SA Trauma

Question 1

What is the first thing you should do if a trauma patient comes in?

Answer 1

• Assess the whole patient for life-threatening injuries –deal with these first! These are important to check before checkingforlimb usage
  
  • Airway
  • Breathing
  • Circulation
• Provide adequate analgesia, antibiotic cover and fluid support – adequate analgesia should be provided, can also allow you to assess the animal more readily if they are more comfortable. Antibiotics, esp if open fracture. Fluid support to maintain circulation
• Decontaminate and prevent any further contamination of open wounds
• Support grossly unstable fractures –a bit later in assessment andmanagement
• Assess for any neurological signs –the most important thing beyond initial assessment is whether there are any neuro signs Assessment of the trauma patient

Question 2

Why is analgesia essential for a trauma case?

Answer 2

They will likely be in huge amounts of pain

If they are more comfortable, you can assess them better also

Question 3

What should all animals involved in an RTA have done as part of the further investigation after airways, breathing and circulation has been checked?

Answer 3

They should always have their chest radiographed - its very easy to miss miaphragmatic hernia and pneumothroax on a normal clinical exam

US of chest may be useful to identify fluid

Check integrity of urinary tract

Check for internal haemorrhage

Monitor patient constantly

Question 4

What is happening on this radiograph of a dog thats been involved in an RTA?

Answer 4

Haemothorax

Question 5

What is happening on this contrast study radiograph of an animal that has been in an RTA?

What are treatment options?

Answer 5

Assessment of bladder function

At first it looks intact but can then see some leakage into the abdomen as can see free contrast agent

You might leave this and see if it will self heal, may need further treatment

Question 6

What are the classifications of open fractures?

Answer 6

• Type I -small wound. Little contamination. Treat as closed fracture. May even miss that there has been an open fracture! Treat as if it is. Ab given and wound opened and cleaned as a consequence
• Type II –extensive wound communicating with the fracture. Larger wound, may be able to see fracture within the soft tissues
• Type III –very extensive soft tissue damage and fractured bones are seen protruding through the skin. See relatively frequently, esp distal tibia in cat –comes through small amount of soft tissue in that area. Will be clearly visible and very heavily contaminated

Question 7

What is a type I classification of an open fracture?

Answer 7

• Type I -small wound. Little contamination. Treat as closed fracture. May even miss that there has been an open fracture! Treat as if it is. Ab given and wound opened and cleaned as a consequence

Question 8

What is a type II open fracture classification?

Answer 8

• Type II –extensive wound communicating with the fracture. Larger wound, may be able to see fracture within the soft tissues

Question 9

What is a type III open fracture classification?

Answer 9

• Type III –very extensive soft tissue damage and fractured bones are seen protruding through the skin. See relatively frequently, esp distal tibia in cat –comes through small amount of soft tissue in that area. Will be clearly visible and very heavily contaminated

Question 10

What can a shearing injury also be looked at like?

Answer 10

Shearing injuries could be looked at as a type 3 open fracture

Question 11

What kind of things do you need to assess with a shearing injury?

Answer 11

Assess:

• blood supply
• damage to deeper tissues:
  
  • nerves and ligaments –more difficult to assess. Ligaments –can check collaterals are intact, if lost malleolus, then the collateral ligaments will have gone with it
• bones
• superficial soft tissues
• These most commonly occur on the medial aspect of the hock or the radiocarpal joint –primarily as they are distal part of limb and little amount of soft tissue to protect them

Question 12

What should you do to treat an open fracture before any surgical intervention etc?

