Advice on cat fracture- urgent please!

Re: Advice on cat fracture- urgent please!

Edward Jones — Sun, 05 Sep 2010 21:06:04 GMT

I had a blind-leading-the-blind nightmare case with a distal femoral fracture (simple transverse) simply due to the musculature contracture that made reduction next to impossible. I can't remember how it was resolved (probably don't want to remember!), but I know the dog was running around on 4 legs with no apparent issues in next to no time. I do remember the movement of the patella was largely unaffected, however, so that was in the dogs favour.

I'm often grateful for the huge potential for healing our patients frequently demonstrate.

Re: Advice on cat fracture- urgent please!

Mark Holmes — Sun, 05 Sep 2010 17:51:36 GMT

I don't know why it seems more daunting. If it goes wrong it can usually be fixed where as if you screw up an anastamosis or a slenectomy the dog may well be dead or nearly so. I find it a little daunting never the less!

Re: Advice on cat fracture- urgent please!

Sara Ramsey — Sun, 05 Sep 2010 16:35:12 GMT

I would like a very basic orthopaedic course, I've been qualified seven years and have always managed, embarrassingly to avoid anything orthopadic. I'm not sure why it seems more daunting that soft tissue surgery.

Re: Advice on cat fracture- urgent please!

Tim Cheyne — Fri, 13 Aug 2010 08:20:03 GMT

[quote user="Malcolm Ness"]

[quote user="Tim Cheyne"]how little pain they seemed to feel (endorphins production?). [/quote]

or poor recognition of signs of pain by the clinician.............[/quote]

I couldn't say. I wasn't a clinician in those days nor had shown any intention of becoming one but the vets that I met with our injured cats seemed quite competent even without the modern gizmos.

[quote user="Malcolm Ness"]

[quote user="Tim Cheyne"]Even today, if 'proper' treatment was not feasible, I would hesitate to recommend amputation or euthanasia before 'cage' rest had been tried for a few days[/quote]

Conservative management continues to be a valid option in the treatment of many fractures and the treatment of choice in some. That is neither new-fangled nor old-fashioned, merely good medicine that depends on well-informed clinical decision making.

[/quote]

Exactly; I couldn't have put it better myself.

Tim.

Re: Advice on cat fracture- urgent please!

Ros — Thu, 12 Aug 2010 19:37:00 GMT

[quote user="Malcolm Ness"]Is the time right to run the course again?[/quote]

I would certainly be interested

Re: Advice on cat fracture- urgent please!

Utlendigur — Thu, 12 Aug 2010 14:48:33 GMT

[quote user="Jillian Hall"]

Are these usually easy to reduce (assuming they're not too old)? Is there much chance of implant failure?

[/quote]

I usually find the trick is to reduce them with the stifle fully extended - otherwise the main problem is that the distal fragment rotates caudally. I usually part drill a little depression on the surface of the distal femur above the fracture and use a pair of pointed reduction forceps with one point in the depression and the other in the intercondylar space to hold everything together while I put the wires in. I usually bend the pins over (seems like I'm in the minority but I saw one done at a University where a 6wk or so post op xray showed lovely union but only one wire - luckily the collimation wasn't good and the other wire was visible stuck to the bladder. I also vaguely remember a JSAP article about a wire migrating into the pericardium of a yorkie which I think was from a similar fracture.

Re: Advice on cat fracture- urgent please!

Malcolm Ness — Thu, 12 Aug 2010 09:01:49 GMT

[quote user="Tim Cheyne"]how little pain they seemed to feel (endorphins production?). [/quote]

or poor recognition of signs of pain by the clinician.............

[quote user="Tim Cheyne"]Even today, if 'proper' treatment was not feasible, I would hesitate to recommend amputation or euthanasia before 'cage' rest had been tried for a few days[/quote]

Re: Advice on cat fracture- urgent please!

Tim Cheyne — Wed, 11 Aug 2010 13:31:41 GMT

[quote user="Michael Woodhouse"]

I've seen some horrific fractures heal in cats with just cage rest. They are [on the whole] sensible and quiet whilst heeling.

[/quote]

I agree with Michael. At a time when orthopaedic procedures were nowhere near as advanced as they are today (neither in animals nor in humans), immobilisation of fractures with a splint or plaster cast (often not possible in a cat) and 'bed' rest was about the only treatment option. It was common for a cat involved in an RTA to disappear for several days before dragging itself home to hide in its favourite dark corner with food being taken to it. It was surprising how soon they were hobbling about and how little pain they seemed to feel (endorphins production?). Even today, if 'proper' treatment was not feasible, I would hesitate to recommend amputation or euthanasia before 'cage' rest had been tried for a few days.

