Pet health

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Fracture Management

Bone fractures in pets are a relatively common occurrence in veterinary medicine. Injuries to pets can occur many ways, with the most common being vehicular trauma (hit by car). This brief article is meant to inform owners that not all fractures should be managed the same way and that as fracture repair advances in the human orthopedic field so are the advances in the veterinary field. No longer do we need to rely on pins, wire, and a prayer. The advanced surgical techniques can be thanked due to our increasing appreciation of biomechanics and the different forces on various areas of the body. Many times I have been asked “can you cast that fracture?” The answer to the question is “sometimes”, however most fractures encountered have a much higher chance of healing with some sort of surgical fixation (internal or external). I always remind owners that with our canine or feline patients, they will be trying to use the fractured limb much sooner than we would, which means more pressure on our support. Also, be reminded that when we have a forearm (or upper arm) fracture we won’t be required to walk on it like our pet counterparts.

Our first goal with fracture fixation is how can we make this fracture stable immediately, that will last through the healing process. To do this the surgeon must have a full understanding of biomechanics to appreciate the different forces on the bone (tension, compression, etc). There is no such thing as “cookie-cutter” fracture repair. While many fractures are similar, none are exactly the same. Some may be comminuted (multiple pieces), develop fissures (splits down the long axis of the bone), exposure to the outside (open, contaminated), and be intra-articular (enter into the joint) and require special consideration. It is rare, in the day with veterinary specialists that limbs need to be amputated due to the fracture – the more common reason for amputation would be due to severe neurologic impairment (no feeling, etc). Other goals with fracture fixation include: how do we minimize trauma to soft tissue (skin,muscle, etc), minimize bleeding, minimize infection risk, and maintain blood flow and clots that initially develop around the fracture site that aid in quicker healing.

Fracture repair has evolved over the years from full exposure and full reconstruction of the bone (even with multiple fragments) to minimal reconstruction biological osteosynthesis) and soft tissue disruption (Minimally Invasive Plate Osteosynthesis (MIPO)). This articles goal is to introduce the reader to some of the newer technologies available to the veterinary surgeon and your pet. These techniques are aimed at early recovery and return to function of your pet. I would be remiss if I didn’t mention that exercise/crate restriction is needed during the post-operative phase and can be 8-12 weeks in duration, depending on the type of fracture and age of pet. Please follow the advice of your veterinarian.

Early plates that are still used today (and many times the appropriate choice) are called Dynamic Compression Plates (DCP) or Limited Contact – Dynamic Compression Plates (LC-DCP). There are many cases where this is either the most appropriate option or the only option. The plate must be placed flush against the bone after the bone is reconstructed or supported. Screws go through the plate into the bone through pre-drilled holes. Remember wood-working concepts, as the threaded holes in the bone accept the advancing screw, the screw starts to bring the bone to the plate as you tighten the screw. This bone-to-plate interface (touching/squeezing) is where this type of repair gets it strength. If there is no bone to plate contact, this becomes a very weak fixation. This also demands that the plate is precisely contoured to the bone before application. Some downsides to this fixation is that the fracture must be fully exposed and manipulated (delayed healing, increased risk of infection, soft tissue trauma to an already traumatized area) and that if not perfectly pre-contoured it could weaken the repair or offset the fracture alignment to a degree. There are advantages to this type of fracture repair as well, such as allowing the bone to accept some of the weight bearing load (if a two piece fracture), being able to compress the fracture ends and being able to compress fissures and fragments through the use of screws placed in “lag” (compression) fashion. So there is definitely a place for this type of fixation and in appropriate cases can be the best option.

DCP plate

DCP plate used to stabilize a radius fracture.

