Welcome to our joint meeting today. I am very happy that you all switched on. For all those who do not know me, my name is Thomas Rieker, I am Head of Medical of Anicura Germany. And in the Bones & Beyond series, I am super happy that we are talking about something today that is extremely important, because it has a significant impact on success, namely the first evaluation. And you can have the best screwdriver behind it, if you have made some mistakes beforehand that you should not have done, you will not be able to correct the result. And I am super, super proud today that we were able to win Martin Unger for holding this seminar for us today. And I looked up how long I have known Martin and I am shocked, because that is more years than probably the age of some of our participants. It is 32 years, Martin, that was 1993, the first time you did your residency in Zurich. I have already told you that he did a residency, which he also completed with a diploma in 1993. Before that, he studied in Munich. And who does not know Martin Unger? Martin Unger is what you would call a great educator. I think that is perhaps already in the family's DNA. His father was already very active in this matter and the Unger family has, so to speak, co-invented and created the Flimsa small animal days. They have now moved to Rabella with a super exciting program and Martin organizes it as before. Martin does an immense amount for us in Alicura and Eric Wauters wrote to me again, that Martin is always there and does a lot for us. He has accompanied many as a mentor, as an educator over the years. He is always a friend, he is always helpful and I am happy that we have been maintaining a friendly relationship for over 30 years and that is very helpful. But that is not what it is about today, it is about the topic. I would like to welcome our second speaker, Britta Kiefer-Hecker. She also studied, as we all do in Munich, and did her doctoral work in the field of nutrition and worked there. Britta knew a lot, she has an academic background, she has already taken up many positions in the industry for HILS and also worked in practice and in this respect I am now looking forward to a super exciting seminar with the two of you. And I don't forget to thank HILS in particular, without their friendly cooperation, we would not have been able to put this webinar on its feet. And now I turn myself off and say, hey, Martin, go, have fun. Thank you very much, Thomas. With the flower I will now open a flower shop, because that is more than I am usually used to. And knowing it for a long time does not mean that it is good, but I hope that we will have a good session now. It is a bit unusual for me, I talk a lot about fractures, but then I usually do a pop-tory with a lot of X-rays, with a lot of fractures, with a lot of fixation methods, how to do it best, but that is not our topic today, but we want to see how the first evaluation influences it, so that we want to hear relatively little about the fractures today. What is specific about our cats is that we often don't know how the whole thing happened. And since we don't have this preliminary report, we very often have a situation that it is a polytrauma. Most cats with fractures are free-rangers, either come home lame, are brought directly to the clinic because they may have been run over by a car, or drag themselves home and are then brought to you. The second thing that is different with the cat is that with the dog, the fractures are often not fresh, because these patients were 4-5 days or longer away before they came home again, and most of the time the accident was the beginning of the departure and they only found themselves back or dragged home after days. What also makes cats a bit difficult is that they cannot be examined very well. An examination of lameness in a cat is a real challenge. It starts with the fact that you can't really do it on your own, so that you can take a good look at the process, how it works. Most of the time it just lies with us, from the owners it is usually brought into the basket or put on the table, so that we can't see if they can stand, if they can walk, where the problem lies. What makes it even more difficult, especially if they have a fracture and are painful, is that they are usually not cooperative during the examination. That they then scratch, bite and try to simply defend our examination is unfortunately often, and that makes it difficult and requires a bit of sensitivity, patience and slow progress. What may also be said is that cats are always described as super patients for fractures because the results are so good. But we may have to think that they may not be quite as good as we always think, because we may not be able to judge it so well. Because you can't let a cat run ahead and notice a slight lameness, but most cats that have problems just move less, don't run too much and small lamenesses are often not noticed by owners. If we now go into the topic, then I would actually like to subdivide it into two groups. We are actually talking about fractures and that is the fracture patient. But since a very large part of our cats that have fractures are actually polytrauma patients, we actually have to look at two groups. Once a group of the pure fracture patient and it will be about them in the second part of the lecture and then on the other side the polytrauma patient. That they are flowing transitions is clear, that can be the cat that has stuck its leg somewhere in the house and only has a green wood fracture as a pure fracture patient and that can be this really severe polytrauma with skull, brain trauma, abdominal, thoracic