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BRINKER, PIERMATTEI, AND FLO’S HANDBOOK ISBN-13: 978-0-7216-9214-2

OF SMALL ANIMAL ORTHOPEDICS AND FRACTURE ISBN-10: 0-7216-9214-1
REPAIR, Fourth Edition
Copyright © 2006, 1997, 1990, 1983 by Elsevier Inc.

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Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of the practitioner, relying on their own experience and knowledge of the patient, to
make diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor
the Authors assume any liability for any injury and/or damage to persons or property arising out
or related to any use of the material contained in this book.
The Publisher

ISBN-13: 978-0-7216-9214-2
ISBN-10: 0-7216-9214-1

Publishing Director: Linda Duncan

Senior Editor: Liz Fathman
Developmental Editor: Shelly Stringer
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Senior Project Manager: Anne Altepeter
Senior Book Designer: Julia Dummitt

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

PREFACE
The publication of the fourth edition of Brinker, Piermattei, and Flo’s Handbook of
Small Animal Orthopedics and Fracture Repair comes soon after the ninety-third
birthday of Wade O. Brinker. Wade will receive the “Founder’s Award” from the
American College of Veterinary Surgeons this year in celebration of a lifetime of
contributions to our profession. This book is but one small contribution of the
many he has made. Recently, Wade explained very clearly and firmly that his moti-
vation in founding this book was to establish a solid reference for veterinary students
and practicing veterinary surgeons. Through the years we have tried to maintain a
balance of information in a straightforward, well-illustrated, and understandable
manner that will not only challenge the avid veterinary student, but also provide a
reasonable, though not exhaustive, reference for the practicing clinical surgeon.
Twenty-three years have passed since publication of the first edition. With each
edition, we note the introduction of many new concepts and fixation strategies (e.g.,
biologic osteosynthesis). These new developments validate the very same principles
that Wade has stressed from the first pioneering days of veterinary surgery. Surgical
values of respect for tissue, surgical efficiency, aseptic technique, and appropriate
planning will always be relevant to the optimal healing of our patients. Although
Wade’s active participation ended with the second edition, his influence continues to
permeate every page of this text.
With the fourth edition, sections have been expanded to reflect common and
accepted improvements with external fixators, interlocking nails, and plate fixations.
An introductory chapter on canine arthroscopy has been added to introduce the
student to the value of minimally invasive joint surgery. Sections on hip dysplasia,
cruciate ligament rupture, and patella luxation reflect continuous progress in treatments
of these common conditions.
We continue to be blessed with the artwork of F. Dennis Giddings. Our publisher
has changed from W.B. Saunders to Elsevier. This conversion has been seamless, and
we thank the new publishing staff for their patient efforts.
Readers will also note the addition of a new author, Charlie DeCamp, who has
worked diligently to balance the wealth of information from the first 20 years to
that which will be most relevant to students and surgeons in the next 10 years. Two
of us (GF and DP) are making our final contribution to this work, which we started
with Wade in 1981. We sincerely strive to move this textbook forward in time, and
Wade will be with us, every step of the way.

DONALD L. PIERMATTEI
GRETCHEN L. FLO
CHARLES E. DECAMP

v
To Wade O. Brinker and all the surgeons before us,
and to the families behind us.
1
Orthopedic Examination
and Diagnostic Tools

GENERAL EXAMINATION

An orthopedic examination must begin with an adequate history and general

physical examination. A systemic approach to the examination ensures that multi-
ple problems are discovered. The animal’s general health should be ascertained
before focusing on the orthopedic complaint. The entire examination varies with
case complexity, a history of recent trauma, the intended use of the animal (e.g.,
breeding, showing, racing, hunting), and economics dictated by owners. Severely
traumatized animals with hemorrhaging wounds and unstable fractures that
could become open fractures obviously need different immediate steps; these
animals are not discussed in this chapter. This chapter focuses on the examination
for orthopedic problems (Table 1-1) and presents some of the diagnostic tools
available.

History
Specific historical information is useful for categorizing orthopedic problems to
rule out. This information includes breed, age, gender, occurrence of trauma, owner
identification of limb(s) involved, chronological progression of the problem, efficacy
of treatments tried, and variability with weather, exercise, and arising from recum-
bency. Other features, such as fever, inappetance, lethargy, and weight loss, may
indicate some systemic problem, such as inflammatory joint conditions, or a rup-
tured bladder after trauma.
Certain historical facts and deviation from the “normal” presentation of certain
orthopedic conditions alert the clinician to investigate further by asking appropriate
questions or performing additional tests or procedures. For example, a 10-year-old
dog that falls down two stairs and sustains a fractured radius and ulna should be
carefully scrutinized for pathological fracture. Normally, chronic luxating patellas
usually do not suddenly cause a carrying-leg lameness, and cruciate ligament
rupture may have become the more recent problem. Chronic osteoarthritic condi-
tions usually do not cause severe pain. In older animals with severe progressive
pain, neoplasia must always be considered. With pelvic fractures, trauma to the
chest, abdomen, or spine often occurs. Answers to specific questions help assess con-
current problems. For example, knowing whether the recumbent animal has been
eating, voiding large pools of urine, or moving the legs spontaneously is helpful.
3
4 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

TABLE 1-1. CAUSES OF LAMENESS IN THE DOG (EXCLUDING FRACTURES

AND MINOR SOFT TISSUE INJURIES)
Pelvic Limb Forelimb

GROWING DOG
1. Hip dysplasia 1.OCD—shoulder
2. Avascular necrosis (Legg-Calvé-Perthes) 2.Luxation/subluxation shoulder—congenital
3. Avulsion of long digital extensor 3.Avulsion supraglenoid tubercle
4. OCD—stifle 4.OCD—elbow
5. OCD—hock 5.UAP
6. Luxating patella complex 6.FCP
7. Genu valgum 7.UME
8. Panosteitis 8.Elbow incongruity
Medium to large breeds = 1, 3-8 a. Congenital
Toy to small breeds = 2, 6 b. Physeal injury
Chondrodystrophied breeds = 1, 2, 6, 8 9. Radius curvus
10. Retained cartilaginous cores (ulna)
11. Panosteitis
12. HOD
13. Congenital shoulder luxation
Medium to large breeds = 1, 4-7, 8b, 9-12
Toy to small breeds = 2, 8, 9, 13
Chondrodystrophied breeds = 2?, 5, 8a, 8b, 9, 11, 13

ADULT DOG
A. Arthritis (or continuum): 1-7 A. Arthritis (or continuum): 1-6, 8, 9
B. Luxating patella complex B. UME
C. Panosteitis C. Panosteitis
D. Cruciate/meniscal syndrome D. Bicipital tenosynovitis/biceps rupture
E. Inflammatory joint disease E. Calcification of supraspinatus tendon
F. Neoplasia F. Contracture of infraspinatus or
Medium to large breeds = A1, A 3-7, B, F supraspinatus
Toy to small breeds = A2, B, D-F G. Bone/soft tissue neoplasia
Chondrodystrophied breeds = A1, A2, B, D-F H. Luxation/subluxation—shoulder
I. Inflammatory joint disease
J. HO
K. SCM
Medium to giant breeds = A, 7, 11, I, J, K
Toy to small breeds = 2, G, H, I, J, K
Chondrodystrophied breeds =2(?), A-5, A-8,
A-9, C, H, I, J, K

OCD, Osteochondritis dissecans; UAP, ununited anconeal process; FCP, fragmented coronoid process; UME, ununited
medial epicondyle; HOD, hypertrophic osteodystrophy; HO, hypertrophic osteopathy; SCM, synovial chondrometaplasia.

