Hello, everybody, and welcome to, this, webinar. My name is, Ivan, and, I'm a, a surgical specialist. Currently, I work as a consultant in a company called, 3D, and, my main interest in area, of clinical work, and research has been, small and orthopaedics.
We're gonna be talking about, fracture repair today. In juvenile patients. Hopefully, I'll be able to give you some tips and tricks, so we'll make your clinical work a little bit easier.
In regards to a declaration of conflict, they just said I'm consulted for, for a company that really and I don't have any other conflicts of interest that I need to declare. The learning objectives of today's session would be to identify the challenges of fracture fixation in . Growing patients, I will introduce you to, the Solta Harrisification, which should be able to, to use for the description of the fractures.
We will review the options for reduction and the advantages and disadvantages in different fracture configurations. We will also discuss the consequences of trauma to the device. And about possible complications in relation to the fracture repairs.
So, I will start with just a brief anatomy review and we will just discuss briefly what is the, the specific feature of the juvenile bone that makes it different and requires different approach to the fracture assessment and fixation. As you know, Puppies, their bone is very soft, and it's soft mainly for, for, for two main reasons because it has low mineral content and it has some higher content of water. This soft bone actually is it works into their advantage because this makes the bone very elastic and makes it relatively resilient to any, any kind of trauma.
And they can absorb a lot of trauma without suffering any significant fracture and significant consequences. Another big advantage to the And the difference to the skeletal immature bone is that it is surrounded by very thick periosteum. That periosteum itself is attached very loosely to the bone.
However, because it's very thick, that also works as an internal spring and usually makes those fractures. Not often very displaced. The other thing, last but not least, is that actually we need to appreciate that the juvenile patients, they are in hyperanabolic state and any fracture, any trauma heals very quickly, bone remodels immediately, and I would say probably in 23 weeks, the younger patients, you can see complete remodelling and healing of the bone, which is very important because it makes The decision making and the treatment a bit more urgent than another.
A fracture if that will have, for example, in a skeletal mature patient. Another specific feature to the juvenile bone is that they have ices. The vices.
They are, I would say like a. Specific areas of the bone, which are mainly contained and they are compromised of several zones with different degree of cell organisation and extracellular matrix. Those faces they are located in the.
Proximal and distal metaphysis of the bone and their main function is that they Make the the bone grow inland. There are separate vices and ossification centres called apothesis which are Situated in areas of the bone where there is an attachment to large muscle group on tendon, the most common and obvious examples for that is the hypothesis on the tibial tuberosity where the patellar tendon inserts the hypothesis on the greater trochanter in the femur where the middle and deep t muscles attached, and I would say another more common is the electronon where the triceps muscles attach. What is the, the structure itself of those devices, as I said, they are comprised of several zones, which, depending on the, on the area, consist of different cells and amount of extracellular matrix.
If we look on picture B, the most proximal zone is resting. It's called the resting zone. So this is the zone that's closest to the articular surface.
And the closer the bone, or the oppothesis, of the bone, and the more distal that we go or closer to the paphysis, we can see that the cells, they start to organise themselves and The amount of extracellular matrix reduces. Why is this important? Because we know that the the physeal fractures, they occur in the hypertrophic zone, as you can see, into the picture.
So they do not appear at the same level, but I would say an exemplary fracture line is exactly there, and it's important thing to know. On the provided tables, I have given you an examples according to the, to the references, when is the approximate closure of the devices, both in cats and dogs. You can also look at the references, on your free time.
It's worth reading. The thing that is very specific and you need to, to, to be mentioned is that as you can see on the left-hand side, the table where the the time of foreclosure of the devices in the cats are are written, we can see that a lot of the of the the cats fights they close. After a year or a year and a half, which is important to know, in regards to, when you're doing radiographic assessments and, when you're doing your, your fracture planning.
It's something that can be considered normal in more, elderly, elderly cats. For example, If we're talking about, the vis, the proximal tibia or distal femur, we can see it in the cats, that 1.5 or even up to 2 years old, and that is normal radiographic finding.
It's also worth noting that, during their development, the devices close. Under the influence of the sexual hormones, which suggests that if we early neuter the patients they usually grow. Longer and their bones are actually bigger.
So it is some another thing that it's worth knowing and understanding about how the bones grow and they're affected by different hormones. What is the usual fracture configurations in in juvenile patients and what more, more specific. So, if we're talking about fractures of the, the offices of the, of any of the bone, they can be complete, which basically suggests that the fracture line extends, on a door on the frontal or sagittal view, from one cortex to the other.