trauma and everything. And often our patient is somewhere in between, but for the sake of simplicity, let's just divide it into a fracture patient who doesn't have anything great or the real polytrauma patient. So we look at the fracture patient during the triage, it is one extremity, there are several, we look if it is a closed or open fracture, we look if the patient is still ambulatory and then we do a little bit of thinking because of anesthesia and the whole process, whether it is a young, healthy patient or rather an old and perhaps sick patient. That's what we have as a triage for the normal fracture patient. With the polytrauma patient it looks completely different. First we have to see if the patient is stable at all, is he life-threateningly ill, if so, where are the internal injuries, what does the neurostatus of the patient do, especially if there is a skull-brain trauma with it. And then, of course, we also have to look at the orthopedic things again, is he ambulatory or not, is one or more extremities affected and does the whole thing possibly involve open and further injuries. This also makes the treatment plan a bit different. With the normal fracture patient, we look at a clinical examination and an orthopedic examination. We always put the patient, I'll mention that a few more times later, because that's important. If you don't put patients down and see if they can really stand on all four legs or on three and not just on the fractured one, then unfortunately you always overlook something. We then x-ray the fracture to be able to assess it. If we are not sure whether it is perhaps a trauma patient who should have internal injuries, then we would rather do an overview x-ray on the safe side in two levels and a laboratory examination beforehand and that for the operation preparation. And then we are actually already there, so that we can also talk a little bit about the cost planning and the prognosis and the other things with the owner. With the polytrauma patient, however, stabilisation is actually first and foremost in the foreground. There we know the famous ABC that we have to go through. I don't want to go into that now, that would blow up the lecture. Here, too, overview x-rays are something that you do. Then there may be special x-rays that you look at what is necessary for further x-ray images. In the case of blurred abdomens, ultrasound, laboratory examination and in the case of patients who are sometimes in lateral position, are stubborn, can hardly move, even a CT scan can be what brings the best results. Now let's take a quick look at the polytrauma patient, because that's a patient, if you see him, you might not be able to treat him yourself. That will be a patient that you may send on to the transfer clinic. And now it is actually very important for you, before you send him away, that you discuss the prognosis and the costs with the owner. And when you discuss the prognosis, in this case it is not just about fractures, but also about all the internal injuries. You have to weigh this whole thing and if you want to discuss the costs, then you not only have the operating costs, but you usually have station costs and post-treatment costs. That means you have the owner in front of you, you may know him because he is the patient who usually comes to you. That means you have to discuss with him first of all where the whole trip is going. Is this a case that I am transferring to another clinic that needs to be treated accordingly? In addition to the prognosis and the costs, the owner's compliance also plays a role, because it is crucial that the owners can basically carry the post-treatment, that they can go to the doctor on a regular basis, that they can keep the patient calm, that they want to do the whole thing and, of course, that they pay the costs for the whole thing. With the polytrauma patient, in addition to the overview, we often do special X-ray recordings and look at these special X-ray recordings and see that the fracture is better represented or if we have to see more details in the other area, then we do the overview recordings. In the laboratory, we said, we need an ultrasound at the beginning. It may be that we still need circulation checks and then, and this is important for you, if you have the opportunity and you have a patient who is polytraumatized and, for example, has a massive pneumothorax and already has clear dyspnoea, then a thoracoscopy can be the first measure of importance for you. Also the abdominal anesthesia, to see if we may have urine in the abdomen, what could still be there in the case of an internal injury, is a possibility for you. And to clarify this beforehand can possibly also be decisive, whether you then come to an agreement with the owner, whether the patient is further cared for or whether it can be the decision for these individual patients that you go to euthanasia with such a polytrauma patient. The question we always get, after the stabilization, pain and infusion therapy has been done, should there be an antibiotic as a pet doctor? The antibiotic is actually only for open injuries and it would of course be nice if we got the same mirror, unless it was an old injury beforehand. The first thing to consider is whether the skin barrier is still intact. If the skin barrier is intact, we don't need an antibiotic. If the skin barrier is doubtful, it may be that it is not open at all, but that we have massive hematomas, that we have fluid, that we already have exudation from the tissue, then this is also a case that should be provided with antibiotics. And if the patient has a wound and especially a wound