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Fracture management
/content/chapter/10.22233/9781910443163.chap22
Fracture management
- Authors: Sorrel Langley-Hobbs and Nigel Harcourt-Brown
- From: BSAVA Manual of Rabbit Surgery, Dentistry and Imaging
- Item: Chapter 22, pp 283 - 304
- DOI: 10.22233/9781910443163.22
- Copyright: © 2013 British Small Animal Veterinary Association
- Publication Date: January 2013
Abstract
Rabbits are popular pets and many are presented to veterinary surgeons with a history of sudden lameness caused by a fracture. For many clinicians this is a daunting prospect. This chapter covers the various types of fracture in rabbits, how to formulate a treatment plan, treatment options, and assessment of the patient and fracture. It goes on to address orthopaedic surgery, the management of specific fractures and postoperative complications. Operative Techniques: External fixation of a tibial fracture.
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Figures
/content/figure/10.22233/9781910443163.chap22.ch22fig1
22.1
An incomplete splint made from half a 5 ml syringe case has been used to stabilize a minimally displaced fracture of the radius and ulna; the splint was applied to counteract bending forces across the fracture. The splint allows movement at the carpus and elbow and therefore minimizes fracture disease such as joint stiffness; in addition the foot is left uncovered. However, the splint does not provide stability against rotational or shear forces at the fracture site. © 2013 British Small Animal Veterinary Association
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22.1
An incomplete splint made from half a 5 ml syringe case has been used to stabilize a minimally displaced fracture of the radius and ulna; the splint was applied to counteract bending forces across the fracture. The splint allows movement at the carpus and elbow and therefore minimizes fracture disease such as joint stiffness; in addition the foot is left uncovered. However, the splint does not provide stability against rotational or shear forces at the fracture site.
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22.2
A complete splint immobilizes the joint above and below the fracture site but the anatomy of both the fore- and hindlimbs makes placement of these splints difficult in rabbits. (a) A piece of finger splint has been used to encircle a fractured tibia by being bent under the hock and over the stifle. This was used to immobilize a serious distal tibial fracture temporarily prior to repair with external fixation the following day. (b) This rabbit has a distal tibial fracture that was treated by intramedullary pinning and external skeletal fixation (see
Figure 22.18
). The bandage was placed around the limb to reduce swelling for 48 hours postoperatively. The ear is also bandaged to keep an intravenous cannula in the ear vein. © 2013 British Small Animal Veterinary Association
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22.2
A complete splint immobilizes the joint above and below the fracture site but the anatomy of both the fore- and hindlimbs makes placement of these splints difficult in rabbits. (a) A piece of finger splint has been used to encircle a fractured tibia by being bent under the hock and over the stifle. This was used to immobilize a serious distal tibial fracture temporarily prior to repair with external fixation the following day. (b) This rabbit has a distal tibial fracture that was treated by intramedullary pinning and external skeletal fixation (see
Figure 22.18
). The bandage was placed around the limb to reduce swelling for 48 hours postoperatively. The ear is also bandaged to keep an intravenous cannula in the ear vein.
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22.3
Lateral radiograph of a young rabbit with a comminuted femoral fracture. There is poor bone density associated with a diet containing insufficient calcium with high phosphorus. This caused nutritional secondary hyperparathyroidism and osteopenia, and resulted in fractures occurring after minimal trauma. There is a double cortical line in the proximal femur, which is a radiological sign of osteopenia (
Lamb, 1990
). © 2013 British Small Animal Veterinary Association
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22.3
Lateral radiograph of a young rabbit with a comminuted femoral fracture. There is poor bone density associated with a diet containing insufficient calcium with high phosphorus. This caused nutritional secondary hyperparathyroidism and osteopenia, and resulted in fractures occurring after minimal trauma. There is a double cortical line in the proximal femur, which is a radiological sign of osteopenia (
Lamb, 1990
).
