Fracture Management Flashcards
1
Q
what is the nurses role in fracture surgery?
A
analgesia provision and care of the patient prior to surgery
preparation for aseptic surgery
equipment gathering and set up for theatre
trolley assistant for surgery
post-op care
discharge of patient to the owner
2
Q
when prepping the surgical trolly what should you consider?
A
tidy easy to find instruments sharps tray handles in the same direction commonly used instruments in a tray or separate area
3
Q
how should the patient be prepped for fracture surgery?
A
positioned correctly for the surgeons preferred approach
hanging limb used for scrub
clipping of limb but foot may not be necessary
4
Q
how does hangling limb prep work?
A
limb is suspended from celing/IV stand by rope / chain attached to foot which is bandaged.
may be used for limb prep before surgery or limb may be hanging throughout
5
Q
when will the foot need to be clipped?
A
if surgery is to be performed on the foot
6
Q
if the foot has not been clipped how is contamination of the surgical site prevented?
A
foot should be covered with sterile vet wrap or draped
7
Q
what specialised drapes may be used for fracture repair?
A
Opsite
Ioban
8
Q
what is the purpose of Opsite or Ioban drapes?
A
minimise contact between the skin and the implant to reduce the risk of SSI
9
Q
what is fracture reduction?
A
the process of replacing the fracture segments in their original anatomical position
10
Q
what are the two overarching methods of fracture reduction?
A
closed
open
11
Q
when can closed fracture repair be performed?
A
rare
recent fractures
stable fractures - once reduced they will stay in place
lower limb
12
Q
why are lower limb fractures easier to reduce closed?
A
less soft tissue so easier to palpate
13
Q
what is involved in closed fracture reduction?
A
traction
counter traction
manipulation
bending
14
Q
what is the difference between traction and counter traction?
A
counter traction involves pulling another part of the body/ limb away so that the full effect of traction (pulling on the fracture to reduce) is utilised
15
Q
what is the main method via which most fractures are surgically repaired?
A
open techniques
16
Q
what is the main difficulty during open fracture reduction?
A
overcoming muscle contraction
17
Q
what equipment can be used to overcome muscle contraction during open fracture repair?
A
levers e.g. hohmann retractor
bone holding forceps
muscle relaxants used occasionally
18
Q
why are muscle relaxants often not that useful for fracture reduction?
A
muscle usually inflamed so abnormal and drugs may not have full effect
19
Q
identify the 2 instruments in this image
A
L) reduction forceps
R) bone holders
20
Q
what is involved in the process of toggling?
A
fracture is bent to around 180 degrees
ends of bone are engaged
limb straightened with bone in place
21
Q
what fractures are most suited to reduction by toggling?
A
transverse fractures
22
Q
describe a transverse fracture
A
at right angles to the long axis of the bone
23
Q
is toggling more or less traumatic than traction?
A
less even though it looks awful!
24
Q
what are the main choices for fracture fixation?
A
conservative management external coaptation external skeletal fixation (ESF) with or without open fracture reduction and repair internal fixation combination of many
25
what equipment is involved in internal fixation?
pins, bone plates, interlocking nails
26
what are the main implants available for fracture repair?
```
pins
wire
screws
ESF
plates (and screws)
combined or alone
```
27
what are pins mainly used for in fracture repair?
intramedullary pins
28
what is the function of intramedullary pins?
lie within the bone to line it up
29
describe an intramedullary pin
stainless steel smooth pins with trochar tip
30
are intramedullary pins often used on their own?
no
31
why are intramedullary pins rarely used on their own?
they don't prevent rotation of fracture
32
what are intramedullary pins usually combined with?
plates or ESF
33
what are the main types of intramedullary pins?