in the fractured area, then you should consider whether you can clean it a little bit, whether you can remove the dirt that may come from the street and from the accident and then it would be good if this wound was covered, so that neither on the inside nor on the transport nor in the clinic any new bacteria may come along that may cause us much greater worries than the original ones. Here is another example for such a polytrauma patient, on the right with a massive hematoma and organs, on the left the patient who only has a pulmonary thorax, on the one hand, on the other hand, a slight shadowing. After we have stabilized it, the question now is whether an emergency operation is necessary, is it a patient that I will send on right away? Emergency operations and transplants may be necessary if it is about larger hernias, like the hernia that we see here on the right, if the urethra is injured or if you need an additional thorax drainage with the suction of the thorax that cannot be stabilized. Thank you very much, Martin, for the wonderful introduction to this exciting topic. I am very happy that I can supplement the nutrition here, which is already an extremely important topic, even if it is not as much about the seconds and minutes as with you in surgery. Let's jump in here. It is actually the case that an appropriate nutrition and supply of nutrients is crucial for a good recovery of the patient. Nevertheless, it is not a matter of course that this also works well in practice. From a traditional point of view, we often focus on nothing per oath, i.e. that we don't eat anything at first. There is nothing to eat and we already have a phase in preoperative care where we should let the animal fast. The animal itself usually struggles with other problems than taking care of the nutrition, which is why the appetite is often zero and we recognize a refusal to eat, either due to the condition of the patient, the physical or the physical and the environment in practice. And sometimes the practice itself lacks the routine for the topic and we have insufficient feeding plans, not the right things ready, not the right nutrition ready, not the right regime. That's why I'm very happy that we can get started here. Since we are focusing on surgery, I would like to address the question of preoperative fasting first. As we have already seen, we are looking at several patients in different situations today. In this respect, of course, we cannot specify a time, a duration that suits everyone. We have to have the goal in front of our eyes. The goal is to minimize the stomach volume while maintaining hydration at the same time and also to optimize the pH value of the stomach, especially to prevent esophagitis or regurgitation. If we look at human medicine, there is a recommendation to keep patients sober for about six hours for solid food, while clear fluids are often allowed up to two hours before the anesthesia. So we have to decide very individually when we stop feeding and of course also depending on the condition of the patient and what we have available. It is certain that after surgery, nutrition should be started as soon as possible. Why? Because longer fasting also affects the gastrointestinal tract in the sense that the gastrointestinal barrier is also dependent on the nutrients that reach the colonocytes via the intestinal lumen. The intestinal cells are therefore not sufficiently supplied via blood supply, but the intestinal cells also want to absorb short-chain fatty acids and other substances from the digestive tract. We definitely need a strong intestinal barrier in order to maintain the immune system of the patient. We also need a lot of nutrients for wound healing, for example proteins for muscle building, skin healing and so on. On the other hand, we also have to take into account that our anesthetics also have an effect on the gastrointestinal tract. We have a change in the peristalsis, we have a delayed gastrointestinal emptying. In this respect, again post-surgery, we have to take a close look at the whole patient-specific approach. Fortunately, there are also helpers who help us make these decisions. If we have a fractured patient who is stable, where we have a little longer time to take care of the surgery appointment, then it is also very good that we deal with the nutrition before the surgery. It is always the case that the gastrointestinal tract is adjusted to this and I should therefore also weigh my nutrition accordingly. There are also helpers from the WSAPA, e.g. questionnaires for the nutrition of pets. Perhaps the patient is also so worried that I say, hmm, with this food he can continue to go to the station or home after the surgery. Of course, this has the advantage that the patient is in tune with it, is used to it, the gastrointestinal tract and also the perception, what is my food, which is an important issue for the cat, then fits. If, for example, the patient has been barfed before, I of course already have the hygienic risks of raw meat and that would be something that I would not necessarily keep after an operation. So there is often also the recommendation to change the diet. And that's why you should set a diet plan for afterwards and if you are also more free in the timing before the operation. What we also have to consider, especially with these polytraumatic patients, is whether the animal has been fasting for a long time. As Martin has described, the cat that has only been brought home after days, it may be that it has not eaten anything for days. And I have to be extremely careful when I start with the nutrition, because that can over-claim the metabolism, so