Cr*p week, the tax man and a mast cell tumour!

Re: Cr*p week, the tax man and a mast cell tumour!

Utlendigur — Tue, 05 Feb 2013 23:03:33 GMT

[quote user="Charlotte Marshall"]Around us they seem to always smash them to blazes[/quote]

I've noticed that too. We used to see loads of simple femoral fractures - now they tend to be a lump of bone and the top and bottom and mush in the middle.

Re: Cr*p week, the tax man and a mast cell tumour!

Charlotte Marshall — Tue, 05 Feb 2013 22:52:02 GMT

My first pinning I think the boss held my hand and done one by myself since in 15 years! Around us they seem to always smash them to blazes and certainly require something a bit more complex. My current boss is keen on orthopaedics and tends to do it all. I did do a 2 day course on orthopaedics but seem to have done less surgery since than I did before! Not helped by the fact that although it is a skill I feel i should have it is not an area I am particularly interested in.

Re: Cr*p week, the tax man and a mast cell tumour!

Sarah Keir — Tue, 05 Feb 2013 18:37:34 GMT

I am a Glasgow 2002 graduate - looking back critically at my university education, it completely unprepared me for practice. I got far more out of 'seeing practice' withsome lovely chaps, learning how to formulate differential lists, how to communicate with clients, how to spay cats and rabbits and cow caesars etc. I found the science grounding good to go back to for first principles but the clinical years were too focused on learning each disease in turn rather than how to approach a case from the ground up - pattern recognition rather than problem solving. Professors were also too keen to show off the wild and unusual things rather than the mundane common things, in everything from medicine to orthopaedics. It has taken me 10years to unlearn this way and I'm still working at it.

One day of practical neutering in a charity clinic, one vet with 4 students and a couple of spays. There was a rabbit in that day to be spayed and I shiver thinking of the experience. One day of cadaver surgery. I can't remember exactly what we did but as someone mentioned, I think a laryngeal tie back in a dog was one of then - something I have never done or even referred for someone else to do.

My sister graduated last year from the Dick and from the very start they had communication classes and when doing anatomy they had to do problem solving on what surgies in these areas might involve, what potential problems could they see... But 10years is a long time...

Re: Cr*p week, the tax man and a mast cell tumour!

Rob Loxley — Tue, 05 Feb 2013 18:13:33 GMT

[quote user="Elizabeth Billimore"]How did people learn to pin femurs? Did you just crack on after looking at fossum or did you have a friendly boss who scrubbed in with you the first few? Or did you do some good cpd?[/quote]

All of the above, in addition to the anatomy and basic orthopaedic & surgical principles learnt at vet school.

[quote user="Wren"]There is no basic surgery happening in vet schools[/quote]

I just don't believe that's the case, though yes I agree that a lot of the surgical experience/practice comes down to EMS placements.

Re: Cr*p week, the tax man and a mast cell tumour!

Evelyn Barbour-Hill — Tue, 05 Feb 2013 12:43:37 GMT

[quote user="vetbl.locum"]I guess i really dislike idea of amputation but it seems to be used as a quick solution these days which is very sad.[/quote]

And also insane. If I've got this right, the development of really sophisticated fracture repairs aiming at utter perfection has led to the condemnation of simpler techniques, leaving amputation as the only alternative? This would seem to be the opposite of progress.

[quote user="Wren"]Vet schools are trying to do two totally opposing things - to act as a referral hospital, by definition only operating on cases that the general practitioner has neither the experience nor facitilies to cope with; and attempting to turn out students competent in basic surgery. There is no basic surgery happening in vet schools (as a rule - some do neutering clinics or have a first opinion practice etc.) and the surgery which does happen is necessarily more complicated than most vets will ever need to learn pre-qualification. Twas ever thus.[/quote]

But some teachers manage – did manage – to do both.

[quote user="vetbl.locum"]What would RSPCA view on this?[/quote]

"What's the political angle?" probably.

[quote user="vetbl.locum"]ps where is spell checker ?[/quote]

In the bin, I hope.

Re: Cr*p week, the tax man and a mast cell tumour!

vetbl.locum — Tue, 05 Feb 2013 12:27:56 GMT

Was a long long time ago but read book (well looked at drawings) , explained to client that as large animal vets we were not greatly skilled at pining but we 'give it a go ' They had little money so no chance referal even if you could find someone .

It worked well , fairly simple op but doubt if I would do that thesedays.

Not been in practice for a while now , so please bear with me.

I am right in thinking that the dog with fractured femur that started discussion had leg removed rather than pin nor cage rest ?

