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The tibia and fibula

image of The tibia and fibula
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Abstract

Fractures of the tibia and fibula are commonly seen in small animal practice. This chapter deals with fractures of the proximal tibia and fibula, fractures of the tibial and fibular diaphyses; fractures of the distal tibia and fibula. Avulsion of the tibial tubercle; Separation of the proximal tibial physis; Tibia – medial bone plating; Tibia – intramedullary pinning; Tibia – external skeletal fixation; Separation of the distal tibial physis; Fractures of the medial and lateral malleoli.

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Figures

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24.1 Avulsion of the tibial tubercle. (a) Mediolateral radiograph of the normal stifle of a 6-month-old Greyhound. (b) Contralateral joint of the same animal, showing complete avulsion of the tubercle. (c) Mediolateral radiograph of the normal left stifle in a 4-month-old Tibetan terrier. (d) Contralateral joint of the same animal, showing a partial avulsion of the tibial tubercle.
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24.2 Mediolateral radiograph of the stifle of a 6-month-old Shetland Sheepdog showing a Salter–Harris type II fracture of the proximal tibial physis with caudal rotation of the epiphysis.
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24.3 Mediolateral radiograph of the stifle of a 5-month-old Border Terrier showing a minimally displaced Salter–Harris type II fracture of the proximal tibial physis and an intact fibula.
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24.4 (a) Proximal metaphyseal–diaphyseal fracture in a 7-month-old Chinese Crested Dog that had fallen from its owner’s arms, where the fracture surface of the proximal fragment is concave (most commonly reported). (b) A similar fracture in a 15-week-old German Shepherd Dog cross where the fracture surface of the proximal fragment is convex.
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24.5 Dorsoplantar radiograph showing a displaced Salter–Harris type I fracture of the distal tibial physis and fibula in a 5-month-old Dobermann.
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24.6 Malleolar fractures. (a) Fracture of the medial malleolus resulting in loss of collateral ligament support. (b) Dorsoplantar radiograph of a medial malleolar fracture in a 9-month-old Retriever cross. (c) Mediolateral and (d) dorsoplantar radiographs showing caudal luxation of the tarsocrural joint associated with fracture of the lateral malleolus in a dog. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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24.7 (a) Dorsoplantar radiograph of a hock showing complete loss of the lateral malleolus, as a result of a shearing injury, in a 4-year-old Cavalier King Charles Spaniel. (b) Management of the injury by application of a Rudy boot fixator to the medial aspect of the distal limb. This confers stability on the joint and allows good access to the wound whilst soft tissue healing takes place.
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24.8 (a) Avulsed tibial tuberosity. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission. (b) Allis tissue forceps encircling the straight patellar ligament are used to apply traction to the avulsed fragment and reduce the fracture; one or two K-wires are then driven across the fracture site to maintain reduction. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission. (c) A figure-of-eight tension-band wire is added to counteract the pull of the quadriceps muscle group. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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24.9 (a) Mediolateral and (b) caudocranial postoperative radiographs showing a repaired tibial tuberosity avulsion in a 5-month-old Airedale. The fracture was stabilized using two K-wires and a figure-of-eight tension-band wire. (c) Postoperative radiograph of a repaired tibial tuberosity avulsion in a 7-month-old Border Terrier. The fracture was stabilized using a single K-wire and a figure-of-eight tension-band wire. (d) Postoperative radiograph of a repaired partial tibial tuberosity avulsion in a 5-month-old Staffordshire Bull Terrier. The fracture was stabilized using a K-wire and figure-of-eight suture of polydioxanone.
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24.10 Distal migration of the tibial tuberosity due to premature growth plate closure following repair of a tibial tuberosity avulsion. The implants had been removed after 4 weeks.
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24.11 The use of a Hohmann retractor to facilitate reduction of a proximal tibial physeal fracture. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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24.12 (a) Fracture of the proximal tibial physis in a 5-month-old West Highland White Terrier stabilized with a single K-wire and a figure-of-eight tension-band wire. (b) Preoperative and (c) postoperative radiographs of a proximal tibial physeal fracture in a 7-month-old Boxer. The fracture has been stabilized with a combination of a K-wire medially and a bone screw laterally through the metaphyseal component.
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24.13 (a) Medial exposure of the tibial diaphysis. (b) Medial exposure of the proximal and distal segments of the tibia for application of a bridging plate to stabilize a comminuted fracture in a 6-year-old English Bull Terrier using a minimally invasive strategy. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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24.14 (a) Preoperative and (b) postoperative radiographs of a 4-month-old Pomeranian with a short oblique fracture of the tibia treated with stacked veterinary cuttable plates. Although the plate holes are round, it was possible to place screws slightly eccentrically in the plate holes leading to compression of the fracture during screw tightening. (Courtesy of T Gemmill)
