Professional Documents
Culture Documents
6 June 1996
APPLICATION OF THE FIXATOR duce edema and limit displacement of fragments, per-
WITH CLOSED REDUCTION forming surgery within 7 days of injury to avoid severe
Closed repair with external skeletal fixation of radial muscle contraction and displacement of bones, and
and tibial fractures is based on functional limb realign- sound knowledge of regional anatomy to avoid major
ment using external skeletal traction; external manipu- neurovascular bundles and muscles and to gain maxi-
lation of fragments; and, if possible, percutaneous frac- mum bone purchase.15
ture reduction with pointed pelvic reduction forceps. Before surgery, the limb is clipped, scrubbed, and
Key elements for successful results include presurgical suspended in a hanging position from a ceiling hook or
support of the limb with a Robert-Jones bandage to re- intravenous fluid stand4,15,16 (Figure 1). Suspension of
the limb provides circumferential access
for pin placement and proximal and dis-
tal joint alignment in a parallel plane; in
addition, suspension overcomes muscu-
lar contractions and thus permits frac-
ture reduction. Suspension can be en-
hanced by lowering the surgical table
after connecting the paw to the stand or
ceiling hook, thereby elevating the ani-
mal’s body off the table. This technique
uses the weight of the patient to main-
Figure 5A Figure 5B
build the type II configuration (Figures 4 and 5). Proxi- Infection of the pin tract can be a major or minor
mal pins placed in the mediolateral plane of the tibia are condition, based on degree of inflammation, patient
inserted in the wide, massive caudal aspect of the bone. discomfort, and character of the drainage.22,23 Excessive
As with radial pin placement, lateral soft tissue channels pin motion and skin or soft tissue tension contribute
can be created to guide pins exiting from the bone. directly to infection. Minor infection of the pin tract is
characterized by a slight, serous drainage with little pa-
POSTSURGICAL CARE tient discomfort. It is often a normal consequence of
After pins are placed, any tension of the skin around transfixation, and controversy remains regarding the
a pin should be relieved with a small stab incision. need for treatment. Some surgeons advocate letting a
Controversy exists regarding proper postsurgical care of crust form around the pins, whereas others prefer daily
a limb treated with external skeletal fixation.20,22 Some cleaning with an antiseptic solution. Major infection of
surgeons use bandages to minimize swelling around the the pin tract consists of a persistent, copious, purulent
pins, and sterile gauze is packed around the pins and discharge with considerable patient discomfort. Major
under the connecting bar for variable times.20,23,24 An- sepsis of the pin tract is characterized by bacterial infec-
tibacterial ointment can be placed at the junction of tion, necrosis of soft tissues, and possibly, focal os-
the pin–skin interface to reduce bacterial contamina- teomyelitis. Treatment includes cleansing of affected
tion. Elastic bandage material should be placed around sites with an antiseptic solution, applying topical an-
the external skeletal fixator to keep the sponges in place tibiotics and bandages, removing loose pins, and ad-
and to prevent damage to the frame. Some surgeons ministering systemic antibiotics based on the results of
prefer to leave the limb uncovered and to control post- deep bacterial culture and antimicrobial sensitivity test-
surgical swelling and reactions at the junction of the ing.
pin–skin interface with daily hydrotherapy.21,25 Premature loosening of pins is corrected by removing
At our clinic, the pin–skin site is covered by antibiot- the pin. This complication is the result of improper
ic-ladened gauze sponges, and the limb is wrapped with drilling (excessive speeds or hand motion) or location
soft, padded bandages for 24 to 48 hours to control of the pin in fissures. If the pin is still essential to the
swelling from the original trauma and surgery. Daily stability of the external skeletal fixation, another pin
hydrotherapy is then performed to maintain cleanliness should be inserted in the bone in the same vicinity.
of skin tracts and to reduce swelling, pain, and muscle Pressure necrosis of the skin occurs when clamps and
spasm.26 For home care, clients are instructed to clean connecting rods are placed too close to the skin surface,
pin–skin sites daily with cotton-tipped applicators and thus not allowing sufficient space for postsurgical tissue
dilute chlorhexidine or warm water. swelling. The clamps should be placed 1 to 2 centime-
Pin clamps should be checked weekly to ensure tight- ters away from the skin surface. Treatment for skin
ness. Radiographs should be obtained at approximately necrosis consists of hydrotherapy and physical therapy
4- to 6-week intervals to evaluate healing. Examina- to reduce swelling. In addition, topical medication
tions are based on signalment of the patient and type of should be applied to affected sites and the bandage at
fracture. As bone healing progresses, the fixator can be the pin–skin interface should be packed to reduce mo-
disassembled by removing pins to decrease stiffness, tion.