We can have incomplete fractures or fissures like in the image. A on the right hand side, where the fissure line or the fracture line extends only from one side and doesn't reach the other side of the cortex. These fractures are called incomplete, and they also have this specific name called a greenstick fracture, and they're very typical for the.
Juvenile juvenile patients. Another type of typical fractures is the physeal fractures, which I think it's called is quite intuitive. The reason being is because there are no actual devices in the skeletal mature patients, hence, it cannot be any fractures that occur through there.
In regards to the fracture of the devices, there is a classification system that's implemented and it is borrowed from. Human surgery and that calcification system, the salt harves system is mainly used to help describing the fractures and also communicating between, between vets and surgeons what would be the, the best way forward, and, when we're talking about referral on the case. So the sort cover classification comprises of six separate types.
Type 1 is a complete separation along the devices. Type 2, as you can see on the picture, the fracture line. Goes first along the faces and then goes.
Proximal or distal into the metaphysis. Type 3 and type 4 are intra-articular fractures, and it's something that affects the decision making. With type 3, the fracture line goes along the devices and then goes across the epiphysis, whilst in fracture type 4, the fracture line goes from the metaphysis.
Across the faces and then goes into the Epiphhysus Fracture type 5 and 6 from the Saltahar classifications, they are almost we can consider them incomplete, and they are also described as crushing fractures. Those crushing fractures, they usually result in partial like in type 6 or complete closure of devices. Which has some consequences in the development of the patient because with the complete closure of the of the devices, we usually get.
Symmetrical and shortened limb. Whereas in type 6, we usually get angular limb deformity because at the time at the site where the fracture on the. Twice is closed, the growth rate is either slowed down or completely stopped, whereas on the other side, the bone grows.
Normally, and that usually results in the formation in different planes. Very recently, another, type of classification for, for fractures in juvenile patients have been adopted. This was reported, actually, very recently, end of last year.
And, it relates mainly to the fractures of the tibial tuberosity, apothesis, and the epiphysis of the proximal proximal tibia. It is a classification that's also integrated from human surgery. As you can see, there are 5 types of fractures.
Type 1 is complete or incomplete separation of the tibial tuberosity. Apothesis where it displaces proximally with type 2 we have partial displacement of the tibial tibiotuosity apothesis which extends slightly caudal. Into the epiphysis type 3.
We have complete fracture through the epiphysis of the proximal tibia, which includes the tibial tuberosity hypothesis, and as you can see, and you can expect that is an intra-articular fracture. With type 4, we have complete elevation and separation of the apothesis and epiphysis. And with type 5, we have Addition to the type 4, I'll describe it like that where a piece of the metaphysis is.
It's also within the, the fracture line. These are essentially can be described as So the highest type fractures and you can see it on the right hand side, which is similar. It's gonna be really up to you whether you want to prefer one or the other type of classification when you're communicating with your colleagues in regards to the description of the fractures.
It is interesting to talk a little bit about the demographics of the physio fractures and their prevalence. We can see almost 40 years ago, when the yo fractures were Reported, we can see approximately that like 30-35% of them were distal femoral fractures, which were followed by the distal humeral fractures. Interestingly, 40 years later, we can see like a complete shift, of the prevalence and the presentation of these type of fractures where more than half of the, of the patients that are presented with all the harves fractures are presented with distal humeral fractures.
Moreover, if you look into the paper, by the RC group, we can appreciate that the majority of those proximal of distal humeral fractures actually lateral condylar fractures. And that corresponds probably due to French Bulldogs being more popular and being very, very common. As a, as a pet, but unfortunately.
As probably many of you know, they suffer from, from, from these conditions. And I think this is a direct reflection of the, the prevalence of these type of fractures. The reference on the right hand side is also by the RBC group and its reports on the common fractures.
Yeah, of the devices in cats. In the, in that situation, the most common type of fractures that we see in cats are the distal fractures of the distal femoral vices or the tibia. When we are presenting and when we.
Assessing our fractures, it is important to use a systematic approach and systematic approach. Requires using the fracture assessment works assessing separately the mechanical, biological, and clinical factors. As you can see on the presented diagrams, and the mechanical factors are usually related to the number of limbs that are injured, if they are related to the, to the size of the dog and the, the configuration of the fracture.