Early fracture fixation that tried to minimize soft tissue trauma while providing a strong fixation was the external skeletal fixator (ESF) which encompasses both linear and circular external fixation. These allow the surgeon to place pins of varying sizes in the bone, where the ends remain outside of the limb and connect to a bar or ring for support. Case selection is key as with any type of repair and they certainly have their place in fracture fixation. Surgeon experience and knowledge of repair mechanics is necessary. Some ideal cases may be (but not limited to): some juvenile fractures, open (infected) fractures, intra-articular (or near joint) fractures, etc. The benefit of this fixation is that once the bone is healed, all the implants are removed. Also, sequential removal of pins can be performed to destabilize the repair – which can be beneficial in fractures that are delayed in healing.

A linear external fixator used to stabilize a tibial fracture.

A linear external fixator used to stabilize a tibial fracture.

An external fixator used to stabilize a tibial fracture

An external fixator used to stabilize a tibial fracture

More recent repair options are locking plates. Many companies have began production of locking plates and this article is not meant to show favoritism to any company. The basic concept with this technology is that the screws used actually lock into the plate to provide more stabilization. Previous designs (see above) depended on the bone to plate interface. Locking plates are dependent on the strength of the screw to plate interface, which is typically much stronger. Screws “lock” into the plates by either a conical locking mechanism (Morse taper phenomenon – for all the engineers in the audience) or by threading into the plate (threads on the screw heads match the threads in the plate holes). Many hours of mechanical testing has gone into these types of plates both on the human and veterinary side and have proven their strength. A benefit of this increased strength is the need for less screws than in the earlier described plate designs. We can achieve our desired strength of fracture repair with less implants (less can be more with regards to fracture fixation). Another big benefit is that we no longer are so concerned about contouring the plate to the bone , which allows us to not touch the fracture site to aid and facilitate healing. Remember standard plates bring the bone to the plate as the screw tightens, with the locking plate design, as the screw contacts the plate and locks the bone stays stationary. This design also allows us to perform MIPO techniques with a strong fracture fixation. By in large, this type of fracture fixation is leading the way in both human and veterinary surgery. The downside is that these plating systems are usually only available at veterinary surgical centers, but again they offer a great advantage to fracture management.

Preoperative tibia/fibula fracture

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Fracture repaired using a minimally invasive (MIPO) technique and locking plate.

Again, when deciding what type of fracture fixation is best there are many factors to consider and that decision would be made best by your veterinary surgeon. Also, not all types of fixation have been mentioned in the article. We are very fortunate to be living in this time where veterinary medicine is advancing so we can provide greater benefit for our best friend and loyal family members.

– Kevin Benjamino DVM, DACVS

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Brachycephalic Obstructive Airway Syndrome – Treatment

Elongated soft palate

Elongated soft palate

Shortened soft palate

Shortened soft palate

The mainstay of treatment for BOAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation. Typically medical management is used after (and in conjunction with) surgical management.

There are many questions that arise when considering surgical management and one of the biggest is when do you consider surgery? BOAS can be seen even in puppies and it is recommended that an evaluation be performed in dogs that are predisposed to this condition. Early management can halt or delay the progression that is typically seen, especially laryngeal collapse.

There are various methods to widen the nares(nostrils). The most common technique is the vertical wedge resection, where a wedge of tissue is removed with the apex of the triangle at the dorsal surface. An absorbable suture can be placed to control bleeding. It is important to make sure that the nares is wide enough to increase airflow.

An elongated soft palate is one of the most common features of BOAS. The assessment and skilled resection is key. If too much is removed, then there is a communication between the oropharynx and nasopharynx. If not enough is removed then the problem still exists.  The most common technique employed is resection with metzenbaum scissors and suture. Sharp excision of the soft palate generally ensures the least amount of inflammation. Other methods, such as CO2 laser and Ligasure, have been described and can be successful. Complications that can arise are as follows: bleeding, inflammation, chronic granulation tissue formation, and further elongation of the soft palate over time.

As mentioned previously, the presence of everted saccules characterizes the patient with stage I laryngeal collapse. There is some controversy as to whether or not everted saccules should be addressed surgically.