Kirschner wires
Steinmann pins
arthrodesis wire
34
when are intramedullary pins used on their own?
in metacarpals or metatarsals as they are splinted on either side by other bones and so risk of rotation is reduced
35
how many cerclage wire be used alongside intramedullary pins to repair fractures?
cerclage wire can be placed around the fracture area while pins are placed down through the bone
36
what is the risk of using cerclage wire?
can loosen and interfere with fracture repair
37
what are the complications associated with intramedullary pins?
if too long or too short they won't effectively stabilise fractures, can be difficult to retrieve
if too long they can lead to seroma due to irritation or sciatic neuropathy if severe hindlimb damage
fracture non-union
38
what is an interlocking nail?
stainless steel pin used as intramedullary with holes in that is locked in place using screws or bolts
39
what is the purpose of interlocking nails for fracture fixation?
prevents rotation and axial collapse
40
when are interlocking nails most often used?
long bone fracture repair
41
what is a jig?
matches to intramedullary pin and sits on the outside of the limb
lines up with holes on the pin within the leg so that screws can be placed in 'blind'
42
how can interlocking nails be inserted?
```
insert nail into medullary cavity
attach jig
mark bone with awl where screws need to be placed
drill appropriate sized hole
measure depth
place screw/bolt
```
43
is interlocking nail fixation often performed?
no - useful but equipment is not commonly found in practice
44
what is a key benefit of interlocking nail fracture repair?
minimal interference with blood supply at the fracture site which aids healing
screws prevent collapse of limb as take some of the weight
45
what is the most common implant used to repair fracture?
bone plates and screws
46
what is the aim of using bone plates and screws?
restoring bone structure to restore weight bearing function and enable healing
47
what screws may be used with bone plates?
self-tpping or non-self tapping
48
what can bone plates be made of?
```
stainless steel (most common)
titanium alloy
```
49
what are locking screws?
have a thread on the head which can lock into the thread on the bone plate to ensure they are held in firmly
50
what are the functions of bone plates?
compression of bone fragments
neutralisation of fracture forces
bridging a fracture
51
what is the effect of compression on fracture healing?
friction increases the stability of repair
creates primary bone healing
there is load sharing between the bone and the implant which reduces implant failure
52
how are bone plates used to neutralise fracture forces?
bone is reconstructed to anatomical shape by lag shoes or wire
plate is applied to support the bone after reconstruction by contouring it to the bone
53
when are bone plates used to bridge fractures?
unreconstructable (comminuted) fractures - bones in small pieces
54
how is a plate used to bridge a fracture?
used to shore up / support fragments
| either large plate or multiple
55
where is weight borne when bone plates are used to bridge fractures?
all weight on plate
56
when are bone screws used?
combined with a plate or interlocking nail
| used in isolation for fractures of cancellous bone
57
when are bone screws never used in isolation?
for diaphyseal fractures
58
why are bone screws never used for diaphyseal fractures?
slower healing and greater forces through bone
| screws alone are not strong enough
59
what are the main types of bone screws?
locking
self tapping
non-self tapping
60
what are the functions of bone screws?
secure a plate to the bone to support a fracture during healing
to compress fragments together in lag fashion to enable rapid healing without a callus
61
when are lag screws especially useful?
near a joint as callus is reduced
62
how are lag screws placed?
drill a hole that is the size of the screw threads in the near or cis cortex and then insert a guide in this hole to drill a hole in the far or trans cortex with a drill bit the size of the core diameter of the screw.
When the screw is inserted it engages with the far cortex but not with the near cortex so it tightens the two pieces of bone together
63
how can you prevent lag screws from cutting the bone cortex when inserted?
a washer (small metal disc with a hole in it) is used around the screw head to distribute the force more evenly
64
what is the aim when repairing articular fractures?
perfect reduction
65
why is perfect reduction of articular fractures required?
to reduce the risk of arthritis and maintain joint mobility
66
how articular fractures treated?
open reduction and internal fixation (ORIF)
| compression
67
how does external fixation work?
pass through the skin into the bone
68
what is full pin ESF?
pin goes right through bone and out to skin on other side
69
what is half pin ESF?
pin only protrudes from the skin on one side of the bone
70
what pins can be used for ESF?
smooth
| threaded
71
what are smooth ESF pins used for?
very small fractures
72
what are the most often used ESF pins?
threaded
73
what are the 2 main ways that ESF pins can be threaded?
