1. Treating Fractures Medical Environmental Research Learning INstitute

2. Goals Proper triage Prognosis and repair options for various fractures Post-op care and protocols Audience  Rehabbers\first responders  Veterinarians who are interested in doing orthopedics Medical Environmental Research Learning INstitute

3. Why bother? We are generally dealing with healthy birds Prognosis can be quite good Recovery can be very dramatic Medical Environmental Research Learning INstitute

4. Factors affecting prognosis Bone exposure Proximity to a joint Chronicity – is the patient emaciated? Our patients have to be close to perfect for a successful outcome. Medical Environmental Research Learning INstitute

5. Immediate needs\goals Stabilize the bird Immobilize bones  Prevent desiccation Prevent further stress and injury Medical Environmental Research Learning INstitute

6. Stabilization Most fractures are not immediately fatal, but shock and stress are.  Warm fluids SQ\IO BID\TID  Pain control with meloxicam and butorphanol  Start antibiotics if open fracture or if surgery will be needed Baytril 25 1 ml\kg SQ with fluids once, then 15 mg\kg SQ\PO BID (NOT IM) Medical Environmental Research Learning INstitute

7. Wound care Clean the wound. Always wear exam gloves when cleaning wounds Have a lot of flush ready…you will need it Medical Environmental Research Learning INstitute

8. Irrigation Warm NaCl or LRS is always best H 2 O 2 should never be used For dirty wounds, can use dilute betadine solution Medical Environmental Research Learning INstitute

9. Debridement Very painful and very stressful Very little can or should be done without anesthesia Medical Environmental Research Learning INstitute

10. Bone exposure Must prevent desiccation by covering with skin, if possible. THIS IS AN EMERGENCY  Can use temporary sutures if necessary  Can also use collagen\gel dressings Cover with Silvidine cream and saline-soaked Telfa non-adherent dressing Start systemic antibiotic (Baytril is my first choice) Surgery ASAP Medical Environmental Research Learning INstitute

11. Stabilization Figure 8 bandage for ulna\radius\metacarpal fractures Figure 8 + body wrap for humerus and coracoid fractures Padded splint +\- ball wrap for fractures distal to the knee Not much can be done for femur fractures. Surgery indicated ASAP. Medical Environmental Research Learning INstitute

12. Velcro wraps Medical Environmental Research Learning INstitute

13. Orthopedic supplies Medical Environmental Research Learning INstitute

14. Orthopedic supplies Medical Environmental Research Learning INstitute

15. A few more points Examine entire bird including eyes.  Don’t want to put a bird thru surgery if they are NR anyway If surgery is necessary, do it quickly.  Ideally within 2-3 days of admission Medical Environmental Research Learning INstitute

16. Ulna fracture Probably most common fracture Usually a closed fracture If alignment ok, figure-8 bandage may be enough Or an intermedullary (IM) pin placed from the elbow Medical Environmental Research Learning INstitute

17. Ulna fracture – post-op Goal is to Prevent callus from bridging to the radius Provide reasonable alignment Medical Environmental Research Learning INstitute

18. Ulna fracture Medical Environmental Research Learning INstitute

19. Ulna fracture - closeup Medical Environmental Research Learning INstitute

20. Ulna fracture – 4 weeks later Pull pin when fracture is stable on palpation and there is radiographic evidence of a mature callus. Medical Environmental Research Learning INstitute

21. Ulna\radius combo fractures Almost always open with massive soft tissue trauma Very difficult to splint. Needs surgery immediately. Medical Environmental Research Learning INstitute

22. Ulna\radius combo – post-op IM pin in ulna IM pin sometimes placed in radius but this can interfere with the wrist joint Radius normally heals well if ulna is stabilized Medical Environmental Research Learning INstitute

23. Extremely comminuted Medical Environmental Research Learning INstitute

24. 5 weeks later Medical Environmental Research Learning INstitute

25. Don’t rush into surgery Medical Environmental Research Learning INstitute

26. 4 days later… Medical Environmental Research Learning INstitute

27. Shuttle pins

30. Humerus fractures Very variable.  Midshaft, distal, proximal  Transverse, oblique  Comminuted or simple Can have severe soft tissue trauma. Severe muscle contracture common. Bone exposure VERY common Immediate stabilization requires a figure-8 wrap + body wrap. Medical Environmental Research Learning INstitute

31. Long oblique, midshaft\distal Medical Environmental Research Learning INstitute

32. Long oblique, midshaft Cerclage wires allowed for a very stable fixation Medical Environmental Research Learning INstitute

33. Transverse, midshaft, comminuted Medical Environmental Research Learning INstitute

34. Transverse, midshaft Massive soft-tissue swelling distal to the fracture is poor prognostic indicator IM pin + external fixator tie-in Medical Environmental Research Learning INstitute