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22.4
A distal tibial fracture in a rabbit. Close examination (b) shows fissures in the distal fragment, extending to the epiphysis and possibly into the joint. © 2013 British Small Animal Veterinary Association
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22.4
A distal tibial fracture in a rabbit. Close examination (b) shows fissures in the distal fragment, extending to the epiphysis and possibly into the joint.
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22.5
This 3-year-old male neutered Dwarf Lop had osteomyelitis and a septic arthritis originating from the os calcis. The affected area was opened on the lateral aspect, and radical debridement of necrotic tissue performed. Over the next 6 weeks the owners diligently removed all the necrotic tissue, pus and fibrin twice daily and covered the wound with Manuka honey; daily injections of penicillin/streptomycin were given subcutaneously for a month. The rabbit recovered from the infection. © 2013 British Small Animal Veterinary Association
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22.5
This 3-year-old male neutered Dwarf Lop had osteomyelitis and a septic arthritis originating from the os calcis. The affected area was opened on the lateral aspect, and radical debridement of necrotic tissue performed. Over the next 6 weeks the owners diligently removed all the necrotic tissue, pus and fibrin twice daily and covered the wound with Manuka honey; daily injections of penicillin/streptomycin were given subcutaneously for a month. The rabbit recovered from the infection.
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22.6
(a) Forelimb radiograph from a 6-year-old male Dwarf Lop that was presented moribund. There were multiple fractures throughout the skeleton. The ‘punched hole’ appearance’ of the bones is highly suggestive of plasmacytic lymphoma. (b) Radiograph of the tibia of a 7-year-old neutered female Dutch rabbit that presented with sudden-onset lameness. Soft tissue swelling and the ‘moth-eaten’ radiographic appearance of the bone around the fracture made a tumour the most likely differential diagnosis. Cytological analysis of a fine-needle aspirate showed cells with typical signs of malignancy. The histopathological diagnosis was squamous cell carcinoma. The rabbit was euthanased. © 2013 British Small Animal Veterinary Association
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22.6
(a) Forelimb radiograph from a 6-year-old male Dwarf Lop that was presented moribund. There were multiple fractures throughout the skeleton. The ‘punched hole’ appearance’ of the bones is highly suggestive of plasmacytic lymphoma. (b) Radiograph of the tibia of a 7-year-old neutered female Dutch rabbit that presented with sudden-onset lameness. Soft tissue swelling and the ‘moth-eaten’ radiographic appearance of the bone around the fracture made a tumour the most likely differential diagnosis. Cytological analysis of a fine-needle aspirate showed cells with typical signs of malignancy. The histopathological diagnosis was squamous cell carcinoma. The rabbit was euthanased.
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22.7
Surgical anatomy of the forelimb. The nerves, arteries and veins have more branches than shown in these diagrams; only the major branches are illustrated. Anatomy is variable between individuals; these illustrations are only a guide. (a) Lateral view. 1 = Supraspinatus muscle; 2 = Deltoid muscle overlying infraspinatus muscle; 3 = Teres major muscle; 4 = Radial nerve and artery; 5 = Heads of the triceps muscle (a = long; b = lateral); 6 = Adductor pollicis longus muscle; 7 = Lateral digital extensor muscle; 8 = Lateral ulnar muscle; 9 = Ulnar artery and nerve; 10 = Flexor carpi ulnaris muscle; 11 = Extensor carpi radialis muscle; 12 = Biceps muscle; 13 = Cutaneous branch of axillary nerve; 14 = Brachialis muscle. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. (b) Medial view. 1 = Latissimus dorsi muscle; 2 = Subscapularis muscle; 3 = Radial nerve; 4 = Brachial artery; 5 = Biceps brachii muscle; 6 = Radial carpal extensor muscle; 7 = Median artery and nerve; 8 = Superficial digital flexor tendon; 9 = Deep digital flexor muscle; 10 = Ulnar nerve; 11 = Medial head of triceps muscle; 12 = Tensor of the antebrachial fascia; 13 = Long head of triceps muscle; 14 = Teres major muscle. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. © 2013 British Small Animal Veterinary Association