Answer 12

1. sterile water-soluble gel in wound
2. wide clip
   
   • Do this before you try to clean!! Clip itupand get all hair out of the way and once you have done this: 3.copious lavage
   • Warm haartmans and 19g needle, squeeze into it and remove as much debris as you can.
   • In early stages, it is contaminated, but not infected. Might become infected later due to hospital contamination –nosocomial infections! So always be aware of this, so always be sterile when touching and dealing!
   • Can remove bits of skin etc. that are clearly dead. But if you are unsure –leave it! Want to maintain as much soft tissue structures as you can
3. swab for bacteriology culture
   
   • Rare
4. IV broad-spectrum antibiotics
5. sterile dressing
   
   • Cover thewound! Prevent any further contamination

Question 13

What are Pavlectics 6 basic principles with regards to an open fracture?

Answer 13

• Prevent further wound contamination
• Remove foreign debris and contamination
• Debride dead and dying tissue
• Provide adequate wound drainage
• Provide a viable vascular bed
• Select an appropriate method of closure

Question 14

What is primary closure of a wound/open fracture?

Answer 14

This refers to wound closure immediately following the injury and prior to the formation of granulation tissue. In general, closure by primary intent will lead to faster healing and the best cosmetic result. Most patients presenting within 8 hours of injury can have the wound closed by primary intent. Simple and clean facial wounds, by virtue of the rich vascular supply to the face and the need for a good cosmetic result, can be closed by primary intent as late as 24 hours after the injury.

Question 15

If primary closure is not an option for a wound/open fracture, how else can it heal?

Answer 15

If primary closure is not an option,

• delayed primary closure
  
  • (pre-granulation)-3-5 days later
• secondary closure
  
  • (granulation tissue present–5-10 d)
  • Granulation tissue–pink,sometimes slightly fibrous but fairly vascular tissue. When you have this, you know the woundisnotcontaminated as the wound would not heal like this when contaminated
• second intention healing –leave wound to heal by natural process
• But don’t underestimate the time and cost that this can take! Can take several weeks and sometimes, you might be better to do something like attempt primary closure or refer on to do a skin graft –these can be quicker and less expensive than allowing secondary intention to take place
• granulation, contraction and epithelialisation
  
  • Epithelialisation –around edge of wound, see pink line –cells migrate across surface of wound to cover it.

Question 16

What is epithelialisation?

Answer 16

Epithelialisation –around edge of wound, see pink line –cells migrate across surface of wound to cover it.

healing by the growth of epithelium over a denudedsurface.

Question 17

Which one of these wounds is ‘hyper-mature’ and what is this?

Answer 17

Chronic vs ‘healthy’ granulation tissue

Granulation tissue –can becomehyper mature. If it becomes a little paler and a bit fibrous (like left), this is too mature –needs to be more like right, redder and ‘angrier’

Question 18

What dressing and bandages should you use for an open fracture/wound?

Which ones change and which stay the same?

Answer 18

• Primary (contact) layer changes
  
  • adherent to wound

Other two layers stay the same:

• Secondary layer –absorbent (avoid maceration) e.g. cotton wool, softban
• Tertiary layer –supportive and allows evaporation –on the surface. Protects dressing from further contamination from environment e.g. Vetwrap, Elastoplast Dressings and
• Also support dressing –rob jones for example –especially if fracture is unstable
  
  • Also helps with animals discomfort

Question 19

Give an example of a secondary layer to a bandage for an open wound/fracture?

Answer 19

It is absorbent

e.g. cotton wool, softban

Question 20

What is the tertiary layer of a dressing? give an example

Answer 20

Supportive and allows evaporation, on the surfacec

Protects underlying dressing from further contamination from environemnt

E.g. vetwrap, elastoplast

Question 21

The primary (contact) layer changes depending upon the stage the wound is at, depending on the degree of damage to the tissues.

What primary layers could you use suring the DEBRIDEMENT STAGE?

Answer 21

Debridement stage: adherent

• wet-to-dry–straight forward,just a swab that you moisten with Hartman’s, place on wound and put light dressing over that, to allow it to dry out. Remove next day. Debride takes away dead tissue as it adheres to tissue as it dries. MOST EFFECTIVE
• dry-to-dry
• Hydrogel

Question 22

The primary (contact) layer changes depending upon the stage the wound is at, depending on the degree of damage to the tissues.

