Tibial fracture plating in a young dog

本站添加: 2026-05-13

[00:00:02]Hi guys, this is Charles and one of the surgeons at the Animal Emergency Center in Melbourne, Australia.

[00:00:08]Just grab that corner and pull it down.

[00:00:10]And I'm operating I'm going to have to get new gloves, please. Can I hand that off to you, please? Can I get new gloves, please?

[00:00:18]Uh operating on a little puppy that has a multiple uh comminuted tibial fracture. It's not particularly displaced, but it does come pretty close to the uh physis both top and bottom. And so um it's also very difficult because of the Just grab on both sides because of the proximity to the proximal end of the tibial bone, it's it's um virtually impossible to stabilize the joint above. Um and so conservative management really was not an ideal option.

[00:00:58]Um if you haven't already done so, please subscribe to our channel. Make sure you turn on notifications so you'll get a ding on your phone the next time we live stream.

[00:01:06]All right, so I'm going to make a medial approach. That's the tibia if you feel your own tibia. Can I get somebody over here helping? Um if you feel your own tibia, you'll see that the skin uh and the soft tissue is actually thinnest over kind of the medial or craniomedial component.

[00:01:25]And so that's why we make that approach.

[00:01:29]Um so we have to travel through the the least amount of tissue.

[00:01:35]Um and then we're just going to isolate the fracture, compress it, and then start placing cerclage wires.

[00:01:48]And then we'll put our plate on.

[00:01:52]And then I'll probably do a pin and tension band on the tibial tuberosity portion of the fracture.

[00:02:11]Yeah, no problem. Um So, it's interesting. A lot of people, I can tell from my YouTube stats that a lot of people are not subscribed that watch. And a lot of people don't turn on notifications. And that's one of the best parts of being a member of this channel is that if you turn on notifications, you can actually watch these surgeries live.

[00:02:33]And so, yeah, turn on full notifications and then you'll get a ding on your phone whenever I live stream.

[00:02:40]The benefit of watching live >> [clears throat] >> is that you can ask me questions as we go. And I think that's the real educational benefit.

[00:02:49]I know that some people just geographically and time zones and stuff can't watch live.

[00:03:06]Can see that and as is trying to vacuum Is the suction turned on?

[00:03:13]Let's just see if Yeah, it is.

[00:03:17]Um trying to evacuate the smoke as much as possible.

[00:03:23]The smoke evacuation is not something that we did when I was in training, but there is some suggestion that Well, there's definitely um a lot of carcinogens in the smoke.

[00:03:38]Uh it's not clear to me that um there's a higher risk of cancer or nasal cancer throat cancer in surgeons.

[00:03:50]It seems like with the amount of cautery that use, if there was an issue that we probably would have a higher risk, but um but the standard is for OH&S, operational health and safety and stuff like that, is that we should evacuate the smoke, and I don't have any problem with that at all. So, that's thick periosteum there.

[00:04:34]I beg your pardon?

[00:04:35]Yeah.

[00:04:46]>> [snorts] >> All right, so that's majority of the main part of the fracture there, but we also have an issue with the proximal physis.

[00:04:56]The tibial tuberosity physis up here.

[00:05:03]And then also we have a spiral fracture that's extending all the way down to the distal tibia down here.

[00:05:18]All right, so the first thing that I'm going to do is just compress that.

[00:05:23]Do we have um some bone clamps in here?

[00:05:27]Yeah.

[00:05:33]Uh yeah, let me just try this guy here.

[00:05:38]Let's see if I can just get that compressed.

[00:05:48]I think it's still a little bit displaced.

[00:05:59]So, it's a little bit of a um art form to get it reduced by twisting back and forth. So, you can see that I've almost got it perfect now.

[00:06:15]So, I'm twisting one fragment against the other to get them to slide.

[00:06:25]Okay, so that's reduced really nicely.

[00:06:31]Could probably go just a little bit more.

[00:06:42]So, I'm putting it on obliquely to try to get one fragment to slide past the other one.

[00:06:59]Okay.

[00:07:02]All right, so that the main part of the fracture is reduced.

[00:07:07]We are in the metaphyseal region and so it's going to be a little bit tricky to get cerclage wires to stay.

[00:07:13]>> [snorts] >> Um because it's kind of conically shaped like this and so um there may be a tendency for the cerclage wires to slide.

[00:07:29]Um can I get you pleased to just start cutting off Give me about five. Five?