```
negative profile (Ellis)
positive profile (Imex)
```
74
what are negative profile (Ellis) pins like?
thread is cut out of the pin itself
75
what are positive profile (Imex) ESF pins like?
thread is laid on top of the pin
76
what types of ESF pins can be positively or negatively threaded?
end threaded
77
what types of ESF pins can be positively threaded only?
centrally threaded
78
what is the role of interface ESF pins?
end is roughened to help stick to putty
79
on negative profile (Ellis) ESF pins where must the junction between screw and thread be located?
in the medullary cavity of the bone as this is a weak point on the screw
80
identify the two ESF pins in this image
top: positive profile (Imex)
bottom: negative profile (Ellis)
81
why are connecting bars needed in ESF?
connexts pins
82
what can connecting bars for ESF be made from?
stainless steel / carbon
| acrylic / putty
83
what is the benefit of stainless steel / carbon connecting bars for ESF?
reusable
| rounded ends
84
what is the benefit of acrylic / putty connecting bars for ESF?
light
no limit to pin size
no limit to pin closeness
no protruding ends to irritate
85
what is the disadvantage of stainless steel / carbon connecting bars for ESF?
heavy (although carbon is lighter)
| all clamps need to be in a straight line and so pins must be as well
86
what is the disadvantage of acrylic / putty connecting bars for ESF?
removal and adjustment is more difficult
87
what is the role of clamps in ESF?
connection of pins to bars
88
what are the 2 main makes of ESF clamps?
SK
| KE
89
what are the advantages of clamps for ESF?
adjustment and pin removal is generally easier
| reusable (although may deform)
90
what are the disadvantages of clamps for ESF?
need to be carefully constructed otherwise they won't work
limit to pin size
limit to bar size
91
what is a tied in intramedullary pin?
IM pin is left long and connected to ESF via seperate connecting bar or by bending the bar
92
what is useful about a tied in IM pin?
prevents migration of IM pin and increases stability
| useful at joints
93
what is used to surgically repair avulsion fractures?
pin and tension band
94
what are avulsion fractures?
those pulled by tendons or ligament attachment
95
what bones are at risk of avulsion fracture?
```
olecranon - triceps
greater trochanter - gluteals
medial malleolus - medial collateral lig
acromion of scapula - deltoid
calcaneus - gastrocnemius
tibial tuberosity - quads
```
96
why are IM pins no good for avulsion fractures?
pin will be bent due to pressure of triceps
97
how can an olecranon avulsion fracture be treated?
figure of 8 tension band applied
| pull of triceps is offset by tension band
98
what is the principle of tension band wire?
active distracting forces are counteracted and converted into compressive forces
99
how can a tibial tuberosity avulsion fracture be treated?
reduce fracture
place 2 K wires perpendicular to fracture
drill hole through bone distal to fracture
place cerclage wire in figure of 8 pattern around K wires
bend K wire and cut ends
100
how does tension band wire work?
pins hold the fracture in place
wire attaches to the pins on either side and moves through a hole created distally to the fracture site
when tension is applied to the fracture this then pulls on the wires which then pull the fracture repair even closer together
101
why should the surgical assistant be familiar with each procedure?
so they may participate in surgery
102
what is the benefit of knowing the sequence of events involved in a surgery?
allows the assistant to ensure that instruments are available and presented to the surgeon in an orderly fashion
103
what is the main role of the surgical assistant during orthopedic procedures?
managing surgical table and passing instruments correctly
assisting with surgical retraction and haemostasis
ensuring that diagnostic samples are not lost and transferred appropriately to sample pots
keeping bone grafts safe and reminding the surgeon to use it
swab count
running a continuous suture and cutting sutures
104
describe how to correctly pass a surgical instrument
in a decisive manner
tip of instrument visible and handles placed in surgeons waiting hand
slap instrument firmly into the palm of the surgeon in proper position of use
105
how should instructions for fracture post-op care be given?
written and verbal
106
what should be discussed with the owner on discharge of the surgical fracture patient?