that it would potentially be possible, in the worst case, that the patient would not survive the whole story. I don't want to go into detail what this refeeding syndrome is. I just want to briefly illustrate that the liver is changing here, because in such a situation the whole metabolism is based on protein depletion. That's why the animals also lose a lot of muscle mass very quickly after losing fat. And that is the situation in which the patient may be. And in this respect, it is also important that if I start feeding here, I start it slowly first, so that the system is not surprised by the flood of nutrients. And secondly, that I start with a food that also has a high protein content, so that the metabolism does not have to switch back immediately, because it cannot switch to a normally balanced food. With the cat, we have a special situation. Martin has already touched on that. And that's why I wanted to briefly quote a few things that I mainly have from the Consensus Guideline and Management of the Inhabitants Hospitalized Cat. I think such guidelines are always excellent, because they complement one's own experience. And they are always very good to get to yourself. They are mostly open access. In this respect, I would like to appeal to our listeners to always look for such guidelines, if you also want to create a protocol and want to make a sensible approach for the whole team. So, with the cat, we have many things that influence here. First of all, as we said earlier, the food is something that the cat knows. We often know the situation of neophobia with cats, the fear of new things. I don't know, I don't eat. In this respect, of course, it is very strongly perceived here, especially in the stress situation in the clinic, whether the food is something familiar. First of all, the smell is perceived. Then, even if it is even tried, consistency and thus taste. Or also the presentation. How are the naps? Is it a nap like at home, used, or a completely different one? Of course, the environment still plays a role in the first place. And it's good if I can adjust to it in the clinic. What sounds, what smells, what lighting? Cats don't like to be observed when eating. So, if I have them on station and put something in front of them and say, eat it now or don't eat it, and I stare at them, then that can be the only mistake, which is why they don't take it. Also an important tip for the animal owners at home, which is to say, leave the cat alone and don't stare at whether it is now eating the new food or not. Often it is good if you, for example, hang up the cage so that it can move back to the station again. Then, of course, all the negative feelings that can be in the situation. Loss of self-determination is very important for the cat. It is now forced to be in the clinic, to sit there, to bear the light and the sounds and the smells. That's why it's good if you try to make it as comfortable as possible, to somehow give it a place to retreat, to cover it up or to hang it down. For example, if the cat is stressed or has pain, it is of course quite clear that we will do something about it. And you always have to keep that pain in mind. Or nausea is also a measure that I have to consider first before I expect the animal to start eating on its own. And then it is often not the food, but the circumstances. And I have to work very carefully with the staff at the station to make sure that this is focused. And then, of course, the physical impairments of the animal, depending on the situation. For the environment, there are also things that I can teach the team in general. Or hopefully many of you already have that in your routine, that people should be calm, that they should behave slowly. It is best to react predictably. That you focus less on sensitive body parts during the examination. The face can often be a very big stress situation for the cat. That you don't fixate the animals, never this packing on the neck. These are ancient tips that are obsolete now. These are things that should definitely be taken into account. And since I often don't know where the journey is going with the patient, what do I discover with his polytrauma, it is of course ideal if I have Timon Equipment ready for all possible treatments. So that I can provide for the cat quickly. Back to the focus on butter itself. Butter distribution must always be according to energy requirement. There is a formula that always fits. That's 70 calories per kilogram of body weight, per metabolic kilogram of body weight. That means the measured, weighed body weight up to 0.75. There are also tables that tell you that. More practical is the lower formula 30 times the simply weighed kilogram plus 70. But that only applies from 2 kilos, which is not necessarily given to every patient. First of all, I have to know the energy requirement in rest. That is the RER, resting energy requirement. And that is the energy requirement that is often enough for me when the animal is at the end of the operation. But of course I shouldn't provide this energy requirement to the animal ad hoc after the operation, but rather many smaller meals so that I can reduce the stomach load and also the gastric acid production. And as I said, I can also reduce the risk of nausea or reflux. This amount of energy, this amount of rest energy, is also sufficient if I only provide it to the patient on the third day, especially if I don't know how much food he has taken in advance. That means I would increase it slowly, only a third on the first day, especially if he eats in a hurry anyway, or if I'm on sun food anyway, two thirds on the second and three