Because as you're aware, Highly commuted and a fragmented fracture requires a lot more mechanical stability and stability than, for example, a simple transverse fracture that because of the indentations is relatively stable in some of the forces that are applied. The biological factors they. Usually relate to the health condition of the patient itself.
In our particular situation, the juvenile patient, they have high biological score because of their extreme anabolic rate, usually they're healthy. The other thing that is important and it's worth consideration in regards to the biological factors, is the soft tissue coverage of the fracture, whether the, the fracture is through the the opposite hand, we have cortical bone fracture or so theharis, type of fracture where we're gonna be treating and stabilising cancer as bone. Amount of injury and obviously the amount of surgical trauma that we induce with our procedure.
The clinical factors, they are mainly related to the factors that will affect the fracture healing, but they will affect the fracture healing into the perio operative. Period. And the main clinical factors are only compliance and patient comp compliance as well.
Obviously, non-compliant owner with a very boisterous, patient is gonna have a lot lower, score on the clinical factor assessment which will suggest that we need to take that into account when we're doing our fracture line. In general, what would be the, the, the challenges of juvenile fracture fixation. As we mentioned earlier, one of the biggest challenge is that the bone is very soft.
The soft bone is Problematic because it usually Affects the the holding, the holding and retention of implants. Hence, for example, if you're gonna be using screws, ideally we need to use cortical screws, with higher. Higher and bigger pitch of the thread which will increase the screw bone interface and that will make it less likely for them to pull out.
It's not impossible to use locking screws, for example, if we need to, but from my mechanical point of view, cortical screws should be preferred and utilised as possible. The size of the fragment is also a big challenge because very often if the fracture is into the into the devices, the bone fragments are very small. They're also very close to the joints and often we have very important stabilising structures attached to them, like the collateral ligaments or big tendons like the patellar tendon, which we have into the tibial tuberosity.
Another challenge is that actually, we always, have trauma to the devices, but that's obvious through a displaced fracture or it's gonna be something that we're gonna understand that it is a consequence like in the sod Harris type 5 or type 6 fracture where the face is closed. It is something that we need to always take into consideration and obviously. If we are concerned about that, that needs to be communicated with the owners, that issues like shortening of the limb or limb deformity can be expected because of that trauma.
Unfortunately, it's something that we cannot really predict whether it's going to happen and it is really a matter of us just monitoring the patient and evaluating. a time of . The visio closer whether any deformity are going to develop.
What would be the, the best fixation methods? As I said earlier, we always need to approach the fracture. Treatment systematically.
First, we start with the assessment of the biological, mechanical, and clinical factors. In those cases, we need to consider what is the And the state of the patient and how strong our construct needs to be in order to allow no bone healing, we need to consider the forces that are acting on the fractures as you previously know and you are aware there are 3 main groups of forces. We have axial forces, which are usually tension, compression, or shear.
We have bending forces, and we have rotational or torsional forces acting on the fracture. A separate type of force is what we call ulsion, and this is the force that's acting mainly on the hypothesis where large muscle groups or tendons attached. What you need to know is that the moment you fix your fracture, you're almost like on the clock because Every fracture fixation is a race between implant failure.
And bone healing. Fortunately, majority of times in juvenile patients, bone healing is very quick. Hence, not so rigid fixation is required and implant failure is very rare to see in these type of fractures.
Different fixation methods, we can talk a lot about it. I would just mention the main methods and some key, key differences that we can use in regards to internal fixation. We can use pins, and pins are used mainly into the physio fractures, tension band will be added when we have and will require fixation of hypothesis just to counteract that extreme pull from the large muscle groups or the Big tendons?
A very interesting concept that we can use in a juvenile patient is called elastic osteosynthesis. So this was first described the beginning of this century. And what is the principle is that We use a relatively small plate with a long working len and a small number of screws fixating the plate to the bone.
We usually use cortical screws and the, the main basis and the main principle behind is that The elasticity of the plate will counteract the Loosening of the screws, hence, the more the plate bends and the plate and the plate moves on a molecular level, that makes it less likely for the. Screws to pull out. It is interesting and very important to note that this concept of elastic osteosynthesis should be applied only in patients that are not older than 4 or 5 months of age.
Reason being is after 5 months of age. The mechanical properties and the healing potential of the bone changes quite a bit and usually, it's closer to the properties of a skeletal mature bone. Hence, principles that are used for skeletal mature bone fractures should be employed.
