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Fracture of the Long Bones

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Fracture of the Long Bones Fracture of the Long Bones 2 Kenneth D Newman1, DVM, MS, DACVS; David E Anderson , DVM, MS, Diplomate ACVS 1Private practice, Ontario, Canada 2Professor and Head, Agricultural Practices, Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66506, Phone 785-532-5700, Fax 785-532-4989, email [email protected] Fracture management in alpacas and llamas pres­ ing on the fixation method that is ultimately chosen ents a unique and interesting challenge to the veterinary to provide the best option. Sedation, using xylazine surgeon. The increasing popularity of camelids in North hydrochloride (alpacas 0.3 mg/kg IV, llamas 0.2 mg/kg America means veterinarians are more likely to see them IV), can facilitate patient positioning during radiographs as patients; therefore, dealing with camelid fractures is and therefore prevent further soft tissue damage and quickly becoming part of the normal caseload. Because result in better quality radiographs. Though xylazine is of the relatively high commercial value of most camelids, reported to be contraindicated in pregnant animals since clients will usually be willing to pursue treatment. it may precipitate early parturition during the third Camelids are considered to be excellent patients trimester, the authors have not observed any pregnancy for the treatment of orthopedic injuries because of their complications associated with the use ofxylazine. In the relative low body weight, their ability to ambulate on event of insufficient sedation achieved using xylazine three legs postoperatively, and tolerate external coap­ alone, butorphanol tartrate (0.05 mg/kg IV or 0.1 IM/SQ) tation devices and prolonged periods of recumbency for can be added to provide greater analgesia. recuperation after surgery. 27 For these reasons, the vet­ erinary surgeon has a full repertoire of repair techniques Patient Care During Recovery from Fracture available to choose from when determining the ideal repair option. Not surprisingly, the scientific literature Postoperative management has lagged behind the relatively rapid rise in camelid Postoperative management plays a crucial role 0 popularity; there are currently 62 case reports on ca­ in the success of fracture healing, and cannot be em­ "d 1 7 12 17 19 23 ('[) melid long bone fracture fixation. , - , , - This paper phasized enough. Though the surgery may have been ~ ~ will review the published literature on the management successful, improper management of the patient postop­ (') (') of long bone fractures. Fracture management includes eratively can lead to frustrating complications: implant ('[) en the preoperative, intraoperative and postoperative failure, re-fractures, cast sores, and nerve damage have en time periods. Emergency treatment, clinical workup, been reported in the literature. Fortunately, we have 8-:r:n principles of fracture repair, treatment, and prognosis observed these complications rarely. Regardless, a sec­ q- for specific long bone fractures and their complications ond repair attempt increases expenses and potential for [ will be discussed. complications, therefore decreasing the likelihood for a o· successful outcome. p Diagnosis The type and duration of antibiotic therapy is de­ The hallmark clinical sign of a limb fracture is a termined on a case-by-case basis. Open fractures, the non-weight-bearing lameness; however, other differen­ greater degree of soft tissue damage and fracture com­ tial diagnoses need also be considered. 9 Other clinical minution typically require longer periods of antibiotic signs include swelling, pain, and crepitation at the therapy, compared to simple closed fractures. Postopera­ fracture. In the author's experience, fractures involv­ tive analgesia is predominantly provided by using non­ ing the femoral head tend to be more subtle, since some steroidal anti-inflammatories (NSAIDs) such as flunixin weight bearing is possible. The neurovascular supply meglumine, phenylbutazone, and etodolac (Etogesic®). to the distal limb must be assessed prior to surgery to The use ofNSAIDs is not without some risks, including critically evaluate for neural or vascular compromise. gastrointestinal ulceration (ie: C3), delayed bone heal­ Compromise to these structures can have a significant ing, and kidney failure. The prolonged use of NSAIDs impact on the success of any fracture repair and may should be under veterinary guidance. The cardinal signs change the treatment options. Good quality radiographs of adverse effects include inappetence, oral ulceration, of at least two orthogonal views are required to properly and edema formation. Opioids, such as butorphanol or access the configuration of the fracture in order to deter­ fentanyl