Preoperative planning in veterinary orthopaedics

Preoperative planning in
Veterinary Orthopaedics
CAPT. DR. RAVI RAIDURG
M.V.Sc (Surgery), PhD
Associate Professor & Head,
Department of Surgery & Radiology, Veterinary College,
Vinoba Nagar, Shivamogga 577 204, Karnataka, India
Phone: +919449827183, E mail: raviraidurg@gmail.com 1

raviraidurg@gmail.com
2
PROGENY PPAK WEBINAR SERIES

S.No Webinar Topics
1 Preoperative planning in Veterinary Orthopaedics
2 Evolution of Internal Fixation in Veterinary Orthopaedics
3 Methods of fracture repair in Veterinary Orthopaedics
4 Plate Osteosynthesis – Terminologies and Instrumentation
5
Open Reduction and Internal Fixation (ORIF) for long bone
fracture repair in dogs
6
Management of long bone diaphyseal fractures with minimal
invasive plate osteosynthesis (MIPO)in dogs
3
PROGENY PPAK WEBINAR SERIES

For every fracture,
there are more than one method of
fixation that will lead to acceptable
results
4

For every fracture,
there are more than one method of
fixation that will lead to acceptable
results
and
many more that will lead to
unacceptable results
5

Preoperative planning
in Veterinary Orthopaedics
Aim : Introduce the concept of “ Preoperative planning in
Veterinary Orthopaedics”
Learning Objectives
At the end of this session you should be able to:
• Describe Fracture healing (Primary vs Secondary bone healing)
• Describe Fracture Classification
• Describe AO Fracture Classification of Long bones (eg AO 32 A3
???)
• Derive a Fracture Patient Assessment Score (FPAS) and describe
factors (mechanical, biological and clinical) which support the score.
• List Preoperative planning in MIO (Minimally Invasive
Osteosynthesis)
6

S.
No
Topic
Time
(min)
Slides
1 Introduction 10 01-12
2 Case presentations 15 13 - 39
3 Fracture healing
20
40 – 47
4 Fracture classification 48 – 59
5 AO Fracture classification of long bones 60 – 68
6 FPAS (Fracture Patient Assessment Score)
30
70 – 79
7 Treatment guidelines based on FPAS 80 – 140
8
Preoperative planning in MIO
(Minimally Invasive Osteosynthesis)
10 141 – 158
9 Summary 05 159 – 160
7
SESSION OUTLINE (90 Min)

Cases presented to Veterinary
College Shivamogga (2015 – 2018)
Humerus
8

Case example
14 Year old, 5 kg dog (SPITZ) ie
GERIATRIC DOG
Diaphyseal long oblique /
Spiral fracture
9
How could I fix this
1. POP cast (Conservative
method)
2. Wiring
3. External fixator (ESF)
4. Internal fixator
IMP
IMP + wiring
IMP + Thomas splint
ILN (Interlocking Nails)
TENS (Titanium elastic nail system)
PO (Plate osteosynthesis ie Bone plating)

Results of the Poll
10

Case example
14 Year old, 5 kg dog (SPITZ) ie
GERIATRIC DOG
Diaphyseal long oblique /
Spiral fracture
11
Internal fixator
1. IMP
2. IMP + wiring
3. ILN (Interlocking Nails)
4. Lag Screw with Plate osteosynthesis (Bone plating)

Results of the Poll
12

Case No 1
13

Humerus
Case No 4946_25 Nov 2015
14
A 14 Year old, 5 kg dog ie GERIATRIC DOG
Diaphyseal long oblique / Spiral fracture

Humerus Case No 4946_25 Nov 2015
15

16

17

18

19
6 th Week Post Operative

20

Case No 2
21

Humerus
Case No 8698 dated 07 Dec 2015
22
A 05 mth, 45 kg dog ie JUVENILE DOG
Diaphyseal Transverse fracture with longitudinal slit in distal fragment

Humerus_ Case No 8698 dated 07 Dec 2015
A 05 mth, 45 kg Great Dane Pup ie JUVENILE DOG
Diaphyseal Transverse fracture with longitudinal slit in
distal fragment
23

24
distal fragment

Humerus_ Case No 8698_GD_07 Dec 2015
Diaphyseal Transverse fracture with longitudinal slit
in distal fragment
25

26
distal fragment

27
distal fragment

28
distal fragment

29
10 th Post Operative day
distal fragment

303 rd Week Post Operative day
distal fragment

31
3 rd Week Post Operative day
distal fragment

32
17 th Week Post Operative day
distal fragment

Humerus_ Case No 8698_GD_07 Dec 2015
Diaphyseal Transverse fracture with longitudinal slit
in distal fragment
33
30th Month Post Operative day

Case No 3
34

Humerus
Case No 10148 dated 27 June 2016
35
A 2 ½ Year old, 22 kg Mudhol Hound dog
Transverse fracture in distal fragment