With patients that have grade II and III laryngeal collapse surgical correction is more difficult. When collapse is present it is always recommend to correct what is correctable, however the larynx will never be functional again. Some propose modified laryngeal tieback procedures with mixed outcomes. A permanent tracheostomy becomes a very viable option. By performing a permanent tracheostomy the entire upper airway is by-passed.

When counseling owners, generally dogs affected with BOAS have a favorable prognosis. Success is solely dependent on progression of disease. Education of owners should start when the patient is a puppy to avoid worsening. When a patient progresses to laryngeal collapse prognosis decreases greatly, as well as hospitalization time.

 

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Brachycephalic Upper Airway Syndrome (BUAS) – diagnosis

Diagnostic testing:

In addition to direct visualization of structures it is wise to evaluate both the neck and chest. This is most commonly performed with radiographs (X-rays). Structures to evaluate include the oro/nasopharynx, trachea, lungs (for pneumonia, etc), and cardiac disease. If cardiac disease is suspected due to auscultation and radiographs, an echocardiogram is recommended. A complete blood count (CBC), chemistry and urinalysis should be performed prior to anesthesia to assess total body function and if your pet is a good anesthetic and surgical candidate.

A very important part of the diagnostic workup performed just before surgery is the oral examination. One way to evaluate the upper airway is endoscopy of both the larynx and esophagus. This will provide a very thorough evaluation of the soft palate, ventricles and laryngeal function.

Direct visualization is the most common way of diagnosing the associated factors of the brachycephalic dog. The nares are narrower than a normal dog and the airflow is distorted.  For a sedated oral exam, the patient is typically anesthetized (light plane of anesthesia). Evaluating the laryngeal function in these dogs is very important in differentiating laryngeal paralysis from laryngeal collapse.

The mainstay of treatment for BUAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation.

 

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Brachycephalic Upper Airway Syndrome (BUAS) – physical exam

Most commonly the history of patients with BUAS are very similar. Generally, owners notice snoring and gradual progression of inspiratory stridor. Many times this will occur while the patient is a puppy and continue into adulthood. Other signs that are noted are increasing frequency of dyspnea especially during exercise or a hot environment. Another sign to look for in addition to the other is vomiting and/or regurgitation. This can be a compounding problem as it predisposes the pet to aspiration pneumonia.

On physical exam one of the first things that can be directly visualized is the nares being stenotic. The observant examiner will also note an increased upper respiratory noise with inspiratory stridor on auscultation(listening with a stethoscope. Typically the rest of the general physical examination is within normal limits.

Prior to performing a sedated oral exam various differentials should be on the list and should include neoplasia (oral/pharyngeal masses/cancer), tracheal collapse, laryngeal paralysis, lower airway disease and cardiac(heart)disease. Both lower airway diseases and cardiac disease can greatly exacerbate upper airway signs and if the patient is stable, these should be addressed first or at least concurrently.

Our next segment will be an overview of the surgical treatment and then we can wrap up this topic.

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Happy Holidays

I want to take a moment to thank everyone for their continued interest and support of this blog. Your continued support has meant a lot to me and allowed me to continue to post various topics. I want to wish everyone Happy Holidays during this joyous time of the year! I wish you all the best in the New Year too! Keep your pets safe throughout this time, but definitely spoil them (we want them to ring in the New Years without any ailments)! Please continue to follow this blog!

Seasons Greetings!!

Kevin

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Brachycephalic Obstructive Airway Syndrome (BOAS)

What makes up BOAS? The most common components of this disease are both stenotic nares(nostril) and an elongated soft palate. These two features are commonly seen. Other components are everted saccules, hypoplastic trachea, and secondary laryngeal collapse. In dogs that have stenotic nares the cartilage that makes up the nares is generally thicker and more condensed and oftentimes more medially displaced which causes an obstruction. Also, the conchae(cartilage in the nasal passageway) can be altered and displaced causing further airway turbulence and obstruction.

