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tvpjournal.com | September/October 2015 | TOday'S VeTerinary PracTice a PracTiTiOner'S Guide TO FracTure ManaGeMenT Peer reviewed 25 bone and/or wound with a sterile dressing. 4. Apply temporary fxation, which may include only a soft padded bandage, such as a Robert Jones bandage, or a splint, such as a fberglass, spoon, or plastic splint, incorporated into the Robert Jones bandage. 5. After bandage/splint placement, take a radiograph to ensure alignment. 6. With open fractures, change the temporary bandage daily to allow for wound care prior to defnitive fxation. Unfortunately, since external coaptation is only recommended for fractures distal to the elbow and stife, temporary stabilization of humeral and femoral fractures should not be attempted. In these cases, hospitalization with confnement to a crate (along with analgesic relief) may be ideal while awaiting defnitive fxation. Primary Fixation Ideal fractures for primary fxation using external coaptation include incomplete diaphyseal tibial fractures in young dogs, sometimes referred to as "greenstick fractures." These fractures are often incomplete, minimally or nondisplaced, and have an intact fbula that increases stability overall. Benefts versus Risks. Benefts of external coaptation for primary fxation include avoidance of a surgical procedure and less cost for the client. The risks, however, include: • Potential fracture instability, resulting in poor healing (delayed, nonunion, or malunion) • Frequent bandage changes, especially if the bandage becomes wet or soiled • Limb stiffness from lack of mobility and/or osteoarthritis from joint immobilization • Cast sores (63% morbidity with external coaptation 1 ) (Figure 1). Another risk is eventual need for surgery if healing fails to progress, which is especially of concern in small breed dogs with radius/ ulna fractures. Although these fractures may be minimally displaced and appear to lend themselves to external coaptation, in small breed dogs the blood supply in the distal radius is decreased compared with large breed dogs, putting small breed dogs at a higher risk for healing complications. 2 In small and toy breed dogs, 83% of distal radius/ulna fractures addressed with external coaptation alone result in malalignment or nonunion. 3,4 Therefore, internal fxation is recommended for these fractures in small and toy breed dogs. Technique. Ideally, sedate or anesthetize the patient for fracture alignment and splint placement. Then apply a soft padded bandage and fberglass splint made specifcally for the patient. The splint should span the joint above and below the fracture, and be padded enough to prevent pressure sores and prevent movement of the limb within the bandage. Radiographs should be obtained after bandage application to confrm appropriate fracture reduction. Follow-Up. Initially, the bandage may need to be changed every 1 to 3 days, especially if a wound is present that requires ongoing management. Otherwise, change the bandage a minimum of every 10 to 14 days to assess the limb for pressure sores or other bandage complications, such as contracture, rotational malalignment, or dermatitis. Instruct the client to keep the bandage clean, dry, and intact as well as to monitor the patient's toes for any evidence of swelling or pain. In puppies with greenstick fractures, radiographs can be obtained as soon as 2 to 4 weeks after the injury due to rapid bony healing. A bony callus, spanning a minimum of 3 cortices on orthogonal FIGURE 1. Morbidity associated with external coaptation: The end of the bandage became wet, but the bandage was not changed. The result was a moist dermatitis that led to tissue sloughing and signifcant soft tissue trauma. Not only did the fracture still need to heal, but the lesion required extensive wound management and reconstruction.