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11 November 2000 V
Supracondylar Femoral
FOCAL POINT
★Choosing appropriate orthopedic
Fractures in Adult
implants and surgical techniques
is critical to the successful
management of supracondylar
Animals
femoral (SCF) fractures in adult
animals. University of Tennessee
David A. Lidbetter, BVSc, MVS, CertSAS, MACVSc, MRCVS
University College Dublin
KEY FACTS Mark R. Glyde, BVSc, MVS, MACVSc, MRCVS
F
emoral fractures are commonly repaired in small animals. Midshaft dia-
■ Traditional repair methods such physeal fractures are the most common femoral fractures, followed by frac-
as intramedullary pinning and tures of the distal epiphyseum. Supracondylar femoral (SCF) fractures oc-
standard bone plating may not cur infrequently in adult animals.1 The major texts and veterinary scientific
provide ideal stability for SCF literature cover the management of growth plate injuries in immature animals
fractures. and midshaft femoral fractures in adults in some detail; however, far less infor-
mation is available on the management of the often more challenging distal frac-
■ Alternative devices should be tures.2–8 In humans, SCF fractures are a common fracture in which two distinct
considered to stabilize SCF patient populations exist: Younger people sustain these fractures as a result of
fractures in adult animals. high-velocity trauma, and elderly people with osteoporosis often sustain them
after minimal trauma.9–20 Various orthopedic implants and techniques, including
intramedullary (IM) pinning, blade plating, buttress condylar plating, dynamic
compression plating, interlocking nailing, Zickel supracondylar nailing, and
double plating, are employed in humans to repair the fractures.9–20
Management of distal femoral fractures in young animals is typically straight-
forward because of the simple nature of the fracture and the innate potential of
young animals to heal rapidly. The fractures normally occur through the weak
zone of hypertrophy in the physis; the surface of the fracture often interdigitates
in a W shape, giving the repair some inherent stability.21
Small Animal/Exotics Compendium November 2000
TABLE I
Devices Used to Repair Supracondylar Fractures in Adult Animals
Repair Devices Indications Relative Contraindications Important Points
Intramedullary pins Use as adjunct fixation Most SCF fractures Poor rotational stability
Crossed K-wires Cats; small dogs; transverse, Comminuted, cortical defect Simple technique; requires
short oblique fractures fractures limited equipment
Rush pins Cats; small dogs; transverse, Comminuted, cortical defect More difficult technique;
short oblique fractures fractures requires specialized equipment
DCP Many SCF fractures, Chondrodystrophoid breeds Avoid trochlear ridge and
particularly more proximal of dogs; very distal fractures intraarticular screw placement;
fractures use care with capsule closure
Reconstruction Cats; small- and medium-sized Large dogs; comminuted or Requires load sharing with
plate dogs; chondrodystrophoid cortical deficit fractures bone; contour to distal caudal
breeds of dogs femoral bow
Plate/rod Most breeds and sizes of dogs Some cats and small dogs; Place bicortical screws in
and cats; comminuted and very narrow medullary canals metaphysis; place monocortical
cortical defect fractures screws in diaphysis
Modified type I All breeds and sizes of dogs and SCF fractures with an Use positive-profile pins; avoid
ESF cats; comminuted, open SCF articular component quadriceps
fractures
Customized hook Most breeds and sizes of dogs; Use extra care with cats and Modification of existing DCP
plate most fracture configurations small dogs required
Interlocking nails Most breeds and sizes of dogs Chondrodystrophoid breeds Requires specialized equipment
and cats; more proximal SCF of dogs; some cats with very and training
fractures distal fractures
Tibial head Large-breed dogs; most fracture Animals weighing <25 kg Right-sided plates are used for
compression plate configurations left-sided fractures
Hybrid circular Most SCF fractures; most SCF fractures with an Technically difficult; requires
ESF breeds and sizes of dogs and articular component specialized training and
cats; very distal fractures equipment
DCP = dynamic compression plate; ESF = external skeletal fixator; K = Kirschner; SCF = supracondylar femoral.
however, either a full-open approach, mini-approach, or exposure with only a minor increase in morbidity, com-
open-but-do-not-touch approach is employed.25,26 Typical- bines the approach to the lateral femur with a tibial
ly, because of the instability of these fractures and their dis- crest osteotomy and proximal reflection of the straight
tal location, an approach to the shaft of the femur is com- patella ligament and quadriceps group.10,27 The firmly
bined with a lateral approach to the stifle as described by attached periosteum and joint capsule should be elevat-
Piermattei and Greeley.27 ed from the distal lateral condylar region when a bone
An alternative technique, which provides excellent plate repair of the femur is applied.
drodystrophoid breeds in which marked caudal bowing ture.8 Guidelines for pin size and screw number have
of the condylar region precludes using standard bone been published; a pin diameter of no greater than 50%
plates in more distal fractures.36 When only one or two of the medullary canal at its narrowest point is recom-
screws are placed in the distal fragment, crossed K- mended. Because screw placement in the diaphysis is
wires should be used for additional stability. often extremely difficult, it may only be possible to
place screws in the metaphyseal regions.