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22.7
Surgical anatomy of the forelimb. The nerves, arteries and veins have more branches than shown in these diagrams; only the major branches are illustrated. Anatomy is variable between individuals; these illustrations are only a guide. (a) Lateral view. 1 = Supraspinatus muscle; 2 = Deltoid muscle overlying infraspinatus muscle; 3 = Teres major muscle; 4 = Radial nerve and artery; 5 = Heads of the triceps muscle (a = long; b = lateral); 6 = Adductor pollicis longus muscle; 7 = Lateral digital extensor muscle; 8 = Lateral ulnar muscle; 9 = Ulnar artery and nerve; 10 = Flexor carpi ulnaris muscle; 11 = Extensor carpi radialis muscle; 12 = Biceps muscle; 13 = Cutaneous branch of axillary nerve; 14 = Brachialis muscle. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. (b) Medial view. 1 = Latissimus dorsi muscle; 2 = Subscapularis muscle; 3 = Radial nerve; 4 = Brachial artery; 5 = Biceps brachii muscle; 6 = Radial carpal extensor muscle; 7 = Median artery and nerve; 8 = Superficial digital flexor tendon; 9 = Deep digital flexor muscle; 10 = Ulnar nerve; 11 = Medial head of triceps muscle; 12 = Tensor of the antebrachial fascia; 13 = Long head of triceps muscle; 14 = Teres major muscle. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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22.8
Surgical anatomy of the hindlimb. The nerves, arteries and veins have more branches than shown in these diagrams; only the major branches are illustrated. Anatomy is variable between individuals; these illustrations are only a guide. (a) Lateral view. 1 = Middle gluteal muscle; 2 = Sciatic nerve; 3 = Semitendinosus muscle; 4 = Semimembranosus muscle; 5 = Tibial nerve; 6 = Fibular nerve; 7 = Popliteal artery; 8 = Adductor brevis et magnus muscles; 9 = Vastus lateralis of quadriceps muscle; 10 = Rectus femoris muscle. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. (b) Medial view. 1 = Caudal vena cava; 2 = External iliac vein; 3 = Tensor fascia lata muscle; 4 = Vastus medialis of quadriceps muscle; 5 = Medial saphenous vein; 6 = Tibia; 7 = Cranial tibial muscle; 8 = Caudal and cranial medial saphenous vein; 9 = Cranial tibial artery; 10 = Saphenous artery; 11 = Gastrocnemius medial head; 12 = Gracilis muscle; 13 = Semitendinosus muscle; 14 = Femoral artery; 15 = Femoral vein. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. © 2013 British Small Animal Veterinary Association
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22.8
Surgical anatomy of the hindlimb. The nerves, arteries and veins have more branches than shown in these diagrams; only the major branches are illustrated. Anatomy is variable between individuals; these illustrations are only a guide. (a) Lateral view. 1 = Middle gluteal muscle; 2 = Sciatic nerve; 3 = Semitendinosus muscle; 4 = Semimembranosus muscle; 5 = Tibial nerve; 6 = Fibular nerve; 7 = Popliteal artery; 8 = Adductor brevis et magnus muscles; 9 = Vastus lateralis of quadriceps muscle; 10 = Rectus femoris muscle. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. (b) Medial view. 1 = Caudal vena cava; 2 = External iliac vein; 3 = Tensor fascia lata muscle; 4 = Vastus medialis of quadriceps muscle; 5 = Medial saphenous vein; 6 = Tibia; 7 = Cranial tibial muscle; 8 = Caudal and cranial medial saphenous vein; 9 = Cranial tibial artery; 10 = Saphenous artery; 11 = Gastrocnemius medial head; 12 = Gracilis muscle; 13 = Semitendinosus muscle; 14 = Femoral artery; 15 = Femoral vein. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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22.9
(a) The femur of a giant continental rabbit with a distal femoral intracondylar fracture that was plated with a 2.7 mm reconstruction plate and screws. (b) Postoperatively, an additional fracture occurred proximal to the plate. This fracture was possibly a result of the screw hole causing a stress riser in the brittle rabbit bone, or of an unrecognized fissure. © 2013 British Small Animal Veterinary Association
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22.9
(a) The femur of a giant continental rabbit with a distal femoral intracondylar fracture that was plated with a 2.7 mm reconstruction plate and screws. (b) Postoperatively, an additional fracture occurred proximal to the plate. This fracture was possibly a result of the screw hole causing a stress riser in the brittle rabbit bone, or of an unrecognized fissure.