36
Humerus

37
Humerus

38
Humerus

39
Humerus

Preoperative planning in Veterinary
Orthopaedics
40

Learning Objectives
At the end of this session you should be able to:
• Describe Fracture healing
(Primary vs Secondary bone healing)
• Describe AO Fracture Classification of Long bones (eg AO 32 A3 ???)
• Derive a Fracture Patient Assessment Score (FPAS) and describe factors
(mechanical, biological and clinical) which support the score.
• List Preoperative planning in MIO (Minimally Invasive Osteosynthesis)
41

FRACTURE HEALING
PRIMARY BONE HEALING
SECONDARY BONE HEALING
42

FRACTURE HEALING
• Rigidly stabilised fracture fragments with direct
contact between them heal by migration of ‘cutting
cones’ (comprising osteoclasts and osteoblasts)
from one fragment to the other, resulting in
reformation of lamellar bone (Haversian
remodelling) without any requirement for precursor
tissue or callus.
• The lack of a callus phase can be very important in
some cases, particularly when joints are affected.
43

FRACTURE HEALING
• ‘Gap healing’, in which rigidly stabilised fragments
are separated by a gap of up to 1 mm, is a slight
variation of this mechanism.
• The space is initially filled by lamellar bone
orientated at 90° to the long axis of the bone,
which enables the cutting cones to migrate across
the gap and reorientate the lamellar bone.
44

FRACTURE HEALING
• Clinical union takes significantly longer to achieve with primary bone healing than
secondary bone healing, and therefore relies on implants for longer.
• Primary bone healing can only be obtained with the use of internal fixation due to the
requirement for absolute rigidity with less than 2 per cent strain at the fracture site.
45

FRACTURE HEALING
• Fragments separated by a gap of more than 1 mm or with an interfragmentary strain
greater than 2 per cent will undergo secondary bone healing.
• This involves the formation of tissues (ie, callus) that can cope with the strain occurring
at the fracture site. As increased stability is conferred by the callus, the next tissue in the
sequence forms, which increases stability still further and, in turn, allows the next tissue
to form, until bone tissue can once again fill the fracture gap.
46

47

Learning Objectives
At the end of this section you should be able to:
48

Fracture classification
■ Cause
■ Open or closed
■ Extent of bone damage
■ Number and position of fracture lines
■ Direction
■ Location
■ Forces acting on the fracture
■ Stability
■ Degree of soft tissue damage
49

CAUSE OF THE FRACTURE
Intrinsic
■ MUSCULAR (eg, tibial tuberosity avulsion secondary to quadriceps muscle
contraction).
■ PATHOLOGICAL (eg, secondary to a primary bone neoplasm).
■ STRESS (a multiple low-grade trauma can eventually result in a fracture).
Extrinsic
• Extrinsic fractures are caused by external trauma (eg, a
• road traffic accident).
50

OPEN/CLOSED FRACTURE
• Radiographs should be examined for signs of gas shadows within the soft tissue
planes that may suggest communication with the external environment.
• Open fractures should be graded
51

■ OPEN VERSUS CLOSED
• Open fractures are more challenging to treat due to the risks of infection and the
potential for damage to the soft tissues surrounding the bone. The importance of
soft tissue damage is reflected in the grading system used to describe these
fractures:
GRADE 1. The skin has been punctured by a sharp bone fragment that has usually
retracted back beneath the surface. There is typically only mild soft tissue damage
associated with the relatively small wound;
GRADE 2. The skin lesion is due to extrinsic trauma leaving a variable-sized soft
tissue deficit and more severe damage to the surrounding tissues. Foreign material may
be present within the wound;
GRADE 3. There is extensive loss of multiple tissue types due to extrinsic trauma. The
fracture is usually fragmented due to the high-energy nature of the injury.
Neurovascular injury is likely and could cause complications.
52

EXTENT OF BONE DAMAGE
Incomplete
■ GREENSTICK. Young animals can fracture one cortex, with the opposite cortex
undergoing plastic deformation rather than fracture (like snapping a green stick).
■ FISSURE. Radiographs should be examined carefully for fissures leading away from
a fracture line, as they can greatly increase the complexity of the repair or progress to a
full fracture if not addressed. A fissure is often associated with comminuted fractures.
■ DEPRESSED. Depressed fractures usually occur in the skull.
Complete
• Complete fractures involve both cortices of the bone.
53

NUMBER AND POSITION OF THE FRACTURE LINES
■ SIMPLE. One fracture line without small fragments of bone.
■ SEGMENTAL. Two or more fracture lines that do not communicate with each other.
■ COMMINUTED. Two or more fracture lines that do communicate with each other.
This type of fracture is usually associated with high-energy trauma and therefore
extensive soft tissue damage.
54

55
DIRECTION OF FRACTURE LINES
■ TRANSVERSE. The fracture line is perpendicular to the long axis of the bone.
■ OBLIQUE. Generally, a fracture that is 1·5 to two times longer than the diameter of the
bone (or longer) is considered oblique. The point when a short oblique fracture is
classified as a transverse fracture is a unclear.
■ SPIRAL. The fracture line curves around the bone (usually due to a twisting force)
creating a complex three-dimensional fracture.

