Decision Making for Fractures

Question 1

What are the locational categories of fracture?

Answer 1

Diaphysis, metaphysis, epiphysis

Right or left

Question 2

What are the categories in the Salter-Harris classification scheme?

Answer 2

Type I - physis
Type II - physis and metaphysis
Type III - physis and epiphysis
Type IV - physis, metaphysis, epiphysis (articular fracture)
Type V - Crushing injury to the physis

Question 3

T/F: Physeal fractures can lead to growth deformities

Answer 3

True

Question 4

Define simple fracture

Answer 4

• One or two fracture lines
• Usually low velocity forces
• Little energy dissipated to the surrounding soft tissues

Question 5

Define comminuted fracture

Answer 5

• Three or more fragments whose fracture lines interconnect
• Highly comminuted - 5 or more fragments
• Usually the result of high velocity forces
• High energy dissipated through fracture propogation and the surrounding soft tissues

Question 6

Define segmental fracture

Answer 6

Usually three fragments whose fracture lines do not interconnect

Question 7

Define avulsion fracture

Answer 7

Insertion point of a tendon or ligament is fractured and distracted from the rest of the bone

Question 8

Describe types of displaced fractures

Answer 8

Cranial
Caudal
Lateral
Medial
Overriding

Question 9

Define transverse fracture

Answer 9

Fracture line is perpendicular to the long axis of the bone

Question 10

Define oblique fracture

Answer 10

Fracture line is at an angle to the long axis of the bone

• Short oblique: <45 degrees
• Long oblique: length is at least 2-3x width of the bone

Question 11

Define spiral fracture

Answer 11

Special type of oblique fracture; fracture line curves around the diaphysis

Question 12

Reducible vs. non-reducible

Answer 12

Reducible - single fracture line or no more than two to three large fragments

Non-reducible - multiple small fragments

Question 13

Complete vs. incomplete fracture

Answer 13

Complete - complete disruption of the bone cortex

Incomplete fracture - a portion of the bone cortex is intact therefore there is some inherent stability (Greenstick fracture in young animals)

Question 14

What are the overall goals of fracture repair?

Answer 14

Bony union

Return to normal function

Question 15

What are considerations before repairing a fracture?

Answer 15

Evaluation of the fracture, patient, and client
Method of reduction, sequence of implant application, whether or not bone graft will be used and type of bone graft, perioperative antibiotic use

Question 16

What perioperative data must one collect on a fracture patient?

Answer 16

Age
Weight
Health
Activity level
Other orthopedic disease
Rads of fracture and contralateral limb
Client expectations and ability to perform postoperative care

Question 17

What forces act on a fracture site?

Answer 17

Tension - pulling
Compression - pushing
Shear
Bending
Rotational - torsion

Question 18

How does the fracture assessment score help the surgeon?

Answer 18

Allows surgeon to select appropriate equipment for stabilizing fracture

Question 19

In general, how does fracture scoring work?

Answer 19

High score - few complications

Low score - more complications

Question 20

Factors for determining strength of fixation

Answer 20

• Number of limbs involved
• Other orthopedic diseases
• Patient size
• Activity level
• Can load sharing be achieved (reducible vs. non-reducible)?
• Non-reducible fracture, implant carries weight until callus forms

Question 21

T/F: Oblique fractures are ideal for load sharing

Answer 21

False; transverse fractures are ideal for load sharing

Question 22

T/F: It is not necessary to repair mid-diaphyseal ulnar fractures

Answer 22

True

Question 23

What sorts of biologic factors determine how quickly a callus forms?

Answer 23

Age of patient
Open vs. closed fracture
Low energy vs. high energy fracture
Open vs. closed reduction
- Bridging osteosynthesis: minimal or no manipulation of soft issues
Location and bone fractures
- Cancellous bone heals better than diaphyseal bone
- Distal tibia vs. mid-femur (femur has more soft tissue and will heal better)

Question 24

Patient and Client factors that can affect healing

Answer 24

Willingness to follow post-op care instructions
- External skeletal fixator vs. bone plate
Post-op patient cooperation
- Temperament
Anticipated post-op limb function

Question 25

Describe a high score (8-10) fracture

Answer 25

• Heal successfully with few complications
• Less stress on fixation system
• Less time required for bone healing
• Immediate load-sharing after Sx
  Appropriate implants include IM pin and cerclage wire; Type I external fixator; external coaptation; implants that hold bone through frictional purchase may be adequate (smooth pins)

Question 26

Describe a moderate score (4-7) fracture

Answer 26

• Overlapping mechanical and biological assessment scores
• Immature dog with non- reducible fracture
  . Implant subjected to higher loads after surgery however
  rapid callus formation
• Older dog with a simple transverse fracture
  . Good load sharing but slower healing
• Appropriate implants include bone plate, type I or type Il external fixator, interlocking nail

Question 27

Describe a low score (1-3) fracture

Answer 27

• More complications
• Non-reducible fracture in older patient
• Implant must maintain sufficient strength for at
  least 6-8 weeks e.g. bone plate-IM pin
  combination; lengthening bone plates, interlocking nail; type Il or Ill external fixator; implants should have raised threads to better purchase bone

Question 28

Consequences of poor decision making

Answer 28

Prolonged operating time
Excessive soft tissue trauma
Technical errors
Postoperative complications