What primary layers could you use suring the GRANULATION STAGE?

Answer 22

Granulation stage: dry, non-adherent

• Semi occlusive: absorptive e.g. Allevyn–place on and just absorbs some exudate and stores away from wound
• Occlusive: active rehydration e.g. Granuflex

Question 23

What are the 2 ways you can manage pelvic fractures?

Answer 23

Conservative management

• less invasive, less expense, outcome less predictable (poorer?) and recovery more prolonged. Cage rest, takes 6-8 weeks. Few complications

Surgical management:

• invasive and expensive, but likely to provide more rapid and fuller return to function, rapid pain relief, and potentially better outcomes. Offers much more rapid recovery for the animals –good at giving immediate pain relief and get possibly better return to function, don’t get pelvic narrowing and don’t get distortion of pelvis you don’t get if you manage conservatively

Question 24

What are some things you should consider when deciding whether a patient with a pelvic fracture needs surgery or not?

Answer 24

• is the patient ambulatory? If its up and walking, little advantage of using surgical stabilisation – the fracture might not be unstable, and as a consequence, they are only marginally displaced and can walk easily
• how long has fracture been present? If cat has been away for a week or so and comes back injured with broken pelvis, difficult to move the fragments if been this long! Better to leave it alone
• is the weight-bearing axis involved? Thw hip,Ileal shaft and then sacroiliac joint –weight baring axis, how weight goes from limbtospine–ifnoneofthisisaffected, animalshouldbeable to walkanddoesn’t really need surgery
• is the acetabulum involved? Articular fracture –if its broken, probably needs surgery! Can lead to OA
• is the pelvic canal diameter reduced ? (<50%) If greater than 50% -consider surgery, don’t want chronic constipation problems • is the patient intractably painful? Pelvis and lumbosacral outflow –if you an stabilise fractures, will reduce pain immediately
• are there multiple problems e.g. limb fracture? It wont be able to manage if its got pelvic fracture and other limb fracture
• But presence of neurological deficits (e.g. bladder function) can affect the decisions made regarding fracture repair Usually operate on ilial, acetabular, and bilateral fractures

Question 25

If the patient has a pelvic fracture, but is ambulatory, is surgery indicated?

Answer 25

If up and walking, there is little advantage of using surgical stabilisation - fracture might not be unstable, and as a consequence, they are only marginally displaced and can walk easily

Question 26

If the weight bearing axis is involved in a pelvic fracture, does the patient need surgery?

Answer 26

If it is not affected, animal should be able to walk and doesnt really need surgery

Question 27

How much does the pelvic canal diameter need to be reduced by with a pelvic fracture to warrant surgery?

Answer 27

If greater than 50% narrowed, consider surgery - can lead to chronic constipation problems

Question 28

What is an RTA shunting injury? Does it need surgery?

Answer 28

RTA “shunting injury” * May be stable -if greater than 50% of articular surface that is overlapping, might leave to heal by secondary intention process if pain free?? * can be bilateral * often accompanied by neurological abnormalities –sciatic nerve might be affected * always look for other pelvic fractures * Commonest part of WBA is sacroiliac joint –shunting injury Sacroiliac subluxation or sacral fractures

Question 29

How can you stabilise a shunting injury (sacroiliac subluxation or sacral fracture)?

Answer 29

* Can be managed conservatively if greater than 50% of articular surfaces are in contact * Surgical management can be difficult and is prone to error –repair is difficult. Implants can be mispositioned. LEFT pic –place screw through ileal wing into body of sacrum, easy to miss it –screw can go too far ventrally so not enough bone purchase or dorsally and into SC! * Options include: * large lag screw ±anti-rotational wire * trans-ilialpin –picture on RHS. Using the intact side to anchor that which isn’t intact. \*

Question 30

What is the problem with an ilial fracture and how can you stabilise it?

