SlideShare uma empresa Scribd logo
1 de 7
1 
Proximal Femoral Fracture in an Alpaca 
DANE TATARNIUK, DVM 
- HISTORY: 
Intact male, introduced into pen with other intact males. Acute 
trauma sustained and became non-weight bearing lame on right hind. 
Owner delayed veterinary exam for 2 weeks, presented to rDVM at 3 weeks. 
Presented for surgical evaluation at 3-4 weeks post trauma. 
- RADIOGRAPHIC DIAGNOSIS: 
Short oblique, closed, non-articular fracture of the proximal third of the 
right hind femoral diaphysis, with caudal displacement. Moderate 
mineralization present within the soft tissues surrounding the fracture (callus 
and/or dystrophic mineralization) 
- PRESURGICAL EXAM: 
1. Compartment Syndrome 
- Can get increased swelling, due to the significant fascia surrounding 
the femoral muscles can develop compartment syndrome in dogs 
- Also can occur post-op, requiring suture removal 
2. Nerve function 
a. Pinch lateral skin near digits / hoof to assess deep pain = sciatic nerve 
b. Pinch medial skin near digits to assess deep pain = femoral nerve
2 
- Partial deficits are OK, usually improve with fracture repair 
- Can get increased swelling, due to the significant fascia surrounding the 
femoral muscles can develop compartment syndrome in dogs 
- EXTERNAL STABILIZATION: 
1. None 
- No external coaptation (ie, cast, bandage to stifle) is usually 
indicated. Cast or bandage up to stifle can act as pendulum weight that 
creates a fulcrum effect on the fracture site. 
2. Spica Spint 
- Can use a spica splint in dogs but not practical in large animals 
- ANATOMY: 
1. Greater trochanter: 
- insertion for middle gluteal, 
deep gluteal, piriform 
muscles 
2. Lesser trochanter: 
- iliopsoas muscle 
3. Third trochanter: 
- superficial gluteal muscle 
4. Trochanteric fossa: 
- caudal on femoral neck, 
insertion for internal 
obturator, external obturator, 
gemelli muscles 
5. Sciatic nerve: 
- courses over dorsal border of ischium, passes over caudal aspect of 
acetabulum 
- SURGICAL APPROACH: 
1. Cranial-lateral 
- Most common. 
- Incise fascia lata along cranial border of biceps femoris muscle. -
Retract vastus lateral cranial and retract biceps formis caudally. - Exposes 
most of the diaphysis of the femur. 
- SURGICAL REPAIR THEORY: 
(Specific to transverse and short oblique fractures) 
3 
1. IM pins alone 
- Rotational and axial instability. 
- Can lead to nonunion 
- Predispose to osteomyelitis 
2. Dynamic Compression Plates: 
- Create intrafragmentary compression 
- Proximal fractures, greater trochanter makes it difficult to 
contour plate appropriately to maximize bone to plate interface 
- Femur is unique, during weight bearing, medial cortex is 
subject to compression, lateral cortex subject to tension 
- Bone plates are applied to the lateral aspect
4 
3. Interlocking Nails 
- Useful, but no intrafragmentary compression 
- SURGICAL REPAIR ACTUALITY: 
- Routine cranial-lateral approach 
- Had to incise part of vastus lateralis transversely, as anatomy 
would not retract cranially far enough to facilitate visualization 
- Visualized sciatic nerve coursing from the caudal aspect of the 
greater trochanter, distally along the biceps femoris (caudal to the 
fracture) 
- Significant mineralization and fibrosis tissue present 
- Removed with rongeurs 
- Created significant bleeding = constant suction 
- Isolated both proximal and distal fracture 
- Reduced the fracture using Hohmann retractors 
- Significant remodeling of the fracture ends, no longer clearly 
congruent. Large, sharp fragment off of distal fracture not clearly 
compatible with proximal fracture margins. 
- Attempt to rotate the fracture planes to accompany the sharp 
fragment of the distal fracture, but results in significant lateralization 
(toe-ing out) of the limb. 
- Suspect some muscle contracture influencing malrotation of 
the proximal fracture (still connected to the Coxofemoral 
joint) 
- Decide to perform ostectomy of both the proximal and distal ends of 
the femur fracture. Approximately 1cm of length of bone removed. - 
Ostectomy facilitated adequate congruency of the femur for fracture fixation. 
- Placed pin retrograde through proximal fracture site, exiting 
through trochanteric fossa. Then aligned the proximal and distal 
fractured bones and drove IM pin normograde until it reached the 
metaphysis of the distal femur (used C-arm to ensure not in stifle joint) 
- Very important to be aware of where the sciatic nerve is located when 
doing IM pin placement (increased risk with retrograde placement vs. 
normograde) 
- In theory, IM pin should fill 30 to 40% of medullary cavity 
- Aware that we would be applying bone plate to lateral aspect of 
fracture. Used smaller IM pin to increase ability to place bicorticol 
screws (otherwise would have to place monocorticol screws) 
- Following IM pin placement, then placed hook plate (pre-bent) such 
that the hook of the plate is situated on the greater trochanter of the
5 
femur. 
- Hook Plate: 3.5 narrow dynamic 
compression plate, 8 holes 
- Two prongs count as AO sites of 
fixation 
- Hook plate set comes with a specific 
grill guide that allows you to situate 
the two drill holes on the greater 
trochanter of the femur, at an exact 
distance from each other 
- Fixate the plate by making two 2.5mm drill holes for the prongs of the 
plate (using the drill guide) and then taping the plate in place with a mallot 
(such that the prongs are now in the drilled guide holes) and plate is aligned 
on the femur. 
- Then, placed remainder of screws in neutral fashion 
- Screws placed bicorticol, one screw clearly had some interaction with 
IM pin with tightening (threads of screw touching IM pin) 
- Confirm that screws in proximal aspect of the femur follow into the 
femoral neck but do not engage Coxofemoral joint using C-arm 
- Fibrous callus on medial aspect of femur made using depth gauge 
difficult (some screws too long) 
- After application of hook bone plate, copious lavage 
- Sutured various muscle and fasial layers, #0 PDS 
- Sutured skin, interrupted cruciates, #0 Ethilon 
- Ioban for recovery 
- FLUROSCOPIC IMAGE, POST OP:
- FEMUR FRACTURE REPAIR COMPLICATIONS: 
6 
- Femur has highest rate of non-union and osteomyelitis following 
surgical repair in dogs and cats 
- Nonunion influenced by iatrogenic trauma or devascularization of bone 
segments 
- Quadriceps contracture, fibrosis or adhesions to the fracture callus. 
- Hyper-extends stifle joint. 
- Can have femoral shortening 
- Malalignment, most often rotational. 
- Contracture of muscles rotate the proximal segment 
attached to coxofemoral joint. 
- Can cause varus or valgus deformities of the femoral head / 
neck. 
- Can cause gait abnormalities or patella luxation. 
- Sciatic nerve damage most commonly associated with IM pinning. 
- Often reversible and improves with time. 
- POST-OP: 
- Therapy 
- Managed on 0.1mg/kg Morphine, IV, q4hr for 12 hours
7 
- Managed on 1.1mg/kg Flunixin meglumine, q12hr for 72 
hours 
- Managed on 2.2mg/kg Ceftiofur, q12hr for 5 days 
- Anemia 
- Decreased from PCV 32% pre-op, down to 15% post-op 
- Part due to blood loss intra-op 
- Part due to Mycoplasma hemolamae infection 
- Organism active in times of stress = hemolysis 
- Administered 20mg/kg Oxytetracycline, every 3rd day, 
for 3 doses