Does no one use cage rest (especially cat) as an option these days for femur fracture where cost is a problem?

With such a range of analgesics available now surely cage rest is better than rest of life hopping?

I have pinned & wired several # femur in dogs and cats with good results and cage rested mainly cats again reasonable results . Is vet opinion aginst both these options and ext fixation is gold standard now ?

I guess i really dislike idea of amputation but it seems to be used as a quick solution these days which is very sad.

What would RSPCA view on this?

would value peoples opinions

Thanks

ps where is spell checker ?

Re: Cr*p week, the tax man and a mast cell tumour!

Bibs — Tue, 05 Feb 2013 11:16:48 GMT

How did people learn to pin femurs? Did you just crack on after looking at fossum or did you have a friendly boss who scrubbed in with you the first few? Or did you do some good cpd? I find subject of surgical training quite interesting because it's so random and dependent on your first job a lot of the time.

Re: Cr*p week, the tax man and a mast cell tumour!

Wren — Tue, 05 Feb 2013 09:14:56 GMT

[quote user="Gillian Mostyn"]

[quote user="robloxley"]And TBH if I refer a fracture to the Vet School I'm not anticipating a vet student doing the pinning...[/quote]

but as long as they are supervised....isn't that the point?

[/quote]

And therein lies the dichotomy. Vet schools are trying to do two totally opposing things - to act as a referral hospital, by definition only operating on cases that the general practitioner has neither the experience nor facitilies to cope with; and attempting to turn out students competent in basic surgery. There is no basic surgery happening in vet schools (as a rule - some do neutering clinics or have a first opinion practice etc.) and the surgery which does happen is necessarily more complicated than most vets will ever need to learn pre-qualification. Twas ever thus.

Re: Cr*p week, the tax man and a mast cell tumour!

Gillian Mostyn — Mon, 04 Feb 2013 23:24:45 GMT

[quote user="robloxley"]And TBH if I refer a fracture to the Vet School I'm not anticipating a vet student doing the pinning...[/quote]

but as long as they are supervised....isn't that the point?

Re: Cr*p week, the tax man and a mast cell tumour!

Rob Loxley — Mon, 04 Feb 2013 23:13:42 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="robloxley"]but then fracture repair is hardly a day 1 skill...[/quote]

Doesn't mean it need not be taught, or practised.

[/quote]

It was taught, some practicals and plenty of scrubbing in on surgeries.

[quote user="Evelyn Barbour-Hill"]If students are being taught that intramedullary pinning must always have cerclage wires[/quote]

No, just the basic principles of fracture fixation, the types of forces that need considering and the different equipment/techniques to deal with them

[quote user="Evelyn Barbour-Hill"]that intramedullary pinning is "not an appropriate method of fracture fixation"[/quote]

I only remember being taught not to pin radial fractures in toy dogs as they are prone to non-union

[quote user="Evelyn Barbour-Hill"]When I qualified I reckon most of us had done, in the vet school, an intramedullary pinning almost unaided[/quote]

Is this generally the case (replies sought)?

And TBH if I refer a fracture to the Vet School I'm not anticipating a vet student doing the pinning...

Re: Cr*p week, the tax man and a mast cell tumour!

Busybee — Mon, 04 Feb 2013 19:09:50 GMT

[quote user="Evelyn Barbour-Hill"]When I qualified I reckon most of us had done, in the vet school, an intramedullary pinning almost unaided, and scrubbed in on platings and repairs of what we called the anterior cruciate ligament (by Paatsama's technique).[/quote]

Lucky you - we had no hands on at all, not even wet labs. Got the (mis)fortune to stand in on 8-hour fracture repairs at vet school, though you never got much of a view from standing by the back wall. Only chance was seeing practice with an orthopaedically-minded vet. This was only 3 years ago.

Re: Cr*p week, the tax man and a mast cell tumour!

Evelyn Barbour-Hill — Mon, 04 Feb 2013 19:04:57 GMT

[quote user="robloxley"]but then fracture repair is hardly a day 1 skill...[/quote]

Doesn't mean it need not be taught, or practised. If students now are just getting some high-minded technical lectures and no practical experience, there's something wrong.

If students are being taught that intramedullary pinning must always have cerclage wires, or that intramedullary pinning is "not an appropriate method of fracture fixation" (so never do it )(unless you are a benighted ignorant stupid cackhanded general practitioner, not like us clever chaps in the vet school) there's something wrong.

When I qualified I reckon most of us had done, in the vet school, an intramedullary pinning almost unaided, and scrubbed in on platings and repairs of what we called the anterior cruciate ligament (by Paatsama's technique).