A good appetite probably does not occur with significant internal injuries.
“Urinating” or dribbling small amounts of urine does not mean the bladder is
intact, and voluntary leg movement usually means serious thoracolumbar spinal
injury has not occurred.

Distant Observation
The animal should be observed for general thriftiness and relative weight status.
Patient disposition and potential lack of animal or owner cooperation should be
noted. Sedation should not be used if possible, or at least until the area of involve-
ment is known, because tranquilizers may mask detection of painful regions.
The animal should be observed for body conformation, decreased weight bearing,
trembling, asymmetrical joint or soft tissue swellings, muscle atrophy, and digit
 1—Orthopedic Examination and Diagnostic Tools 5

FIGURE 1-1. Typical forelimb curva-

ture in a German shepherd affected with
ununited anconeal process. Note varus
angulation of the elbows and valgus of
the carpi.

and joint alignment. Dogs with tarsocrural osteochondritis dissecans (OCD) tend to
be very straight legged in the pelvic limb, whereas dogs with elbow problems tend
to have curvature of the forelimbs (Figure 1-1).

Gait
Observing the lameness is helpful before examining the limb. It helps confirm or
contradict owner complaints. Often in an examination room environment, however,
chronic lameness disappears. The gait is observed at a walk and if necessary a trot.
Covert lameness may become apparent with tight circles or stair climbing.
Abnormalities include a shortened stride, dragging of the toenails, “toeing-in” or
“toeing-out,” limb circumduction, hypermetria, stumbling, generalized weakness,
ataxia, crisscrossing of the legs, abnormal sounds (e.g., clicks, snaps), and a head
“bob,” which is a bobbing motion of the head that occurs with foreleg lameness.
The head elevates as the painful leg strikes the ground.

Standing Palpation
With the animal standing as symmetrically as possible, both hands examine the con-
tralateral aspects of the limbs simultaneously, observing for asymmetry produced by
trauma, inflammation, neoplasia, degenerative joint changes, and congenital
defects. Signs to palpate are swelling, heat, malaligned bony landmarks, crepitus,
and muscle atrophy. Muscle atrophy may be palpated directly if the examiner can
grasp around a muscle (e.g., gastrocnemius) or indirectly by discerning a more
prominent adjacent bone (e.g., acromion, trochanter major). With bilateral condi-
tions, experience or radiography is used to distinguish abnormality.

Foreleg
Specific landmarks to observe in the foreleg are the acromion, spine and vertebral
border of the scapula, greater tubercle of the humerus, humeral epicondyles, olecra-
non, and accessory carpal bone, which is located at the level of the radiocarpal joint.
6 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

Scapulohumeral Region
Trauma and neoplasia affect the scapula. The scapulohumeral region is affected
with congenital OCD, developmental calcification of the supraspinatus muscle,
bicipital tendinitis (or rupture), and joint luxation. The lateral aspect is palpated.
The relative position and size of the greater tubercle of the humerus are noted,
which are altered with shoulder luxation or tumors of the proximal humerus.
Muscle atrophy from any chronic (over 3-4 weeks) foreleg lameness is often
detected as a more prominent acromion. Bicipital muscle pain may be elicited by
internally rolling or pressing the belly of the biceps.

Elbow and Forearm

Traumatic and congenital elbow incongruities, congenitally unstable fragments,
fracture, and luxation occur in the elbow. Elbow joint effusion is especially noted
laterally between the lateral epicondyle of the humerus and the olecranon.
Normally, only a thin anconeus muscle lies under the skin. With increased joint
fluid, a bulge occurs between these two bony landmarks in the weight-bearing limb
that often disappears with non-weight bearing. Osteophytes are noted as an extra
ridge lying between the epicondyle and the olecranon. The width of the condyles
is compared to the opposite side and is increased with condylar fracture, elbow
dislocation, or osteoarthrosis. The radius and ulnar regions are palpated for
swelling and malalignment.

Carpus and Paw

The carpal and paw regions are affected with fracture, malalignment, joint swelling,
and proliferative bony changes. Valgus and external rotation of the carpus are
frequently seen with congenital elbow conditions (see Figure 1-1) and with growth
plate injuries. The dorsal carpal and metacarpal regions are palpated for swelling.
Further examination takes place in the recumbent animal.

Neurological Examination
Conscious proprioception of the foreleg is carried out at this point. With the animal
standing with the forelegs parallel, the chest is supported while the paw is knuckled
over on its dorsal aspect. This is repeated several times. The paw should quickly
right itself. A normal animal will usually not even allow the dorsum of the forepaw
to be placed on the floor, unlike the rear limb (Figure 1-2). The neck is flexed and

FIGURE 1-2. Conscious pro-

prioceptive response is elicited
while the dog is standing with
the limbs in a normal position.
The dog is supported while
the toes are turned over and
released. A delay or absence of
the dog’s quickly returning the
toes to a normal position may
mean neurological rather than
orthopedic problems.
 1—Orthopedic Examination and Diagnostic Tools 7

extended to elicit a painful response or stimulation of cervical muscle spasms. The

dorsal spines of the thoracolumbar regions are pressed downward to elicit pain. In
dogs with lumbosacral disease, the pressure in this area may cause a sudden sitting
position.
The thoracic and abdominal areas are palpated before proceeding to the pelvic
limb.
Pelvic Limb
Pelvis
Landmarks to note on the pelvic limb are the iliac crests of the ilium, trochanters
major, tubers ischii, extensor mechanism (quadriceps, patella, patellar ligament,
and tibial tubercle), femoral condyles, distal tibia, fibular tarsal bone, and Achilles
tendon.
Asymmetry of the bones of the pelvis could mean pelvic fracture, hip dislocation,
femoral head fracture, or chronic coxofemoral arthritis. If imaginary lines are
drawn from the wings of the ilium, trochanters major, and tubers ischii, a triangle
is formed (Figure 1-3). With craniodorsal coxofemoral dislocation, the triangle
becomes more acute (Figure 1-4), the trochanter major more prominent, and when
the rear quarters are elevated, the toes on the dislocated side appear “shorter.” With
unilateral ilial fracture and overriding segments, the trochanter major may be closer
to the wing of the ilium than the opposite side. In addition, the lateral musculature
is swollen. The muscles of the cranial and caudal thigh and the gastrocnemius
muscle are palpated.