```
age related implications
when post op x-rays are needed
cage rest?
time frame for weight bearing
suture removal date
buster collar
if physio needed
prognosis
signs of wound infection
```
107
what effect can age have on fracture healing?
there is possibility of premature closure of the growth plate in young animals
108
what are the potential complications following fracture surgery?
fracture instability
loosening or breakage of implants
delayed or non union
infection
109
what must you and clients be looking out for following fracture surgery?
```
lameness
change in limb use
change in shape
swelling
discharge
```
110
what are the considerations for cage rest?
```
suggest books that may help owners if they like
size of cage
what to have in cage
bedding needed
anything to relieve boredom
decreased food intake
```
111
what can be done to relieve boredom on cage rest?
```
games
training
music
sitting with dog
grooming / stroking
give food toys and decrease meal size to take up time eating
```
112
why is triage so crucial in ortho trauma patients?
ortho injuries are usually obvious but can hide less obvious, more serious, injuries
113
what is first aid?
emergency care given immediately to an injured individual
114
what is the purpose of first aid?
minimise injury and future disability
115
what may first aid be required to do in severe cases?
may be necessary to keep the victim alive
116
what are the aims of first aid?
preserve life
prevent suffering
prevent deterioration
117
where do the majority of traumatic fractures/luxations result from?
RTAs - especially cats
118
what percentage of dogs with forelimb injury also have thoracic / abdominal injury?
up to 79%
119
what percentage of dogs with hindlimb injury also have thoracic / abdominal injury?
51%
120
is fracture / luxation or thoracic / abdominal injury likely to be more severe?
thoracic or abdominal injuries are likely to be more immediately life threatening
121
what does the primary survey consist of?
methodical initial assessment to rapidly identify the major life threatening injuries
122
what does ABC stand for?
airway
breathing
circulation
123
what else should be assessed during the primary survey after ABCs?
external haemorrhage
| CNS
124
what possible oral/skull reasons could there be for a patient having breathing difficulties following trauma?
head trauma
fractures (skull, maxillary)
blood clots
ruptured trachea
125
what must be checked when looking at the airway?
patancy
126
during the primary survey of the airway what should you check for?
check mouth for obstruction (e.g. blood clot, FB)
are nostrils blocked
tongue swollen or lacerated
hard palate split
swelling around larynx (e.g. after dog bite)
crepitis
127
what about a patients breathing should be assessed in the primary survey?
rate
effort
adequacy
128
what may indicate a broken jaw?
blood around nose, saliva, unable to close mouth
129
what can be used to assess circulation during the primary survey?
```
MM
CRT
HR and pulse quality
any pulse deficits
pulse in extremities
rectal temp
temperature of extremities
```
130
what may be indicated by cold extremities?
peripheral shut down
131
what circulation parameters can indicate shock?
MM colour
| CRT
132
what are the main types of patient management of shock?
compensated
decompensated (early)
decompensated (late)
133
what are the signs of compensated shock?
```
tachycardia (mild)
tachypnoea (mild)
slightly darker MM
CRT <1 second
normal mentation and BP
```
134
why does compensated shock present the way it does?
increased CO, HR and systemic resistance to maintain blood pressure and perfusion
135
what are the signs of decompensated (early) shock?
```
tachycardia
tachypnoea
pale MM
slow CRT
weak pulse
poor mentation
hypotension
```
136
what is happening during early decompensated shock?
peripheral vasoconstriction to reduce blood flow to peripheral organs, essential organ BP preserved and lactic acid accumulation
137
what must be done if a patient has decompensated (early) shock?
give fluids
138
what are the signs of decompensated (late) shock?