Plate–Rod Combination
The plate–rod technique attempts to synergize the Modified Type I External Fixator
actions of IM pins and bone plates.8,25,26,37–39 This tech- The modified type I external skeletal fixator (ESF),
nique is especially useful in highly comminuted frac- which can be used in all cats and dogs, can be applied
tures or when a significant cortical deficit that cannot to most SCF fractures, including those that are trans-
be anatomically reconstructed is present (Figure 7). An verse, comminuted, or very distal. No implants are
open approach to the femur and stifle should be made, placed at the fracture site and either a complete open
and an IM pin can be placed either retrograde or nor- approach, a limited approach, or closed reduction and
mograde in order to reduce the fracture and aid align- frame application can be used. This type of implant has
ment. The trochlear sulcus and greater trochanter can the potential for less soft tissue and associated vascular
be used as landmarks to avoid rotation of the stifle or damage. Initially, in veterinary practice, the use of ESFs
anteversion of the femoral neck and head. The limb was primarily reserved for the distal limb with less use
should be checked for varus deformation before a plate in proximal limbs owing to the larger mass of soft tissue
is applied to the lateral femur. The plate neutralizes ro- and impingement of the body wall medially. The use of
tational, bending, and axial forces while the pin, which fixators in the femur and humerus in cats and dogs has
is placed centrally in the bone, protects the plate and increased because of the introduction of modified and
guards against bending.25,26,37–39 more complicated strategies and frames.
Although this technique involves a significant num- Simple type I ESFs can be used in SCF fractures;
ber of implants, no attempt should be made during re- however, gaining adequate purchase in the distal frag-
pair to anatomically reconstruct multiple small fracture ment is not always feasible. Placing one or two centrally
fragments. This biological approach to the repair tries threaded positive-profile full pins in the distal condylar
to minimally disrupt the already fragile blood supply to region from lateral to medial allows the use of a bent,
the fracture.25,26,38 A bone graft should also be placed. A additional connecting bar to be passed from the medial
minimum of three monocortical screws and one bicor- side of the distal femur to the lateral proximal femur
tical screw should be used on either side of the frac- (Figure 8).40,41 This increases the stiffness of the frame
and minimizes fracture instability and pin loosening. It pin loosening, and decreased stifle range of motion and
is advisable to use another one or two half-pins in the leg usage.42–44 Although significant complications are
distal fragment, if possible, and four half-pins proxi- uncommon, veterinarians and owners should monitor
mally. Positive-profile pins are used because of their and clean the skin surrounding the pins, encourage
added cortical bone contact, increased pin pull-out controlled physical therapy, and monitor radiographs
strength, and lower incidence of pin–bone interface for evidence of pin loosening.
problems.42–44 This frame is well tolerated by cats and
dogs and results in minimal to no body wall contact Customized Hook Plate
with the frame.45 A customized hook plate has been developed recently
Alternatively, an acrylic frame can be used in the for use in metaphyseal fractures when minimal bone
humerus to connect the lateral type I pins across the stock is a complicating consideration.48 The technique
distal femur to the medial side, then continuing proxi- involves bending a standard DCP and fashioning sharp,
mally over the thigh to the lateral proximal aspect.46 pointed hooks with a hacksaw blade (Figure 9). This
The bending strength of the frame is improved by plac- modified implant can be useful in SCF fractures with
ing an IM pin in the shaft of the femur and then con- small distal targets and can have some advantages over
necting it to the main lateral frame in a “tied-in” con- conventional plates. The same number of screw holes
figuration.47 In SCF fractures, fixators are often placed can be used as in a DCP, with the addition of the fash-
via an open approach because of the difficulty in reduc- ioned hooks. Two parallel holes set the width of the
ing the fractures closed. If an open approach is made to plate apart should be drilled into a distal portion of the
a comminuted SCF fracture, it is usually an open-but- femoral fragment before gently hammering the hooks
do-not-touch approach in which the proximal and dis- into the bone (Figure 10). Drill diameter should be
tal bone columns are reduced, the hip and stifle joints slightly larger than that of the hooks. The fracture
are aligned, and no attempt is made to anatomically re- should be reduced and a screw hole in the proximal
construct the bone column.25,26 fracture fragment filled, securing reduction. The re-
The presence of pins in the distal femur can cause ir- mainder of the screw holes in the distal and proximal
ritation to the joint capsule, retinaculum, and soft tis- fragments should be drilled and filled.
sue. The stifle, being a high motion area, can add to In humans, a dynamic compression screw may be
the irritation. The quadriceps muscle should be avoid- used to compress SCF/intercondylar femoral fractures,
ed, and soft tissue entrapment can be minimized by us- or an AO (Arbeitsgemeinschaft fur Osteosynthesefra-
ing retraction or drill guides. Morbidity associated with gen) blade plate can be used to provide increased sur-
the pins can include pin tract discharge and infection, face area contact of the plate in distal bone.10,11,13,17
Figure 10—Customized hook plate placed using predrilled Figure 11—Surgical application of an interlocking nail.
holes and a mallet.