Stifle
The stifle joint is frequently affected with degenerative, congenital, and traumatic
conditions that include cruciate ligament rupture, patellar luxation, OCD, and
physeal fracture. Stifle palpation begins with locating the tibial tubercle and follow-
ing the patellar ligament proximally. Abnormal deviation of the tubercle from the
midline plane should be noted and occurs with patellar luxation. Normal patellar
ligaments should be taut and approximately pencil thick. The cranial two thirds of
the pencil-like ligament can be grasped. With stifle injury, swelling from the joint
pushes forward around the caudal and lateral aspects of the patellar ligament,
making the ligament less distinct and more bandlike than pencil-like. The patella
is found 1 to 4 cm proximal to the tubercle, but it may be examined better in
the recumbent animal when joint manipulation is possible. With chronic stifle

FIGURE 1-3. If imaginary lines are drawn between

the wing of the ilium, tuber ischii, and trochanter
major, a triangle is formed.
8 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

FIGURE 1-4. With hip dislocation, the triangular

shape becomes altered when compared with the other
normal hip of the dog (compare with Figure 1-3).

swelling and osteophyte formation, the diameter of the femoral condylar ridges is
enlarged; this is assessed 1 to 2 cm behind the patella. In addition, there may be joint
swelling medially between the femur and tibia.

Hock
The tarsocrural joint is affected with traumatic and congenital conditions. Swelling
of the hock joint is detected on the standing animal by palpating between the distal
tibia and the fibular tarsal bone. Normally, only skin, subcutaneous tissue, and bone
are present. Joint swelling from increased fluid accumulation or fibrosis is detected
as a firm, soft tissue mass between those two landmarks. Additionally, swelling
may be detected cranially or medially. The Achilles tendon is examined above the
calcaneus for swelling and continuity.

Recumbent Examination
The animal is placed in lateral recumbency to examine previously noted abnormal-
ities thoroughly. This allows patient restraint and limb manipulations but precludes
simultaneous palpation of the opposite side. Most maneuvers discussed do not
produce pain in normal animals. Pain production gives the diagnostician clues as
to the location of the problem. It may be best to examine the normal side first to
relax the animal and to learn individual responses to certain maneuvers. The veteri-
narian looks for instability, crepitus, painful regions, and altered ranges of motion.
Animals usually do not resist gentle manipulation of abnormal areas. Unfortunately,
many animals do not indicate when a painful area is manipulated, which creates
a diagnostic challenge at times. In general, it is recommended to examine from
the toes proximally. Known abnormal areas or maneuvers that may produce pain
should be examined last to ensure patient cooperation. Maneuvers producing
painful responses should be carefully and gently repeated while immobilizing sur-
rounding tissues to reduce the possibility of misinterpreting the origin of the pain.
Crepitus (a sound or palpable friction sensation) occurs when bone rubs bone,
cartilage rubs bone, or subcutaneous tissues move over air pockets or foreign
materials such as wires, pins, or suture material. The sensations palpated are
characterized as clicks, snaps, clunks, crackling, grinding, or grating. Normal laxity
of the carpal, tarsal, or shoulder regions produces innocent clicks that are mistaken
as crepitus. In some thin dogs, elbow flexion produces clicks when the ulnar nerve
moves over a prominent humeral epicondyle.
 1—Orthopedic Examination and Diagnostic Tools 9

Forelimb
Paw and Elbow
The digits are flexed, extended, and examined for swelling, crepitus, and pain. The
interdigital webbing and foot pads are examined for discoloration, abrasions, and
other conditions. The proximal sesamoid bones are palpated for swelling on the
palmar aspect of the paw at the metacarpophalangeal junction. The carpus is flexed
and extended, and a valgus/varus stress is applied. Swelling detected on the standing
examination is better identified when the exact location of the joint space can be
identified. This helps to rule out joint problems from distal radial swelling seen with
neoplasia or hypertrophic osteodystrophy. The radiocarpal joint space lies at the
same level as the base of the accessory carpal bone.
The elbow is similarly placed through a range of motion. Hyperextension of the
elbow may produce pain in dogs with ununited anconeal process, whereas internal
and external rotation with digital pressure applied at the medial joint line may
produce pain that accompanies conditions such as OCD or fragmented coronoid
process.

Shoulder
Swelling of the shoulder joint unfortunately cannot be appreciated because of its
depth under musculature. The shoulder is examined for pain by flexing and extend-
ing the joint while grasping the forearm with one hand while the other hand
stabilizes the front of the shoulder. OCD usually produces pain with this maneuver.
Bicipital tendinitis or rupture is painful when the tendon is stretched. To produce
diagnostic discomfort, the elbow is extended, and the entire limb is pulled caudally
along the thoracic wall while digital pressure is applied to the proximal medial
humeral region over the tendon (Figure 1-5). With the advent of arthroscopy,
tearing of the medial ligaments of the scapulohumeral joint has been documented
and may be quite common. Under sedation, increased abduction of shoulder can
be compared to the normal side. With the dog in contralateral recumbency, the
acromial process is pushed downward while the extended limb is abducted
maximally. The limb is maintained approximately perpendicular to the spine during
the test. Comparing the abduction angle to the other limb helps establish its
significance.
Fractures of the acromion can cause discomfort and possibly crepitus when the
acromion is manipulated. Shoulder instability may be appreciated, usually in the

FIGURE 1-5. To detect bicipi-

tal tendon pain, the tendon is
stretched by extending the elbow
and bringing the entire limb par-
allel to the thorax. Digital pres-
sure is applied to the tendon in
the proximal medial humeral
region.
10 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

sedated or anesthetized patient, by applying a mediolateral or craniocaudal sliding

motion at the joint level.

Long-Bone Palpation
All areas of the limb are gently squeezed. Long-bone palpation is reserved for the
last part of the examination because pain from bone tumor or panosteitis is exqui-
site at times. To avoid production of pain from pressing normal muscle, the exam-
iner should find muscle planes where the fingers can reach bone. These locations
include the distal radius, the proximal ulna, and the distal and proximal humerus.
Once the fingers touch the bone, a gentle pressure is applied.
Neurofibromas or neurofibrosarcomas must be considered in older dogs with
severe progressive foreleg lameness. In these special cases, deep digital pressure in
the axilla may detect a mass and produce exquisite pain. In addition, ocular signs of
Horner’s syndrome (unilateral miosis, ptosis, and enophthalmos) may be present.
The “mass” may be compared to the other side in the standing animal.

Rear Limb
Paw and Hock
The digits and paw are examined similar to the foreleg. The tarsal region is maxi-
mally flexed, extended, and stressed in varus and valgus angles. Instability, pain, and
crepitus may be produced with fracture, tendon and ligament breakdown (seen
especially in collies and shelties), and OCD of the talus. Achilles tendon continuity
is palpated during flexion and extension of the tarsocrural joint.