```
bradycardia
absent CRT
severe hypotension
cheyne stokes breathing
death
```
139
what is Cheyne Stokes breathing?
deep and fast breaths followed by apnoea
140
what should you assume about the injury of RTA patients until proven otherwise?
severe injury
141
how should mobile trauma patients be handled?
minimal restraint
142
how should recumbent trauma patients be transported?
on an improvised / proper stretcher to prevent further injury
143
what should you do with a patient with a suspected vertebral column fracture?
restrain
144
what is involved in a secondary survey?
through check of whole animal after primary survey and stabilisation of patient
145
what acronym can be used for the secondary survey?
A CRASH PLAN
146
what does A CRASH PLAN stand for?
A - airway -- nose, larynx, neck thoracic inlet
C - cardiovascular - CRT, pulse, BP
R - respiratory - chest wall and lungs
A - abdomen - diaphragm, inguinal, flank, paracostal
S - spine
H - head - eyes, ears, mouth, teeth, tongue
P - pelvis - rectume, perineum, scrotum, vulva
L - limbs
A - arteries and veins
N - nerves - cranial and peripheral
147
what is the aim of the primary survey?
identify and treat serious / life threatening injury
148
when is a secondary survey performed?
only after successful resuscitation and stabilisation of life threatening injuries
149
what is involved in the secondary survey?
history from owner
| thorough physical exam
150
what are the signs of orthopedic injury?
```
recumbency (spinal injury) or severe lameness
limb wound(s) with pain and swelling
deformity
abnormal mobility / instability of limb
crepitation
```
151
what are the major orthopedic injuries?
```
fractures
luxations
subluxations
wounds penetrating joints
tendon laceration / avulsion
ligament strain
muscle lacerations
```
152
define fracture?
disruption in cortical continuity of the bone
153
what is an incomplete fracture?
fracture of only one cortex of the bone
154
where are incomplete fractures seen?
young animals due to the flexibility of bones
155
what is a complete fracture?
both cortexes of bone affected
156
what is luxation?
dislocation - complete disruption of normal relationship between the articular surfaces of the joint
157
what is sub-luxation?
partial disruption of relationship between articular surfaces of joint
158
what are the signs of luxation?
may still weight bear
| abnormal gait and anatomy
159
what is the contact between articular surfaces like in subluxation?
still some contact but abnormal and unstable
160
what order should processes take place during wound management?
```
analgesia
water soluble jelly
clip
flush
debride
bandage
```
161
how much saline should wounds be flushed with?
at least 500ml
162
what is the role of water soluble jelly in wound management?
protects wound from hairs / further contamination while clipping ocurs
163
what is the main first aid for open fractures / luxation?
treat as for laceration
apply sterile hydrogel to exposed articular cartilage or bone
moist wound management
164
how should open fractures / luxations be dressed?
supportively to attempt to restore normal anatomy - use of a splint
sterile dressing of wounds unless minor grazes
165
how should the patient be prevented from injuring themselves further?
cage confinement to prevent/restrict movement
166
when may fracture / luxation patient not be cage confined?
if injuries are only minor
167
what should not be attempted in the conscious patient?
reduction of luxations / fractures
| stabilisation of proximal limb injuries
168
why should fractures / luxations not be reduced in the conscious patient?
too painful
169
when should fractures / luxations reduction be performed?
under GA
170
is stabilisation of proximal limb fractures possible with external coaptation?
no
171
what injuries may be stabilised in the conscious patient?
distal limb (below elbow/knee)
172
why can proximal limb fractures not be stabilised?
difficult to support joints above and below fracture
| muscles will stabilise
173
what is required for all cases with suspected major orthopedic injury?
anaesthesia for radiographic assessment of injury
174
when may a displaced fracture or luxation be reduced?
when patient under GA for radiograph of area
175
what does reduction of fracture / luxation do?
promotes comfort and helps prevent further tissue injury
176
what are orthogonal radiographic views?
views at 90 degrees to each other
177
what can be performed while the patient is under GA for imaging of ortho injury?