Re: Cr*p week, the tax man and a mast cell tumour!

Anne Seawright — Mon, 04 Feb 2013 18:16:12 GMT

[quote user="robloxley"]

[quote user="Utlendigur"]the basic principles - what forces are acting across a fracture, how implants act to counter them and how bone heals/remodels - just don't seem to be part of the vet course[/quote]

They were, at Cambridge when I was there (grad 2004), and I believe still are.

[/quote] Same at Bristol 2004.

Re: Cr*p week, the tax man and a mast cell tumour!

Rob Loxley — Mon, 04 Feb 2013 17:54:08 GMT

They were, at Cambridge when I was there (grad 2004), and I believe still are.

Re: Cr*p week, the tax man and a mast cell tumour!

Utlendigur — Mon, 04 Feb 2013 14:35:25 GMT

[quote user="Wren"]True, but it was a month 1 skill for me.[/quote]

Ditto. Lag screwed a distal tibial fracture in a cat, with a teenage work experience student scrubbed in acting as my bone holding forceps! (wouldn't happen these days).Neither of my bosses were keen on orthopaedics so I ended up doing things by default.

I just get the impression, maybe wrongly, that orthopaedics isn't taught in much detail any more - other than as something that you refer for someone else to fix. We had really good orthopaedic teaching (Bristol late 80s) which taught us how to think about fracture repair from first principles, on the basis that fractures don't always follow textbook patterns, but nowadays, aswell as policemen looking younger, the basic principles - what forces are acting across a fracture, how implants act to counter them and how bone heals/remodels - just don't seem to be part of the vet course, and I think because of that more recently qualified vets are reluctant to attempt surgery or don't know where to start.

Re: Cr*p week, the tax man and a mast cell tumour!

Wren — Mon, 04 Feb 2013 14:02:31 GMT

[quote user="robloxley"]

but then fracture repair is hardly a day 1 skill...

[/quote]

True, but it was a month 1 skill for me. First weekend on call on my own, cat with a fractured femur on a Friday night. No insurance/money and I was unwilling to leave it until Monday morning for the boss to do - it's a long time to sit in a kennel with a swinging leg, NSAIDs or not.

I employed the normograde IM pin method and the cat was weight-bearing by Saturday morning. I subsequently did a couple more cats, a dog and a chinchilla the same way (occasionally retrograde and +/- cerclage wire depending on the circumstances). All did perfectly well and I appreciated that it probably wasn't gold standard fracture fixation. Perhaps new grads these days don't get left on call on their own though? (Glasgow 2000)

Re: Cr*p week, the tax man and a mast cell tumour!

Busybee — Sun, 03 Feb 2013 14:55:08 GMT

[quote user="Michael Woodhouse"]

[quote user="Evelyn Barbour-Hill"]As you put it here. that teaching sounds very dogmatic – was it really like that?[/quote]

Yes - RVC 2006.

It's not the only wrong thing they taught either. Some basic fracture repair as a wet lab would be easy done and have been fantastic experience. Never happened.

[/quote]

No improvement by RVC 2010

Re: Cr*p week, the tax man and a mast cell tumour!

Rob Loxley — Sun, 03 Feb 2013 14:01:21 GMT

When I was at Cambridge the principles of all types of fixation were taught; yes there was little hands-on in real animals (I do remember repairing 'fractured' plastic piping though) but then fracture repair is hardly a day 1 skill...

Re: Cr*p week, the tax man and a mast cell tumour!

Bibs — Sat, 02 Feb 2013 23:13:14 GMT

[quote user="Evelyn Barbour-Hill"]

All sort of true, of course (not sure I see how cerclage wire will increase rotational stability though).

[/quote]

My understanding is the cerclage wire compressed the fracture and therefore counters rotation.

Re: Cr*p week, the tax man and a mast cell tumour!

Bibs — Sat, 02 Feb 2013 22:56:38 GMT

[quote user="Utlendigur"]

I thought the reason for move away from IM pins and cerclage wire is that a more non-invasive approach is now favoured (gardening rather than carpentry) - avoids disrupting the periosteal envelope if it's still intact, avoids disrupting the blood supply, reduces risk of introducing infection etc. I think it probably depends on the case - a normograde IM pin and 2-4 pin fixator might be theoretically good as far as the fracture site is concerned, but not if the patient is a semi-feral unhandlable cat! An IM pin alone isn't suitable but IM pin + cerclage wires (in simple oblique fractures, with enough properly placed wires) works well. I think like most things it follows trends, usually in a circular pattern. CPD I've done in recent years has been in favour of IM pins + external fixators, next was very anti fixators in the femur, next was very pro plating femoral fractures and against pinning, and another promoting interlocking nails ( for those with lots of cash)

[/quote]

You are right about the whole gardener/carpenter thing. It's all coming back to me now. Also I think cerclage wire can be tricky to get tight and secure enough with no soft tissue below etc.