Stifle
The stifle joint is often affected with luxating patellas and cruciate ligament disease,
as well as physeal fractures of the distal femur. With fracture, the stifle is quite
swollen with a history of young animals sustaining trauma. Swelling also occurs
with inflammatory joint conditions and OCD. Localized swelling occurs with
avulsion of the origin of the long digital extensor tendon.

Patellar Luxation. With some animals, there is normal mediolateral movement

within the trochlea of the femur. Luxation out of the trochlea is abnormal and
can cause lameness. Subluxation (patella rides on the trochlear ridge, and “catches”
during flexion) occasionally causes lameness. Luxation may be medial, or less often
lateral, and occasionally in both directions. Luxation of a patella is normally not
a painful maneuver. The examiner should stand caudal to the animal. To begin the
examination, the tibial tubercle is located and its position noted. Noting the medial
location of the tibial tubercle helps avoid misinterpreting a medial luxation (ectopic)
that is replaced into the trochlea (i.e., reduced) from a reduced patella that can be
luxated laterally. Cat tubercles are not as prominent as dog tubercles. The patella
may be found 1 to 4 cm proximally. In small dogs or cats with ectopic patellas, the
patella is palpated as a small, pealike bump on the medial (or lateral) femoral
condyle. It may or may not move with flexion, extension, and digital pressure.
It may or may not be reducible. To luxate a reduced patella medially, the stifle
is extended, the toes are internally rotated, and digital pressure is applied to the
patella in a medial direction (Figure 1-6). Conversely, to luxate a patella laterally,
the stifle is flexed slightly, toes are externally rotated, and pressure is applied in a
lateral direction (Figure 1-7). Sometimes an unstable patella may be luxated simply
by internally or externally rotating the paw. A patella that has been luxated on
examination should be reduced. The stifle should always be examined for cruciate
ligament instability and with the patella reduced.
 1—Orthopedic Examination and Diagnostic Tools 11

FIGURE 1-6. To luxate the patella medially, the stifle is extended and the toes rotated medi-
ally while the patella is pushed medially.

FIGURE 1-7. To luxate the patella laterally, the stifle is partially flexed and the toes are
rotated laterally while the patella is pulled laterally.

Cruciate Ligament Instability. Palpation for cruciate ligament instability can

produce pain and should be performed gently in the relaxed patient. Sedation may
be needed if no abnormality can be detected in the tense animal. Drawer movement
is the sliding of the bony tibia in relation to the femur. Normally, there is no cranial
or caudal drawer movement in the adult animal. Some large puppies have “puppy”
drawer, which lasts up to 10 to 12 months of age because of normal joint laxity.
12 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

Some rotary motion of the tibia is normal and is occasionally mistaken as drawer
movement. In a fresh, fully torn cruciate ligament in a relaxed medium-sized animal,
the tibia may slide 5 to 10 mm (grade 4). In relative terms, larger dogs have less
drawer movement than small dogs. Other factors that diminish full drawer
movement are chronicity, animal tenseness, partial ligament tear, and presence
of a meniscal injury. Increased drawer movement occurs with multiple ligament
tears in the traumatized animal or in cushingoid dogs. If there is patellar
luxation, the patella should be reduced if possible before examining for cruciate
instability.
The tibial compression test, or cranial tibial thrust1 (indirect drawer movement),
compresses the femur and tibia together, and when there is cranial cruciate ligament
incompetence, the tibia slides forward in relation to the femur. This occurs
during weight bearing as well, and its surgical elimination is the basis of the
tibial plateau–leveling procedure for cruciate repair.1 It can be elicited by holding
the stifle in a slightly flexed position while the paw is alternately dorsiflexed as
far as possible and then relaxed. The index finger of the opposite hand lies cranial
to the femur, patellar ligament, and tibial tubercle and detects the tubercle sliding
forward (Figure 1-8). It is repeated several times quickly but gently.2 Interpretation
of this maneuver is more subjective than direct drawer movement but has the
advantage of producing minimal pain in animals with ruptured cranial cruciate
ligaments.
Direct drawer movement is examined by placing the fingers as close as possible
to bone and not soft tissue (Figure 1-9). The index finger of one hand is placed on
the cranial proximal patellar region while the thumb is placed caudally on the
lateral fabella. The index finger of the opposite hand is placed on the cranial aspect
of the tibial crest while the thumb is positioned caudally on the fibular head. With
the wrists held straight and not bent, the femur is held stable while the tibia is
pushed forward (and not rotated), then pulled backward. This is repeated quickly
and gently several times. At first the stifle is held firmly in slight extension, and then
the movement repeated with the stifle held in extension, then in flexion. In large
dogs it is helpful to have an assistant or the examiner’s foot (if performed on the
floor) support the dog’s foot.

FIGURE 1-8. The tibial compression

test produces indirect drawer movement.
With the stifle angle held in slight flexion,
the metatarsal region is dorsiflexed as far
as possible. The index finger of the oppo-
site hand detects the forward movement of
the tibial tuberosity if drawer movement is
present. It is repeated several times.
 1—Orthopedic Examination and Diagnostic Tools 13

FIGURE 1-9. To palpate

direct drawer movement, the
index finger of one hand is
placed on the proximal patel-
lar region while the thumb is
placed caudal to the lateral
fabella. The index finger of the
opposite hand is placed on the
cranial aspect of the tibial
crest, and the thumb is placed
on the caudal aspect of the
fibular head. With the femur
stabilized, the tibia is pushed
forward and then pulled back-
ward. This is repeated several
times and is performed gently
but quickly to detect 1 to 10 mm
of movement of the tibia in
relation to the femur.

Interpretation of Instability. With cranial cruciate ligament rupture, the cranial

end point is “soft,” with no sudden stoppage, because the secondary restraints
of the stifle become taut. When the tibia is pulled caudally, a sudden “thud” is
palpated as the normal caudal cruciate ligament becomes taut. Conversely, with rare
caudal cruciate rupture (usually grade 2 or less of motion), when cranial force is
applied, there is a sudden “thud” that is not present when caudal force is applied.
“Puppy” drawer (grade 2 or less of motion) has a sudden end point cranially
and caudally. It usually disappears by 6 to 9 months of age unless chronic painful
conditions of the hip, stifle, or hock exist.
Inexperienced palpaters of the stifle can make the following five common
mistakes:

1. If the wrists are bent, proper force cannot be applied.

2. If just the fingertips alone touch bone, proper force cannot be applied.
3. If the fingers are placed laterally/medially instead of cranially/caudally,
the skin moves and is misinterpreted as drawer movement.
4. If drawer movement is performed slowly, detection of 1 to 2 mm of motion
is impossible.
5. Tibial rotary movements, which may be normal or excessive,
are misinterpreted as drawer movement.