Answer 30

* Usually long oblique fractures – shown on top left pic * Caudal fragment often displaces medially narrowing the pelvic canal diameter –one of the major reasons it is also another reason why it is important to repair the ileal shaft. Generally put a plate on, but if it long and oblique, can place 2 screws, maybe a bit of cage rest afterwards. Once been stable for a week after this, can start to relax that it wont move any great amount once you have this first weeks initial repair * Well contoured plate ±lag screws * (long oblique -lag screws on own)

Question 31

What are some surgical complications with pelvic fractures?

Answer 31

* Reduction can be difficult especially if the injury is chronic (greater than 5 days old) * Iatrogenic damage to the sciatic nerve is a real risk –emanates from foramina in ventral aspect of the sacrum and runs over ileal shaft, is possible to damage it. * Management of the fractures requires considerable experience – know which ones can benefit from surgery Surgical complications

Question 32

What is the difference between the dorsaocranial aspect of the acetabulum in the dog and the cat? What does this mean with regards to a fracture here and whether it needs surgery?

Answer 32

* Weight bearing mainly in dorsocranialaspect of acetabulum in the dog but mid region in the cat. * Caudal third of acetabular takes less weight in dog, so if fracture here, not unreasonable to treat conservatively. In cat, weight bearing axis is more in mid region, so caudal part may be more important, so cats may need these repaired * Failing to reconstruct fractures of the caudal third can result in poor outcome.

Question 33

How can you repair an acetabular fracture?

Answer 33

* These are particularly difficult fractures to repair –refer? * Most common methods: * plate fixation (acetabular, standard, reconstruction) * U shaped and various sizes. Can place over acetabular and place screws that way * mid-acetabulum: screws, wire and methylmethacrylatecomposite * complex / cost issues --\> femoral head and neck excision (but wait to see what function gained with conservative approach)

Question 34

What can a pubic fracture often be associated with? What does this mean for the bladder?

Answer 34

May be associated with avulsion of pre-pubic tendon / rupture of the body wall –tendon often goes with the fracture and get herniation of ventral abdomen. If you have this, can get bladder in a subcutaneous position and this is detrimental to the animal Rarely occur in isolation

Question 35

How can you fix a mandibular symphyseal separation?

Answer 35

Pretty straight forward repair. Cerclage wire just caudal to canine teeth, place by putting large syringe needle and thread wire behind canine teeth Can use wire or PDS Soft foods for up to 6 weeks - important

Question 36

How can you achieve fixation of a maxillary fracture? What should you consider doing at the same time as this fracture repair?

Answer 36

* Various methods used to achieve fixation including; * Interdental wiring –between teeth, brings fracture together * Acrylic bonding of the canines –resin on canine teeth * Plates –rarely used but can be done –External skeletal fixation * BEARD (Bi-gnathic Encircling And Retaining Device) * Consider placement of feeding tube at the time of any maxillary or mandibular surgery –unless reasonable straight forward fracture, then place this tube when you do the initial surgery! Easy to put in and take out, but then you have the option

Question 37

When surgically fixing a maxillary fracture, what should you consider doing at the same time?

Answer 37

Consider placement of feeding tube at the time of any maxillary or mandibular surgery –unless reasonable straight forward fracture, then place this tube when you do the initial surgery! Easy to put in and take out, but then you have the option

Question 39

If you have separation of the hard palate, what can you do?

Answer 39

Interdental wiring - useful to bring together

Question 40

How can you use acrylic resin to fix a maxillary fracture? What does the animal need enough room to do?

Answer 40

Acrylic resin on canine teeth Make sure jaw is perfectly aligned and place the resin Need enough room for animal to lap water Need anaesthetic to remove resin at the end

Question 41

What is the BEARD technique with regards to fixing maxillary fractures?

Answer 41

* Suture which goes around mouth, mandible andmaxilla in order to maintain alignment of teeth–similar principle to acrylic bonding (resin), stops animal opening mouth * Canine teeth remain locked together

Question 42

What is a tempromandibular luxation? How do they present and how can you diagnose it?