wound care
splint / bandage application
reduction of luxation
178
how should first aid be provided for closed fractures / luxations?
support dressing of limb into reduction or near reduction
179
when may support dressing of the limb in reduction or near reduction be possible?
if distal injury has torn ligaments or tissues resulting in marked laxity
180
when should conscious manual reduction of closed fractures/luxations not be attempted?
if the limb is not obviously markedly unstable
181
how should unstable fractures be supported?
use soft padding
splinting material
conforming and outer protective layer
182
what are the available splinting materials?
fibreglass resin
orthoboard
thermoplastic
plaster of paris
183
how is fibreglass resin activated?
by water
184
how long does hardening of fibreglass resin take?
5 mins
185
what happens during hardening of fibreglass resin?
exothermic reaction
186
what is orthoboard?
plasticised cardboard
187
how is orthoboard moulded?
in hot water
188
what is the benefit of orthoboard?
cheap
189
how is thermoplastic used to create splints?
heat in water or use heat gun
190
what is plaster of paris activated by?
heat
191
what is the benefit of plaster of paris?
cheap
192
what is the disadvantage of plaster of paris?
long time to set and heavy
193
what is needed for long term splinting of injuries?
custom splint to reduce irritation and ensure adequate support
194
what are the 4 layers used for bandaging?
dressing
softban
conforming layer
vet wrap
195
what are the functions of a bandage?
protects wounds and fractures from self-trauma and contamination
supports fracture / luxation pre and post surgery
pressure to aid haemostasis and control swelling
immobilisation for comfort, movement restriction and prevention of further damage
196
when are support dressings used in first aid?
to support the distal limb only (below elbow and stifle)
197
how many layers of bandage should be applied to support fracture / luxation?
all 3 (4 - not always dressing) layers
198
what joints should be supported when applying supportive bandages?
joints proximal and distal to injury
199
should the foot be included within bandages?
yes to ensure prevention of swelling
| nails should be visible
200
what is required when placing splints?
careful application and adequate padding
201
what type of bandage is a splint preferrable to?
padded bandage
202
why is a splint better than a padded bandage?
provide better immobilisation
203
what are the main types of splint?
off the shelf or customised
204
what is required for upper limb fractures?
cage rest prior to repair - no bandaging
205
what are the main off the shelf splints available?
green gutter
206
what is the issue with green gutter splints?
likely to buckle
| rubbing likely
207
what are the main custom splint types?
those using cast material
| tongue depressor / other available material
208
what is the purpose of a robert jones bandage?
immobilise fracture /luxation
controls swelling / oedema
comfort
209
what is the role of a robert jones bandage post op?
support
| controls swelling
210
when may a robert jones bandage be especially useful?
haemorrhage
211
what drugs should be supplied to the fracture / luxation patient?
analgesia (NSAID or opioid)
| antibacterial if open fracture
212
how should bleeding be treated in first aid?
as for laceration
| apply sterile contact layer then generous padding using absorbant layer
213
what can an absorbant layer for the control of haemorrhage be made from?
cotton
214
how long should pressure be applied to haemorrhage via a bandage?
30 mins to 1hr
215
how can severe bleeding be managed?
GA for ligation of bleeder
216
what are the 2 main options for fracture fixation?
non - surgical management
| surgical management
217
what are the non-surgical management options for fracture fixation?
external coaptation
| conservative
218
what are the main surgical options for fracture fixation?
pin and wire
ESF
internal fixation
plate and screws
219
what are the principles of fracture fixation?
return patient to normal function as soon as possible
| create circumstances which allow bon healing to be optimal
220
can fractures be healed non-surgically?
yes - some will heal with this method
221
what are the potential advantages of non-surgical fracture management?
reduce or avoid anaesthesia
avoid the need for open surgical approach and the potential risks
cheaper materials
can be cheaper overall if no complications
222
what are the disadvantages of non-surgical fracture management?
fracture disease
insufficient stability leading to delayed or malunion
malunion
cast sores leading to iscchemia
223
how does conservative management provide stability for bones to heal?
surrounding soft tissue (muscle, periosteum, adjacent bones)provides sufficient stability to keep bones aligned whilst healing
224
what must be minimised while fractures are healing with conservative management?
movement
225
how can movement be minimised while healing a fracture using conservative management?