thirds on the third. If the animal really moves, I of course add another factor. Then I'm not talking about the rest energy requirement, but about the daily energy requirement. And from one to the other, you come up with different factors. The choice of which food I take, of course, has to be specific to my patient. Do I have voluntary food intake or do I talk about sun food? What is the state of health? Do I actually have an animal that has no problems except for the fracture? Then I can assess it nutritionally and physiologically as healthy or do I have the polytraumatized patient? And this also depends partly on wet food or dry food or on individual preferences. Of course, I'm not going to go into the sun feeding and so on any further. But we have different options. Unfortunately, I only had a dog as a scheme for the cat. And it all has different advantages and disadvantages, depending on where and how I put the probe. I just wanted to mention again that this forced feeding with the cat is also something that is no longer recommended, that you wrap it up somewhere and stuff it in your mouth. This is no longer what you consider to be legionaries these days, but rather a probe. From Hills Pet Nutrition there is a product that has proven itself extremely for many, many years to pet animals here. This is ADE. We have switched to 200 gram cans in Europe, which are produced in Verona at Verona. This is a slightly digestible food with a high protein content, with a high amount of omega-3 fatty acids to get inflammation under control again. Of course, there is a plus to electrolytes, which does not mean that you should not use infusions to compensate for electrolytes beforehand if there are problems. With antioxidants and added B vitamins, so that the patient's energy level is as high as possible and is supported. Depending on the size of the probe, I can use this product without diluting it, because when I open the can and stir it, it becomes liquid. It is called fixotroph, this very special consistency. And when I have smaller probes, it makes sense to dilute it with water. Please make sure that the energy density decreases and I have to feed more. That's why there are tables like this. We have a calorie density of 1.3 kilocalories per milliliter with undiluted feeding. And if you halve it with water, then there is the same amount as 200 grams of water. That's 200 milliliters. Then of course we only have half the energy density. So always weigh that here. Even if you take other products, pay attention to the energy density. When I have placed a probe, when can I remove it again? If the animal eats on its own, it is best to wait a few days if the animal can and should stay in the main station for so long. But often, depending on the probe, you can have the animal kept at home. Or even if it eats three quarters of the rest turnover over more than two days on its own. So that I don't have the probe away and the patient doesn't eat anymore. In this respect, these precautions are on the safe side. As an alternative, especially for longer support. Maybe I have a patient who really doesn't look well. And I have the feeling that he would benefit from a long-term feed. So I would then prefer to recommend the OnCare from our product portfolio. This is a relatively new diet for severely ill animals. It is intended here especially for pampering. And of course there is also special taste in dry and wet food. In general, I should focus the monitoring here on my internal management of the clinic. Or also for the animal owner at home. And there are also nice forms from the WSAVA where you can get help. We know that when you tell the animal owner something in practice, it's always just a part of it. The part he takes home with him, a rather smaller part. And so I can support the patient very well with such written documents. In conclusion, a sufficient supply of protein and other nutrients is of crucial importance for the healing and recovery. Please don't let this fall behind. I know the surgery is exciting for the surgeon. And that the patient is in a good mood afterwards. But please don't forget that nutrition is really important so that the patient can recover well. His immune system supports him, he feels good and he has all the nutrients ready for recovery. For each patient, unfortunately, you have to determine the optimal sobering time and the postoperative nutrition plan individually. If, for example, joints are affected, you can also choose joint-supporting food in the long run. For example, we choose our JD, where we have omega-3 feeders in it that support bone retention and lower inflammation mediators. And it really makes sense to give a clear recommendation to the animal owner also for feeding at home. Thank you for your time. And then I will stop my presentation again, so that Martin can continue. And we'll see how it goes with our patient from an operative point of view. I'm really looking forward to it. Now we're going back to the main topic, namely our fractured patient. We're going to leave the polytrauma patient out of this and just take care of the fracture. We have already mentioned a few things that are important and we want to repeat and deepen them again. So one of the very important things is to put this patient down for the first time. So it is important whether this patient is ambulatory or not. And the second thing we have to do is we have to localize the fracture or the trauma. And even if you have a patient now, and I know how hard it is for you when the patient hurts everything, you have an owner next to you, and you say, no, no, no, don't hurt my animal or something, it