Tibial Crest Avulsion

[jabro30]

Aloha Laurie,

Hope you are well, all considering.

I will be seeing a 6 month old Sheltie for continued care of a tibial crest avulsion with Salter Harris II fracture (and a fibula fx on the side. At the end of July, he fell off an embankment when going for a flock of birds. Went to his primary DVM where xrays were performed, but no pathology was seen. Continued lameness and recheck xrays done approximately 2 weeks later showed more evidence of the pathology to the tibia. The dog was referred to the surgeon (about 3 weeks after the initial injury), but surgery was ultimately deemed unlikely to help based of the timing (more ideal to fix within a week of the injury?) and the presence of healing. The dog is being sent over to me expedite healing and “oversight for gradual return to activity and improvement in motor control.” If no improvement in degree of lameness or an angular limb deformity develops, then surgery is to be reconsidered. The dog is toe-touching lame, according to owner.

From the most recent x-rays done with the surgeon (attached), there also looks to be a pretty good slope developing at the tibial crest, which I am a bit concerned about.

Inquiring about guidance for a potential plan. initially:

1) Facilitate bone healing over the next 3-4 weeks. To include PEMF and exercise modification. I read your blog concerning laser therapy over growth plates (it’s nice when all the papers are in one place!) and while I agree the answer is kinda deemed “case by case”, would you have concern about lasering a growth plate that is already compromised/unhealthy?

2) Take care of axial skeleton and compensatory issues with manual therapy and acupuncture.

3) Light ROM for the stifle

4) Exercise? Nothing excessive for stifle flexion/eccentric quad, but weight-bearing/balance?

Once the fracture site has (potentially) healed, then the plan would be to slowly strength the heck out of the quad and glute?

Any thoughts would be greatly appreciated.

Jake

[lehughes]

Hi Jake!

I'm hanging in! Thanks.

So, as I was reading your case description, I was all exciting thinking, "yes! I've seen two of these in the past. I know how this turns out!" But then I saw the rads... ugh! That doesn't look good!

Okay, so at this point, I'd say bone healing and pain management trump. I'd laser! For sure, and I'd not worry about the growth plates. Yes to the PEMF as well... and whatever you'd want on board for pain meds. Beyond that, I sort of waffle back and forth about some kind of a brace to see if you could change the pressures around the joint. (I'd e-mail the rads and that question to both Hero & Orthopets to see what they say).

Axial skeleton stuff - awesome

ROM - as tolerated.

Exercise... I think you need to get this little guy to buy into using that leg. Otherwise it won't matter on down the line, he won't figure he 'needs' to use it. So, walking, swimming, anything low impact. Weight shifting, e-stim glutes and quads. Maybe walking with 'stuff' on the 'good' leg to bug it. With some therapies and pharmaceuticals &/or nutraceuticals to help with the pain, perhaps he's use the leg a bit more as well. Figure of 8's, walking over obstacles. Really, anything non-impacting and 'easy' muscle use, I think would be fair game.

I'd avoid hills, jumping, excessive sit to stands or repetitive sit to stands as an exercise. Nothing where the quads have to strongly contract. That being said, with toe touch weight bearing... the affected leg won't be 'playing along' with any of those things anyways!!!

Okay - those are my thoughts! Keep us updated! Interesting case!

Laurie