```
restrict exercise (cage rest / lead walking only)
provide analgesia (NSAIDs)
prevent weight bearing
```
226
what fractures are suitable for conservative management?
selected fractures of pelvis, scapula or vertebrae
| stable minimally displaced fractures
227
what is involved in cage management of the fracture patient?
restricted activity
| confinement in a room or cage
228
how long should cage rest last for if fracture is being managed conservatively?
4-6 weeks
229
what does the length of cage rest for conservative fracture management depend on?
age of patient
| fracture type
230
where is weightbearing prevented in conservative fracture management?
on affected limb
231
what bone fractures are often managed with prevention of weightbearing?
scapula
232
what methods can be used to prevent weight bearing on a scapula fracture?
carpal flexion bandage
| velpeau sling
233
what is the risk with using slings to prevent weight bearing?
sores
234
what information do owners need about a cage when their pets are undergoing conservative fracture management?
```
size
contents
boredom reduction techniques
nursing care
bed sores and regular turining
```
235
how may patients having conservative fracture management have ambulation assisted?
hoist
belly band
harness - forelimb fractures
sling- hindlimb fractures
236
what must be considered about the home environment for conservative fracture management patients?
non-slip rugs
| ramps where needed
237
where are pressure sores likely?
bony areas (e.g. olecranon, greater trochanter, medial maleolus)
238
what should be included in a care sheet for cage rest?
```
length of confinement and why
requirements
food needs
toys
toiletting
suture removal
follow up checks
recovery and expected time frames
any issues don't hesitate to contact
```
239
what happens during external coaptation?
compressive forces are transmitted to bones by means of interposed soft tissues
240
what is crucial about the application of casts or splints used for external coaptation?
pressure is evenly distributed
241
why do casts or splints used for external coaptation need to have pressure evenly distributed?
to avoid circulatory stasis
242
where should be stabilised during external coaptation?
joints should be immobilised above and below the fracture
243
what should happen to joints distal to the fracture?
should be immobilised - inculding foot
244
why should all joints distal to the fracture be immobilised?
to avoid foot swelling
245
what fractures are suitable for external coaptation?
fractures distal to elbow or stifle
stable fractures
those with 50% overlap of fracture fragments on orthogonal radiographs
fracture of one bone of a 2 bone segment (e.g. radius or ulna fracture)
2 or fewer metacarpal or metatarsal fractures
246
is external coaptation widely used?
yes
247
what are the issues with external coaptation?
high number of complications which can be worse than original complaint
248
what must you do before using external coaptation?
careful case selection
careful application
good post op care
249
what can be used for external coaptation?
```
splint
cast
preformed splint (e.g. green gutter)
custom made splint
```
250
what is the first layer of the cast?
stockinette
251
how many layers of stockinette should be applied?
double layer
252
how long should the stockinette applied as the first cast layer be?
long enough to overlap top and bottom
253
what is crucial when laying the stockinette layer of a cast?
hold taut so there are no creases
254
what is the primary layer of the cast?
water repellent, conformable bandage e.g. softban
255
how may layers should be used for the primary cast layer?
one to 2 layers of 50% overlap
256
where should padding be placed on the primary cast layer?
not too much over bony prominences due to risk of sores and likelihood of cast slipping
can be placed above and below for a donut effect
257
what should be allowed at the top and bottom of the primary cast layer?
excess for overlap
258
what cast material can be used?
fibreglass impregnated polyurethane cast material (Vetcast)
259
what are the benefits of fibreglass impregnated polyurethane cast material (Vetcast)?