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24.15 (a) Preoperative and (b) postoperative radiographs of an oblique tibial diaphyseal fracture in a 9-month-old Labrador Retriever, stabilized using lagged bone screws and a neutralization plate.
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24.16 (a) Preoperative and (b) postoperative radiographs of a comminuted fracture in a 6-year-old English Bull Terrier managed with a bridging plate (same case as Figure 24.13b ).
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24.17 In cases where a bone plate alone is inadequate to provide sufficient stability as a bridging plate, combination (or adjunct) fixation may be utilized. (a–b) Pin–plate fixation used to stabilize a comminuted tibial fracture in a 3-year-old Jack Russell Terrier. (c) A medial bone plate combined with a unilateral uniplanar external skeletal fixator used to stabilize a non-reconstructable, comminuted tibial fracture in a 10-year-old German Shorthaired Pointer. (d–e) Biaxial plating (medial and cranial) of a non-reconstructable, comminuted tibial fracture in a 1-year-old crossbred dog. (a,b,d,e, Courtesy of D Clements)
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24.18 Local irritation over the tibial plate leading to lick granuloma formation. Implant removal and resection of the affected tissue led to an uneventful recovery.
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24.19 (a) Cranial, (b) dorsal and (c) lateral views of the tibia to illustrate the anatomical landmarks for normograde placement of a tibial IM pin. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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24.20 Postoperative radiograph showing repair of a transverse tibial fracture in an adult terrier using a single IM pin. Fracture configurations that lend themselves to use of an IM pin alone are uncommon. Adjunct fixation is normally required (see text).
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24.21 (a) A two-pin unilateral, uniplanar (type 1) external skeletal fixator may be used as an adjunct to IM pinning in order to counteract rotational forces acting at transverse or short oblique fracture lines. (b) Postoperative radiograph of a tibial fracture in a 4-month-old Standard Dachshund, stabilized using an IM pin and a two-pin unilateral, uniplanar (type 1) external skeletal fixator. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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24.22 Use of ESF to stabilize relatively simple fractures either alone or in combination with lagged bone screws or cerclage wires. (a) Postoperative radiograph of a tibial fracture in a 2-year-old cat, stabilized using a four-pin, unilateral, uniplanar (type 1) ESF construct. Note the fibula is intact. (b) A six-pin unilateral, uniplanar (type 1) ESF frame used to stabilize a simple oblique fracture in combination with lagged bone screws. (c) Postoperative radiograph of a tibial fracture in a 5-year-old German Shepherd Dog, stabilized with an eight-pin, bilateral, uniplanar (type 2b) ESF construct. The fracture occurred 2 weeks earlier and had been stabilized with an 8-hole bone plate. Screw purchase had failed in the proximal segment and so management had been revised to use of an external fixator. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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24.23 Postoperative radiograph of a revised (infected plate) fracture in an 8-year-old Labrador Retriever. The site has been stabilized with a modified bilateral, biplanar (modified type 1b) external skeletal fixator with only the distal fixation pin extending laterally and being ‘tied back’ into the cranial connecting bar.
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24.24 A modified bilateral, biplanar (modified type 1b) external skeletal fixator used to stabilize a very distal tibial diaphyseal fracture in a cat.
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24.25 Reduction and fixation of a distal tibial physeal separation. (a) Distal physeal separation with lateral displacement of the pes. The fracture often feels ‘locked’ in this position. (b) The fracture is reduced by toggling the ends (see Chapter 11). A Hohmann retractor, placed in the fracture and used to lever the physis distally, is sometimes necessary. (c) Once reduced, fixation is achieved by normograde placement of one or two K-wires through the medial malleolus. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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24.26 (a) Postoperative radiograph of a distal tibial physeal fracture in a 4-month-old Boxer, stabilized using two K-wires placed through the medial malleolus. (b) Postoperative radiograph of a distal tibial physeal fracture in a 5-month-old Dobermann, stabilized using K-wires placed through both the medial and lateral malleoli.
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24.27 Reduction and fixation of malleolar fractures. (a) Reduced medial malleolar fracture; pointed reduction forceps can be used to maintain the malleolar fragment in position whilst a K-wire or pin is introduced. (b) A second K-wire or pin may then be placed and a figure-of-eight tension-band wire added. (c) Repaired lateral malleolar fracture. (d) Postoperative radiograph showing the use of two K-wires and a tension-band to repair a lateral malleolar fracture in a dog. (e) Postoperative radiograph showing the repair of medial and lateral malleolar fractures in a 9-month-old Jack Russell Terrier. The medial malleolus has been stabilized using two K-wires and a figure-of-eight tension-band wire. The lateral malleolus has been stabilized using a K-wire, which is more readily driven into the distal tibia than the fibular diaphysis. A tension-band is more difficult to place laterally and less necessary than medially because the lateral side of the joint tends to be under compression during weight-bearing. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.

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