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22.10
This young Minilop female rabbit had been restrained during its stay in boarding kennels. After a brief struggle it was unable to use its hindlegs. There is a fracture/luxation between the 6th and 7th lumbar vertebrae. © 2013 British Small Animal Veterinary Association
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22.10
This young Minilop female rabbit had been restrained during its stay in boarding kennels. After a brief struggle it was unable to use its hindlegs. There is a fracture/luxation between the 6th and 7th lumbar vertebrae.
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22.11
(a) A fracture of the distal third of the humerus was stabilized by an intramedullary pin tied into an external fixator frame, with two negative-profile threaded pins above and below the fracture. Insufficient care and cleaning allowed infection to track in along the pins, which all loosened. Because of the mobility of the tissues surrounding the shoulder, a protruding intramedullary pin must be kept clean and removed as soon as possible. (b) Removing all the pins plus a long course of penicillin/streptomycin gave the rabbit a functional leg. © 2013 British Small Animal Veterinary Association
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22.11
(a) A fracture of the distal third of the humerus was stabilized by an intramedullary pin tied into an external fixator frame, with two negative-profile threaded pins above and below the fracture. Insufficient care and cleaning allowed infection to track in along the pins, which all loosened. Because of the mobility of the tissues surrounding the shoulder, a protruding intramedullary pin must be kept clean and removed as soon as possible. (b) Removing all the pins plus a long course of penicillin/streptomycin gave the rabbit a functional leg.
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22.12
This rabbit sustained a condylar fracture at one year of age. Surgical fixation was considered too expensive by the owner so the rabbit was cage rested. After 6 weeks it had regained good mobility considered equivalent to that of a companion rabbit. Radiographs taken 6 weeks after the fracture radiographs are shown here. The rabbit’s progress was monitored over the following 8 years. Although the elbow joint was palpably deformed and the leg slightly shorter than the contralateral limb, the rabbit never showed any obvious signs of pain after the first 6 weeks. © 2013 British Small Animal Veterinary Association
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22.12
This rabbit sustained a condylar fracture at one year of age. Surgical fixation was considered too expensive by the owner so the rabbit was cage rested. After 6 weeks it had regained good mobility considered equivalent to that of a companion rabbit. Radiographs taken 6 weeks after the fracture radiographs are shown here. The rabbit’s progress was monitored over the following 8 years. Although the elbow joint was palpably deformed and the leg slightly shorter than the contralateral limb, the rabbit never showed any obvious signs of pain after the first 6 weeks.
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22.13
Fractured radius and ulna managed by external coaptation. The splint was created from a padded 5 ml syringe (see
Figure 22.1
). (a) The original fracture with a minimally displaced radius and ulna. (b) The fracture 4 weeks after splinting. (c) The healed fracture 8 weeks after treatment. © 2013 British Small Animal Veterinary Association
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22.13
Fractured radius and ulna managed by external coaptation. The splint was created from a padded 5 ml syringe (see
Figure 22.1
). (a) The original fracture with a minimally displaced radius and ulna. (b) The fracture 4 weeks after splinting. (c) The healed fracture 8 weeks after treatment.
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22.14
(a) Mid-diaphyseal radial and ulnar fracture. (b) Repair using external skeletal fixation with four smooth full pins and acrylic bars. (c) Fracture healing after 8 weeks. © 2013 British Small Animal Veterinary Association
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22.14
(a) Mid-diaphyseal radial and ulnar fracture. (b) Repair using external skeletal fixation with four smooth full pins and acrylic bars. (c) Fracture healing after 8 weeks.