```
light weight
comfortable
waterproof
radiolucent
fast setting
```
260
what should be worn when applying cast material?
gloves
261
how is fibreglass impregnated polyurethane cast material (Vetcast) activated?
immerse in water (hot or cold - if not experienced) and squeeze 6 times
262
how should the cast 'Vetcast' be applied?
under a little tension
average of 6 layers (3 up and down)
more layers at bends
avoid wrinkles
263
what should be done once the cast has set?
cast is cut on 2 sides (bivalve) using a cast saw
264
when is cast cutting performed?
when the patient is still under GA or sedation
265
what is the purpose of cutting the cast?
ease of removal if problems
| id another vet does not have a cast saw
266
where are cast cuts often performed?
medial and lateral most common
| cranial and caudal may be stronger
267
what may dictate the location of cast cuts?
if the cast is likely to be used as a splint at a later date
268
how should the bivalved cast be secured once it is cut?
tape together firmly using strips of non stretchy tape
269
what tape can be used to secure the bivalved (cut) cast?
zinc oxide
270
what can be done to avoid sharp cast edges?
fold softban and stockinette over the ends and apply extra padding as necessary
271
where should the extra padding and softban / stockinette be secured?
with tape once folded over and padding added
272
how should the foot of a cast be reinforced to prevent wear?
use extra tape
273
what should the outside of the cast be covered in?
cohesive bandage such as vetwrap
274
what should be visible from the bottom of the bandage?
toes and central pads visible but not protruding
275
what can indicate that the foot in a cast is swollen?
nails will splay out
276
how is a cast removed?
```
easy if bivalved
remove outer layer
cut tape
change padding
check for sores
reapply cast/splint if necessary
```
277
what is the complication rate for external coaptation like?
high - 63%
278
when can external coaptation complications occur?
owner compliance low
difficulties in management
inappropriate case selection
even can occur in cases where selection and management is optimal
279
what soft tissue injury can occur from external coaptation?
ischemic injury ranging from mild dermatitis to avascular necrosis
280
what animals are particularly prone to external coaptation soft tissue injury?
sight hounds
281
how can external coaptation soft tissue injury be prevented?
weekly cast changes
owner compliance
correct amount of cast padding (not too much or too little)
282
what can be the cost of soft tissue injury from external coaptation?
more expensive than original injury
| loss of limb
283
what are the complications with healing of fractures treated with external coaptation?
malunion, delayed union or nonunion
rotation, angulation or shortening
may be functional or non-functional depending on severity
284
what dogs have a high chance of malunion, delayed union or nonunion of fractures repaired with external coaptation?
toy breeds
285
when does fracture disease occur?
during the time necessary for the bone to heal
286
what is fracture disease a result of?
fracture management (immobilisation or decreased weight bearing)
287
what is typically seen with fracture disease?
```
joint stiffness
muscle atrophy
osteoporosis
muscle contracture and fibrosis
adhesions
```
288
why can osteoporosis occur with external coaptation of fractures?
loss of bone density due to reduction in force through bone
289
how can fracture disease be avoided?
aim for rapid return to weight bearing
avoid unnecessary immobilisation of joints by external coaptation
consider other options that cause less fracture disease e.g. ESF or internal fixation
290
do all patients tolerate external coaptation?
no!
291
what discharge instructions should owners of patients with casts be sent home with?
complications that are possible
instructions for care of cast/patient
onus on owner to bring dog/cat back if they are at all concerned
292
what signs indicate that a patient should be returned to the practice?
1. Any change in shape of the splint or cast on the limb.
2. Any excessive chewing of the splint or cast by the animal.
3. Any sign of excessive discomfort.
4. Any unusual or bad odours coming from the splint or cast.
5. Any unexplained soiling of the splint or cast that was not present before.
6. Any pronounced sores that develop at the top of the splint or cast that do not respond to talcum powder application.
7. Swelling of the toes, or the leg above the splint.
8. Inappetance, depression or fever in your pet.
293
how can the owner check the health of the cast limb?
pinch toes
| check for sensation, temperature and comfort
294
what must not happen to a cast?
become wet