56
FRACTURE LOCATION
■ DIAPHYSEAL. Cortical bone is affected
and the
fracture can be described as proximal, mid or
distal.
■ METAPHYSEAL. Cancellous bone
situated towards the ends of the bones
(metaphyses) has differing characteristics of
implant holding and will often heal more
quickly once stabilised than diaphyseal bone.
■ ARTICULAR. Once a joint suffers a
fracture, a degree of secondary osteoarthrosis
is inevitable, but the extent of the
degeneration and effect on joint mobility can
be minimised by appropriate and prompt
fracture management.
■ CONDYLAR.

57
FRACTURE LOCATION
■ PHYSEAL. Fractures involving the physis
of skeletally immature bones are classified
according to the Salter-Harris system.
Smooth implants that cross the physis
perpendicular to the direction of growth and
occupy as little of the physeal area as
possible are ideal for repair in order to
preserve as much growth potential as
possible. Fracture location and configuration
usually dictate implant orientation away from
this ideal, with the result that implants are
removed in very immature animals to allow
continued growth. Unfortunately, despite
gentle handling, growth disturbances are
common following physeal injury and
owners should be made aware of this.

Forces acting on Bone
Bending Torsional Axial compression
Axial tension Shearing

Learning Objectives
• Describe AO Fracture Classification of Long
bones (eg AO 32 A3 ???)
59

AO
FRACTURE CLASSIFICATION OF
LONG BONES
60

1958 AO/ASIF
(Arbeitsgemeinschaft fur osteosynthesefragen)
Maurice Müller, Martin Allgöwer, Hans Willenegger,
Robert Schneider and Robert Mathys (Switzerland)
• Plate and screw osteosynthesis.
• A group of Swiss orthopaedic surgeons formed the
Arbeitsgemeinschaft fur osteosynthesefragen (AO), also
known as the Association for the Study of Internal Fixation
(ASIF).
• The principles for fracture management developed by the AO
group defined the standard of care for fracture
61

62
1958
AO founded in Biel (Bienne)
November 6, 1958, Hotel Elite
Biel (Bienne), Switzerland

63
1958 AO
Founders
Arbeitsgemeinschaft für Osteosynthesefragen
Maurice Müller
Zürich
1918−2009
Martin Allgöwer
Chur
1917−2007
Walter Bandi
Interlaken
1912−1997
Robert Schneider
Grosshöchstetten
1912−1990
Hans Willenegger
Liestal
1910−1998

64
• The first symbol of the alpha-numeric code represents
the fractured bone, humerus is coded as 1, Radius –
Ulna as 2, femur as 3 and tibia which was coded as 4.
• The second symbol represents “location of the fracture”
ie Proximal as 1, middle diaphyseal as 2 and Distal as 3
• Simple (A), wedge (B) and complex fractures (C).
• A1 incomplete fractures.
• A2 indicates diaphyseal simple oblique fractures,
• A3 indicates diaphyseal simple transverse fractures,
• B1 indicates diaphyseal one reducible wedge,
• B2 indicates diaphyseal several reducible wedge
• B3 indicated diaphyseal non-reducible wedge.
• C1 indicates Complex reducible wedge
• C 2 indicates Complex segmental wedge,
• C3 indicates Complex non reducible wedge,
AO 32 A3

65
AO
FRACTURE CLASSIFICATION OF LONG BONES

66
AO

67
AO

68
AO

Learning Objectives
• Derive a Fracture Patient Assessment Score
(FPAS) and describe factors (mechanical, biological and clinical) which
support the score.
69

FPAS
(Fracture Patient Assessment Score)
70

FPAS
• The FPAS is a simple 1 -10 scoring system that is determined
by evaluating pertinent mechanical, biological, and clinical
factors to determine the relative needs of the fracture case.
• The “10” end of the scale indicates ideal conditions (i.e. good
news) and the “1” end represents the most challenging
conditions (i.e. bad news) .
• Acknowledging that each and every orthopedic patient is
different, it is advisable to derive a FPAS for each patient prior
to treatment.
71

