Can I Just Splint This? Decision-Making with Fracture Management

Introduction

When stabilizing appendicular fractures, the choice of conservative versus surgical management is one of the most critical steps. This decision is based on patient, veterinarian, and client factors. The veterinarian’s choice of stabilization and agility in response to changes with the case, the client’s compliance and communication with the vet, and the pet’s activity level and ability to heal all play a role. Some cases require surgery for the best outcome, some cases are well-suited to conservative management, and some cases fall somewhere in between.

Influences on Bone Healing

Bones depend on biological and mechanical factors for healing, and fractures require a minimum ability to heal and a minimum level of stability. Among the factors influencing a fracture’s ability to heal are a pet’s age, the fracture configuration (e.g., simple vs. comminuted), the fracture location (e.g., diaphysis vs. metaphysis), and other comorbidities. The stability of a fracture, or the mechanical environment, is also influenced by the fracture configuration, as well as the pet’s activity, body condition, and, ultimately, the stabilization method chosen by the veterinarian. A three-month-old, otherwise-healthy dog with a simple fracture is much more likely to heal than a 17-year-old cat with a comminuted fracture, even in a relatively unstable environment. It is important to note that a bone in a splint or cast will always be more unstable than a fracture that has been repaired surgically.

Obtaining Radiographs

Appropriate radiographs are essential to assess many of the factors we use to determine the appropriate therapeutic course for fractures. Radiographs should always be based on the orthopedic examination and include a minimum of two orthogonal views with the entire fractured bone included. If joint instability or an avulsion fracture is suspected, stressed views can be obtained to document this excessive laxity. Sedation with adequate analgesia, such as a full mu opioid, is important for musculoskeletal trauma radiography to minimize patient stress and pain and optimize the quality of the images obtained.

Interpreting Radiographs

Once quality radiographs are obtained, the veterinarian can evaluate the fracture’s location, configuration, displacement, soft tissue status, and chronicity, all of which contribute to deciding the course of management. Fractures that are located proximally to the elbow or stifle are ill-suited for conservative management, as it is extremely challenging to provide adequate stability with external coaptation in these locations. Fractures that are transverse and those with intact internal struts (i.e., incomplete fractures, tibial fractures with the fibula intact, and radial fractures with the ulna intact) are ideal for conservative management. Fractures that are comminuted have little inherent stability to facilitate splinting or casting, and the soft tissue envelope surrounding them is likely more traumatized, resulting in a less viable mechanical and biological environment necessary for conservative management. To allow for acceptable healing, fractures that are significantly displaced must be adequately reduced prior to coaptation, with a minimum of 50% fracture overlap in two planes. Fractures that are open, as evidenced by subcutaneous gas on the radiographs, are also poorly suited to conservative management, as frequent bandage changes create an unstable environment for the fracture, and the tissue damage is detrimental to bone healing. Finally, chronic fractures should be carefully evaluated based on their current amount of healing and stability, as surgical intervention may not provide significant additional benefit.

The Decision Tree for Fracture Management

The first question a veterinarian needs to ask themself when deciding between recommending conservative and surgical management is whether the fracture can be appropriately stabilized. As discussed, most fractures above the knee and elbow cannot be stabilized adequately, so surgical management will almost always be the recommendation for humeral, femoral, unstable scapular fractures, and weight-bearing pelvic fractures. Additionally, surgical management will always be recommended for articular fractures, as restoration of the joint surface is imperative for a good outcome.

If the fracture is stabilized for external coaptation, the next question is whether the biological environment is adequate for healing. The veterinarian must consider the pet’s age and any comorbidities, as well as characteristics of the fracture, such as comminution and soft tissue damage. Finally, there should be consultation with the client to discuss various factors, including the time-consuming nature of long-term bandage management and the amount of activity restriction required for healing, which may put limitations on a pet who is a working animal. Weighing these factors can help determine whether external coaptation or surgical stabilization best fits the client and their pet.

There are always exceptions in veterinary medicine. For example, if an animal is very young, the incredible biologic ability of juvenile bone can overcome many factors, including excessive displacement, comminution, and significant instability. However, it is important to note to the client that while non-surgical management may result in bony union in these patients, the long-term outcome may be poor due to malunion or osteoarthritis. Other important exceptions include scapular wing fractures and minimally displaced sacroiliac luxations, which can be managed successfully non-surgically.

Pros and Cons of Operative and Non-Operative Management

In cases where operative and non-operative management are both options for a fracture, it is important to discuss the benefits and costs of each course. Conservative management, due to the less stable fracture environment, can result in longer healing times, particularly in skeletally mature patients. With external coaptation, there should be a conversation about the consequences of long-term bandaging, including muscle atrophy, bandage sores, and joint pain secondary to prolonged immobilization. Finally, there is much less control over the alignment of the limb when opting for external coaptation, so consideration regarding the desired future athletic function of the dog should be included. Even in cases where conservative management is likely to result in healing, a client with a dog intended for work may be better suited choosing surgical management.

In the short run, external coaptation may feel like the less costly option for clients, especially when compared to surgical management. However, including the cost of follow-up vet visits (not to mention time off work and travel) as well as the potential complications of prolonged bandaging, there are instances where surgical management is more financially efficient, and a client may choose that option even when conservative management is an acceptable path.