Fracture Assessment and Post-Operative Complications

Question 1

What does a higher fracture score mean

Answer 1

Most scoring systems suggest that the higher the score the more prone to the fracture will be complications and hence the more robust the repair needs to be

Question 2

Describe how to determine fracture types

Answer 2

two orthogonal radiographs
if complex fracture- CT may be needed

Question 3

when should you give ABs post fracture repair

Answer 3

if surgery took >90mins
soft tissues are not healthy
original fracature open

generally thought to be unecessary

Question 4

List 5 things the degree of post-op restriction’s after fracture repair depend upon

Answer 4

1. Strength of repair
2. nature of fracture
3. age of patient
4. temperament of patient
5. degree to which owner can be relied upon to follow post-op instructions

Question 5

how long to restrict exercise post fracture repair

Answer 5

in garden on lead for 3 weeks and on lead for another 8 weeks
cats restricted to house for 8 weeks

Question 6

List some instructions to give owners if animal has robert jones bandage

Answer 6

keep dry
check toes and top of dressing twice daily
any smell bring in
if off-colour bring in

Question 7

what % reduction do we aim for with a open repair of fracture

Answer 7

100%

Question 8

what % reduction do we aim for with a closed repair of fracture

Answer 8

> 50%

Question 9

List the things you should check after implant placement

Answer 9

check joints not entered
implants are adequate to fix the fracture
implants avoid entering the fracture site
check growth plates are not entered

Question 10

What can happen if plate too large for fracture

Answer 10

risk of fracture at the stress riser (where the plate and bone meet)
can give rise to delayed fracture healing

Question 11

what can happen if plate too small for fracture

Answer 11

may not be strong enough- then it will fail prior to the fracture healing

Question 12

Lista possible post-op complication from using cerclage wires

Answer 12

the wires can loosen and result in fracture instability

Question 13

What is a potential complication of using IM pin in the femur

Answer 13

can damage the sciatic nerve

an affected animal will show a great degree of episodic pain
it will also show a sciatic neuropathy

Question 14

Describe what to do it IM pin migrates

Answer 14

the pin will continue to migrate
DO NOT push it back
movement of the pin suggest that the fracture site is unstable

Question 15

what should you never pin

Answer 15

a radius

Question 16

what can cyclic loading of a plate that has been used to repair fracture lead to

Answer 16

the plate fatigues and will either bend of break

Question 17

What can a plate be used with to protect against bending

Answer 17

IM pin
OR
a very strong buttress plate

Question 18

what force are plates not as good at resisting

Answer 18

bending

Question 19

If the trans cortex is not in tact what does the repair require

Answer 19

buttress fixation

Question 20

What can happen id external skeletal fixator is too weak/strong

Answer 20

weak- it may fail
strong- delayed union may occur

Question 21

List some potential complications of external fixators

Answer 21

pin tract sepsis
premature pin loosening
iatrogenic bone fractures
placing too close to skin can cause pressure necrosis

Question 22

List the aetiologies of osteomyelitis

Answer 22

introduction of infection at time of surgery
result of open fracture
uncommonly as a result of haematogenous spread

Question 23

List the clinical findings of osteomyelitis

Answer 23

lame
swelling, warmth and pain at fracture site
discharging sinus in more chronic cases
acute case- pyrexia

Question 24

List 5 radiographic findings of osteomyelitis

Answer 24

1. proliferative changes to periosteum
2. sclerotic margin to infected area
3. bone lysis around implants
4. Development of involucrum (a cavity in the bone) and sequestrum (a dense piece of necrotic bone within the involucrum)
5. Soft tissue swelling

Question 25

Describe how to treat osteomyelitis

Answer 25

acute- ABs (preferrably after culture) chronic- remove necrotic bone and sequestrum, stabilise fracture with compression, open medulla to allow blood vessel access, give appropriate ABs (6-8 weeks)

Question 26

How can quadriceps contracture occur

Answer 26

as a result of an unstable femoral fracture repair- usually an IM pin muscle contracture between the callus and quadriceps intermedius

Question 27

Describe how to treat quadriceps contracture

Answer 27

once process starts very hard to stop surgical- section quads, remove adhesions, apply a rigid for of fixation such as a plate recurrence is very common

Question 28

why should we avoid IM pins in femoral fractures of young dogs

Answer 28

quadriceps contracture

Question 29

what is malunion

Answer 29

fracture heals but with incorrect alignment

Question 30

List possible causes of malunion

Answer 30

inaccurate reduction of the fracture loss of initial reduction

Question 31

what type of malunion are well tolerated

Answer 31

craniocaudal plane well tolerated lateromedial plane less well tolerated

Question 32

List the causes of non and delayed unions

Answer 32

instability due to nature of fracture or repair chosen avascular bone or trauma to soft tissue infection resulting in instability

Question 33

Describe how to treat delayed unions

Answer 33

patience increase analgesia- to encourage weight bearing stage down fixator to encourage bone loading physio to encourage limb use

Question 34

List the 2 types of non-unions

Answer 34

atrophic non-union hypertrophic non union

Question 35

describe atrophic non union

Answer 35

bone is atrophic and will not heal can place a large bridging plate or amputate

Question 36

Describe hypertrophic non union

Answer 36

Elephant’s foot appearance Debride and open the medullary cavity Apply bone graft or equivalent such as cancellous bone chips Rigidly fix and compress

Question 37

Decsribe how to manage open fractures

Answer 37

a wide clip copious lavage with hartmanns swab for bacteriology culture IV broad spec ABs sterile dressing

Question 38

where is contamination of open fractures most likely to come from

Answer 38

Us - bacteria on the animal and we accidentally put it in the wound

Question 39

List 3 management options for skin loss in open fractures

Answer 39

1. delayed primary closure 3-5 days 2. secondary closure 5-10 days - starting to granulate at this point 3. second intention healing

Question 40

Describe open wound/ fracture dressings in the debridement stage

Answer 40

adherent dressing are used to hydrate and debride the wound

Question 41

Describe the open wound/fracture dressing in granulation stage

Answer 41

dry and non-adherent. These are used to dry the wound and allow it to epithelialise

Question 42

Describe ABs to use in open fractures/wounds

Answer 42

ABs not always indicated even for grossly contaminated if using use narrow spec

Question 43

what are non traumatic bone infection

Answer 43

Occasional haematogenous infections are seen in the metaphyseal region of the juvenile animal but this is rare