The distal limb

image of The distal limb
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This chapter looks at the distal limb, its anatomy, surgical considerations, metacarpal and metatarsal bone fractures, fractures of the sesamoid bones, fractures of the digits. Intramedullary pinning of metacarpal/metatarsal fractures; Application of a modified type 2 external skeletal fixator to metacarpal/metatarsal fractures; Permanent nail removal (ungual crest osteoctomy); Distal digital amputation (distal digital osteoctomy).

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Image of 26.1
26.1 A dorsopalmar radiograph of the metacarpus of an 8-year-old Shetland Sheepdog that had sustained multiple fractures several years previously. A synostosis, a non-union fracture and severe osteoarthritis of the third metacarpophalongeal joint are present. Note the rotation of digits 3, 4 and 5.
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26.2 Palmar aspect of the paw of the Shetland Sheepdog in Figure 26.1 . Note the hyperplasia of digital pad 5. This dog presented with acute onset lameness due to septic arthritis of the distal interphalangeal joint of digit 5.
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26.3 A fracture of the third metatarsal bone in a racing Greyhound treated with a veterinary cuttable plate applied to the dorsal aspect.
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26.4 Lag screw reconstruction of a comminuted fracture of the fifth metacarpal in the left metacarpus in a racing Greyhound. The repair has been augmented using a laterally applied type 1 external skeletal fixator.
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26.5 A dorsoplantar radiograph of a young cat, which had fractured all four metatarsal bones. IM dowel pins have been toggled into the second and fourth metatarsal bones giving excellent alignment. A modified type 2 external skeletal fixator was then applied.
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26.6 A dorsoplantar radiograph of a cat with fractures of the second, third and fourth metatarsal bones. The IM pins have been inserted through slots burred through the dorsal cortices. Note how small the pin diameter is compared with that of the medullary cavity. This will provide limited resistance to digital rotation.
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26.7 (a) Application of combined IM pin and external skeletal fixator with a dorsal acrylic connecting mass. The position of the two transverse pins is shown; the proximal pin is through the central tarsal and fourth tarsal bones, and the distal pin is through the proximal metatarsal bones. These pins are then bent dorsodistally and axially to overlie the metatarsus. (b) IM pins are inserted into two or more of the metatarsal bones, bent back on themselves to lie dorsal to the metatarsus and incorporated into the acrylic mass together with the transverse pins. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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26.8 A dorsoplantar radiograph of the metatarsus of a racing Greyhound showing sclerotic changes of the proximal diaphysis of the third metatarsal bone, which represents a healing response to non-displaced cortical stress fractures. Continued rest resolved the lameness.
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26.9 A comminuted, displaced fracture of the third metatarsal bone in a racing Greyhound. The treatment was kennel rest with no external support. The dog successfully returned to the track after 13 weeks.
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26.10 A displaced distal fracture of the fifth metatarsal bone in a racing Greyhound. This was aligned using a temporary IM pin followed by fixation with a type 1 external skeletal fixator for 6 weeks.
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26.11 Bipartite second sesamoid bone (arrowed) in a Greyhound.
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26.12 A fractured second sesamoid bone in a racing Greyhound. Note the distraction of the proximal fragment and the sharp demarcation of the fracture edges.
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26.13 (a) An intraoperative photograph of a surgical repair of comminuted, articular fractures of the first phalanx of digits 3 and 4 of the right forelimb treated with transarticular external skeletal fixators before the application of the acrylic putty. (b) A postoperative radiograph showing the external skeletal fixators spanning both the metacarpophalangeal and proximal interphalangeal joints. The comminuted fractures involve the proximal articulations of both bones. Applying the fixators under tension has resulted in good reduction.
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26.14 A spiral fracture of the second phalanx treated with a transarticular external skeletal fixator with two pins in the third phalanx.
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26.15 The IM pin has been inserted into the distal fragment to emerge through the metacarpophalangeal/metatarsophalangeal joint. Both bone fragments are elevated to allow the protruding pin to be slotted into the proximal medulla. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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26.16 An IM pin is introduced into the dorsal slot and driven along the medullary cavity across the reduced fracture. Note that the pin has a much smaller diameter than the medulla to allow some bending during insertion. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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26.17 The configuration of a modified type 2 external skeletal fixator with the temporary IM pins prior to withdrawal. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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26.18 (a) Distal digital ostectomy. The skin has been incised a few millimetres from the nail and retracted to show the subcutaneous part of the nail. The nail and underlying ungual process are removed using bone cutters at the angle indicated by the line. The dorsal aspect of the distal interphalangeal joint is just proximal to the cut. (b) The distal digit is held between the surgeon’s thumb and forefinger allowing the remnants of the nail and ungual process and crest to be removed using rongeurs. Closure of the skin using two or three simple sutures should not be under any tension; if present, further bone removal will be necessary. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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26.19 (a) To start the distal digital amputation the skin and digital pad are incised about 2 mm to 4 mm proximal to the nail. (b) The third phalanx has been excised, the condyles of the second phalanx removed with bone cutters and the pad sutured to the dorsal skin. The elliptical skin excision shown on the palmar/plantar aspect of the digit repositions the pad over the bone stump of the second phalanx, when closed with simple sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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