[00:07:37]Like this long. So, I'll go ahead and do the first one.

[00:07:52]>> So, I'll get my first cerclage wire around it to um just try to hold the fracture still.

[00:08:03]And I'm using my freer elevator to try to avoid some of the muscle.

[00:08:25]And I always twist my wires the same direction, so I always twist them clockwise.

[00:08:30]Just cuz it's a little easier if you have to go and remove them if you know that you put the wires in, you know how you have to twist them to take them out.

[00:08:40]And I'm pulling on the cerclage wire as I'm twisting to make sure my twists are even. And I usually go back just a little bit on each twist because it wants to slide and kind of correct itself.

[00:09:03]And I don't know if you guys saw the um the pre-op x-rays, um but uh it is a a long oblique fracture, but it also has a fissure that's extending distally.

[00:09:21]So, I should be able to remove this now cuz it's a pretty stable fracture.

[00:09:27]So, where's my wire passer? The wire passer is here.

[00:09:32]So, guidelines with cerclage wires, they're about 17 of them, I last I checked.

[00:09:38]Um So, we want to make sure that they're kind of between 7 and 10 mm apart.

[00:09:48]You want to stay more than about 5 mm away from the fracture line, the fracture itself.

[00:09:56]You can't use cerclage wires by themselves, unless it's a greenstick fracture. You have to use some other type of axial [snorts] stabilization.

[00:10:17]Um they have to be tight.

[00:10:19]You have to have cortical continuity.

[00:10:25]Usually, we leave about three twists.

[00:10:29]On the dog, the twists have to be even.

[00:10:37]So, you can see as I tighten and I go back, it'll slip often a little bit.

[00:10:45]So, that's really just about perfect there.

[00:10:55]Uh ideally, we don't want to bend our wires over because that weakens them.

[00:11:44]>> You want to make sure your wires are big enough.

[00:12:18]All right, so I'm very happy the main part of the fracture is stabilized. I will still put a plate on it. I'm just going to look down here to see if there's a fissure.

[00:12:29]So I thought there was based on the pre-operative graphs.

[00:12:45]Can I get the table up a bit more, please?

[00:12:50]I think it's tilting downward. Tilt it up, please. So that it'll be the other Yeah, other way.

[00:12:56]Yeah, that's great.

[00:12:58]Thank you.

[00:13:01]Um yes, you can do lag screws instead of wire.

[00:13:06]Um All right, so I'm just going to see where the distal end So the distal end of my tibia is all the way down here. So I think that I can put my plate and looking at my pre-operative graphs, my plate can go probably all the way down to here.

[00:13:29]Uh no, that's okay. So, there's a collateral ligament right there.

[00:13:37]Actually, that's an extensor tendon.

[00:13:40]Collateral ligament's a little bit further down.

[00:13:44]All right. So, let's have a look at a plate here.

[00:13:54]That's about right.

[00:14:13]Actually, I will need a needle, please.

[00:14:14]Thanks, Cindy.

[00:14:50]Okay, so that's the proximal end of the tibia there.

[00:15:02]Okay, and that's the distal end right there.

[00:15:04]So, the physis is right about there.

[00:15:08]All right. So, I'm just seeing if I'm going to have to flare this a little bit, and I am.

[00:15:16]All right. I'll get some plate vendors, please.

[00:15:22]>> [snorts] >> I'm just putting a very gradual bend.

[00:15:59]A little bit more distally.

[00:16:07]Thank you.

[00:16:12]So, that's my the bend that I've put in the plate there.

[00:16:22]So, that's great.

[00:16:26]I do have some risk with that distal screw going into the joint, so I'll just have to be really careful with that. Can I get a wire driver, please, and some little pins?

[00:17:11]>> [bell] >> Um, and those those uh pins proximal and distal are just telling me where the joint is.

[00:17:41]Um, can I get a the smaller bone clamp, please?

[00:17:53]We don't have anything smaller in here, do we?

[00:17:56]No.

[00:17:59]Yeah.

[00:18:17]Do we have our um AO What's that?

[00:18:25]The the AO attachment, right?

[00:18:41]I beg your pardon?

[00:18:46]You cannot Yeah, that was also in his uh visiting vet student from Belgium just made a point that you can also make little notches in the metatarsal bone so that the the the wire does not slide down. The other thing you can do is a pin going all the way across that acts as a as a block.

[00:19:20]>> And are we still Are we looking for a smaller bone clamp as well? Great, thank you.