35. External fixator configurations Medical Environmental Research Learning INstitute

36. External fixator configurations Medical Environmental Research Learning INstitute

37. External fixator configurations Medical Environmental Research Learning INstitute

38. External fixator configurations Medical Environmental Research Learning INstitute

39. External fixator configurations Medical Environmental Research Learning INstitute

40. External fixator tie-in Disadvantages  Technically more challenging. Placing pins can cause damage.  Increased surgical time  More pin tracts to take care of  Very difficult\impossible in small birds? Advantages  Fixation is MUCH more rigid  Can remove wrap sooner ( 1 week vs 5 weeks).  Definitely the treatment of choice Medical Environmental Research Learning INstitute

41. Distal humeral fracture Medical Environmental Research Learning INstitute

42. Distal humeral fracture Medical Environmental Research Learning INstitute

43. Proximal humeral fracture Medical Environmental Research Learning INstitute

44. Proximal humeral fracture Medical Environmental Research Learning INstitute

45. Collapsed, comminuted fracture Medical Environmental Research Learning INstitute

46. One month later! Released Jan 10, 2009 Medical Environmental Research Learning INstitute

47. Metacarpal fracture Figure-8 wrap can work. Seem to take a long time to heal May attempt IM pin +\- external fixator in large bird Medical Environmental Research Learning INstitute

48. Coracoid fracture COHA window strikes Very difficult to palpate Surgery is NOT indicated Treat with figure-8 + body wrap for 2 weeks with intermittant PT. Prognosis is good Medical Environmental Research Learning INstitute

49. Coracoid fracture Medical Environmental Research Learning INstitute

50. Coracoid fracture Medical Environmental Research Learning INstitute

51. Femur fracture Large muscle mass. Can be missed on physical exam. Usually midshaft Bumblefoot can result in opposite foot if not adequately stabilized. Splints\wraps are not effective Medical Environmental Research Learning INstitute

52. Femur fracture IM pin can migrate\fall out. THIS DOES NOT WORK WELL. External fixator tie-in MUCH more rigid. Luckily, there is a lot of room for “slop” Should blunt the pin at the stifle Medical Environmental Research Learning INstitute

53. Femur fracture – tie-in fixator Medical Environmental Research Learning INstitute

54. Femur fracture – tie-in fixator Medical Environmental Research Learning INstitute

55. Femur fracture – tie-in fixator Medical Environmental Research Learning INstitute

56. Tarsometatasus Very little soft tissue covering. Tissue distal to fracture can become necrotic if blood supply is compromised. Toe swelling is bad prognostic indicator. Temporary padded splint +\- ball wrap +\- coat-hanger side bars can be effective temporarily or in very young birds. Bumblefoot can result in opposite foot if not adequately stabilized. Medical Environmental Research Learning INstitute

57. Tarsometatasus TM has a C-shaped cross-section. Must be very careful when placing pins. Medical Environmental Research Learning INstitute

58. Tarsometatasus Medical Environmental Research Learning INstitute

59. Tibiotarsus External fixation is usually best choice IM-pin or shuttle pin + external fixator tie-in are also options Much more soft tissue covering than TM. Pin placement can be difficult  severe swelling  tibiotarsus has odd cross-section Medical Environmental Research Learning INstitute

60. Typical protocol - part 1 Day 0 – Admission and stabilization Day 0-4 – Butorphanol 2 mg\kg IM BID Day 0-10 – Meloxicam 0.25 mg\kg PO BID Day 1 – Surgery – major procedures receive fluids via IO catheter. Day 2-7 – Pins are cleaned daily and triple antibiotic ointment applied Day 4 – Begin physical therapy under anesthesia Medical Environmental Research Learning INstitute

61. Typical protocol- part 2 Day 5-21 – Physical therapy continues 3 x weekly. Anesthesia required for most of it Day 10 – Radiograph and every 10-14 days thereafter Day 21 – Wrap can likely be removed Week 3-6 – Physical therapy continues 2 x weekly without anesthesia Medical Environmental Research Learning INstitute

62. Typical protocol - part 3 Week 6 – Remove fixation and move to small (10x10 ft) outdoor cage to allow limited exercise Week 8 to10 – Move to large (50-100 ft) flight cage with gradually increased forced exercise Week 12 – Release! Medical Environmental Research Learning INstitute

63. Physical therapy Importance of PT cannot be overstated. If you are not prepared to do PT frequently and humanely (i.e. with anesthesia) then patient should be euthanized or transferred to another facility. Medical Environmental Research Learning INstitute

64. Physical therapy Medical Environmental Research Learning INstitute

65. Having said that… Medical Environmental Research Learning INstitute

66. Flight training Medical Environmental Research Learning INstitute

67. The release Last Six Months Total54 Good candidates38 Released22 (57%)* * This includes failures due to unrelated problems such as irreversible eye trauma, severe emaciation, death from unknown causes. Medical Environmental Research Learning INstitute

68. Thank you Dave Scott, DVM Carolina Raptor Center P.O. Box 16443 Charlotte, NC 28297 704-875-6521 x105 dscott@carolinaraptorcenter.org Medical Environmental Research Learning INstitute