FPAS
72
1 ☺10
Marked instability Moderate instability Mild instability
MECHANICAL
Non-Load-Sharing Partial Load-Sharing Ideal Load-Sharing
Large Patient Size Medium Patient Small Patient Size
FACTORS
Multi-limb dysfunction Moderate multi-limb Single limb dysfunction
CLINICAL
FACTORS
Unwilling to follow-up Questionable followup Willing/able to follow-up
Owner
Unable to restrict activity Willing to try Able to restrict activity
Intolerant of activity restrict Somewhat tolerant Tolerant of activ. restr..
Patient
Rambunctious Active, but responsive Calm
Intolerant of treatments Difficult to treat Easy to treat
BIOLOGICAL
FACTORS
Severe tissue injury Moderate tissue injury Minimal tissue injuryLocal Factors
Comminuted Transverse/Oblique Spiral Greenstick
Open Fx – Type III Type II Type I Closed Fracture
Previous radiation Tx
Systemic Geriatric Mature Adult Immature Patient
Factors Debilitated/ill Compensated illness Healthy
Second-hand smoke?

FPAS
MECHANICAL FACTORS
73

FPAS MECHANICAL FACTORS
74
The amount of loading that a given
fixation device must withstand is
influenced by the following factors:
• palpable stability of the fracture zone,
•
• the number of dysfunctional limbs,
•
• the patient’s coordination and agility
•
• the patient’s weight,/size, and
•
• the degree of “load-sharing”
anticipated between the fixation
device and the bony column.
1 ☺10
MECHANICAL
FACTORS
CLINICAL
FACTORS
Owner
Patient
BIOLOGICAL
FACTORS
Second-hand smoke?

75
Fig 1: Ideal load-sharing Fig 2: Non-load-sharing Fig 3: Partial load-sharing
The mechanical FPAS shifts downward (toward 1) when
there is multi-limb dysfunction, a large, clumsy patient,
and/or the anticipation of a non-load-sharing
osteosynthesis.

FPAS
CLINICAL FACTORS
76

FPAS CLINICAL FACTORS
77
• Poor patient/owner compliance leads to excessive
patient activity and/or insufficient physical
therapy.
• Fracture treatment plans should be made with
possibility of poor exercise restriction kept in
mind.
• Poor anticipated compliance shifts the FPAS
downward. Since poor patient/owner compliance
invariably increases the mechanical demand upon
the fixation, the clinical FCAS is averaged with
the mechanical FPAS to derive a total mechanical
score.
• Sometimes owner compliance concerns cause
us to avoid the use of External Skeletal
Fixation.
• In attempt to shift the FPAS toward 10, I spend
extra time with pet owners explaining the
importance of exercise restriction as well as the
potential consequences of failing to do so
(especially in challenging fracture cases).
1 ☺10
MECHANICAL
FACTORS
CLINICAL
FACTORS
Owner
Patient
BIOLOGICAL
FACTORS
Second-hand smoke?

FPAS
BIOLOGICAL FACTORS
78

FPAS BIOLOGICAL FACTORS
79
• Bone healing is influenced by
• local factors(fracture zone):
open fractures, severe soft tissue
disruption, and previous local
radiation fields.
• Systemic factors: old age,
cachexia, and systemic illness.
• Each of these local and systemic
factors will shift the biological
FPAS toward 1. Conversely, bone
healing is more rapid in closed
fractures with minimal soft tissue
injury, and in young, healthy,
well-nourished patients; each of
which shifts the FPAS toward 10.
1 ☺10
MECHANICAL
FACTORS
CLINICAL
FACTORS
Owner
Patient
BIOLOGICAL
FACTORS
Second-hand smoke?

TREATMENT GUIDELINES
BASED ON PRE-OPERATIVE FPAS
80

81
FPAS 1 – 3

82
FPAS
1 – 3
1 ☺10
MECHANICAL
FACTORS
CLINICAL
FACTORS
Owner
Patient
BIOLOGICAL
FACTORS
Second-hand smoke?
AO 32 C1

• Cases in which the overall FCAS =1-3 require an orthopedist who
is an expert (5-10 years of frequent use) with the chosen fixation
system.
• Fixation systems considered are bone plates, interlocking nails
(IN), or plate + IM pin combinations, ESF +/- IM pin.
Percutaneous application of an internal fixator is a consideration.
• There is no room for technical or judgment error or excessive soft
tissue manipulation.
• A careful balance between mechanical stability and preservation of
soft tissue integrity is vital as dictated by the mechanical and
biological FPAS.
• There is significant risk of complications requiring surgical
revision even with logical use of the FPAS, error-free application of
the fixation, and attentive postoperative care.
83
FPAS 1 - 3

• When mechanical FCAS = 1-3, strict attention must be paid to maximizing
fixation strength. The fixation device must be modern and its application
must use flawless technique.
• When biologic FCAS = 1 -3 or preoperative radiographs suggest that
anatomic fracture reconstruction is unlikely or extremely cumbersome
(non-reconstructable), the surgical priorities shift from anatomic
reconstruction to spatial alignment, preservation of soft tissue viability and
rigid fixation capable of withstanding the stresses of non-load-sharing
fixation for the estimated healing period.
• Closed (percutaneous) approaches are desired and can often be applied to
the radius and tibia utilizing a hanging limb position.
• Such applications to the humerus and femur are challenging; Open But Do
Not Touch (OBDNT) applications are used if needed. Cancellous bone
grafting is employed in open approaches.
• Attentive convalescent care and monitoring is critical.
84
FPAS 1 - 3

