Acute management of orthopaedic and external soft tissue injuries

image of Acute management of orthopaedic and external soft tissue injuries
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Many animals with orthopaedic injuries or wounds also have injuries to vital organ systems. While potentially life-threatening problems are a priority, temporary and emergency management of wounds and fractures should not be ignored. This chapter describes the emergency treatment of wounds, including burns, and musculoskeletal trauma.

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17.1 Schematic diagram illustrating the incidence of thoracic injuries associated with fractures in specific areas.
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17.2 A puncture wound in a 5-year-old Lurcher. (a) The dog became non-weight-bearing 4 hours after a walk. (b) The foot was swollen and hot and there was splaying of the toes. After clipping, a small sealed puncture wound was identified on the dorsal aspect of the paw. Surgery was performed: the puncture wound was opened and the tract debrided and flushed; no foreign body was found. A 5-day course of antibiotics was prescribed postoperatively and the dog’s lameness fully resolved.
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17.6 Early management of a dog with bilateral fractures, prior to surgical stabilization. (a) Craniocaudal and (b) mediolateral views of a grade I open radius and ulna fracture; air is visible under the skin shadow adjacent to the fracture on the medial aspect. (c) There is a closed distal humeral supracondylar fracture in the left forelimb. (d) Small wound associated with the open fracture prior to treatment. (e) Using aseptic technique whenever possible, water-soluble jelly is applied to the wound prior to clipping to prevent hair entering the wound. (f) The wound is flushed with a 19 G needle, 20 ml syringe and lactated Ringer’s solution. (g) A splinted bandage is applied to support the grade I open radius and ulna fracture. (h) A spica splint is applied to support the supracondylar humeral fracture. (i) Definitive stabilization of the radius and ulna fracture is achieved with a type 1b external skeletal fixator once the patient is stable for anaesthesia. A non-adherent dressing (e.g. Primapore) is applied to the small wound.
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17.8 (a) Avulsion or shear injuries on the medial aspect of a dog’s antebrachium and carpus. (b) The same dog 10 days later. After the use of wet to dry dressings, and then non-adherent dressings, healthy granulating tissue is present with evidence of early epithelization and wound contraction. At this stage antimicrobial therapy should no longer be necessary.
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17.11 (a) This wound over a dog’s carpus occurred as a result of a dogfight. There is some granulation tissue present but further superficial debridement of the necrotic mucoid layer would be beneficial. (b) ‘Wet to dry’ dressings with sterile swabs soaked in sterile lactated Ringer’s solution are applied to the wounds. (c) The appearance of the wound 24 hours after application of a wet to dry dressing. There has been superficial debridement of the wound and the granulation tissue now has a more healthy appearance.
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17.12 Prioritization of therapy: radiographs of a cat which had recently been involved in a road traffic accident. (a) The cat had a displaced ilial fracture and a sacroiliac luxation; it was unable to ambulate and had neurological deficits. (b) However, the cat was also in respiratory distress with a tension pneumothorax, which required emergency thoracocentesis.
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17.13 (a) A 3-year old female cat was referred with an open tarsal dislocation and fracture after a suspected road traffic accident. (b) The cat had a palpably enlarged abdomen with a fluid thrill on percussion. An ultrasound scan revealed free abdominal fluid and a small bladder. (c) A positive contrast cystogram showed leakage of contrast medium into the abdomen, changes compatible with a tear in the bladder.
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17.15 (a) The hock of the dog shown in Figure 17.8 with a dislocation and an avulsion or shear wound on the cranial flexor aspect of the hock. A non-adherent absorbent dressing (Allevyn, Smith & Nephew) and hydrocolloid gel (Intrasite gel, Smith & Nephew) have been used. (b) The same dog 10 days later, after stabilization of the hock with a transarticular external skeletal fixator and appropriate wound management consisting of daily wound flushing and application of ‘wet to dry’ or non-adherent dressings as dictated by the appearance of the wound.
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17.17 Bandaging the lower limb. (a) The Robert Jones bandage provides a column of support following the conformation of the limb. (b) The carpal flexion bandage prevents weight-bearing but allows movement of the upper limb joints (elbow and shoulder). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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17.18 A commercial splint with Velcro tapes can be applied rapidly to provide temporary support during healing or while awaiting definitive repair.
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17.21 Bandaging the upper limb. (a) The Ehmer sling is a figure-of-eight bandage, which internally rotates the hip and prevents re-luxation. (b) The Velpeau sling provides stability for the shoulder area and prevents weight-bearing by limiting movement of the limb. (c) The spica splint stabilizes the elbow and humerus and can also be used on the hindlimb. The antebrachium is padded with a Robert Jones bandage and there is some padding over the scapula. A flat lateral splint is placed over the midline at the tip of the scapula and all the way down to the foot. The splint can be made from a sheet of thermosetting cast material and pleated for resistance to bending. It is held in place with adhesive tape over the Robert Jones dressing and a body bandage around the thorax. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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17.22 Bandages in use on dogs. (a) Spica splint on a German Shepherd Dog after closed reduction of a lateral shoulder luxation. (b) Robert Jones dressing. (c) Carpal flexion bandage. (d) Hobbles placed on a dog while still anaesthetized after surgery.
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17.23 This cat presented with sudden-onset hindlimb paraparesis. Patellar reflexes were exaggerated and sciatic myotatic reflexes reduced. (a) Ventrodorsal radiograph of the cat’s lumbar spine. There is a left ilial fracture. The unusual sacroiliac joint was considered to be an incidental finding. (b) Lateral radiograph showing a compression fracture of the body of the sixth lumbar vertebra.
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17.25 Temporary neck splinting for an atlantoaxial subluxation fracture. The splint should extend from the mandible to the thorax. Careful monitoring is required; upper airway obstruction and inability to move the chest wall are common concerns.
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17.26 A dog with suspected compartment syndrome. (a) A 2-year-old Greyhound presented with a comminuted humeral fracture with severe brachial swelling and intense pain associated with the area. The dog had intact deep pain sensation and weak pulses distal to the fracture. (b) Close-up view of the brachial area showing the swollen tense brachium. (c) The dog developed severe muscle atrophy and carpal contracture, similar to Volkmann contracture, which is seen in humans as a sequela to compartment syndrome. A transarticular external skeletal fixator was placed across the carpus to prevent further contracture.
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