transdermal patches, may be used to provide mine repair options. Proper patient positioning and a more potent analgesia during the immediate postopera­ good technique chart are fundamental in producing good tive period in selected cases. quality radiographs. Open or closed fractures, hairline The length of hospitalization varies on a case-by­ or non-displaced fractures, the degree of comminution, case basis. Depending on the fracture configuration and or joint surface involvement will have a significant bear- the inherent strength of the repair method, a couple 108 THE AABP PROCEEDINGS-VOL. 42 of days hospitalization may be all that is required. union. Usually, two additional weeks of stall rest is Postoperative transportation represents an additional recommended after clinical union has occurred before (Q) challenge that requires additional planning and careful the patient may safely reintegrate with the herd. n thought. Though most patients may lie down during 0 "'O transportation, they should be transported in a separate Complications '-< ......'"i compartment away from direct contact with herd mates. The perceived incidence of morbidity and mortal­ (JQ There are some situations when prolonged hospitaliza­ ity associated with camelid fractures is now believed to g tion is required until sufficient callus has formed, or to be higher than what previously published case reports > 17 22 8 allow intensive wound management for open fractures. have suggested. • Possible explanations for this ap­ (D ......'"i The disadvantages of prolonged hospitalization include parent increased incidence include the reporting of more (") increased costs and patient stress. Stress associated subtle complications combined with long-term follow-up, § with the initial injury and prolonged hospitalization in a the attempted repair of more complicated fractures by >00 00 strange environment may predispose the development of surgeons, and case report bias. Similar to other spe­ 0 complications, including inappetence (ie: stall sickness) cies, complications of fracture repair include malunion, (")...... and gastric ulceration. The use of NSAIDs can com­ delayed union, non-union, osteomyelitis, implant failure, a...... 7 17 20 22 26 0 pound the risks of these complications developing. The sequestrum formation, and disuse osteopenia. , , - , ~ 0 oral administration of omeprazole may help reduce the Unlike in other species, soft tissue complications also 1-i; formation of gastric ulcers; however, the efficacy of oral include chronic lameness, hyperextension, osteoarthritis, to 0 omeprazole in camelids has recently been questioned. 28 and were more common than implant failure.22 If the < 5· A quiet, docile companion during hospitalization may patient suddenly stops using the affected limb, or there (D help prevent the development of stall sickness, improve is a sudden change in appearance, swelling, and pain ~ ~ appetite, and may even reduce stress. tolerance, veterinary attention is immediately required, (") ,-+-...... The patient's activity after surgery and throughout since these signs indicate complications. The incidence of ,-+-...... the convalescent period must be restricted. A small, dry, complications was not affected by the fixation method.1 0 ~ (D well bedded and ventilated stall that is protected from the Open fractures are more likely to have complica­ '"i elements is ideal. Limited outside access is permitted, tions such as osteomyelitis, compared to closed frac­ 00 0 provided it is dry and the area small. The affected limb tures. 22 Non-union due to the presence of osteomyelitis "'O (D should be inspected daily for use, warmth, signs of swell­ is a frustrating and expensive complication. Successful ~ ing, and surgical site infection. If the patient suddenly management requires rigid stabilization, and often f:; (") stops using the affected limb, or there is a sudden change requires a second surgery to debride and to place an (D 00 21 22 00 in appearance, swelling, or pain tolerance, veterinary autogenous cancellous bone graft. , Typically these 0........ attention is required, since these signs indicate compli­ cases also require prolonged parenteral antibiotics. 00 ,-+- cations. Bandages, when used, need to be kept dry; wet Culture and antimicrobial sensitivity testing may be '"i ~ bandages can cause severe skin irritation and infection. useful for determining antibiotic therapy. Antibiotic­ ~...... Bandages can get wet less obviously by wicking moisture impregnated polymethylmethacrylate (PMMA) beads 0 p directly from the ground. Ideally, bandage changes can placed adjacent to the site of infection may be useful, be done on the farm by the client. On rare occasions, based on the author's clinical impressions. the referring veterinarian may need to facilitate
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