In those patients rather than employing the principle of elastic osteosynthesis. Another option that can be used and it's a good option because it's a relatively elastic minimally invasive fixation. Fixation method is external skeletal fixated.
There are some special considerations in regard to stabilising physio fractures, that are important, to, to note because, that usually will make your life very easier, and, will help with your decision making. So your fractures, you should be aimed to, to be reduced and stabilised. Quite early.
It's not like an emergency life-threatening situation. However, I can assure you that if you try and stabilise a physeal fracture after 3 or 4 days. It's very unlikely that you will be able to reduce the fracture if it's severely displaced.
If you attempt to to disrupt the, the, the, the tissues to help, and improve conformation, in regards to alignment or position of the fracture, very likely that you're gonna cause more damage and actually improve the conformation of the limb. The reason for that is because puppies, they are in a hyperanabolic state, as I mentioned earlier, they heal extremely quickly. Chances those fractures of the devices, try and fix them early.
If you wait too long, unless they are severely displaced, it's very unlikely that you'll be able to reduce them better. You should be very gentle in regards to manipulating of those small fragments. Well because the bone fragment itself is very soft, but secondly, .
Every unnecessary manipulation will damage the. Pieces of the, of the bone and that can cause a premature premature closing. Also, you can disrupt the blood supply and that can impede your fracture healing.
You should avoid bridging devices with your implants, and that is mainly. In relation if you're using plates, so plates are not recommended and they are not a suitable fixation method for yo fracture. Especially in a very, in a very young like.
Usually for stabilisation. Smooth key wires or if you need additional strength, you can use negative threaded LS pins or wires to improve your stability. And there is an important rule of thumb that if you don't want to log the devices, the angle that you insert the key wire, .
Towards the the fight should be larger than 45 degrees. So the angle should be. As you can see on the images on the right, it should be very, very high, almost kind of a .
Higher than than 60, 70 degrees just to allow the almost kind of the, the remaining of the bone to slide off the the devices. The Kwis can be applied in a cross fashion or as a, as a rushin. The respin technique is a specific technique where the The pin enters sys cortex and does not penetrate the transcortex of the fracture, but rather glides and provides elastic stabilisation within the.
Medullary canal. When we do this on the opposite side as well, this provides the dynamic and elastic stability. Hence, it's a, it's a method that can be used for fixation of physio fractures.
It's interesting to note that in order to do a proper ruin technique, you will need. Smooth K wires or pin that have specific elastic modulars, which is different than the elastic modulars of the stainless steel K wires that we usually use for for cross pins. We should always strive for early.
Well function return to function of the limb because this is how the implants heal and the fractures heal, and it's important for the patient. And last but not least, when you're treating your fractures, you should be prepared to remove the implants. In regards to the post-operative care.
It is very important to look after the wound. It needs to be clean and dry. It should be appropriately covered with a dressing.
You should, ideally allow the patient to, to have a collar, to avoid them reaching the surgical site, and if appropriate, it can wear a boot or a bandage. If they were a bandage or needs to be added external quotation within the As an additional method of stabilisation for the fracture, it is important to know that this can be useful and needs to be applied with care. As you know, the patient will have improved comfort, bandages, they will reduce postoperative swelling, and provide additional stability which, can be required occasionally need to be applied with care.
Because fortunately, they can lead to catastrophic complications and need to be carefully rechecked. The bandage needs to be clean and dry and replaced as necessary. If we're using an external scanner or fixator as a stabilisation device.
Ideally, there was some. The, the frame needs to be rechecked every 10 to 14 days and We need to make sure that the clamps are tight and we also need to clean the the the areas around the pins, check for any pin loosening and any. Pin truck discharge cleaning ideally should be done with a very light diluted antiseptic solution.
As with any other surgery, analgesia is of key importance to optimise and speed up recovery of the patient. It also will allow early return to function. As you probably know, in hospital, we can use local anaesthetic, local local regional analgesia, and blocks something that I'll use on a regular basis, even in in in young patients because it really helps during.
The general anaesthesia and helps with the, with the recovery. Additionally, whilst there in hospital, you can use opioids or ketamine. Is necessary depending on the pain levels.
Most operatively. You can use any licenced. Non-steroidal, that's there on the market, or you can add paracetamol if that is required.