Anatomically the soft palate is just caudal(behind) to the hard palate and further divides the nasopharynx from the oropharynx (nasal passage from the mouth or oral cavity). In the normal patient the soft palate will typically extend caudally to just touch (slightly overlap) the epiglottis. In patients with an active obstruction this can be seen to extend 1-2 cm (or more) past the epiglottis. Due to this extension past the epiglottis, this tissue can actively obstruct airflow into the larynx and also become edematous(swollen) and undergo inflammation. Inflammation from this airway obstruction can extend to the tissue surround the pharyngeal region.

Generally considered to be a secondary side effect of the aforementioned conditions, everted saccules can develop due to the presence of increased air pressure of a prolonged period of time. Laryngeal saccules are normal out-pouchings noted adjacent to the vocal folds. Normally they extend outward away from the airway. After being under constant negative pressure these out-pouchings will evert and extend into the caudal laryngeal lumen causing an obstruction. Another secondary effect noted due to the constant high pressure is laryngeal collapse. This generally occurs in later stages of the disease process and will progress in severity. There is a grading scale that is used to assess the condition. Grade I laryngeal collapse is present when the laryngeal lumen is narrowed by everted saccules. Grade II collapse is characterized by both everted saccules and the cuneiform processes begin to collapse inward and fail to abduct during inspiration. Grade III collapse is characterized by the addition of the corniculate processes inwardly folding during inspiration, which signifies complete collapse.

The next posting will go over some of the physical exam findings and what we can do to help these patients out for the long run.

Note the narrow nostrils.

Note the narrow nostrils.

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Upper Respiratory Issues – Brachycephalic Upper Airway Syndrome (BUAS)

Overview:

A very common airway problem seen in small dogs and some bigger dogs is a syndrome termed Brachycephalic Upper Airway Syndrome (BUAS). This disease process affects brachycephalic dogs due to the development of their skull structure. These dogs can be thought of having the same anatomy as a longer nose dog, just in a much smaller area. As one could image, this can cause difficulty in the passage of air as it traverses through the nasal passage and into the naso- and oropharynx causing an increased pressure.

Common breeds that are affected and grouped into the breed type(brachycephalic) range from the Bulldog to the Cavalier King Charles Spaniels. Dogs that are affected by BUAS can present with many different symptoms that all involve the passage of air and include snoring, stridor, exercise intolerance, apnea and even gastrointestinal side effects such as vomiting and regurgitation. There are factors that can worsen the signs such as weight gain, allergies, environment conditions etc. Factors that can be controlled should be addressed.

In the next segment we will look at the physical features of dogs that have brachycephalic upper airway syndrome. Feel free to ask questions.

Pug and stenotic nares - after surgery

Pug and stenotic nares – after surgery

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Treatment for an Intestinal Obstruction

Sorry about the nearly one month lapse in writing. I think it would be good to finish the topic on intestinal obstructions. The biggest question to be asked is, once the diagnosis is made – how do we correct the issue. The answer is one of three: 1. endoscopic removal of gastric foreign material, 2. surgical removal by an abdominal exploratory (or laparoscopy – only if a focal obstruction), and 3. hospitalization and fluids, if and only if , the foreign material is diagnosed as being in the large intestine/colon.

Generally, surgical explore of the abdomen and removal via a gastrotomy, enterotomy, or intestinal resection and anastomosis is recommended. Rather than go into the technical aspects of the surgeries, it would be better to put the emphasis of the importance of early detection and treatment of an intestinal obstruction, especially a complete obstruction. The biggest worry is both where in the gastrointestinal tract and to what extent did the material cause damage to the intestine. This can range from irritation and inflammation to perforation and necrosis (death) of the affected intestine. Early intervention is key in trying to reduce the risk of extensive damage. The more aggressive the procedure required increases post-operative risk to the patient.