Mais conteúdo relacionado

Destaque

Tarsal Anatomy of the Horse
Tarsal Anatomy of the HorseTarsal Anatomy of the Horse
Tarsal Anatomy of the Horse
Dane Tatarniuk
 

Destaque (18)

Equine Orthopedic Field Emergency
Equine Orthopedic Field EmergencyEquine Orthopedic Field Emergency
Equine Orthopedic Field Emergency
 
Clinical Pathology & Equine Arthropathies
Clinical Pathology & Equine ArthropathiesClinical Pathology & Equine Arthropathies
Clinical Pathology & Equine Arthropathies
 
Peritoneal Healing, Cow/Horse
Peritoneal Healing, Cow/HorsePeritoneal Healing, Cow/Horse
Peritoneal Healing, Cow/Horse
 
Case Study - Cannon Bone Laceration
Case Study - Cannon Bone LacerationCase Study - Cannon Bone Laceration
Case Study - Cannon Bone Laceration
 
Equine larynx
Equine larynxEquine larynx
Equine larynx
 
Horse Castration
Horse CastrationHorse Castration
Horse Castration
 
Bisphosphonate Therapy in Horses
Bisphosphonate Therapy in HorsesBisphosphonate Therapy in Horses
Bisphosphonate Therapy in Horses
 