Collateral Ligament Instability. When the collateral ligaments and joint cap-
sule are torn, the stifle will have medial, lateral, or combined instability. Cutting
either of these ligaments alone without cutting the joint capsule does not produce
much instability in research animals. The cruciate ligament(s) is (are) invariably torn
in clinical cases of collateral instability. To detect this instability, the stifle should be
held in “neutral” drawer while a valgus (stifle inward) or varus (stifle outward)
force is applied. The thumb is placed on the fibular head while the index finger
is placed along the medial joint line to perceive the joint opening abnormally with
its respective instability.

Meniscal Injury. Meniscal injury is suspected when the owner hears a click
when the animal walks or when the animal has a severe three-legged lameness
several weeks after acute onset of stifle lameness. In addition, a worsening of
14 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

an improving lameness several weeks to months after cruciate rupture with or with-
out surgical repair sometimes indicates meniscal involvement. Meniscal injury is
suspected when flexion, extension (with and without rotation about the stifle), and
direct and indirect drawer manipulations produce a click, snap, clunk, or grating.
Definitive diagnosis is made on visualizing the unstable caudal horn or a part of it
malpositioned after arthrotomy (see Chapter 18).

Hip Joint and Pelvis

The hip joint and pelvis are often affected by trauma, congenital conditions such
as Legg-Calvé-Perthes disease, and hip dysplasia. Manipulations may cause pain,
crepitus, and instability. The femur is grasped at the stifle, and the hip is flexed and
extended several times. If pain or crepitus is not produced, external hip rotation is
added to the flexion and extension maneuvers. This maneuver frequently elicits
pain in the animal with Legg-Calvé-Perthes disease. Fine crepitus may be heard
when the examiner’s ear or stethoscope is placed on the trochanter major during
these manipulations. Pressing the femur into the acetabulum accentuates the
crepitus (Figure 1-10). This crepitus must be distinguished from hair coat noises.
Suspected fracture and dislocation are further evaluated by radiography.
The sacroiliac joint is examined for instability by gentle manipulation of the wing
of the ilium. The tuber ischii is pressed to detect instability and crepitus. A rectal
examination may detect pubic and ischial fractures.
Hip laxity seen with hip dysplasia may be detected by three methods. First,
Ortolani’ sign is a noise or palpable “thud” produced when an unstable hip is
replaced into the acetabulum.3 To produce this sound while the dog is in lateral
recumbency, the hip is subluxated proximally by grasping the adducted stifle and
pushing proximally while the other hand stabilizes the pelvis. Second, when the
stifle is abducted, downward pressure is applied across the trochanteric region.
A noise is produced as the femoral head glides over the rim into the acetabulum
(Figure 1-11). This can also be done bilaterally with the dog in dorsal recumbency.
The stifles are adducted, pushed proximally, and then abducted to produce the
“thud” (see Figure 16-10, C, D, and E). A third way to detect this instability is to

FIGURE 1-10. To hear finer

crepitus from coxofemoral arthri-
tis, the examiner’s ear is placed on
the trochanter major during flex-
ion, extension, abduction, and
adduction of the hip joint.
Proximal pressure during these
movements accentuates the sounds.
 1—Orthopedic Examination and Diagnostic Tools 15

A B
FIGURE 1-11. Ortolani’s sign is the sound produced when the subluxated hip is suddenly
reduced into the acetabulum. A, To subluxate the hip joint, the stifle joint is adducted while
proximal pressure is applied. B, Reduction of the subluxation occurs when the stifle is
abducted, which reduces the hip, creating a “thud.”

place the dog in lateral recumbency. One palm stabilizes the pelvis with two fingers
on the trochanteric region while the other hand grasps the distal femur and
positions it parallel to the table or floor. The femoral head is alternately levered
laterally and relaxed while the fingers on the trochanter major are alternately
relaxed and then pressed downward. The amount of subluxation in millimeters may
be detected. However, this maneuver is often painful even in normal animals
because of the force applied on the thigh muscles. Muscle tension often masks hip
laxity occurring with hip dysplasia.

DIAGNOSTIC TOOLS

Beyond the physical examination, several tools are available for diagnosing
and evaluating orthopedic diseases and treatments. These include radiography,
fluoroscopy, arthrography, myelography, diagnostic ultrasonography (DUS),
computed tomography (CT), magnetic resonance imaging (MRI), nuclear imaging,
arthroscopy, force plate analysis, kinematic gait analysis, exploratory surgery, biopsy,
clinical pathological tests, arthrocentesis with joint fluid analysis, serology, and
hormonal assay. A brief description of each of these modalities follows, along with
their uses.

Radiography
The most common diagnostic tool used to investigate orthopedic disease is radio-
graphy. The history and physical examination should suggest the area of the
body involved. Radiography is also used to rule out other concurrent common
diseases, such as a large dog with cruciate ligament rupture with concurrent hip
dysplasia. It is extremely useful in detecting and evaluating fractures, joint dis-
locations, osteoarthrosis, neoplasia, joint incongruities, and congenital joint
conditions (e.g., OCD, hip dysplasia). It is also useful in evaluating fracture fixation
and healing as well as in following progress of joint treatments. In general, two
16 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

orthogonal (90 degrees to each other) views of an area are taken. (Special views
are discussed in other chapters for each disease.) Many times, animals even with
fractures may be positioned for radiography without sedation if enough personnel
are available. If personnel are unavailable or state laws prohibit their exposure to
radiation, sedation or anesthesia may be required using appropriate positioning and
restraining devices.

Fluoroscopy
Another modality using radiation is fluoroscopy, with or without image intensifica-
tion. It is occasionally used to detect instability (e.g., shoulder luxation), retrieve
metallic foreign materials (pins, wires, bullets), observe contrast material used in
arthrography, confirm needle placement for myelography and angiography, and
aid placement of surgical implants. Fluoroscopy is a “movie” of radiographic
images, and image intensification enhances the signal to reduce the amount of
radiation necessary to see the images. Spot hard-copy films can be made from
selected images.

Arthrography
An arthrogram is a radiograph of a joint after a contrast substance such as an iodine
solution, air, or both have been injected. Injection techniques are discussed later
in the arthrocentesis section. The most frequent joint undergoing arthrography
is the shoulder joint. Interruption of contrast material flow occurs with bicipital
tendonitis or rupture. Arthrography is useful in identifying obscure cartilaginous
flaps in OCD. The contrast solution we prefer is a half-and-half mixture of sterile
water and 60% Hypaque (diatrizoate meglumine and diatrizoate sodium, used for
intravenous pyelograms). The shoulder of a 30-kg dog should have 2 to 3 ml of this
mixture injected, and radiographs are taken within 5 to 10 minutes, after which the
ionic solution is resorbed or diluted with synovial effusion and loses its contrast
quality. In a recent study, nonionic contrast agents were found to have superior
radiographic imaging qualities because of their decreased absorption rate and joint
fluid influx. However, they are also more costly.4

Myelography
Myelography is the process of injecting the spinal intrathecal space with a water-
soluble nonionic sterile iodine solution to detect abnormal obstruction or deviation
of contrast material flow caused by spinal neoplasia, degenerative disk disease, or
vertebral trauma and instability. Contrast agents, such as iohexol and iopamidol,
are used for myelography.