Tim.

Re: Advice on cat fracture- urgent please!

Martin Atkinson — Wed, 11 Aug 2010 09:45:15 GMT

[quote user="Jillian Hall"]

Are these usually easy to reduce (assuming they're not too old)? Is there much chance of implant failure?

[/quote]

Its usually easy to positively reduce the fracture manually and hold it securely with a pair of bone holding forceps during surgery. I used to fix supra-condylar femoral fractures with a contoured 3 hole compression plate applied laterally. I felt that it was far more stable for post surgical activity than with arthrodesis wires. I agree that premature closure of the growth plate seems to be of minimal significance in these cases and it's probably damaged by the injury anyway.

I don't know if anyone else finds the same but there seems to be far fewer fractured limbs presented these days especially in dogs from RTAs or is it my imagination? Having said that I'll have 3 today!!

Re: Advice on cat fracture- urgent please!

Jillian Hall — Tue, 10 Aug 2010 23:55:23 GMT

I'm encouraged by this:

"This surgery is well within the capability of anyone who can spey a cat provided they have the (fairly basic) equipment to hand."

I wouldn't describe myself as a nervous surgeon at all but I've just never seen these done before. I'm now feeling bad because I had a similar fracture recently and although I could recognise immediately that cross wires would fix it, I opted to amputate as the owners couldn't afford referral.

Are these usually easy to reduce (assuming they're not too old)? Is there much chance of implant failure?

Re: Advice on cat fracture- urgent please!

Evelyn Barbour-Hill — Tue, 10 Aug 2010 19:05:05 GMT

By chance, this popped into my inbox today from Liverpool:

Small Animal CPD Day

Treatment of common fractures with pin and wire

Speakers: John Innes RCVS registered specialist and Rob Pettitt CertSAS

Date: 30^th September 2010

Price: £415.00 Course code: SAP006

It's a bit short notice but if it interests anybody I expect you can get all the necessary on www.liv.ac.uk/cpdvets or something like that.

Re: Advice on cat fracture- urgent please!

Malcolm Ness — Mon, 09 Aug 2010 17:16:21 GMT

I would only ever remove implants if they were causing trouble. I like the old adage "If it's not broken, don't fix it"

It is suggested that implants placed across a physis might cause the physis to close and that is true. Extrapolating from there, some have suggested that very early removal of trans-physeal implants will allow the physis to grow on. I don't believe that.

Re: Advice on cat fracture- urgent please!

Rob Loxley — Mon, 09 Aug 2010 16:21:51 GMT

Malcolm, would you ever consider removing the wires in a VERY young cat?

Re: Advice on cat fracture- urgent please!

Malcolm Ness — Mon, 09 Aug 2010 10:51:53 GMT

No.

Cut the wires flush. Bending them leaves too much material in the joint which can cause lameness post surgery. Also, the epiphyseal bone is typically rather soft and attempting to bend the pins can cause the metal to slice through bone.

If the combined medial and lateral parapatellar approach is used, the fracture can be seen and proper reduction verified before implants are placed.

Re: Advice on cat fracture- urgent please!

Rob Loxley — Sun, 08 Aug 2010 21:41:33 GMT

[quote user="Malcolm Ness"]

Wire are not bent over but cut flush with the bone prior to a routine wound closure. No dressings needed and prognosis is excellent.
This surgery is well within the capability of anyone who can spey a cat provided they have the (fairly basic) equipment to hand.

[/quote]

If it's your first time at doing this, I'd maybe (and humbly) suggest bending the wires over rather than cutting flush: the first one of these I did I had to go back in after taking the postop radiographs and replace the wires as I'd not rotated the distal fragment back round enough cranially. Speaking to a few other people including one specialist, I'm not the first...
YMMV!

Re: Advice on cat fracture- urgent please!

Evelyn Barbour-Hill — Sun, 08 Aug 2010 16:05:37 GMT

[quote user="Sally Everitt"] but I feel that they have gone "out of fashion" and many people are loosing the skills and confidence to appraoch orthopaedic cases in simple ways.[/quote]

I'd second that.

[quote user="sophia guymer"] It is now about 13 yr ago but we had a professor at uni who used to say, if you stick a cat with all its bones on one cage, it will heal!! [/quote]

Sort of thing professors say sometimes. It doesn't work with skulls.

[quote user="robloxley"]The big issue with cage rest alone is that if things don't heal up well it's much more difficult to sort out, and in this case cross pinning will give you a much better chance of a much better outcome to the cat, at not vast extra cost once the cat is already anaesthetised and radiographs have been taken. I'd guess that it might even be quicker and easier than amputating the cat's leg?[/quote]

Oh come now, a hacksaw blade and some hot tar, you can't get cheaper and quicker than that.