Most patients will do well with surgery and recover uneventfully. Standard enterotomies and resection/anastomosis have a 10-15% complication rate when performed according to the literature. The most concerning complication is termed dehiscence (leaking of the intestinal suture line) and require another surgery to repair the area. Unfortunately, with more surgery required, the complication rate increases.

The best word of advice would be to attempt to identify possible foreign bodies and remove them them your pets reach. Some examples would be torn pieces of toys, squeakers from toys that have been removed, string/fishing line from cats, etc. However, if you do find your pets have the common signs – seek veterinary help right away.

An x-ray of a foreign body both in the stomach and within the intestines.

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Common Signs with Intestinal Obstructions

Welcome back. This shouldn’t take too long, but let’s review some of the more common signs seen with intestinal obstructions. The most common sign would be vomiting and generally not a one time occurrence. This will usually be profuse vomiting (but can vary with every patient). Other signs to look for is anorexia (not wanting to eat), lethargy, and abdominal pain. As with any type of foreign body the gastrointestinal tract can become perforated and significantly worse signs can become evident. Whenever an intestinal foreign body is suspected immediate veterinary care (whether your primary veterinarian or an emergency clinic) is highly recommended. Generally these signs will occur very acutely (all of a sudden) once the object begins to obstruct the intestine. We don’t always know what our dogs get into, especially if they are left unattended or go outside in the back and unsupervised. It seems like many owner don’t know what there pet got into and swallowed.

During the initial evaluation, your veterinarian may recommend some diagnostic tests to help support the diagnosis of an intestinal foreign body and justify surgery. Most of the time the physical exam will show, dehydration (high heart rate, dry mucus membranes, etc), evidence of vomiting, pain on abdominal palpation, fever (if perforated intestines) and other various signs. Some dogs when presented early show few signs and are very stable, other dogs show very severe signs and may be very unstable and require aggressive supportive care including aggressive fluid management and other treatments.

The standard diagnostics after initial triage (physical exam, blood pressure, etc) typically include abdominal radiographs (x-rays), complete blood work, possible chest radiographs (if aspiration suspect or in the geriatric dog) and possible abdominal ultrasound if the radiographs are non-diagnostic. Some may also recommend contrast radiographs with barium contrast in an attempt to highlight the foreign body.

Once a presumptive diagnosis is made and the patient is deemed stable surgery generally is the next step. If the foreign body is only in the stomach, endoscopy may be performed succesfully to remove the object.

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Intestinal Obstructions

Hello all!!! I hope everyone is well!!! It has been a busy past few weeks. I recently was in Mexico lecturing, which was very exciting, my first international lecture series. Everyone was great in Mexico, very hospitable, I hope to be invited in the future. The next few weeks will prove to be busy as well – we will see how things go – stay tuned for updates.

I was trying to think of topics to share that might be beneficial for both owner and professional, and thought I would share a little about gastrointestinal obstructions – namely foreign bodies/materials. As a general surgeon, intestinal foreign bodies and obstructions are a common reason to go to surgery. Countless times per week we are faced with the decision of surgery in intestinal obstructions. While eating a foreign body is a major way of causing an obstruction, there can be other reasons as well such as cancer, etc. We will stick to foreign body obstructions in this blog.

Defining the terms: Foreign body refers to any material (ingested, in this case) that is foreign to the body. We are referring to objects swallowed by an animal and can range from fabric, stick, coins, tennis balls, rocks, etc. When an animal ingests an object there are three possible outcomes: 1. passing the object and excreting it in the feces, 2. becoming partially lodges in the stomach or intestines and partially blocking the normal flow of contents, and 3. becoming lodged in the stomach (pylorus) and/or intestines and causing a complete obstruction, not allowing any gastrointestinal contents to pass. These can also occur in the esophagus too.

Now that we got that out of the way, we will start talking about common signs you may see with your pet when they swallow a foreign object. Stay tuned!!!