But usually the recovery is quite quick, so that is not necessary. In regards to the. Antibiotic, and antimicrobial phylaxis, usually by, as a rule of thumb, the fractures where we use implants, we should apply, and, give, very operative, antibiotics, and, other considerations we need to give him is, when the surgery is, unexpected long, more than 90 minutes, or if there is Mm, if there is an open surgical site, which is contaminated by bacteria, preoperative, antibiotics, they will, inhibit the growth of the, contaminating bacteria that usually, transitions from the, from the skin edge and will prevent formation of biofilm over the implant, which is very important and Reduces the risk of perio-operative, .
Actually postoperative surgical site infection. In regards to post-operative antimicrobial therapy, there is, an area where there is no consensus in regards to, what, needs to be used and whether postoperative antibiotics actually reduce the incidence of surgical site infections. The evidence that we have is controversial, and as I said, they, they're often conflicting without, without consensus.
My personal experience is, usually, apart from the very operative antibiotics. I will not give post-operative antibiotics if there is a, there is a closed fracture or a simple fracture that is stabilised relatively quickly. Sometimes if for example, something that I know that it's something that I can do relatively quickly.
Like tibial fracture, I wouldn't even give antibiotics because, in general, once you're confident and you're familiar with the approach stabilisation method, these fractures can be fixed quite quickly. Confinement and exercise is always very important because these puppies, they're always gonna be puppies and they will be doing puppy things. So, .
As But as it sounds, the exercise and activity needs to be controlled. As you can see on the video, a puppy with this level of activity is definitely not appropriate for recovering after a fracture fixation. This will put excessive strain on your implants and more cause may cause some complication.
Hence, straight rest or lead controlled walks are very important. The important to use the limb, but the limb used needs to be controlled, and Should not allow this excessive brisk and high impact movement. It's always very important and something that you always need to consider.
Just make sure that you always give written instructions. To the owner of the patient, obviously communicate everything verbally, but giving it in writing makes things a bit more official and makes it more likely for the instructions to be to be followed. Make sure that you include in writing the time those are the medications.
Exercise restrictions and what level of activity they should have during different periods of recovery. When they need to come to see you for a standard recheck, for example, like for a suture removal or a follow radiography, and obviously what is considered abnormal and what they need to be aware of, . During the recovery, so if they are concerned to the To contact you and come for a recheck.
Additional care that you may employ into your postoperative. Treatments is you can introduce rehabilitation. The majority of these cases, what we'll, what you will need to, to do is to implement passive range of motions, which is important for, for joint health, and so.
Avoid, ankylosis. I would say that these are conditions that actually can Occur very quickly. So maintaining range of motion is very important in patients.
So please consider it, even you can add it in your postoperative instructions that if the patient is not immediately weight-bearing, they should start. Passive range of motions to introduce and kind of a maintain limb function of some sort. Cryoental therapy can be employed.
Very often and becomes actually quite popular. People use different types of laser, which reduce the inflammation and improve comfort. Additional, .
The thing that you can use in as a part of your post-operative rehabilitation is hydrotherapy, but I would say, in the subset of patients that we're talking about today, this is unlikely to be required because most of them recover very quickly and unless there is a serious complication in this intensive rehabilitation is not usually required. Last but not least, and something that is very important. What are the potential complications that you can encounter when you stabilising fractures in juvenile patients.
One of the most common and I would say complication that is directly related to the area where you're placing your implants is joint penetration, because usually when you're fixing physio fractures, you are in a very close proximity to the joint. Insertion of the implants need to be very careful. What I usually do is I'll use a hypodermic needle that will mark my joint space and I will use, a couple of millimetres, offset of, of that needle to make sure that I am penetrating, penetrating the bone.
Yeah, the Potential issue intraoperatively or actually you that you're gonna see in your Post-operative radiographs is suboptimal in placement very often you can. You can miss the, the desired spot. Or for example, you can miss the hypothesis or the epiphysis of the, of the fracture line.
And in order to guide exactly where your implant needs to be placed, you can use another hypodermic needle to mark your faeces. And for in that case, if you have a needle that marks a joint space and then you have another needle that marks your faces, you know that if your entry point is between those two needles, usually you will have really good bone pulls and engages engage of the fragments, and that will. Provide more stability.
Another issue that you can identify is my reduction. Ma reduction usually. Ends up with having suboptimal opposition or suboptimal alignment that can result sometimes in, in deformities which Can sometimes be a very serious, consequences.
So it is the time we need to be extremely critical in regards to what you've done and, how, things should look like in the post-operative radiographs. And don't be, ashamed if you have to, do the work back in theatre because if there is time. To fix a potential issue, it is the right time at your post-operative radiographs when this is first identified.