Re: Advice on cat fracture- urgent please!

Sally Everitt — Sun, 08 Aug 2010 14:13:14 GMT

Dear Malcolm,

"Is the time right to run the course again??"

I would say definately yes, I qualified at a time when these were taught as standard (By Hamish Denny in my case) but I feel that they have gone "out of fashion" and many people are loosing the skills and confidence to appraoch orthopaedic cases in simple ways.

Sally

Re: Advice on cat fracture- urgent please!

Malcolm Ness — Sun, 08 Aug 2010 12:08:24 GMT

Just seen this thread - been out enjoying the sunshine in the hills over the weekend.

Perfectly true to say that if left alone the bone will heal and that applies to all species, not just cats. However, the aim with any fracture case is to do rather more than get the bones to heal - the goal is to restore full, pain-free athletic function.

This is an intra-articular fracture so conservatism will not restore anything like full function. As indicated previously, this is a surgical case. I manage these by open reduction (cranial skin incision centred over st patela ligament then combined medial and lateral parapatellar incisions into stifle joint). Perfect anatomic reduction is achievable and this is ensured prior to fixation with a pair of Kirschner or arthrodesis wires 1.0mm or less in diameter. The wires are started lateral and medial to the articular surface at the cranio-distal extremities of the femoral condyle. The lateral wire is directed proximo-medially across the fracture to exit the distal femoral diaphysis a cm or two proximal to the physis. The medial wire is directed proximo-laterally in similar fashion. Wire are not bent over but cut flush with the bone prior to a routine wound closure. No dressings needed and prognosis is excellent.

This surgery is well within the capability of anyone who can spey a cat provided they have the (fairly basic) equipment to hand.

Some years ago I ran a week-end course called "Pin and Wire fracture repair" it was aimed at general practitioners and occassional orthopaedic surgeons teaching pin and wire techniques from first priciples. There seems to be a poor appreciation of the fact that often these relatively simple, inexpensive techniques are the gold-standard (the present case is an excellent example) and equally these techniques are not being well taught in vet schools.

Is the time right to run the course again??

Re: Advice on cat fracture- urgent please!

Rob Loxley — Sat, 07 Aug 2010 23:31:17 GMT

[quote user="sophia guymer"]It is now about 13 yr ago but we had a professor at uni who used to say, if you stick a cat with all its bones on one cage, it will heal!![/quote]

The big issue with cage rest alone is that if things don't heal up well it's much more difficult to sort out, and in this case cross pinning will give you a much better chance of a much better outcome to the cat, at not vast extra cost once the cat is already anaesthetised and radiographs have been taken. I'd guess that it might even be quicker and easier than amputating the cat's leg?

Re: Advice on cat fracture- urgent please!

sophia guymer — Sat, 07 Aug 2010 20:16:11 GMT

[quote user="Michael Woodhouse"]some horrific fractures heal in cats with just cage rest[/quote]

It is now about 13 yr ago but we had a professor at uni who used to say, if you stick a cat with all its bones on one cage, it will heal!!

Re: Advice on cat fracture- urgent please!

Kate Richardson — Sat, 07 Aug 2010 11:05:49 GMT

Thanks, but must thank two of my nurses who made lots of phone calls and deserves a lot of the credit

Re: Advice on cat fracture- urgent please!

Hannah Wynne Richards — Sat, 07 Aug 2010 09:34:08 GMT

Kate for Secretary General of UN Sounds simple but would have needed a lot of tact to bring this outcome about

Well done

Wynne

Re: Advice on cat fracture- urgent please!

Michael Woodhouse — Fri, 06 Aug 2010 23:23:40 GMT

I've seen some horrific fractures heal in cats with just cage rest. They are [on the whole] sensible and quiet whilst heeling.

Re: Advice on cat fracture- urgent please!

Tim Cheyne — Fri, 06 Aug 2010 13:50:38 GMT

A good outcome indeed. Congratulations on achieving it.

Tim

Re: Advice on cat fracture- urgent please!

Kate Richardson — Fri, 06 Aug 2010 13:17:11 GMT

Update- have spoken to a specialist who has seen the xrays and they don't think this is one which will possibly do ok w cage rest due to patella involvement. Owner has now managed to come up with some money and with some help from a local cat charity, it looks like the cat will go for surgery now, which is great! Cat had been signed over to us but now looking very much like cat will go back to original owner who is very happy at the chance to have her cat back, he's going to get neutralized! and vaccinated and she is going to invest in some pet insurance! Happy days!! Long hard way to learn a lesson about the costs of keeping a pet, but a good outcome