Computed Tomography
CT is specialized radiography in which cross-sectional images of a body structure
are reconstructed by a computer. A CT unit is an apparatus in which the x-ray
source moves in one direction while the x-ray detector moves in synchrony in the
opposite direction (Figure 1-12). This allows detailed vision without obscuration
from superimposed structures. With computer configuration, serial “slices” as small
as 1.5 mm in width may be made through a body part. These machines cost
between $350,000 and $1.1 million, and some veterinary teaching hospitals
have these machines or have access to them at human hospitals. CT’s primary use
 1—Orthopedic Examination and Diagnostic Tools 17

FIGURE 1-12. Anesthetized dog is placed into the gantry of a CT machine. The black
circular region contains the ionizing radiation source.

in small animals is examination of the spine, skull, and brain. CT can also be used
in conjunction with contrast agents. It is very helpful in diagnosing fragmented
coronoid process disease in dogs (see Chapter 12). It is useful in guiding a surgeon
trying to locate a radiodense foreign body or discovering subtle joint fractures.
Two disadvantages of this diagnostic modality are that anesthesia must be used and
that CT is not particularly useful for soft tissue conditions.

Magnetic Resonance Imaging

MRI uses imaging equipment that is even more expensive than for CT ($750,000 to
$2 million) and requires a special dedicated room for its use. MRI produces
computer images of internal body tissues from magnetic resonance of atoms within
the body induced by the application of radio waves. Again, animals must be
anesthetized, and the study is usually performed at human hospitals or modular
units. The main advantage of MRI in human orthopedics is that soft tissue and
articular cartilage can be studied. It is the best noninvasive technique for diagnosing
meniscal and cruciate injuries in humans.

Nuclear Imaging
Nuclear imaging uses radioactive pharmaceuticals injected intravenously that
accumulate in certain organs based on their chemical structure and the carrier
to which they are bound. These radioactive materials accumulate in vascularized
tissues, which can be compared with contralateral limbs to detect increased
vascularity seen with inflammation, trauma, or neoplasia. Radioactive decay emits
gamma radiation that is detected by a scintillation crystal (gamma camera;
Figure 1-13) and transmitted to a dedicated computer for image production.
In animals, technetium-99m methylene diphosphonate (99mTc MDP) is used for
bone scans and is distributed in soft tissues for imaging within 4 to 8 minutes. Bone
uptake may be imaged 2 to 8 hours after intravenous injection. Both phases are
18 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

FIGURE 1-13. Sedated dog is positioned

over the radiation detector or gamma camera
(white object) for nuclear imaging.

scanned with the animal under sedation. The animal must be housed in special
holding facilities while radiation decay occurs. Gamma cameras cost more than
$2000, but the computer that creates the image and hard copy can cost more than
$300,000. In humans, nuclear imaging can be used to detect stress fractures.
In the horse, it is helpful in identifying the anatomical origin of occult lameness.
In small animals, use of nuclear imaging is becoming more popular to detect
early neoplastic, inflammatory, and traumatic lesions. Unfortunately, in the
United States, most state radiation laws require special dedicated rooms to house
animals that have been given radioactive materials. Nuclear imaging is helpful at
times to locate the region of occult lameness. Dogs younger than 3 years of age,
however, have normally reactive physeal plates, which may obscure the detection of
real joint problems.

Diagnostic Ultrasonography
DUS is infrequently used for musculoskeletal problems in small animal medicine.
It has been used somewhat successfully in diagnosing bicipital tendonitis in dogs,
although it was less reliable than arthrography.5 It may be useful for other problems,
such as the evaluation of soft tissue masses and OCD. The application of DUS
in skeletal evaluation is poor because of absorption of sound waves by bone.

Arthroscopy
Arthroscopy involves puncturing a joint with a specialized endoscope after disten-
tion with a liquid or gas for the purpose of exploration and surgical repair if
indicated (see Chapter 8). This modality is extremely useful in human medicine
because there is less surgical trauma, resulting in less pain, shorter hospitali-
zation, less time off work or physical activity, quicker healing time, and less
 1—Orthopedic Examination and Diagnostic Tools 19

adhesion formation. When appropriate arthroscopic equipment became available

to perform therapeutic manipulations, it became more than a diagnostic tool. Many
surgeons became trained in its use, and it is cost-effective. Arthroscopy is also
extremely useful in horses with loose bone or cartilage bodies in joints, especially
when open surgery and the long rehabilitation would cause an economic loss in the
performance individual.
Pet owners frequently ask if small animal veterinarians have the capability to
perform arthroscopy, and the answer at this point is that it is impractical, although
a few referral centers have used it.6,7 Other surgical manipulations, such as ligament
reconstruction, internal fixation of bony fragments, and meniscal repair, require
more sophisticated equipment and surgical training. Dogs usually do not develop
the joint stiffness that people do from open surgery, probably because of their high
pain tolerance. Dogs that could benefit from the commonly available equipment are
those with loose OCD or coronoid fragments. However, these dogs use their legs
immediately after conventional open surgery, thereby minimizing the apparent
advantages of arthroscopy. Additionally, there are no savings in anesthesia or
patient preparation time.

Force Plate Analysis and Kinematic Gait Analysis

Two relatively new research tools used in veterinary medicine to evaluate gait per-
formance are force plate analysis8 and kinematic or motion analysis.9 They are
included in this chapter because they are a more objective means than clinical
impression to evaluate function after certain orthopedic treatments. Some recent
reports compare different treatments for specific conditions (e.g., different cruciate
ligament repairs, total hip replacement vs. excisional arthroplasty) using these
modalities. These tools detect altered gait that may not be apparent on visual
observation.
Briefly, force plate analysis is a system in which the magnitude of weight-bearing
(ground-reactive) force can be measured as the animal steps onto a sensor plate
during gait (Figure 1-14). Multiple passes are completed across the force plate to
acquire representative data. Assessment of lameness grade may now be quantitated.
However, it only measures the force on that single step as the animal strikes the
plate. This tool does not measure problems that owners see, such as stiffness on
arising or lameness after running 3 to 4 miles.
Motion analysis has the advantage of allowing multiple measurements of
successive motions during locomotion. Multiple markers are placed on the skin at
different joint levels. During locomotion, these markers move and are detected by
video cameras, and the signals are sent to a computer (Figure 1-15). Limb move-
ments may be calculated at 60 to 100 measurements per second, which allows
precise definition of normal versus lame gait. Different joint angles and the duration
of stance and swing phases of the gait cycle vary with the joint affected. Thus the
gait of a dog with hip dysplasia may be characterized.10 During most of the stance
phase, hip extension is quicker but has increased extension compared with normal
hip movement. Coxofemoral flexion is more rapid in the early swing phase but
slower in the middle of swing phase. There are also distal alterations in the stifle and
tarsus. Medical or surgical treatments may then be compared to the individual’s
baseline data. In the future, kinetic gait analysis may be helpful in distinguishing
which area is the cause of lameness when multiple abnormalities are found in the
same limb (e.g., elbow arthrosis, calcification of supraspinatus muscle, possible
bicipital tendonitis).
20 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

FIGURE 1-14. This dog is stepping with one

foot on the rectangular force plate.

