Broken Bones – From Triage to Bony Union - … · Broken Bones – From Triage to Bony Union...
Transcript of Broken Bones – From Triage to Bony Union - … · Broken Bones – From Triage to Bony Union...
4/1/2014
1
Broken Bones –From Triage to
Bony UnionSteven G. Baker, DVM, MS, Diplomate ACVS-SA
Staff Surgeon
Grayslake | Chicago | Crestwood | PremierVets.net
Emergency Management
Most fractures are traumatic in nature
Vehicular or similar collision
Stabilization (systemic)
Cover wound if present
History and physical exam (prioritized)
Grayslake | Chicago | Crestwood | PremierVets.net
Diagnostics Pulse oximetry
Blood pressure, ECG
Blood work
Thoracic radiographs
Abdominal radiographs +/- contrast
Neurologic assessment
Orthopedic assessment
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
2
Grayslake | Chicago | Crestwood | PremierVets.net
Diagnostics Pulse oximetry
Blood pressure, ECG
Blood work
Thoracic radiographs
Abdominal radiographs +/- contrast
Neurologic assessment
Orthopedic assessment
Grayslake | Chicago | Crestwood | PremierVets.net
Bladder rupture
Grayslake | Chicago | Crestwood | PremierVets.net
cvm.umn.edu
4/1/2014
3
Diagnostics Pulse oximetry
Blood pressure, ECG
Blood work
Thoracic radiographs
Abdominal radiographs +/- contrast
Neurologic assessment
Orthopedic assessment
Grayslake | Chicago | Crestwood | PremierVets.net
Diagnostics Pulse oximetry
Blood pressure, ECG
Blood work
Thoracic radiographs
Abdominal radiographs +/- contrast
Neurologic assessment
Orthopedic assessment
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
4
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Diagnostics Finally, radiographs of fracture
Include entire bone(s)
Proximal and distal joints for alignment
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
5
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
6
Therapy Fluids
Analgesia
Systemic
Epidural / spinal
Local / regional blocks
Wound care
Temporary stabilization
Appendicular skeleton
Potential spinal fracture
Grayslake | Chicago | Crestwood | PremierVets.net
Describing fractures What bone(s)
Portion of bone
Diaphysis, metaphysis, epiphysis, articular surface
Physeal – Salter-Harris classification
Morphology
Complete v incomplete
Simple v comminuted
Transverse, short v long oblique, spiral, segmental
Displacement
Open v closed
Chronicity
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
7
Grayslake | Chicago | Crestwood | PremierVets.net
Open Fractures
Unique combination of orthopedic and soft tissue injury
Infection
Delayed Union
Non-Union
Veterinary Surgery Small Animal. 2012 Saunders
Grayslake | Chicago | Crestwood | PremierVets.net
Open Fractures - Ultimate Goals
Prevent infection and further soft tissue damage
Address/treat soft tissue
damage
Promote bony union
Restore function
4/1/2014
8
Open Fracture Classification
Type I: An open fracture with a wound smaller than 1 cm
Surrounding soft tissues are mildly/moderately contused. Frequently the external wound is created from the inside out by sharp bone fragments
Type II: An open fracture with a wound larger than 1 cm without extensive soft tissue damage, flaps, or avulsions
The external wound typically is created from the outside in by high energy forces
Open Fracture Classification
Type III: An open fracture with extensive soft tissue damage. Soft tissue avulsion, de-gloving injury, and bone loss are frequently noted. These include fractures with accompanying neurovascular injury requiring repair, gunshot injuries, and traumatic partial amputations IIIA: Adequate soft tissue coverage despite extensive soft tissue
laceration or flaps
IIIB: Extensive soft tissue loss, periosteal stripping and bone exposure
IIIC: Associated arterial injury requiring repair
4/1/2014
9
Wound Management
Confirm patient stable
Classify wound
Copious K-Y (sterile)
Clip wide
Clean surrounding skin
Copious wound lavage
Cut (debride necrotic tissue)
+/- Culture
Cover (bandage) wounds
Rigid external support
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
10
Initial Surgical Debridement
Appropriate debridement irrigation and rapid stabilization (temporary)
No supportive literature on difference in infection rates comparing initial surgical debridement < 6 hours or > 6 hours
Treatment and prognosis of open fractures should not be based on a time interval alone
Soft tissue damage, viability, contamination, infection
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
11
Open Fractures: ANTIBIOTICS
Required component of successful outcome
Timing: < 3 hours after injury significantly lower infection rate compared to 4 hours or greater
Coverage
Type I or II: First generation cephalosporin
Type III: Broader coverage, cephalosporin and fluoroquinolone
Nosocomial Infections (82%)
Grayslake | Chicago | Crestwood | PremierVets.net
Open Fractures – Soft tissue treatment
Restoration of a soft tissue envelope
Pedicle muscle transfers
Microvascular free muscle transfers
Local skin/transposition flaps
Axial pattern flaps
Free skin grafts
Vacuum-assisted therapy
Grayslake | Chicago | Crestwood | PremierVets.net
Open Fracture Treatment
Bone plates, plate rod, interlocking nail and external skeletal fixators
Type I fractures often treated similar to closed
External coaptation not recommended for definitive fixation
Type III/severely contaminated
External skeletal fixator
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
12
Fracture forces Compression
Distraction / tension
Bending
Rotation
Shear
Fragment apposition
Grayslake | Chicago | Crestwood | PremierVets.net
Bone Healing - physiology
Primary bone healing
Direct osteon formation across fracture site
Cutting cones
Contact v gap healing
Requirements
Rigid immobilization
Anatomic reduction
No callus formation