Pastern Arthrodesis
Pastern ArthrodesisPastern Arthrodesis
Pastern Arthrodesis
 
Large Animal Orchiectomy
Large Animal OrchiectomyLarge Animal Orchiectomy
Large Animal Orchiectomy
 
Tenoscopy - Equine Flexor Tendon Sheath
Tenoscopy - Equine Flexor Tendon SheathTenoscopy - Equine Flexor Tendon Sheath
Tenoscopy - Equine Flexor Tendon Sheath
 
Shockwave Therapy in Horses
Shockwave Therapy in HorsesShockwave Therapy in Horses
Shockwave Therapy in Horses
 
Surgical Complications
Surgical ComplicationsSurgical Complications
Surgical Complications
 
Conformation by dr. beeman
Conformation by dr. beemanConformation by dr. beeman
Conformation by dr. beeman
 
Equine Carpus Anatomy
Equine Carpus AnatomyEquine Carpus Anatomy
Equine Carpus Anatomy
 
Thoracotomy in Cattle & Horses
Thoracotomy in Cattle & HorsesThoracotomy in Cattle & Horses
Thoracotomy in Cattle & Horses
 
Tarsal Anatomy of the Horse
Tarsal Anatomy of the HorseTarsal Anatomy of the Horse
Tarsal Anatomy of the Horse
 
Equine Nerve & Joint Blocks
Equine Nerve & Joint BlocksEquine Nerve & Joint Blocks
Equine Nerve & Joint Blocks
 
Platelet Rich Plasma (PRP) Therapy
Platelet Rich Plasma (PRP) TherapyPlatelet Rich Plasma (PRP) Therapy
Platelet Rich Plasma (PRP) Therapy
 