FPAS 1 - 3
Case no 10295
Femur_26 July 2016 AO 32C1
85

FPAS 1 - 3
Case no 10295, 26 July 2016, Femur
86
Preoperative Planning

FPAS 1 - 3
Pre Op Post Op
87

Post Op 03 Weeks Post Op
88
FPAS 1 - 3

89
FPAS 4 – 6FPAS 4 – 6

90
FPAS
4– 6
1 ☺10
MECHANICAL
FACTORS
CLINICAL
FACTORS
Owner
Patient
BIOLOGICAL
FACTORS
Second-hand smoke?
AO 13 A1

• Cases in which the overall FPAS = 4-6 require an orthopedist with considerable
experience (3-5 years of frequent use) with the chosen fixation system.
• Fixation systems considered are bone plates, interlocking nails (IN), plate + IM
pin combinations and ESF +/- IM pin fixation. Minor technical error or slightly
excessive soft tissue manipulation often causes failure.
• The balance between mechanical stability and preservation of soft tissue integrity is
important and is not forgiving in these patients. Attentive postoperative care is
important. There is risk of implant complications, but revision surgeries are
uncommon if logical application of the FPAS, error-free application, and
thoughtful convalescent care are employed.
91
FPAS 4 - 6

• When mechanical FPAS = 4-6, the need for fixation strength cannot be ignored.
• When biological FPAS = 4-6, preservation of fracture zone viability remains a
priority.
• Surgical approaches may be percutaneous or OBDNT if anatomic reconstruction is
not a goal.
• Open approaches can be used if it will aid anatomic reconstruction (and thereby
load-sharing) of reconstructable fractures. Cancellous grafting is employed
whenever open approaches are used.
92
FPAS 4 - 6

FPAS 4 - 6
Case no 15503_21 Apr 2018 AO 13 A1
93

FPAS 4 – 6
Case no 15503_21 Apr 2018_Humerus
Case no 15503_21 Apr 2018 AO 13 A1
94

FPAS 4 – 6
Craniolateral approach Fractured ends
95

FPAS 4 – 6
IMP in situ LCP on caudal aspect
96

FPAS 4 – 6
97

FPAS 4 – 6
Post Op_18 hrs_22.04.2018 4th Month Post Op_21.08.2018
98

FPAS 4 – 6
AO 13 A1
99

100
FPAS 7 – 9

101
FPAS
7– 9
1 ☺10
MECHANICAL
FACTORS
CLINICAL
FACTORS
Owner
Patient
BIOLOGICAL
FACTORS
Second-hand smoke?

• Cases in which the overall FPAS = 7-9 require an orthopedist
with a thorough academic training and some clinical
experience (1-2 years) with the chosen fixation system.
• Fixation systems considered are bone plates, interlocking nails
(IN), intramedullary pin + full cerclage wire, plate + IM pin
combinations and ESF +/- IM pin fixation.
• Minor technical errors or slightly excessive soft tissue
manipulation are usually tolerated.
• The balance between mechanical stability and preservation of
soft tissue integrity is important, but somewhat forgiving.
102
FPAS 7 - 9

• When mechanical FPAS = 7-9, fixation strength is often not
the great priority.
• When biological FPAS = 7-9, a full open approach is used
when it will aid anatomic reconstruction of reconstructable
fractures (to achieve load-sharing); otherwise, closed or
OBDNT approaches are used with non-reconstructable
fractures.
• Cancellous grafting is often employed with many open
surgical approaches, but may be less critical in these cases.
103
FPAS 7 - 9

FPAS 7 - 9
Case no 17633_11.01.2019
104

FPAS 7 - 9
Case no 17633 dt 11.01.2019 Preoperative Plan
105

FPAS 7 – 9
Case no 17633_11.01.2019_Mandible
3.5 mm, 06 hole Recon LCP
106

FPAS 7 – 9
WIRING
107

FPAS 7 – 9
3.5 mm, 06 hole Recon LCP
108

Ravi Raidurg., Chandrashekharappa M and Naveen M
(2020): Plate osteosynthesis for mandibular body
fracture repair in a Mudhol Hound using Locking
Reconstruction Plate. Ind J Vet Surg: 40 (2): 144.
109