Slower than secondary
Grayslake | Chicago | Crestwood | PremierVets.net
vet.upenn.edu
Bone Healing - physiology
Secondary bone healing
Phases
Inflammatory
Soft callus
Hard callus
remodeling
Requirements
Immobilization
Vascular supply
Faster than primary
Grayslake | Chicago | Crestwood | PremierVets.net
aovet.org
4/1/2014
13
Fixation options
External
Coaptation
PROS: no destruction of blood supply, less cost, less anesthetic risk, less invasive
CONS: owner compliance, pet tolerance, frequent changes, muscle atrophy / contracture, soft tissue wounds
FORCES: partially counteracts bending and rotation, not shear
TYPES: many
Grayslake | Chicago | Crestwood | PremierVets.net
Definitive Stabilization (External Coaptation)
Distal to elbow/stifle
Incomplete fractures
Simple minimal/non-displaced
Young
Financial constraints
Cost of bandage changes or
complications
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
14
Grayslake | Chicago | Crestwood | PremierVets.net
Reduce further injury:
Soft tissue (neurovascular)
Musculoskeletal
Attenuate painful stimulus
Prevention of open fracture
Temporary Fracture Stabilization
Bandage Anatomy
Tape stirrups
Primary Layer (if wound)
Adherent
Non-adherent
Secondary Layer (absorb and support)
Cast Padding
Kling
Tertiary Layer (support and protect)
VetWrapRIGID SUPPORT
Grayslake | Chicago | Crestwood | PremierVets.net
Bandage Anatomy
Open v closed toe
Advantages of open
Swelling
Slippage
Temperature
Ease of stirrups
Advantages of closed
Less digit mobility
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
15
Types of Rigid Support
Grayslake | Chicago | Crestwood | PremierVets.net
www.3M.com
anicareas.com
alfavet.bg
Cast v splint
Preformed
Metal
Plastic
Custom
Fiberglass
Orthoplast
GUIDE TO THE DISSECTION OF THE DOG, SEVENTH EDITION, 2010 Saunders Elsevier
Temporary Fracture Stabilization
Humerus
Spica or nothing
Radius/Ulna (or distal)
Modified Robert Jones
Femur
Spica or nothing
Tibia/Fibula (or distal)
Modified Robert Jones
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
16
Splints
Applications
Temporary support
Destabilization after casting
Support for partial immobilization
Primary fixation for certain
fractures
Grayslake | Chicago | Crestwood | PremierVets.net
Bandage Complications
Moist dermatitis
Muscle atrophy
Skin necrosis / gangrene
Valgus deformity of the forelimb
Amputation of limb or digits
Death
Closely monitor bandages and digits
Swelling, warmth, odor, moisture
Grayslake | Chicago | Crestwood | PremierVets.net
63% developed soft tissue injury
60% mild, 20% moderate, 20% severe
Can occur at any time frame, no association with duration of cast/splint
Cost of treatment 4-121% cost of original orthopedic procedure
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
17
External Coaptation
Toy breed
Distal radius/ulna fracture
High risk of malunion or nonunion
Why?
High interfragmentary strain
Poor apposition
Decreased intraosseous blood supply
Grayslake | Chicago | Crestwood | PremierVets.net
Fixation options
External
External skeletal fixator (ESF)
FORCES STABILIZED: potentially all 5
PROS: fracture site not disturbed, implants easily removed, dynamization, adaptable to 3D anatomy
CONS: patient / owner compliance, pin tract drainage, implant loosening or breakage, soft tissue damage
TYPES: Ia, Ib, II, III, circular, Ilizarov, ring, hybrid, tie-in, transarticular, acrylic, etc.
Typically secondary bone healing
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
18
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
19
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
20
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
21
Grayslake | Chicago | Crestwood | PremierVets.net
ESF adaptability
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
22
Grayslake | Chicago | Crestwood | PremierVets.net
Fixation options
Internal
Intramedullary pin
FORCES: partial bending; not rotation, shear, or apposition
Rarely used effectively alone
Pin + wire
FORCES:
Only used in very specific fracture configurations
Long oblique diaphyseal
Not radius
Rush pins
Cross pins
Grayslake | Chicago | Crestwood | PremierVets.net
Fixation options
Internal
Cerclage wire
PROS: fragment apposition
CONS: minimal counteraction of bending forces
Must be combined with other fixation
Can produce shear forces
Must perfectly reconstruct cylinder
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
23
Fixation options
Internal
Bone plates
FORCES COUNTERACTED : all
PROS: early return to function (usually), excellent fragment apposition, massive variety of types, locking technology
CONS: cost, invasiveness, potential for stress protection
Can add IM pin or cerclage wire for additional stabilization
Option of application in neutralization, compression or buttress fashions
Potential for minimally invasive plate osteosynthesis
Grayslake | Chicago | Crestwood | PremierVets.net
Fixation options
Internal
Interlocking nail
FORCES COUNTERACTED: all
PROS: minimal disturbance of fracture site, faster healing, potential for dynamization
CONS: cost, implant removal exceedingly difficult, technical problems
Only amenable to specific fracture configurations in certain bones
Secondary bone healing
New system (I-LOC by Biomedtrix) is promising
Grayslake | Chicago | Crestwood | PremierVets.net
biomedtrix.com
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
24
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
25
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
26
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
27
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
28
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
4/1/2014
29
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net
Grayslake | Chicago | Crestwood | PremierVets.net