[00:19:27]>> [snorts] >> Uh that's the one I want right there.

[00:19:30]Sorry? That one.

[00:19:32]Thank you.

[00:19:36]And go ahead and mount our 2.8.

[00:19:47]So, I've got this great little bone holding clamp.

[00:19:50]It's going to work really nicely to try to compress that plate down onto the bone.

[00:20:14]All right, I should be good to go.

[00:20:26]2.8? Yes, 2.8.

[00:20:46]And switch to a driver.

[00:20:49]So, measuring what it measures on the zero. You always have to make sure that you check what it measures on the zero.

[00:20:54]This is about 4 mils.

[00:20:59]So, I'll take a 20 two, please. Okay.

[00:21:31]>> Can we go ahead and take off that proximal pin?

[00:21:34]So I don't cut my glove with it.

[00:21:40]All right, and then I'll go down distal.

[00:21:52]Thank you.

[00:21:59]And I've picked up the fibula as well with that screw.

[00:22:13]I'll take a 30, please. 30 long.

[00:22:16]Yes.

[00:22:25]Thank you.

[00:22:28]And we'll switch to the wire driver, please.

[00:22:38]Thank you.

[00:22:44]Switch back to the A O.

[00:23:24]>> 32, please.

[00:23:37]Thank you.

[00:23:49]I'll go to a 2.5 mil drill bit.

[00:23:56]Is that it?

[00:23:59]All right. So, my last screw down here, I'm going to use a cortical screw in order to direct it away from the joint surface.

[00:24:23]So, that if I use a locking screw, it would be directed straight to the joint. And so, 34, please.

[00:24:36]Yes. So, this is a cortical screw and intentionally cortical and directed away from the joint surface.

[00:24:57]All right, then I'll take this out.

[00:25:00]Take off our bone clamp.

[00:25:04]I'm just going to run it through a range of motion to make sure Yeah, there's no crepitus there.

[00:25:09]So, that's great.

[00:25:11]All right, so I can take out my two things here and then I'll probably just put one more top and bottom.

[00:25:20]Um What do What uh So, I'll go locking on the bottom.

[00:25:28]And I'm going to go cortical on the top.

[00:25:32]Yep, thank you.

[00:25:43]And then I have to decide whether I'm going to put a pin and tension band through that growth plate.

[00:25:55]26 locking See if that stopped bleeding. Yep.

[00:26:19]I screwed the uh the vessel closed.

[00:26:26]And so, 2.5, please.

[00:26:43]Okay.

[00:26:48]>> [snorts] >> 22, please.

[00:27:11]Uh cortical.

[00:27:21]Uh 24, no? Uh 20 is fine.

[00:27:27]Yeah.

[00:27:35]Uh and so, there's a question about do I need to fill all the screws? You definitely do not have to fill up all the screws.

[00:27:42]Um and there's some evidence that suggests that leaving um screws empty increases the speed with which the fracture heals.

[00:27:53]Can I get a screwdriver, please?

[00:28:02]I'm just going to go through and make sure these are all tight.

[00:28:08]The stability of a locking screw is dependent on a head being really firmly engaged in the plate. [snorts] All right. I might just put one more screw in the middle here. I'll do a locking.

[00:28:48]>> [snorts] >> There's a comment there, why put in a cortical screw after a locking screw?

[00:29:15]Saying that that screw is going to do nothing. I disagree with that because the screw or the plate is right up against the bone, so it still is going to provide some stability. I'll take a 24, please.

[00:29:40]>> [screaming] >> Take a screwdriver, please.

[00:29:46]All right, so I'm very, very happy with the stability of this repair.

[00:29:53]I think it looks great.

[00:29:56]Um So now I just need to expose my tibial crest.

[00:30:16]Check with the other side. Uh No, that's right. Um actually So just Do you need some bone wax?

[00:30:41]Um Let me just see how I go.

[00:30:48]Might have that just retracted proximally there.

[00:30:51]I'll get some Metzenbaum scissors, please.

[00:30:55]And thumb forceps, please.

[00:30:58]Thank you.

[00:31:02]But that is a fair comment about repositioning that cerclage wire. I mean, that cerclage wire is really not doing much given the stability of this whole repair.

[00:31:19]Uh can I get some lap sponge, please?

[00:31:30]All right. So, um I'll just take See what size pins I'm going to put in there.

[00:31:42]062s.

[00:32:19]Cuz it's running right into my screw.

[00:32:40]>> Okay.