FIGURE 1-15. Kinematic gait (motion) analysis. Multiple markers are attached to the ani-
mal and then gaited between video cameras that send marker location signals to a computer.
As many as 100 measurements per second can be made. Joint angles and duration of gait
phase may be analyzed. (Courtesy Dr. Charles DeCamp.)
 1—Orthopedic Examination and Diagnostic Tools 21

Exploratory Surgery
Exploratory surgery is often used to assess a condition totally or to discover the
origin of joint, muscle, or bone problems. For example, a mature dog with a swollen
stifle without drawer movement or patellar instability may have a partial cruciate
tear, a previous OCD lesion, inflammatory joint disease, synovial tumor, or synovial
chondromatosis. Exploratory surgery allows gross inspection of the joint as well
as the opportunity to obtain biopsy specimens. Tissues removed should be of
sufficient volume to be representative and to allow for histopathology, micro-
biology, or both.

Arthrocentesis
Arthrocentesis involves puncture and aspiration of joint fluid. Fluid may be grossly
inspected, cultured, or analyzed for cell types and numbers (see Table 6-3), protein,
viscosity, and glucose content. In addition, arthrocentesis allows instillation of
medications, dye, or air for arthrography. As with all joint injections, the hair is
clipped and surgical scrub applied. Spinal needles (18-22 gauge) are used. Care must
be taken to avoid scratching the articular surfaces and make a “clean” puncture
to avoid blood contamination. The appearance of joint fluid confirms proper
needle placement. If no fluid appears, the needle is reintroduced in the same region,
moved slightly, or approached from the other side of the joint if possible. Often,
with swollen inflamed joints (rheumatoid arthritis), minimal extracellular fluid
is present.
The injection techniques for various arthrocentesis sites are as follows:

Coxofemoral joint. The needle is introduced just cranioproximal to

the trochanter major, aimed slightly ventrally and caudally
(Figure 1-16).
Stifle. With the stifle flexed, the needle is introduced medial or lateral to the
patellar ligament midway between the femur and tibia. Lack of fluid could
mean the needle is in the fat pad or cruciate ligaments (Figure 1-17).
Alternatively, the needle may be aimed carefully toward the femoral condyle
just below the patella. There is less fat pad interference, but the needle may
scratch the femoral surface.

FIGURE 1-16. Arthrocentesis of the cox-

ofemoral joint. The needle is introduced prox-
imal and cranial to the trochanter major and is
directed somewhat ventrally.
22 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

FIGURE 1-17. Arthrocentesis of the stifle joint. With the knee

flexed, the needle is introduced just medial or lateral to the mid-
portion of the straight patellar ligament.

Tarsocrural joint. With the tarsocrural joint hyperextended (that distends

the joint caudally), the needle is inserted lateral or medial to the fibular
tarsal bone and aimed cranially toward the middle of the joint
(Figure 1-18). If swelling appears to be more cranially, a cranial approach
can be used.
Shoulder joint. The needle is inserted about 1 cm distal to the acromion process
and just slightly caudal to it (Figure 1-19). If fluid is not found, the needle
should be “walked” in different directions from the same skin puncture site.
If the forearm is pulled distally (separating the humerus from the scapula),

FIGURE 1-18. Arthrocentesis of the

tarsocrural joint. With the hock held in
extension, the needle is introduced lateral
to the fibular tarsal bone and aimed
toward the middle of the joint.
 1—Orthopedic Examination and Diagnostic Tools 23

FIGURE 1-19. Arthrocentesis of the

scapulohumeral joint. The needle is intro-
duced about 1 cm distal to the acromion
process of the scapula. If no fluid is
obtained, an assistant may gently pull the
forearm distally to “open” the joint space.

sometimes the needle is introduced in the center of the joint rather than
under the capsule lateral to the humeral head.
Elbow joint. The elbow is hyperextended to allow the joint to distend caudally.
The needle is introduced lateral to and alongside the olecranon and inserted
cranially toward the middle of the joint until contact is made with the
humeral condyle (Figure 1-20).
Carpal joint. The carpal joint is located with thumbnail pressure during joint
motion. This joint is located on the same level as the base of the accessory
carpal bone. The needle is introduced from the dorsal cranial aspect of the
joint (Figure 1-21).

Other tests that may help diagnose systemic musculoskeletal disorders include
testing for infections affecting muscle and joints (e.g., toxoplasmosis, Lyme disease),

FIGURE 1-20. Arthrocentesis of the elbow joint. With the elbow in

extension, the needle is introduced just lateral to the olecranon.
24 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

FIGURE 1-21. Arthrocentesis of the carpal joint. The

joint lies on the same level as the base of the accessory carpal
bone. With the joint flexed, the needle is introduced at the
midline of the joint.

endocrine myopathies (hyperadrenocorticism, hypothyroidism), immune-mediated

myopathies, and immune-mediated joint disease (rheumatoid arthritis, systemic
lupus erythematosus). These tests include hematology, serology, histochemical
staining of muscle, serum enzymes, electromyography, and cytology of swollen
tissues.

References
1. Slocum B, Devine T: Cranial tibial wedge osteotomy: a technique for eliminating cranial tibial thrust
in cranial cruciate ligament repair, J Am Vet Med Assoc 184:564-569, 1984.
2. Henderson RA, Milton JL: The tibial compression mechanism: a diagnostic aid in stifle injuries,
J Am Anim Hosp Assoc 14:474-479, 1978.
3. Chalman JA, Butler HC: Coxofemoral joint laxity and the Ortolani sign, J Am Anim Hosp Assoc
21:671-676, 1985.
4. Van Bree H, Van Ryssen B: Positive contrast shoulder arthrography with iopromide and diatrizoate
in dogs with osteochondrosis, Vet Radiol Ultrasound 14:203-206, 1995.
5. Rivers B, Wallace L, Johnston GR: Biceps tenosynovitis in the dog: radiographic and sonographic
findings, Vet Comp Orthop Trauma 5:51-57, 1992.
6. Lewis DD, Goring RL, Parker RB, et al: A comparison of diagnostic methods used in the evaluation
of early degenerative joint disease in the dog, J Am Anim Hosp Assoc 23:305-315, 1987.
7. Van Bree H, Van Ryssen B, Desmidt M: Osteochondrosis lesions of the canine shoulder: correlation
of positive contrast arthrography and arthroscopy, Vet Radiol Ultrasound 33:342-347, 1992.
8. Anderson MA, Mann FA: Force plate analysis: a noninvasive tool for gait evaluation, Compend Cont
Educ Pract Vet 16:857-867, 1994.
9. Allen K, DeCamp CE, Braden TD, et al: Kinematic gait analysis of the trot in healthy mixed breed
dogs, Vet Comp Orthop Trauma 7:148-153, 1994.
10. Bennett RL, DeCamp CE, Flo GL, et al: Kinematic gait analysis of canine hip dysplasia, J Am Vet
Res 7:966-971, 1996.
2
Fractures: Classification,
Diagnosis, and Treatment

A fracture is a complete or incomplete break in the continuity of bone or cartilage.