I've heard that placing multiple smaller IM pins used to be used to counter rotation in the past but has now fallen out of use, it's interesting.

Re: Cr*p week, the tax man and a mast cell tumour!

Clair Firth — Sat, 02 Feb 2013 22:35:03 GMT

[quote user="Michael Woodhouse"]

Yes - RVC 2006.

It's not the only wrong thing they taught either. Some basic fracture repair as a wet lab would be easy done and have been fantastic experience. Never happened.

[/quote]

Here in Vienna it's very similar - we have had all sorts of orthopaedic lectures...been permitted to observe the residents any number of times during ortho surgery.....but actually touched a pin or plate? Never! But we do have an elective course on a Friday and Saturday where we get to pin broken bones in cadavers - I'll be signing up for that next year. Quite ridiculous that it's left to an elective course but it doesn't seem that different anywhere else, unfortunately

Re: Cr*p week, the tax man and a mast cell tumour!

Michael Woodhouse — Sat, 02 Feb 2013 22:26:30 GMT

[quote user="Evelyn Barbour-Hill"]As you put it here. that teaching sounds very dogmatic – was it really like that?[/quote]

Yes - RVC 2006.

It's not the only wrong thing they taught either. Some basic fracture repair as a wet lab would be easy done and have been fantastic experience. Never happened.

Re: Cr*p week, the tax man and a mast cell tumour!

Mark Hedberg — Sat, 02 Feb 2013 22:19:52 GMT

Single IM pin may not be au fait; but it does work. Quite a few dogs and cats I pinned like this (admittedly in the middle east where I was delighted to have pins, full stop!)

Re: Cr*p week, the tax man and a mast cell tumour!

Utlendigur — Sat, 02 Feb 2013 21:52:24 GMT

[quote user="Evelyn Barbour-Hill"]Yes 'tis, in a simple more-or-less transverse femoral fracture, not too near the distal end. The natural jaggedness of the fracture ends interlocks and provides sufficient resistance to rotational forces.. The surrounding muscles compress the fragments together.[/quote]

If it is "naturally jagged" - some aren't. I'd agree if you are talking about a young animal which is going to heal quickly, but I've seen at least 2 "more or less transverse" mid shaft femoral fractures in mature animals treated that way that became delayed unions/non-unions. I'd rather play safe and add a 2 pin fixator.

[quote user="Evelyn Barbour-Hill"] a little shortening of the bone after healing....., are of no importance.[/quote]

Definitely agree - as long as both ends are pointing in the right direction Especially useful for haggises or anything else that has to negotiate steep hillsides

[quote user="Evelyn Barbour-Hill"]PS: as for avoiding disrupting the periosteal envelope, intramedullary pinning is clearly best!. While plating is surely worst. Then, plating and external fixation both involve boring new holes (lots of 'em, for a plate!) transversely across the bone, creating new weaknesses. Mechanically, something purely intramedullary has a lot of advantage. [/quote]

Plus why make ops unnecessarily long and complicated

Re: Cr*p week, the tax man and a mast cell tumour!

Evelyn Barbour-Hill — Sat, 02 Feb 2013 21:20:48 GMT

[quote user="Utlendigur"]An IM pin alone isn't suitable [/quote]

Yes 'tis, in a simple more-or-less transverse femoral fracture, not too near the distal end. The natural jaggedness of the fracture ends interlocks and provides sufficient resistance to rotational forces.. The surrounding muscles compress the fragments together.

In a more oblique fracture it can still be sufficient although the greater the obliquity the more one needs the wires (properly placed, of course.) Even in fractures where it's far from ideal ( near the distal end, for instance) it can be entirely adequate and very suitable for cases that have to be done cheaply.

Another thing that people forget is that in cats and dogs (which have four legs with paws on, not two arms with hands on and two legs with feet on, and don't stand upright on two extremely straight legs) a little shortening of the bone after healing, a little lumpiness or other deformity, are of no importance.

PS: as for avoiding disrupting the periosteal envelope, intramedullary pinning is clearly best!. While plating is surely worst. Then, plating and external fixation both involve boring new holes (lots of 'em, for a plate!) transversely across the bone, creating new weaknesses. Mechanically, something purely intramedullary has a lot of advantage.