It's not time to have this fixed in 2 to 3 weeks when actually the, the actual fracture. Might have already been healed. A very common issue when you're using KYS is protrusion of the K wires through the skin.
This can happen very often, especially in the distal extremities. I can see in the picture on the left-hand side, especially if you're using a bandage as an adjunct, stabilisation. Method, and, that usually makes the pins to, to put through through the.
For the skin, . And a pin migration is also a problem that can be encountered, especially if the fracture is not stabilised well enough for the pin migration, the way to get around it or to prevent it is to bend the pins. Pin bending is something that needs to be done very carefully and I usually Bend the pins away from the bone, because if you bend the pin against the bone at the point of bending.
Usually, because of the soft consistency of the bone, that literally cuts through the bone like butter, and you will Loose bone purchase and your implant placement will be suboptimal. How you, how you get around that. As I said, you either bend the pin away from the bone, not against the bone, or you can cut the pin very, very short, and leave it straight.
The problem with leaving a straight pin, as you can see on the picture, in the middle is that it can cause soft tissue irritation and potentially protrusion, which will require Removal of the implant when the fracture is healed or to a stage if that is too severe in regards to what are the consequences to the ices. As I said, several times earlier. There can be partial complete closure of the devices on the picture of the on the radiograph on the left hand side, you can see that this is a partial closure devices which fortunately have not led to any significant deformity.
However, on the picture on, on the radiograph on the right-hand side, you can see complete closure of the distal femoral vis which have led to, Shortening of the limb. Fortunately, with that limb, the discrepancy between men is about 10%, which is usually well tolerated by the patient, and they don't have significant consequences about that. So this is overall as a review of the fracture fixation methods and the Information that you need to have in mind and consider every time when you are faced with one of these fractures, and I will present several cases, .
Just to exercise the decision making. The first case is, little Pippin. Pippin is a 4 month old domestic short hair.
He was still not neutered, but vaccinated, and, he was, wandering outside. And suddenly, one day, his, family came home and, yeah, he just came back limping on the classic cut history. He was non-weight bearing.
On the left pelvic limb and she was holding it in a very awkward and abnormal position when we did radiographs . Of the, of the femur and the pelvis and subsequently the, the torsal joint. What we identified was quite fascinating.
I can't say. There was a ventral luxation of the femur, in those cases, what is very common is that the femoral head goes into the operator foramen. We could see sortharris type.
One, fracture of the, or volson fracture of the later trocant, and also, which is something that I find very uncommon. There is a, there was a Additionalwataharris type 3 fracture of the, of the distal tibia. This was able to be visualised by doing a stress radiograph in, in valgus because that opens the, the fracture line most as you can see.
On the, on the mediallateral view, there is no massive displacement. We can only appreciate some soft tissue swelling, potentially joint diffusion on the radiographs. But when we do a stress radiograph, we can see that there is a separation of the devices.
So it is something worth considering and having. Into your Decision making and as an approach when you have these type of fractures or these kind of injuries that you know where the injuries but you can't really demonstrate it. So in that case, you'll probably try.
Stress radiographs which can help visualise Something that you won't able to, to do on a plane radiography. In these cases, what, we know the mechanical factors, we have one injured limb. We have a young patient, so from a biological point of view, it is, it is a, it is a good score.
There is a quite high concentration of the stress, into those fragments because the Apothesis of the greater Jacantta, as I said, is an insertion of the gluteal muscles. The medial meniolus with the sore fracture is an insertion for the medial collateral ligaments. So those fractures, they need to be stabilised quite, quite firmly and quite significantly.
On top of that, we have another, another, not a minor injury. We have, luxation of the Coccxofemoral joint on the same leg. What we did as an approach is After intraoperative reduction of the coccofemoral joint and digital stabilisation of the great tubercle tracantus, sorry, the coccofemoral joint was very stable, so it did not require any additional stabilisation, and that required only stabilisation of the Greater Tokanda, which as you can see was done with 3 separate K wires and tension band wire with To twists in a similar fashion was stabilise them.
This the malar fracture, the anatomical integrity of the fractures is, was reduced very well. And I was happy with the, with the lymph function in regards to closure, of the, of the soft tissues that was returned and was done in layers. On the video below, you can see little Pipin on the day following the fracture, fracture repair is already, again, being a very happy cat.