110
FPAS 10

111
FPAS
10
1 ☺10
MECHANICAL
FACTORS
CLINICAL
FACTORS
Owner
Patient
BIOLOGICAL
FACTORS
Second-hand smoke?
AO 32 A2

• Cases in which the overall FPAS = 10 are ideal for building
experience in fracture treatment or in getting comfortable with a
new fixation system.
• Fixation systems considered are bone plates, interlocking nails (IN),
ESF or intramedullary pin + full cerclage wire combinations.
• An academic training background is presumed, but little previous
clinical experience is required because minor technical error or
excessive soft tissue manipulations are almost uniformly tolerated.
The balance between mechanical stability and preservation of soft
tissue integrity is not particularly critical and novice surgeons may
opt for relatively “mechanical” or “biological” fixations with little
fear of failure.
112
FPAS 10

• When mechanical FPAS = 10, success can achieved even with less
than ideal fixation devices and systems.
• When biological FPAS = 10, a full open approach can safely be used
for anatomic reduction of reconstructable fractures (which is the
case for most of these patients).
• Extensive surgical time and tissue manipulations, which commonly
occur with less experienced surgeons, are tolerated for these
patients.
• Bone grafting is not necessary for these cases. Because many of
these patients are skeletally immature, care should be taken to
preserve physeal function and to avoid manipulations that may risk
soft tissue contractures (ie, quadriceps contracture). Additionally,
early restoration of limb function is vital for normal skeletal
development in dogs < 6 months of age.
113
FPAS 10

FPAS 10
Case no 16059_04 July 2018 AO 32 A2
114

FPAS 10
Case no 16059_04 July 2018 AO 32 A2
115

FPAS 10
Case no 16059_04 July 2018 AO 32 A2
116

FPAS 10
Case no 16059_04 July 2018 AO 32 A2
117

• Apparently the TITANIUM nail came out from proximal end 03 days after
surgery (Informed telephonically).
• Case was not presented for re evaluation as it was presented from small town
THIRTHAHALLI (70 km away).
• Post operative video showed animal to be highly AGILE.
• 11th week Post Op radiograph showed “Formation of good callus”
118
FPAS 10

FPAS 10
Case no 16059_04 July 2018 11th week Post Op
119

CONCLUSION FPAS
120

• The FPAS will help you know when to treat a fracture yourself and when to
recommend referral to a surgical specialist.
• What should be the “Fixation system” based on the surgeons experience with a
chosen fixation system.
• You can also use the FPAS as a tool by which you can monitor your progress (or the
progress of those you are mentoring) as an orthopaedist over time.
121
CONCLUSION FPAS

Case example
1 ½ Year old, 18 kg dog (Dobermann)
Distal third oblique fracture
Duration = 02 days old #
122
1. POP cast (Conservative
method)
2. Wiring
3. External fixator (ESF)
4. Internal fixator
IMP
IMP + wiring
IMP + Thomas splint
ILN (Interlocking Nails)
TENS (Titanium elastic nail system)
PO (Plate osteosynthesis ie Bone plating)

Results of the Poll
123

Case No 4
124

Humerus
Case No 11506 dated 17 Jan 2017
125
1 ½ Year old, 18 kg dog (Dobermann)

Case example
1 ½ Year old, 18 kg dog
(Dobermann)
Distal third oblique
fracture
126
Internal fixatIon (ORIF)
1. PLAN A - PO ( Lag screw + 3.5 mm LCP)
2. PLAN B - PO ( Wiring + 3.5 mm LCP)
3. PLAN C - PO PLATE ROD TECHNIQUE
( IMP + Wiring + 3.5 mm LCP)

Case example
(Dobermann)
fracture
127
Surgical approach to the bone
• Medial approach
• Lateral approach

Case example
(Dobermann)
fracture
128
• Medial approach
• Lateral approach
Cranial / Caudal / Medial / Lateral PLATING

Case example
(Dobermann)
fracture
129
• Medial approach
• Cranio - Lateral approach
Cranial / Caudal / Medial / Lateral PLATING

Humerus Case No 11506 dated 17 Jan 2017
A 1 ½ Year old, 18 kg dog (Dobermann)
130

131

132

133

134

135

136

OPEN REDUCTION & INTERNAL FIXATION (ORIF) OF RIGHT
HUMERAL DISTAL THIRD SPIRAL FRACTURE IN A DOBERMANN
BY PLATE ROD TECHNIQUE
Case no 11506 dated 17 Jan 2017
Department Of Surgery and Radiology, Veterinary College, Vinoba Nagar,
Shivamogga 577204
0 day Post Op 6th Week Post Op 9th Month Post Op

138
01 YEAR Post Operative

Lesson learnt
• 1. ORTHOGONAL Radiographic views ie TWO views at 90 °
angle.
• 2. Decide “Method of fracture repair” based on “FPAS” and
“Availability of Instrumentation” and “Availability of Expertise
w.r.t particular method of fracture repair system”.
• 3. Have PLAN “A’, PLAN “B’ & PLAN “C” for a fracture
repair.
• 4. Execute your Plan accordingly
139

