Poppy Newton a 1 year old, neutered female cocker spaniel presented to Fitzpatrick referrals on the 3rd April 2007. Poppy had been involved in a road traffic accident.
Poppy had sustained numerous fractures including: spiral fracture of the left femoral metaphysis, a left caudal ilial fracture and ischial symphyseal separation, spiral fracture of the right mid tibial metaphysis, mid metaphyseal oblique fractures of metatarsal 2 and 3 of the right leg, comminuted butterfly fracture of the left humeral metaphysis. Poppy also sustained a luxation and significant shear injuries of the left hock. On presentation she had a PCV (packed cell volume) of 16%; Biochemistry was within normal limits for all parameters.
The first priority was to stabilise poppy for surgery. Since Poppy’s PCV was only 16%, it was decided that a blood transfusion would be needed to improve her chances of survival through surgery. Half a litre of whole filtered blood was transfused at a rate of 10ml/kg/hr. Since Poppy’s condition was critical, transfusion reactions are rare and there was only 1 possible donor available no cross match was made. Poppy did have a reaction to the blood transfusion over the first 3 hours, her temperature increased and she started to deteriorate. The decision was made to stop the transfusion after she had had a bout 200mls of whole blood. Her PCV was 25% when the blood transfusion was stopped. IV colloids were used along with crystalloids.
The following day surgery was performed to fix all of the pelvic limb fractures and the hock luxation. The PCV was measured before surgery at 22%. The left pelvic limb constituted the most significant challenge and therefore this was repaired first. There was considerable soft tissue injury, haemorrhage and bruising, in addition to compound injuries penetrating the skin in the hock. All injuries were treated with String Of Pearls (SOPTM) plates. The caudal ilial fracture was treated with a 5-hole SOPTM plate, the comminuted femoral fracture was treated with an 11-hole SOPTM plate. The damage to the ligaments and soft tissue combined with irreparable damage to the talus and distal tibia of the left hock required a pantarsal arthrodesis to be carried out, this was achieved with a 13-hole SOPTM plate applied at an appropriate standing angle following debridement of the cartilage surface. The arthrodesis was augmented with Osteo-AllograftTM, canine cancellous bone chips and demineralised powder. The right tibial fracture was repaired with a 10-hole SOPTM plate. The metatarsal fractures of the right hind foot were realigned and stabilised using countersunk intramedullary pins. We decided to leave the humeral fracture until poppy’s condition had improved so she was not under anaesthesia for too long and to minimize blood loss from surgery – even though all pelvic limb fractures were repaired with SOP™ plates in less that 2 ½ hours. The significant soft tissue injuries of the left hind leg were managed with bandaging and use of Intrasite gel™ aided healing through secondary intention.
Post-operative radiography revealed satisfactory alignment and stability of all implants. Intensive care nursing was required throughout the following days.
Post operatively poppy’s PCV was monitored very closely to check that it was not still falling. It remained above 20% so further blood transfusions were not required. There was significant post operative swelling so two hourly massage was carried out for the first 48 hours dropping to 6 times daily over the following week. To relieve pain a fentanyl infusion was installed for the first week post operatively along with carprofen. Clavulanic acid potentiated amoxicillin was administered to prevent infection of the damaged soft tissue.
Poppy’s medical condition improved between 6th April and 12th April. Her PCV slowly increased to 25.5% by 10 April 2007. Consistent physical therapy and massage of the limbs improved her comfort and range of motion of the pelvic limbs. Intensive physical therapy was required with multiple overnight nursing but eventually she was strong enough to contemplate fracture repair of the left humerus which was undertaken on the 13th April. The humeral fracture was characterised by a spiral segmental distal diaphyseal fracture encroaching the distal metaphysis. The fracture was re-aligned using an intramedullary pin from the medial epicondyle driven up the humeral medulla (retrograde), the fracture was then held in position with a fracture distractor and then supported using a medially applied SOPTM plate. Post-operative radiography revealed satisfactory alignment and stability and in the days subsequent to repair.
Poppy’s progress was assessed on two occasions since and at final check on 11th May, radiography revealed satisfactory healing of all fracture sites. Poppy is very comfortable and is running around happily. However, the left pelvic limb was still impaired in terms of motion because of fibrosis and restriction in range of motion of the left stifle primarily. This is a predictable sequel to the degree of soft tissue and osseous trauma and may limit the ultimate functional capability of the limb.
Physical therapy has been intensively applied and Poppy had since made very good progress and is running around without discomfort. However, normal motion of the left stifle is still not possible and a mechanical lameness is evident. Nevertheless, Poppy is very happy and should have a very satisfactory quality of life in the longer term. Hydrotherapy will be useful in both short and long term and Poppy will stay on a nutraceutical containing chondroitin sulphate and glucosamine (SynoquinTM) to attempt amelioration of arthrosis in the longer term.