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22.15
The fractured metatarsus in this rabbit was stabilized by first placing a pin in the 5th metatarsal in a retrograde manner. Metatarsals 3 and 4 were then toggle-pinned. This was attempted in metatarsal 2 but an intraoperative radiograph showed the pin to be outside the distal medullary cavity, so it was replaced. The foot was splinted in a padded gutter splint for 4 weeks. The long pin in the 5th metatarsal was removed when the bones had healed; the rest were left in situ. © 2013 British Small Animal Veterinary Association
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22.15
The fractured metatarsus in this rabbit was stabilized by first placing a pin in the 5th metatarsal in a retrograde manner. Metatarsals 3 and 4 were then toggle-pinned. This was attempted in metatarsal 2 but an intraoperative radiograph showed the pin to be outside the distal medullary cavity, so it was replaced. The foot was splinted in a padded gutter splint for 4 weeks. The long pin in the 5th metatarsal was removed when the bones had healed; the rest were left in situ.
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22.16
(a) Craniocaudal view and (b) mediolateral view of a femoral fracture, which was treated conservatively. There is evidence of callus formation and healing. © 2013 British Small Animal Veterinary Association
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22.16
(a) Craniocaudal view and (b) mediolateral view of a femoral fracture, which was treated conservatively. There is evidence of callus formation and healing.
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22.17
Healed fracture of the femoral neck. This radiograph of the pelvis of a young male was taken while he was anaesthetized for castration. The owner had noticed a strange gait. © 2013 British Small Animal Veterinary Association
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22.17
Healed fracture of the femoral neck. This radiograph of the pelvis of a young male was taken while he was anaesthetized for castration. The owner had noticed a strange gait.
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22.18
Radiographs of the Rex rabbit shown in
Figure 22.2
, taken 8 weeks postoperatively. The distal tibial fracture was treated by intramedullary pinning and external skeletal fixation. A small fissure fracture was present in the distal fragment and one cerclage wire was placed around this to prevent its dissipation. The fracture had healed uneventfully and the external fixator was removed at this stage. © 2013 British Small Animal Veterinary Association
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22.18
Radiographs of the Rex rabbit shown in
Figure 22.2
, taken 8 weeks postoperatively. The distal tibial fracture was treated by intramedullary pinning and external skeletal fixation. A small fissure fracture was present in the distal fragment and one cerclage wire was placed around this to prevent its dissipation. The fracture had healed uneventfully and the external fixator was removed at this stage.
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22.19
Radiograph of the fractured hock of an adult spayed female Dwarf Lop rabbit that was 10/10 lame with a hot, swollen, painful hock that was discharging pus. There was evidence of severe ulcerative pododermatitis on the contralateral hock. The rabbit was euthanased. © 2013 British Small Animal Veterinary Association
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22.19
Radiograph of the fractured hock of an adult spayed female Dwarf Lop rabbit that was 10/10 lame with a hot, swollen, painful hock that was discharging pus. There was evidence of severe ulcerative pododermatitis on the contralateral hock. The rabbit was euthanased.
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22.20
Calcaneal fracture repair in a young Flemish Giant. Whilst not obvious on the initial radiograph (a), the fractured calcaneus was severely fissured and therefore difficult to stabilize. Small-gauge cerclage wire pulled through the bone and did not stabilize the fracture (b). Postoperative infection led to a septic arthritis that resolved on long-term penicillin/streptomycin injections. The rabbit had a functional end result, with 1/5 lameness; this was considered satisfactory and preferable to amputation. © 2013 British Small Animal Veterinary Association
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22.20
Calcaneal fracture repair in a young Flemish Giant. Whilst not obvious on the initial radiograph (a), the fractured calcaneus was severely fissured and therefore difficult to stabilize. Small-gauge cerclage wire pulled through the bone and did not stabilize the fracture (b). Postoperative infection led to a septic arthritis that resolved on long-term penicillin/streptomycin injections. The rabbit had a functional end result, with 1/5 lameness; this was considered satisfactory and preferable to amputation.