Answer 42

* Deviation of jaw away from side of luxation * Inability to close mouth * May present similarly to maxillary fracture * Diagnosis based clinical signs and radiographic examination

Question 43

How can you treat a temperomandibular luxation?

Answer 43

* Place wooden dowel into angle of jaw as caudal as possible * Apply dorsal pressure to rostral mandible –will bring joint ventrally * Normally reduction is easily achieved * Feed soft foods for several days and they rarely dislocate

Question 44

What is a capital physeal fracture?

Answer 44

One such growth plate is called the capital physis and is located at the head of the femur bone. This head forms the ball of the hip joint. When a fracture occurs through this growth plate the cap of the head of the femur slips off; hence this fracture is referred to as a “slipped cap.” Epiphysis remains in the acetabulum attached to the teres ligament

Question 45

What can be seen in these radiographs?

Answer 45

Capital physeal fracture One such growth plate is called the capital physis and is located at the head of the femur bone. This head forms the ball of the hip joint. When a fracture occurs through this growth plate the cap of the head of the femur slips off; hence this fracture is referred to as a “slipped cap.” Epiphysis remains in the acetabulum attached to the teres ligament

Question 46

What is the treatment for a capital physeal fracture?

Answer 46

* Stabilised with 2-3 K-wires or a lag screw -care to avoid penetration of the articular cartilage! * “Apple-coring” common 3-6 weeks post operatively due to revascularisation of the femoral neck and subsequent bone remodelling. Not usually a clinical problem. * Premature physeal closure and development of DJD is common * Poor healing reported in the Burmese cat which might result in a salvage procedure, e.g. Femoral Head and Neck Excitionor total hip replacement – might be genetic problem with the breed.

Question 47

Which breed of cat has poor response to a capital physeal fracture? What should you do?

Answer 47

Poor healing reported in the Burmese cat which might result in a salvage procedure, e.g. Femoral Head and Neck Excitionor total hip replacement – might be genetic problem with the breed.

Question 48

How common is patellar luxation in the cat? Any breeds? What is it associated with?

Answer 48

* less common than in dogs * higher incidence in pure breeds e.g. Abyssinian and Devon Rex * hereditary component (but not as well defined as in dogs) * association with hip dysplasia

Question 49

What is the clinical presentation of patellar luxation in the cat? What should you be careful of and why?

Answer 49

* clinical presentation: often unwillingness to jump and awkward gait * feline patella can often feel quite lax, so don’t diagnose unless showing clinical problem

Question 50

What is the treatment for patellar luxation in the cat?

Answer 50

* similar management and treatment protocols as to dog * surgery technically more difficult than in dogs due to size, may be higher morbidity

Question 51

How common is cranial cruciate ligament rupture in the cat? What is it often associated with? How should you treat?

Answer 51

* uncommon in isolation * usually traumatic * obese cats predisposed * treated conservatively, or using extra-capsular suture

Question 52

How can cats get total disruption of the stifle? How can you treat it?

Answer 52

* Traumatic * Often involves both cruciate ligaments, the medial collateral ligament and menisci * Extra-capsular suture plus prosthetic collateral ligament (±meniscectomy) * Often requires trans-articular skeletal fixator to maintain joint reduction

Question 53

What is patellar fractures in cats also associated with - what should you always check?

Answer 53

Associated with retained deciduous canines - so always check teeth Some problem with mineralisation of the bones,get fracture of bone and inability to fix stifle and also problems with fractures elsewhere

Question 54

How can you fix a patellar fracture in a cat?

Answer 54

can attempt repair but rarely will they heal, if not too distracted – leave them alone! If needs to be treated –cerclage wire is probably best to manage it Patellar fracture

Question 55

What is the signalment for a patellar fracture?

Answer 55

Young cat Minimal trauma Unable to fix stifle Associated with retained deciduous canines 'knees and teeth syndrome'