2024 07:16:58 GMT

This is pretty much what I decided after discussing with an orthopedic surgeon. But then they took the cat to anoter vet who vey uncollegially said that unless it is operated this very day he would have to amputate the whole leg, and it is my fault..

RE: Surgery or not - fractured metacarpal

Andy Moores — Sat, 15 Jun 2024 10:50:47 GMT

Hi Stigen,

You can make arguments either way for surgical/non-surgical management. The fracture is quite displaced. The fracture will no doubt heal without surgery but it will heal as a malunion. This is probably not going to have a significant effect on the cat in the short-medium term but malalignment of the metacarpophalangeal joint over the longer term could have consequences. If managing non-surgically then I would bandage for 2-3 weeks if tolerated by the cat -the bone will heal quicker if immobilised, the cat will be more comfortable if the fracture is not unstable and the bandage may help to align the fracture better.

Andy

RE: Surgery or not - fractured metacarpal

David Mills — Fri, 14 Jun 2024 19:31:57 GMT

Leave it well alone, it'll heal fine with MCP3 intact.

I don't even bother bandaging these anymore, just adds more weight and faff, rests and NSAIDs for a couple of weeks and all will be well