still makes sense to palpate this patient. You should look at where the fracture is, once to make targeted X-rays, but also not to overlook that he may have more than one fracture, so that, in principle, maybe a paw is broken next to the thigh or toes are broken at the bottom, so that you don't overlook something and then in the end have another patient who still doesn't walk afterwards. The non-ambulatory patients are really difficult for us, because they can have very different reasons. They can be neurological, they can be affected by multiple extremities due to fractures, or there can be other injuries besides the fracture. Let's take an example here, this is a patient who came in front of me, the leg in front of me was aching, it was very clear, it was a radius ulnar fracture, it was planned for an operation right away, now we're doing a radius ulnar fracture osteosynthesis. But the patient that was put in front of me, he didn't stop, he immediately let himself fall back to the side. We then found out from the clinical examination that the ankle was thickened at the back and then in sedation and corresponding pain therapy, because this is often no longer possible with such a patient, stress x-rays were taken and we found that he also has a tendonitis and thus an instability. So the non-ambulatory patient, who may have been affected by multiple extremities, has other orthopedic traumas, or perhaps has a neurological disorder, should be examined particularly intensively. And that's important, because before you send him on with the patient or plan a therapy, you have to be able to address the prognosis a little. And that's the important point. And I have to say, the GP is often the very important factor for the surgeon who operates it later. The owner communication is very important for the expectation, and this expectation often has to do with how good the compliance of the owner is and whether we get a good result in the end. The first thing that interests the owner, of course, is whether this patient must be operated on. And that's something you have to decide first. Is it a fracture that can be treated conservatively or is it an operative care? We'll get to the examples later. The second thing that is very important for the owner is what the prognosis is. Is it a fracture from which I can assume that afterwards, when it's taken care of, I have a patient who can lead a normal life, who can get as old as normal and can actually lead a pain-free and laziness-free life? Or will it be a patient with whom we actually have to expect that he has permanent limitations? And if he has that, then you have to take a good look at this patient and discuss it very well with the owner whether he wants it. And there is such a system, it comes from the American, it's called Fracture Patient Assessment Score, with which you actually try, when you get the patient presented, to be able to make a as good a prognosis as possible. And then you try to summarize all the factors that are important for the prognosis in a fracture patient and then get a result from it to then discuss the prognosis with the owner. And this prognosis is not just from an obvious fracture, which you can see right away, but the prognosis is also dependent on the biological factors that affect the patient. It is dependent on the mechanical factors of the fracture, but there are also so-called patient and owner factors that play a very important role whether we can make a successful osteosynthesis or conservative fracture care in the end. Because actually, only when all the factors come together, we will also have a good result. I'll go into this Fracture Patient Assessment Score for a moment. This is a table that you have made, where you can actually almost call numbers and then finally be able to say about the number value, is this a patient who is most likely completely good again and everything is fine? So this is a patient who has a 10 on the scale, or here it says little risk, so a very low risk that it doesn't go well, or the green color that you say yes, that's okay. The counterpart is of course the 1 with the red color. And there you can already see from the biological factors that age plays a role. And here very young animals, animals that are still growing. They already have an active bone production at the moment and thus also have a fast bone healing. So that would be a very positive factor. If I have a geriatric patient, then that is sometimes a negative factor, regardless of what the fracture looks like. A healthy patient, positive. A sick, diabetic patient, cushioning patient or one on cortisone, bad factor. If the soft tissues have been injured in the accident and have been massively involved in compassion, imagine a paw fracture, the car has driven over it, or the lower leg in the lower area, you have almost no soft tissue in the mantle, then the blood supply is also usually very significantly limited. These patients also heal much worse and thus the chance that they will get a good result is not as good as if they have a fracture in the good soft tissue mantle, for example in the thigh, pelvis area, upper arm area, where they get a good blood supply and a good healing possibility. From the bone itself, the spondylosis bone heals better, of course, than the cortical bone. Although the disadvantage of spondylosis is that there is usually a very joint-like fracture, which means that we have other problems that we have to take into account. But if we only look at it from a biological point of view, then of course a fracture in the spondylosis area would be ideal. As far as the type of trauma is concerned, it