which enhances fracture remodeling. Loose pins (usual- Soft tissue impalement increases patient morbidity.
ly smooth, centrally positioned pins or the most proxi- Percutaneous pins usually push aside rather than trans-
mal threaded pin near the high-motion region of the fix neurovascular bundles. If profuse hemorrhage due
stifle or elbow joint) are removed first, and tight pins to vascular laceration occurs during surgery, treatment
are removed after confirmation of clinical and radio- includes pin removal, temporary cancellation of
graphic union. Experimental data reveal increased me- surgery, and application of a Robert-Jones bandage for
chanical strength and primary bone remodeling in tib- 24 to 48 hours. Percutaneous pins can also be placed
ial osteotomies destabilized by reducing type III to type through myotendinous structures, which leads to mus-
I fixators at 6 weeks after surgery.27 cle pain, reduced physical activity, and decreased joint
mobility. Treatment involves pin removal and insertion
COMPLICATIONS at another site or selection of an alternate mode of fixa-
Potential complications with the use of an external tion.
skeletal fixator can be avoided by adhering to the basic
guidelines and principles of external skeletal fixation CLINICAL CASES
application. Common problems often relate to the fixa- A summary of 14 dogs with radial and tibial fractures
tor and not to fracture healing. treated with external skeletal fixation applied in a
Labrador retriever Hit by car Comminuted mid-shaft left radius and II, double None 6 years IV
9 years old, 33 kg ulna lateral bar
Labrador retriever Hit by car Comminuted midshaft left tibia and II None 4 months III
3 years old, 21 kg fibula
Sheltie cross Hit by car Oblique midshaft right radius and distal II Pulmonary contusion and 3 months III
2 years old, 24 kg ulna edema
Great Dane Hit by car Open comminuted distal right tibia II Metatarsal and phalangeal 2.5 years III
1 year old, 40 kg fractures; degloving injuries
on the left shoulder and hock
Border collie Railroad tie Comminuted midshaft right radius and II None 2 years III
4 years old, 14 kg fell on leg transverse midshaft ulna
Siberian husky Hit by car Transverse midshaft right radius and ulna II None 7 months IV
7 years old, 30 kg
Transverse midshaft femur; delayed union I Refracture due to
second trauma
Pomeranian Jumped off Bilateral transverse distal radius and ulna II None 1.5 years IV
1 year old, 3 kg bed (both limbs)
Vizsla Jumped out Comminuted midshaft right tibia and II None 6 months IV
8 years old, 24 kg of truck fibula
Labrador retriever Jumped out Comminuted midshaft left radius and II with None 2 years IV
3 years old, 40 kg of boat oblique midshaft ulna intramuscular
pin in ulna
Labrador retriever Hit by car Comminuted midshaft right radius and II Right hip dislocation 1.5 years III
10 years old, 30 kg transverse distal ulna
The Compendium June 1996
The Compendium June 1996 Small Animal
IV
IV
IV
Patients ranged in age from 7 months to 10 years and
function: I = no functional limb usage; limb carried most of the time. II = slight functional limb usage; limb carried during running but set down during walking.
varied in weight from 3 to 40 kilograms. Labrador re-
trievers were the breed most frequently seen, probably be-
cause of their popularity in the Northwest. Motor vehicle
Follow-Up
1 year
1 year
The open or closed nature of the fractures could not al-
ways be discerned from the medical records and, excluding
one case, all injuries involved the radius and ulna or tibia
and fibula. A type II (bilateral-uniplanar) fixator was used
in all animals to stabilize the fractures. In dogs treated be-
Concurrent Injuries
None
None
III = moderate functional limb usage and partial weight bearing; lameness evident. IV = complete, normal functional limb usage. file, threaded pins in proximal and distal positions was
used. Metal connecting bars were used in all dogs.
At the time of follow-up, 9 of 14 dogs were charac-
terized by a lameness score of IV (normal function). In
the remaining 5 dogs, which were characterized by a
grade III (moderate function) lameness score, 3 dogs
Fixator Type a
II
II
TABLE I (continued)
CONCLUSION
Closed reduction, external skeletal fixation, and in-
traoperative skeletal traction are useful approaches for
type II = bilateral-uniplanar configuration.
fibula
Hit by car
Labrador retriever Kicked by
History
Labrador retriever
3 years old, 40 kg
2 years old, 33 kg
Signalment