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Retrograde pin insertion using a small vice and Alm retractors.
Retrograde pin insertion using a small vice and Alm retractors. © 2013 British Small Animal Veterinary Association
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Retrograde pin insertion using a small vice and Alm retractors.
Retrograde pin insertion using a small vice and Alm retractors.
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Pre-drilling with the smooth trocar-tipped end of the threaded pin; small artery forceps are used to retract the tendons and skin.
Pre-drilling with the smooth trocar-tipped end of the threaded pin; small artery forceps are used to retract the tendons and skin. © 2013 British Small Animal Veterinary Association
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Pre-drilling with the smooth trocar-tipped end of the threaded pin; small artery forceps are used to retract the tendons and skin.
Pre-drilling with the smooth trocar-tipped end of the threaded pin; small artery forceps are used to retract the tendons and skin.
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The clamps are placed and tightened, and the pins can then be cut.
The clamps are placed and tightened, and the pins can then be cut. © 2013 British Small Animal Veterinary Association
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The clamps are placed and tightened, and the pins can then be cut.
The clamps are placed and tightened, and the pins can then be cut.
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© 2013 British Small Animal Veterinary Association
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Radiograph of a traumatic fractured tibia in a 10-month-old male Netherland Dwarf rabbit.
Radiograph of a traumatic fractured tibia in a 10-month-old male Netherland Dwarf rabbit. © 2013 British Small Animal Veterinary Association
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Radiograph of a traumatic fractured tibia in a 10-month-old male Netherland Dwarf rabbit.
Radiograph of a traumatic fractured tibia in a 10-month-old male Netherland Dwarf rabbit.
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The tibial fracture was stabilized by placing two 1.2 mm IMEX interface pins tied into a 1.2 mm Kirschner wire. Mediolateral and craniocaudal radiographs taken at 5 weeks postoperatively showed healing to have progressed sufficiently to allow the intramedullary pin to be removed.
The tibial fracture was stabilized by placing two 1.2 mm IMEX interface pins tied into a 1.2 mm Kirschner wire. Mediolateral and craniocaudal radiographs taken at 5 weeks postoperatively showed healing to have progressed sufficiently to allow the intramedullary pin to be removed. © 2013 British Small Animal Veterinary Association
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The tibial fracture was stabilized by placing two 1.2 mm IMEX interface pins tied into a 1.2 mm Kirschner wire. Mediolateral and craniocaudal radiographs taken at 5 weeks postoperatively showed healing to have progressed sufficiently to allow the intramedullary pin to be removed.
The tibial fracture was stabilized by placing two 1.2 mm IMEX interface pins tied into a 1.2 mm Kirschner wire. Mediolateral and craniocaudal radiographs taken at 5 weeks postoperatively showed healing to have progressed sufficiently to allow the intramedullary pin to be removed.
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Mediolateral and craniocaudal views showing good evidence of tibial healing at 9 weeks; there was insufficient union to remove all external fixator pins.
Mediolateral and craniocaudal views showing good evidence of tibial healing at 9 weeks; there was insufficient union to remove all external fixator pins. © 2013 British Small Animal Veterinary Association
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Mediolateral and craniocaudal views showing good evidence of tibial healing at 9 weeks; there was insufficient union to remove all external fixator pins.
Mediolateral and craniocaudal views showing good evidence of tibial healing at 9 weeks; there was insufficient union to remove all external fixator pins.
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Final tibial radiograph taken at 14 weeks. The external skeletal fixator pins were removed at this time.
Final tibial radiograph taken at 14 weeks. The external skeletal fixator pins were removed at this time. © 2013 British Small Animal Veterinary Association
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Final tibial radiograph taken at 14 weeks. The external skeletal fixator pins were removed at this time.
Final tibial radiograph taken at 14 weeks. The external skeletal fixator pins were removed at this time.