Learning Objectives
• List Preoperative planning in MIO
140

PREOPERATIVE PLANNING IN MIO
141

• KEY POINTS
• High quality radiographs of both affected and normal contralateral limb
segments are critical to adequate surgical planning.
• Additional imaging modalities, including CT and intra-operative fluoroscopy
(C arm image intensifier), may be necessary to identify the full extent of
lesions and to assist with reduction and fixation.
• Loco-regional anatomy thorough knowledge is a prerequisite in MIO.
• Fracture specific patient positioning is necessary to guarantee continuous
visualization of adjacent joints and to allow unhindered procedures throughout
surgery.
142

143
ORTHOGONAL VIEWS

PREOPERATIVE IMAGING
• High quality radiographs of both affected and normal contralateral limb segments
are critical to adequate surgical planning ie (ORTHOGONAL VIEWS)
• Image quality greatly impacts diagnostic accuracy and therefore operative planning
and execution.
• To enhance patient comfort and improve quality of care, avoid motion artifacts, and
optimize image quality, appropriate pain management, up to general anesthesia,
should be provided during diagnostic imaging.
144

Importance of Orthogonal
views in Orthopaedics
145

PREOPERATIVE IMAGING
• Imaging of the contralateral segment is highly recommended in MIO for several
reasons:
1) it optimizes preoperative implant selection, particularly with regard to length and type
(e.g. plate vs. interlocking nail)
2) it allows comparison with the fractured segment to identify normal vs. abnormal
structures and
3) it allows accurate comparative evaluation of postoperative alignment.
146

ADDITIONAL IMAGING MODALITIES
• CT scan: The major benefit of computed tomography is its ability to generate
sectional images and allows a 3-D reconstruction of the fractured bone(s). It also
provides detailed images of the fracture configuration and fragment displacement
(Figure 2).
• The use of 3-D imaging helps in understanding complex intra-articular fractures
and improves preoperative planning. Furthermore, 3-D reconstruction is beneficial
in evaluating fragment distribution and can be used to guide reduction maneuvers.
• The main shortcoming associated with CT imaging is the cost. However, because
the benefits of accurate planning and subsequent avoidance of intra-operative
complications likely overcomes this limitation, CT imaging should be considered
an integral part of pre-operative planning when using MIO.raviraidurg@gmail.com
147

ADDITIONAL IMAGING MODALITIES
• MRI is useful in the diagnosis of central nervous system lesions, its application in
appendicular traumatology is limited.
• Ultrasound is not readily used in the diagnosis of appendicular musculoskeletal
trauma.
• C arm imaging is of great help in MIO
148

SURGICALAPPROACHES
• Loco-regional anatomy thorough knowledge is a prerequisite in MIO as direct
visualization of the fracture site is not available to the surgeon.
• Surgeon relies exclusively on percutaneous landmarks and on intraoperative
fluoroscopy to achieve fracture reduction, to restore alignment and to complete
fixation.
• Because a comprehensive 3-D understanding of the bone’s anatomy is necessary to
enable adequate implant contouring and fixation, using dry specimens, during pre-
operative planning and in the operating room in addition to CT reconstruction, is
highly recommended.
149

IMPLANT SELECTION
• The choice of a specific implant is made based upon fracture configuration, patient
signalment and the surgeon’s preferences.
• Once a fixation system is selected, specific implant dimensions must be determined.
Appropriate templating is mainly based on the preoperative radiographs of the
contralateral intact side, corrected for magnification. In contrast, implant position is
based on a detailed evaluation of the fractured bone. The fracture pattern, including
the presence and extent of fissures, as well as the spread of the fragments, should be
carefully evaluated as it may influence the choice and/or position of an implant.
150

151
A 05 mth, 45 kg GREAT DANE PUP
Diaphyseal Transverse fracture with longitudinal slit in distal fragment
A 05 mth, 45 kg Great Dane Pup
distal fragment

152
IMPLANT SELECTION
• As an example, the choice of a bone plate
may be ill advised for the repair of a
comminuted tibial fracture with medial
longitudinal fissures extending in the
proximal and/or distal metaphysis.
• In such a case, the choice of an
interlocking nail (ILN)with locking
bolts oriented in the sagittal plane
may be more appropriate.
distal fragment

PATIENT POSITIONING
• Preoperative planning includes identification of optimal patient positioning on the
surgery table.
• The importance of this step is often underestimated and it should be emphasized
that adequate positioning is essential to the smooth execution of the surgical
procedure from fracture reduction to restoration of alignment to proper implant
position.
• Ultimately, patient positioning may also affect the post-operative outcome.
153

PATIENT POSITIONING
• From an anesthetic standpoint, the final patient position should allow easy access to
airways, prevent ventilation compromise, permit adequate monitoring and allow the
utilization of an extra-corporal warming apparatus.
154