A fracture is accompanied by various degrees of injury to the surrounding soft
tissues, including blood supply, and by compromised function of the locomotor
system. The examiner handling the fracture must take into consideration the
patient’s local and overall conditions.

CLASSIFICATION OF FRACTURES

Fractures may be classified on many bases, and all are useful in describing the
fracture.1-3 These bases include causal factors; presence of a communicating exter-
nal wound; location, morphology, and severity of the fracture; and stability of
the fracture after axial reduction of the fragments.

Causal Factors
Direct Violence Applied to Bone. Statistics indicate that at least 75% to
80% of all fractures are caused by car accidents or motorized vehicles.

Indirect Violence. The force is transmitted through bone or muscle to a distant

point where the fracture occurs (e.g., fracture of femoral neck, avulsion of tibial
tubercle, fracture of condyles of the humerus or femur).

Diseases of Bone. Some bone diseases cause bone destruction or weakening to

such a degree that trivial trauma may produce a fracture (e.g., bone neoplasms,
nutritional disturbances affecting bone).

Repeated Stress. Fatigue fractures in small animals are most frequently encoun-
tered in bones of the front or rear foot (e.g., metacarpal or metatarsal bones in
the racing greyhound).

Presence of Communicating External Wound

Closed Fracture. The fracture does not communicate to the outside.
25
26 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

Open Fracture. The fracture site communicates to the outside. These fractures
are contaminated or infected, and healing at best may be complicated and delayed
(see Figure 2-3, A).

Location, Fracture Morphology, and Severity

The system used for location, morphology, and severity of long-bone fractures is
based on the classification system adopted by AO Vet, which was developed to
allow fractures to be alphanumerically coded for easy data retrieval by computer.3
It is based on the system used by the Arbeitsgemeinschaft fur Osteosynthese
and Association for the Study of Internal Fixation (AO/ASIF) group for documen-
tation of human fractures.4 It permits grading of the complexity of fracture config-
uration and relative stability after reduction, thus providing information regarding
appropriate treatment and prognosis (Table 2-1).
Localization of the fracture is provided by numbering each long bone (1, humerus;
2, radius/ulna; 3, femur; 4, tibia/fibula) and dividing each bone into 1, proximal;
2, shaft; and 3, distal zones. As a measure of severity, each fracture is typed as
A, simple; B, wedge; or C, complex (Figure 2-1). Each grade is further grouped into
three degrees of complexity (e.g., A1, A2, A3) depending on the type and extent
of bone fragmentation. Thus the simplest shaft fracture of the humerus would be
characterized as “1 2 A1.” Proximal and distal zones may require individual
descriptions to accommodate the specific bone morphology (Figure 2-2).
Additional specific nomenclature can be applied to each of these descriptions to
convey more information. The orientation of the fracture line relative to the bone’s

TABLE 2-1. THE AO VET ALPHANUMERIC MORPHOLOGICAL FRACTURE

CLASSIFICATION SYSTEM
Localization Fracture Morphology
Bone 1 2 3 4 Segment 1 2 3 − Type A B C Subdivision 1 2 3
Group A1, A2,
•••C3

Redrawn from Unger M, Montavon PM, Heim UFA: Vet Comp Orthop Trauma 3:41-50, 1990.

A B C

FIGURE 2-1. Diaphyseal fracture types.

A, Simple fracture. B, Wedge fracture. C, Complex
fracture. (Redrawn from Unger M, Montavon PM,
Heim UFA: Vet Comp Orthop Trauma 3:41-50,
1990.)
 2—Fractures: Classification, Diagnosis, and Treatment 27

A B C

FIGURE 2-2. Proximal and distal long-bone fracture types. A, Extraarticular fracture.
B, Partial articular fracture. C, Complete articular fracture. There are some special cases in
the proximal humerus, radius/ulna, and femur because of their specific anatomy.

long axis allows the following descriptions:

Transverse Fracture. The fracture crosses the bone at an angle of not more than
30 degrees to the long axis of the bone (Figure 2-3, D).

Oblique Fracture. The fracture describes an angle of greater than 30 degrees to

the long axis of the bone (Figure 2-3, E).

Spiral Fracture. This is a special case of oblique fracture in which the fracture
line curves around the diaphysis (Figure 2-3, F).
The extent of damage can be described as follows:

Incomplete Fracture. Most often used to describe a fracture that only disrupts
one cortex, an incomplete fracture is called a greenstick fracture in young animals
because of the bending of the nonfractured cortex (Figure 2-3, B). Fissure fractures
exhibit fine cracks that penetrate the cortex in a linear or spiral direction. In skele-
tally immature animals the periosteum is usually left intact (Figure 2-3, C).

Complete Fracture. A complete fracture describes a single circumferential

disruption of the bone. Any fragmentation that results in a defect at the fracture
site must be smaller than one third of the bone diameter after fracture reduction
(see Figure 2-3, D).

Multifragmental Fractures. Also known as comminuted fractures, multifrag-

mental fractures have one or more completely separated fragments of intermediate
size. These fractures can be further described as follows:

Wedge fracture. A multifragmental fracture with some contact between the

main fragments after reduction (see Figures 2-1, B, and 2-3, G).
Reducible wedges. Fragments with a length and width larger than one third the
bone diameter (Figure 2-3, G). After reduction and fixation of the wedge(s)
to a main fragment, the result is a simple fracture.
28 Part I—Diagnosis and Treatment of Fractures, Lameness, and Joint Disease

A B

C D E F G H I
FIGURE 2-3. Descriptive nomenclature of diaphyseal fractures. A, Open. B, Greenstick.
C, Fissure. D, Transverse. E, Oblique. F, Spiral. G, Reducible wedge. H, Nonreducible
wedges. I, Multiple or segmental.

Nonreducible wedges. Fragments with a length and width less than one third
the bone diameter and that result in a defect between the main fragments
after reduction of more than one third the diameter (Figure 2-3, H).
Multiple or segmental fracture. The bone is broken into three or more
segments; the fracture lines do not meet at a common point (Figure 2-3, I).
This is a special case of a reducible wedge fracture.

Proximal and distal metaphyseal zones require specific nomenclature to describe

the wide variety of extraarticular and intraarticular fractures seen in these locations,
as follows:

Extraarticular Fractures. The articular surface is not fractured but is separated

from the diaphysis (see Figure 2-2, A). These are typically called metaphyseal
fractures. In a physeal fracture the fracture-separation occurs at the physeal
line or growth plate. This type occurs only in the young, growing animal
(Figure 2-4, C).
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