Femoral Fracture in an Alpaca

  • 1. 1 Proximal Femoral Fracture in an Alpaca DANE TATARNIUK, DVM - HISTORY: Intact male, introduced into pen with other intact males. Acute trauma sustained and became non-weight bearing lame on right hind. Owner delayed veterinary exam for 2 weeks, presented to rDVM at 3 weeks. Presented for surgical evaluation at 3-4 weeks post trauma. - RADIOGRAPHIC DIAGNOSIS: Short oblique, closed, non-articular fracture of the proximal third of the right hind femoral diaphysis, with caudal displacement. Moderate mineralization present within the soft tissues surrounding the fracture (callus and/or dystrophic mineralization) - PRESURGICAL EXAM: 1. Compartment Syndrome - Can get increased swelling, due to the significant fascia surrounding the femoral muscles can develop compartment syndrome in dogs - Also can occur post-op, requiring suture removal 2. Nerve function a. Pinch lateral skin near digits / hoof to assess deep pain = sciatic nerve b. Pinch medial skin near digits to assess deep pain = femoral nerve
  • 2. 2 - Partial deficits are OK, usually improve with fracture repair - Can get increased swelling, due to the significant fascia surrounding the femoral muscles can develop compartment syndrome in dogs - EXTERNAL STABILIZATION: 1. None - No external coaptation (ie, cast, bandage to stifle) is usually indicated. Cast or bandage up to stifle can act as pendulum weight that creates a fulcrum effect on the fracture site. 2. Spica Spint - Can use a spica splint in dogs but not practical in large animals - ANATOMY: 1. Greater trochanter: - insertion for middle gluteal, deep gluteal, piriform muscles 2. Lesser trochanter: - iliopsoas muscle 3. Third trochanter: - superficial gluteal muscle 4. Trochanteric fossa: - caudal on femoral neck, insertion for internal obturator, external obturator, gemelli muscles 5. Sciatic nerve: - courses over dorsal border of ischium, passes over caudal aspect of acetabulum - SURGICAL APPROACH: 1. Cranial-lateral - Most common. - Incise fascia lata along cranial border of biceps femoris muscle. -
  • 3. Retract vastus lateral cranial and retract biceps formis caudally. - Exposes most of the diaphysis of the femur. - SURGICAL REPAIR THEORY: (Specific to transverse and short oblique fractures) 3 1. IM pins alone - Rotational and axial instability. - Can lead to nonunion - Predispose to osteomyelitis 2. Dynamic Compression Plates: - Create intrafragmentary compression - Proximal fractures, greater trochanter makes it difficult to contour plate appropriately to maximize bone to plate interface - Femur is unique, during weight bearing, medial cortex is subject to compression, lateral cortex subject to tension - Bone plates are applied to the lateral aspect
  • 4. 4 3. Interlocking Nails - Useful, but no intrafragmentary compression - SURGICAL REPAIR ACTUALITY: - Routine cranial-lateral approach - Had to incise part of vastus lateralis transversely, as anatomy would not retract cranially far enough to facilitate visualization - Visualized sciatic nerve coursing from the caudal aspect of the greater trochanter, distally along the biceps femoris (caudal to the fracture) - Significant mineralization and fibrosis tissue present - Removed with rongeurs - Created significant bleeding = constant suction - Isolated both proximal and distal fracture - Reduced the fracture using Hohmann retractors - Significant remodeling of the fracture ends, no longer clearly congruent. Large, sharp fragment off of distal fracture not clearly compatible with proximal fracture margins. - Attempt to rotate the fracture planes to accompany the sharp fragment of the distal fracture, but results in significant lateralization (toe-ing out) of the limb. - Suspect some muscle contracture influencing malrotation of the proximal fracture (still connected to the Coxofemoral joint) - Decide to perform ostectomy of both the proximal and distal ends of the femur fracture. Approximately 1cm of length of bone removed. - Ostectomy facilitated adequate congruency of the femur for fracture fixation. - Placed pin retrograde through proximal fracture site, exiting through trochanteric fossa. Then aligned the proximal and distal fractured bones and drove IM pin normograde until it reached the metaphysis of the distal femur (used C-arm to ensure not in stifle joint) - Very important to be aware of where the sciatic nerve is located when doing IM pin placement (increased risk with retrograde placement vs. normograde) - In theory, IM pin should fill 30 to 40% of medullary cavity - Aware that we would be applying bone plate to lateral aspect of fracture. Used smaller IM pin to increase ability to place bicorticol screws (otherwise would have to place monocorticol screws) - Following IM pin placement, then placed hook plate (pre-bent) such that the hook of the plate is situated on the greater trochanter of the
  • 5. 5 femur. - Hook Plate: 3.5 narrow dynamic compression plate, 8 holes - Two prongs count as AO sites of fixation - Hook plate set comes with a specific grill guide that allows you to situate the two drill holes on the greater trochanter of the femur, at an exact distance from each other - Fixate the plate by making two 2.5mm drill holes for the prongs of the plate (using the drill guide) and then taping the plate in place with a mallot (such that the prongs are now in the drilled guide holes) and plate is aligned on the femur. - Then, placed remainder of screws in neutral fashion - Screws placed bicorticol, one screw clearly had some interaction with IM pin with tightening (threads of screw touching IM pin) - Confirm that screws in proximal aspect of the femur follow into the femoral neck but do not engage Coxofemoral joint using C-arm - Fibrous callus on medial aspect of femur made using depth gauge difficult (some screws too long) - After application of hook bone plate, copious lavage - Sutured various muscle and fasial layers, #0 PDS - Sutured skin, interrupted cruciates, #0 Ethilon - Ioban for recovery - FLUROSCOPIC IMAGE, POST OP:
  • 6. - FEMUR FRACTURE REPAIR COMPLICATIONS: 6 - Femur has highest rate of non-union and osteomyelitis following surgical repair in dogs and cats - Nonunion influenced by iatrogenic trauma or devascularization of bone segments - Quadriceps contracture, fibrosis or adhesions to the fracture callus. - Hyper-extends stifle joint. - Can have femoral shortening - Malalignment, most often rotational. - Contracture of muscles rotate the proximal segment attached to coxofemoral joint. - Can cause varus or valgus deformities of the femoral head / neck. - Can cause gait abnormalities or patella luxation. - Sciatic nerve damage most commonly associated with IM pinning. - Often reversible and improves with time. - POST-OP: - Therapy - Managed on 0.1mg/kg Morphine, IV, q4hr for 12 hours
  • 7. 7 - Managed on 1.1mg/kg Flunixin meglumine, q12hr for 72 hours - Managed on 2.2mg/kg Ceftiofur, q12hr for 5 days - Anemia - Decreased from PCV 32% pre-op, down to 15% post-op - Part due to blood loss intra-op - Part due to Mycoplasma hemolamae infection - Organism active in times of stress = hemolysis - Administered 20mg/kg Oxytetracycline, every 3rd day, for 3 doses