155
PATIENT POSITIONING
• From a surgical standpoint, the patient should be positioned so as to facilitate all surgical
phases including approach, reduction maneuvers as well as implant insertion and fixation. It
must also permit unrestricted C-arm mobility around the patient so that intra-operative views of
adjacent joints in both sagittal and frontal planes can be easily obtained throughout the surgical
procedure
Figure: Pre-operative view of the operating room set up illustrating proper positioning of the patient
for the treatment of a humeral fracture. The chest has been elevated to allow unrestricted C-arm
motion around the limb. In turn, this provides intra-operative views of the joints adjacent to the
fracture in 2 orthogonal planes and facilitaes restoration of alignment.

Importance of preoperative planning
• Tibial fractures have the highest rate of non-union after those
of the radius (25% and 60% of all non-unions, respectively).
• The majority of fracture complications come as a result of
poor decision-making by, rather than poor technical
expertise of, the attending veterinary surgeon.
• Pre-operative assessment of the fracture and planning the
repair helps to limit complication rates of tibial fractures.
( Glyde Mark and Arnett Richard 2006 : Tibial fractures in dogs and cat:
options for management. Irish Veterinary Journal., 59 (5), 290 – 295.)
157

Summary / Take Home Points
• 1. ORTHOGONAL Radiographic views are MUST ie TWO
views at 90 ° angle.
• 3. Always have PLAN “A’, PLAN “B’ & PLAN “C” for a
fracture repair.
158

159
THANK YOU

THANK YOU
SINGLE Take Home Point
Always have PLAN “A’, PLAN “B’ &
PLAN “C” for a FRACTURE REPAIR
160
DOI: 10.13140/RG.2.2.14258.63683

• 1. Always perform complete and thorough physical examination
of the animal presented with history of “vehicular accident”.
• 2. ORTHOGONAL Radiographic views are MUST ie TWO views at
90 ° angle.
• 3. Not all fractures need to be “OPERATED” on the same day of
presentation
• 4. When in doubt about handling the orthopaedic case, then
“STABILISE” the animal by “FIRST AID” and “ROBERT JONES
BANDAGE” and REFER to immediate nearest “Veterinary
orthopaedic surgeon” after duly consulting him / her.
(Remember he/she too is another human being like you and
NOT a MAGICIAN)
161

• 6. Perform a “ASEPTIC SURGERY”.
• 7. Always have PLAN “A’, PLAN “B’ & PLAN “C”.
162

• Bone healing occurs even during INFECTION, provided the
Bone fragments are in apposition.
• Preoperative ANTIBIOTICS
• Premptive ANALGESIA
163

Cases presented to Veterinary College
Shivamogga (2015 – 2018)
• 14 Year old, 5 kg dog (SPITZ) ie
GERIATRIC DOG
• 05 mth, 45 kg dog (GREAT DANE) ie
JUVENILE DOG
Diaphyseal Transverse fracture with
longitudinal
slit in distal fragment
• 2 ½ Year old, 22 kg dog DOCILE DOG
(Mudhol Hound)
Transverse fracture in distal fragment
• 03 Year old, 28 kg dog (Dobermann),
HYPERACTIVE BREED
Oblique / Spiral distal third fracture
• 03 Year old, 38 kg dog (Rottweiller),
FEROCIOUS BREED
Oblique / Spiral distal third fracture
164

• Conventional method (POP cast / Thomas splint / Velpeau sling)
• IMP & wiring
• IMP and Lag screw
• ESF (Type ?)
• TIE – In Configuration (IMP + ESF)
• ILN (Size ?)
• Plate Osteosynthesis
o Size of Plate
o (ORIF / MIPO)
o Plate – rod technique
For every fracture,
there are more than one method of fixation that will lead to acceptable results
and
many more that will lead to unacceptable results
165
Pre – Operative planning

Triage of the fracture patient
166

TRIAGE OF THE FRACTURE
PATIENT
■ Stabilisation and triage should take priority over investigation of potential fractures,
even though orthopaedic injuries are often obvious when a trauma patient is presented
for treatment.
■ Open fractures should be covered immediately with a sterile dressing while basic first
aid is being performed.
■ Blunt trauma patients may have significant internal injuries such as pneumothorax,
diaphragm rupture, pulmonary contusions or urinary tract rupture, which require
investigation and treatment before the more obvious fractures are managed.
■ Triage should follow the ABC mnemonic:
• – Airway
• – Breathing
• – Circulation
■ Once the patient is stabilised, fractures below the stifle and elbow can be stabilised
with splints or modified Robert–Jones dressings pending radiographic assessment.
■ POCUS (Point of care Us ie Bedside Us)
167

Preoperative planning in veterinary orthopaedics

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