These implants are generally too large to use in most 8 mm and accept 2.0-, 2.7-, 3.5-, and 4.5-mm screws.49
animals; however, the customized hook plate follows The largest nail that fits the medullary canal should be
similar principles to that of the blade plate. The tight chosen. The nail should be long enough to place the
security of the hooks is less important than is their con- screw holes 2 cm from the fracture site, and nails of
tact in the bone.10 Screws can be placed through the similar length and contralateral limb radiographs
hooked area, thus the number of screws in the distal should be used to ensure that the pin is seated in distal
fragment is not reduced yet the points of contact are metaphyseal cancellous bone.49–51 The distal fragment
increased.48 The drawback of this technique is that be- in SCF fractures may need to be overreduced. The nails
cause an aiming jig is not available for screw placement, are usually placed in normograde fashion; however, an
moderate force may be needed to hammer the hooks opening in the proximal cortex may be made using a
into the bone holes. This does not, however, detract separate pin in a retrograde fashion.
significantly from the technique. Similar to the DCP, Because the nails have been customized for animals,
the modified hook plate may cause difficulty in closing problems with aiming and executing the technique
the joint capsule and can affect the patella if the plate is have been ameliorated. Nails are now made with more
positioned too close to the trochlea ridges. distal screw hole placement so that they can be applied
The technique is adaptable and has been used suc- to SCF fractures. An obstacle with this technique is the
cessfully in medium to large dogs. Care may be needed inability to lodge the pin distal enough to gain screw
in small dogs and cats to ensure adequate width is pres- purchase below the fracture line; occasionally, a single
ent for the hooks to be placed distally. screw hole below the fracture line is necessary. This
should not significantly alter stability at the repair
Interlocking Nails site.51
Adapted from human medicine, the Dueland inter- The ILN is an adaptable system requiring specialized
locking nail system is designed for veterinary patients.49 equipment, which can be used for most sizes and
The nails are solid, surgical stainless steel with screw breeds of adult animals. It can be used in transverse and
holes at either end. An open approach to the femur is comminuted fracture patterns. Complications with the
usually made and limited muscle reflection is necessary. technique include problems with screw aiming and
Screws should be inserted through the bone to engage placement, breakage of the nail at the screw hole, and
the nail, thereby preventing rotation of the fracture and sciatic nerve damage if the nail protrudes from the in-
axial collapse (Figure 11).49–51 Interlocking nails (ILNs) tertrochanteric fossa.49
offer the advantage of positioning the implant centrally
in the bone, thereby providing excellent bending Tibial Head Compression Plate
strength. Three nail models are available with lengths The tibial head compression plate is primarily for use
from 140 to 230 mm. Nail diameters range from 4.7 to in dogs weighing more than 25 kg. The design of the
can lead to luxation or abnormal wear. In addition, it line data can be used throughout the recovery period to
can be difficult to adequately close the joint capsule be- quantify progress. Early use of the limb is of paramount
cause of the presence of the implant. The common per- importance; therefore, range-of-motion exercises
oneal nerve, which lies caudal to the lateral fabella on should be performed daily. The limb should be iced be-
the medial surface of the biceps, must be visualized be- fore each session and massaged before beginning vigor-
fore fracture repair to prevent iatrogenic damage. ous physical therapy. Exercises can include sit-stand,
short leash walks, treadmill walking, or walking up in-
POSTOPERATIVE REHABILITATION clines. Supervised hydrotherapy in a bath or underwa-
Supracondylar femoral fractures predispose the ani- ter treadmill can begin after suture removal. At dis-
mal to soft tissue complications. Quadriceps contrac- charge, owners must be thoroughly educated regarding
ture and tie-downs, which are seen more frequently in care and procedures, and regular follow-up visits should
immature animals with fractures, can also occur in ma- be encouraged.
ture animals.60 Often, the quadriceps may be damaged To avoid soft tissue disease, active physical therapy
by the trauma involved in creating the SCF fracture. must be continued until fracture healing is completed.
After open surgical repair, the muscle is prone to un- Further therapy after this time will help reverse muscle
dergo fibrosis and to scar to the underlying periosteum. atrophy and improve long-term limb function.
Signs of quadriceps contracture begin subtly and in-
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About the Authors
Orthop Trauma 12:108–117, 1999. Dr. Lidbetter is affiliated with the Department of Small Ani-
56. Lewis DD, Radasch RM, Beale BS, et al: Initial experience mal Clinical Sciences, University of Tennessee, Knoxville.
with the IMEX circular external skeletal fixation system: Use Dr. Glyde is affiliated with the Department of Veterinary
in bone lengthening and correction of angular and rotational Surgery, University College Dublin.
deformities. Vet Comp Orthop Trauma 12:118–127, 1999.