[00:32:44]And then I'll take another 062.

[00:33:23]All right.

[00:33:25]I need to drill a hole down here to accept my cerclage wire.

[00:33:33]Uh maybe just a pin like an 062.

[00:33:54]Okay. And then I'll take a piece of cerclage wire about that long.

[00:34:22]Uh hold on to that, please. Can I get my my um cauter- uh cautery is here.

[00:34:37]>> For your elevator, please. It's here.

[00:34:57]Okay, and then I'll take a needle driver, please.

[00:35:01]Can you hold on to that?

[00:35:04]Uh smaller needle driver.

[00:35:31]Okay, and then wire twister, please.

[00:35:42]So, the same applies. I have to pull as I'm twisting.

[00:35:55]Okay, and then pin cutters, please.

[00:36:04]All right. So, that is down there.

[00:36:09]And then I have to try to bend my pins.

[00:36:41]>> That's a bit long.

[00:36:53]Okay, and then a wire twist here, please.

[00:37:00]Um so, the reason why I've put in the um pin and tension band is because the fracture went up through the growth plate as well. And I was debating whether or not I was going to do that.

[00:37:13]The concern being that it is a growing dog, and so that potentially could impede growth of the Yep. Growth of the um growth plate.

[00:37:24]But, I just I did not want that to fracture off in the recovery period.

[00:37:32]So, we can always pull the wire out if we need to later.

[00:37:43]Uh and so, that's a very common question. Will it the wire damage the soft tissue? Generally, it doesn't.

[00:37:51]Um usually, it doesn't cause any problem at all.

[00:37:54]So, can I Please get some OPDS?

[00:37:58]So, I'm really happy with that repair. I think that's very, very solid.

[00:38:05]Uh Thank you. Thumb forceps, please. Thank you.

[00:38:24]Mhm.

[00:38:28]>> So high, it's basically like a TPLO um closure. So, it's just the pes anserinus over the plate.

[00:38:53]That can come out. That's fine.

[00:39:01]Leave that one a bit long.

[00:39:03]Yep.

[00:39:11]Uh We've gone a bit dark here.

[00:39:43]So, I'm going to get some nice periosteum covering the plate.

[00:39:47]Proximally, distally, I am going to run into a little bit of a problem getting that covered.

[00:40:23]>> And adequate soft tissue coverage of the plate is really important to prevent infection.

[00:41:04]And you can see as I get farther distal there's less and less soft tissue available.

[00:41:14]And if it wasn't for that fissure extending all the way down, I would not have gone this far distally with the plate.

[00:41:23]And I guess the alternative would have been to put on a shorter plate and then just like lag screwing across.

[00:42:12]The owners were warned that all of this may have to come out when the fracture's healed.

[00:42:24]The dog's insured, so that makes it a lot easier.

[00:42:44]I'm just going to come down over the top and try to get a little better soft tissue coverage of those wires.

[00:42:52]Actually, the the wires in the tibial crest, cuz I don't want a seroma to form.

[00:43:09]Um and then question about recovery, so we're just going to really restrict activity for about 8 weeks.

[00:43:23]So, I'm just trying to pull some of that thick connective tissue up over.

[00:43:45]Imagine this dog will be weight-bearing probably tomorrow.

[00:43:49]Toe touching.

[00:43:52]Oops.

[00:43:54]Just run that for me, please.

[00:44:43]>> So, we'll try to do a video of the post-op x-rays.

[00:44:46]You should Well, you do already have the pre-op x-rays on Vet Dojo, not on Vet Line.

[00:44:52]But, you'll have it on Vet Dojo, so should be shifting over to Vet Dojo anyway.

[00:45:05]Do you want just 3-0 PDS for internal?

[00:45:08]Uh 2-0's fine.

[00:45:16]Okay.

[00:45:19]All right, I'm just going to check my alignment one more time.

[00:45:22]So, that looks great. We do have a little bit of swelling out here.

[00:45:27]Do you need to do some soft bandage?

[00:45:30]Uh No, I think just a uh Primapore.

[00:45:34]All right, so we're just going to do a um intradermal suture pattern uh to close the rest of that. If you haven't already done so, please subscribe to our channel and make sure you turn on notifications.

[00:45:47]So, that is one of the best parts of this channel is having notifications on so that you can watch these live.

[00:45:52]Um thanks a lot for watching and I have got another exciting case that I hope to live stream later on, but we have to do a CT scan first. Anyway, we'll see you again soon.