also plays a role, we have a so-called high or low-velocity trauma, and the way in which this injury occurs has a relatively large role. So if you have a gunshot wound and the whole tissue around it is destroyed, then with such a high-velocity, the chances of healing are much lower than with a mild trauma. And what may not be so obvious for you, but depending on where the fracture is and how the access is, the iatrogenic damage can also play a role in the fixation. So small accesses, minimally invasive approaches, are often better if possible. Biologically, this is something that we have completed, and then we go to the second large group, which we also look at a bit isolated again, which is the mechanical group, and it is very easy to understand. Everything that leads to a load-sharing and a good load after the fixation, preferably even with a compression, these are things that have a very good prognosis. Things where the contact is still there, so that we can position the axis, the direction, everything well, the length of the leg, also usually have a very good one. Complex fractures, where there are large debris fields, it starts to get difficult to find the axis correctly. The load is all on the implant, because the bone doesn't carry anything at all. Of course, our risk gets worse. What many people underestimate a bit is also when a patient has fractured more than one leg. So a patient who has fractured two legs does not have twice the prognosis for one leg, but the prognosis gets worse, because he can't do the weight shift to the healthy. He can't spare so much. The risk of an implant failure is lower. And here is something from Little Dog and Toy Dog and so on. We're talking about cats here, but massively overweight cats, poorly muscled, simply have a bad prognosis than cats that are well muscled and light. Here are a few examples. The simple fracture, a tibia fracture here with intact fibula. If you put an implant in there, we have good load sharing, a loadable osteosynthesis, that's just a good option. A complex one, we understand open fractures, multifragment fractures, are of course more difficult to assess. And if there are multiple fractures, then the whole thing gets even more difficult. A special fracture, and we'll get to that very shortly later, I'll show you in the first two pictures, is the pelvic fracture, because the pelvis as a closed box has its own character again. Here is an assessment of the localization. There, joint-like fractures are a bit more difficult. As you can see now, a thigh-neck fracture with a proximal fracture, that's very difficult. And also from affected bones, from the access here, we already talked about it earlier, the tibia, femur, possibly radius and foot fractures are still easier to see than, for example, humerus, pelvis or scapula. These patients with multiple bones and if the joints are still affected. In addition to the mechanical factors, a last factor plays a role. And that's the owner and the patient. If I have an owner who brings good compliance, then it's a very valuable situation. He will do the follow-up checks accordingly, he will do physiotherapy, he will go through the association treatment. Bad compliance can lead to a lot of problems. And the second is also the animal patient. A patient who hardly lets himself be touched, who scratches, bites, who sits in the back corner, the cat, which needs anesthesia for each association change, are certainly also negative factors. And if you then count them all together, then you come from these three factors, mechanical, biological and clinical, to a total result. And you will see whether this total result from all three factors goes more towards green and ten or more towards red or bad. This is your first assessment and you have already made a prognosis with it. You can already say a little bit how elaborate the follow-up treatment will be, how elaborate the costs will be. And now, of course, it will play a role for you, is it a patient you can treat yourself or is it a patient you send on? Conservative, that's what you can do often. Operative, many will be able to send the patient on. And now let's go over the primary, let's go over the primary care that you do regardless of whether you send it on or do it yourself. As primary care, we had already mentioned before, every fractured patient deserves a pain therapy. The standard today is morphine for this. Since we have relatively little side effects and a very good pain effect. So we take heavy-duty methadone with us. Buprenorphine is also good. For animals that are clinically healthy, that have a good perfusion in the tissue, steroidal anti-phlogistics would not be a good method to give the same. And we sometimes add scabapentin, although the pain effect usually only occurs a little over the days and sometimes not so much because it is very strong with fractures. But it helps sometimes in the handling of the patient, which is also a little reassuring. We talked about the antibiotics. If we need one, then the penicillin is the means of choice. Association treatment makes sense when it comes to fractures of the knee and elbow. And of course when it comes to open wounds. And the means of choice is the Robert Jones Association. This is the association with which we can calm the fracture, by compressing the soft parts and thus preventing further swelling and oedematization. And with which we also do a clear pain therapy, because these bones no longer bounce around and make further pain reactions. That is the most important thing. What is possible for you are possibly conservative therapies for pelvic fractures and for fractures that