There is a mild observing lameness, but the limb function is very good and very immediate, which is what we desire. And I would say that probably this is something that you would expect when you have this type of By fractures, the limb function usually, Is, is very good immediately or stop. Four weeks later, I saw Pippin again, for clinical assessment, and, repeated radiography.
He was doing very well, and, there were literally no concerns, with, his, from his own. There was no pain or manipulation of the limb, so he was very happy. On the radiograph, we can see that the greater juanttahysis.
Is already closed. I can see that it's closed on the contralateral limb, so those ones were left in place and it was the same with the. These tibial devices, nos were there.
So happily 4 weeks later, after horrible trauma, people were discharged and he went back to be a happy kitten again. The next case, it's very similar scenario, is that 3 month old male, sidehound called Sky. So Sky, bless him, he did like the, the classic side hound thing.
He went out running, and he just came back limping. And so he was just non-weight bearing on his, left pelvic limb. What, you could appreciate on a clinical examination is that he was not using his leg.
And there was quite a significant swelling into the mid area, and that was also quite painful. No. On palpation.
On the radiographs, what we can see is that there is a long oblique fracture of the tibia, probably with a very small community fragments. The fibula is intact and there is not a massive displacement of this fracture line. So considering that, this patient is, very young.
The healing potential is great, and, the fracture line is not completely. Displaced, what I elected is was for a type one A frame of external skeletal fixator that will provide enough stability but at the same time will be, not too rigid, and will allow rapid bone healing with return of the limb function. What is good and versatile about External skeletal fixators and that actually after the initial placement of your pins before.
Finalising the construct, you can adjust. The pin position and improve alignment and position based on your post-operative radiography and you can and you can do that in the radiography room. You don't have to go back in theatre to adjust the position of the pins in radiation to the, to the connecting bars.
Once you're satisfied with the alignment and the opposition, you can add additional. Pins, as in this case, a 3 pin was added in the proximal and distal fragment. Sky was seen 2 weeks postop for a standard.
Maintenance of the frame to clean the pins and assess the wound. Everything was well as expected, clinically, sky was doing very well. Control radiograph were taken, as you can see, there is already like a quite Obvious, bone remodelling and cause of the, of the bone, at this stage, because I could still visualise, the fracture line, despite that, there was obvious bridging of the fracture line, I decided to leave the Frame for 4 to 2 weeks.
So Two weeks later, Sky came back, again, there were no concerns in regards to the function and use of the limb. And we repeated the radiographs, as you can see on the radiographs, it's already like complete remodelling of the bones, so this was completely healed and I was happy to remove the frame at that point. Once the frame was removed, we can see.
That there is mild deformity that has been induced and this is in a sense of inducing recurvatum of the tibia, procurvatum and recurvatum deformities usually a well tolerated, by, by patients, and this is unlikely to clinically affect the function of the ne. If it's something in the area of torsion, virus, and valgus, it is something that you need, you will need to address and be very critical. When you're assessing your postoperative radiographs, to make sure you're corrected as and when necessary.
The next case, that I will present, is, Flora. Flora is another hound, with, again, classic history, as all hounds do. They go run in the park and just came back and they were just like, nobody knows what actually happens with them.
But occasionally, owners can report that. They have heard like a scream or like a loud noise, but that's not always the case. So Flora came back, she was laying.
Her knee was quite painful, was quite swollen, and I could appreciate the, abnormal movement in the area. When we did radiographs, what we can see, on the medialateral radiograph is that, we have a sohar type 2 fracture of the dystaliasis of the femur. It is very interesting because of the superimposition and the position of the limb that on the called the cranial radiograph, you could, you could barely appreciate that there is any abnormality.
Hence it's very important, as has been discussed for many times, to make sure that you always get 2 or 12 views of every area of interest when you're assessing for fractures or any other abnormalities because often due to the superimposition of structures and . Presenting a three dimensional structure in a two-dimensional image, you can underappreciate or miss something significant. So what we did, with the flora, we use the standard approach to the lateral stifle, which requires also lateral paraatellar rotomy.
We open the, the, the fracture site. It is very important. When you're opening completely the, the fracture site and the area of the spices, to be gentle with the manipulation, the fragments, to be gentle with suction just to avoid that excessive damage to the soft bone and the ices itself.
In this case, how, and what actually helps with the, the reduction is hyperextension of the stifle, usually if you hyperextend this fracture, having, . A very invented. Outline usually wages very well and stabilises and reduces itself very well and requires minimal effort in terms of maintaining that when you're starting to place your implant.
In this case, because flora is very Big dog I used, instead of 2, I used 4 cross pins. They were each 2 millimetres just for extra security. And you can even appreciate that they still look quite small, but I think that this was required in order to Provide enough stability for this fracture and ensure and avoid invental healing.
6 weeks post-op, when Flora came back for recheck, clinically, she was doing very well, although there was a very slight git abnormality, so her sta was a little bit more extended if you compare it to the contralateral. What we could see, on the followup radiographs is that there is a complete closure of the these two femoral faces. The fracture itself has completely healed.
So from this perspective, implant removal is not necessary, but The abnormality that will remain is the closure of the devices and potentially that will lead to shortening of the leg. In this case, if in the future. The shortening of the limb affects the patient clinically.
You may consider lengthening procedures, but it's something that you're not really proactive with, but you are rather reactive. The last case that I want to share with you, and hopefully that will be, enough, we're gonna give you like a good idea about, . Fractures in, in puppies, is the fracture of a former north female entire French bulldog.
Being a puppy, she was just being very happy, playing with, other puppies, but she just stumbled in the park and, it was described it, they, they heard this horrible, horrible scream. And after that, she was just non-weight bearing her, with her left limb, and she was just holding the, the knee inflexion. When she came back and presented to me, there was also, obviously abnormal movement in the stifle.
It was quite swollen and quite painful. We took radiographs and what we can appreciate, is, . So the hardest type 2 fracture, which involves the tibial tuberosity hypothesis and the proximal tibial epiphysis, which using the, the neural classification is a type 5 fracture, but also we can see, minimally displaced.
Segmental fracture of the fibula, which is a concurrent injury. I think the, the reason for this, why it's not displaced is as I mentioned before, they have a very thick periosteum and that's usually not cured. No fracture together.
So the obvious thing to do here is to fix the tibial tuberosity because it is greatly displaced and if it's not fixed, the patient is not gonna have functional stifle. The important thing to note is that despite that there is a minimal displacement of the Proximal tibial epiphysis. It's also worth either trying to reduce it or if you cannot reduce it, stabilise it because what usually happens on a micro motion level is that during weight bearing, if you fix the Tibial tuberosity, the load of the leg will be transferred only on the plateau, and this is gonna likely can lead to tibial plateau shift, which will increase the tibial plateau angle over time and will predispose this patient to developing a cranial cruciate ligament disease.
So, in these fractures, even if they are minimally displaced, it's worth addressing them because that if, if they're not addressed, that adds just a bit of degree of unpredictability in regards to the outcome and how the the leg will function in the future and what's gonna develop. So in this case, I use the standard approach to the to the proximal tibia. I used the classicin tension bandwire for the tibial tuberosity.
And I also fixed the, the tibial plateau with 3 additional K wires. I did try to reduce it, but obviously, with such minimal displacement, even if you try to reduce it, which requires again, hyperextension of the stifle, the displacement, is Often minimal, and you can't really get it perfect. So in that case, you just fix and stabilise the, the.
Fragments as they are, as you can see, the pins are bent and they are bent only on the medial side. The reason why they're bent on the medial side is I'm putting them in tension like that purely because it will be a lot easier to remove. And just draw several small stab incisions on the medial side of the thigh.
Whilst if you're having a pin that you need to remove naturally, that requires a lot more dissection and just identifying the pin is a lot harder due to the largest soft tissue envelope. The patient came back 4 weeks postoperatively. As you can see, there is still quite, .
Large remodelling of the bone, there is there is some colours that you can see on the medial aspect in the cold the cranial bone . Image, the febrile fracture has completely healed. We can see that the patellar tendon is a bit irritated and .
There is some increased soft tissue swelling. There was also some mild irritation, from the pins on the soft tissues. So considering that, all the fractures have healed, I was happy to remove, these implants and I just removed them through a couple of small tiny.
Skin incisions and just pulled out the pins. The Wire was left in place because usually that will require a lot. Larger dissection and it's hard to be done on the just sedation, which is something that you do for for a postoperative radiographs.
And there was no issue with the tension but it's with the band itself, so it's not a problem if you just lose it. The removal of the pins will Release the restriction of the vices that was caused by the implants. So hopefully, the growth of the limb will continue as, as normal or let's say as close to normal as possible because as you can see from the radiograph, there is already a partial closure of the vices, which can lead to the complete closure to mature.
This is the last case for me. So I'll be happy to answer any questions.