only have cracks or are hardly dislocated. For pelvic fractures, those where there are really only slight shifts, where the pelvic canal is wide enough, where these things have been preserved, conservative therapies are possible. Actually, if the supporting axis is disturbed by the spine via the iliopsoas joint into the pancreas, then you should tend to operate on it, because that would also be the cause of pain in today's prescribed therapies. So, such shifted patients should be operated on. Here again the plaster treatment, but we are already coming to the end a bit. I will now quickly go through the last things. Here the plaster treatment. This is something you can do yourself. Plaster treatment, only two layers of batting, very thinly padded. It has to sit well. We do it like this, at the bottom there is a glue strip, medial and lateral. We put a batting layer over it, compress it slightly with crepe, and then the plaster is wrapped, so that it is in a straight anatomical position, and we can leave it on for up to six weeks. The same with metatarsal fractures, we only do it with rails, and these rails can also stay for several weeks. If you are doing a conservative therapy, then it is important that you do regular checks during the band therapy. You have to look, if you have applied such a plaster, whether the paws are well bleeding, that the lymph nodes are not swollen, that there are no general disorders. Otherwise, you prefer to change the band once more and do not let it arrive for six weeks. And if you go over bone points and you do band changes, please always pay attention to the decubitus prophylaxis and make sure that we do not get a decubitus. Operatively, open fractures and tumors in the growth curve should be sent immediately as an emergency. Cervical fractures and proximal fractures can be sent electively. Here are some examples of them. I wanted to go into the cervical things a little more, for time reasons, so that you still ask questions, but leave something out. And then I would like to briefly go into the fractures, namely the two of our big cats. We see them again and again and they are often overlooked and we see them too late. If you have one of our big cats today, who may suddenly go lame from the age of three quarters of a year to two years and no real major trauma is known, they should still be well examined. They have what is called slipped capital epiphysis. This is also a fracture, behind which, however, probably another pathomechanism is located. And if you can provide it early, if you get it fresh, you can sometimes provide it directly, operatively. Otherwise, usually only a femoral head-neck excision and an artificial joint are possible. After treatment, maybe a short check every few days. It is important that you always check the function. An osteosynthesis that is well done, the patients should be able to walk on it. They should have good mobility and the legs should not have any axial deviations. They should perform X-ray checks depending on the age of the animal, after three to eight weeks. And they should be well stored, so that you can assess them and thus possibly incite them. Implant removal should then be done if the patient has complaints, for example, because implants change, if there is an infection or if it is a very young animal or the location is far distal and implants would disturb there. There, implant removal is usually useful. That was a bit of a pig's gallop at the end, because we talked a little longer about nutrition. And that's why I tried to make the other a little faster. Now we only have a few minutes left and I'll pass it on to Thomas so that he can initiate the questions and the discussion. Thank you very much for your attention. Yes, thank you very much, Britta. Thank you very much, Martin. And in fact, we currently have two questions. I have already allowed myself to answer some of them. Stefanie Adolf asks, in what dosage do you give gabapentin? I would have said 50 mg per cat. I'm curious what you do. Thomas, I even have to say that these are some of the questions that I basically answer, because I'm not the person who has the numbers of drugs in his head. I'm very banal now and say, let's take a quick look at that and with me, of course, it happens in the clinic that most people have gone home from the clinic, that I don't even give it to them. But before I say something wrong, with me the numbers are always there and I don't really give out medication dosages like that. Everyone should look it up themselves. Okay, that's consistent. Good. Then we still have, in which unit is the RER calculation in joules or calories, or kilocalories in this case? I think the question is clearly for you, Britta. Say again, I didn't understand the state acoustically. In which unit is the RER calculation? Okay. Exactly, in kilocalories. Okay. Good, thank you. That was the question from Angelika Meissner. She also asked if we could translate that. I took that with me for my team. Are there any more questions for people? We don't have any more in the chat either. Good. Then I would like to, it's 2 p.m. thank you both again very warmly. Dear Britta, dear Martin, it was fun. Thank you very much for your presentation. It was very exciting. I think we're all a little smarter than we were at 1 p.m. because we learned a lot. I would like to thank you very much. And in that case, we conclude the meeting. Thank you very much to everyone. And thank you very much to everyone who attended the meeting today. And maybe even those who will have it recorded for another year in the future. Thank you very much. See you. Ciao. Thank you and goodbye. Bye.