Post Op Femoral Fracture
Posted: Mon Jul 02, 2018 12:02 am
Aloha Laurie!
I hope you are well
Stumped about a case and was wondering if I could get your input:
Banjo is a 12 yr old MC Australian Shepherd who initially presented to me 6-weeks post-op for continued non-weigh- bearing lameness after repair of a long oblique comminuted fracture of the proximal 1/3 and distal 1/3 of left femoral diaphysis, with a minimally displaced fracture of the left femoral neck (he had a bit of a run-in with a tractor).
No complications intra-op or immediately post-op. The owners report that after the surgery, Banjo was intermittently toe-touching lame (never fully weight-bearing), but about two weeks ago, the owner came home and Banjo was completely non-weight bearing. He subsequently went to his primary vet, where a small (<4mm) superficial puncture was present at the top of the suture line that had a mild amount of purulent discharge present (no draining tract) – a C&S was performed revealing a rather resistant bacteria (Pseudomonas). In the time it took to get the culture results, the puncture healed without any antibiotic intervention
On initial presentation to me, Banjo was off all pain medications. He was 5/5 lame on LH standing and walking, with decreased CF extension (20 degrees less than contralateral limb) and empty end feel. His SIJ lacked any mobility and had left sarcotuberous ligament/lumbar discomfort. Trigger points associated with left sartorius and quad (and traps, latissimus), with mild tenderness at left iliposaos and QL. Adductors/pectineus tender, but not overtly painful. No discomfort on actual palpation of left femur and skin over incision site looked great. Diffuse (disuse) muscle atrophy all throughout the left pelvic limb.
Neurologically, delayed/normal CPs on left hindlimb. Normal patella/sciatic reflex, with mild decrease in hock flexion during withdrawal. Superficial dermatomes seemed normal.
I did manual therapy on the hip and SIJ, acupuncture, electroacupuncture, and laser therapy. We did some initial ther-ex, but nothing too heavy as I was thinking pain/soft tissue restrictions were a large part of his symptoms.
After the initial appointment, I recommended some exercises to gain more CF ROM (tummy tickles), some weight displacement exercises, and techniques to improve afferent nerve sensation (in case of a neuropathy). I also started gabapentin and an NSAID to help rule-out the possibility of pain contributing to his symptoms.
In the time between my second appointment (about 4-5 days later), the owner reports Banjo appeared "happier", but weight-bearing status did not change. My PE showed better hip extension (left hip improved by about 8 degrees) and with less myofascial trigger points. His degree of hock flexion during withdrawals was normal, too. During Cavalettis, his demonstrated good hip flexion/extension, but stops hip extension when he is about to place the left hindlimb. Otherwise my PE didn’t change much and he was still 5/5 lame.
Thinking that we were making headway in pain, trigger point mitigation, and hip mobility, I tried to encourage weight-bearing with a variety of techniques: different irritants on pedal surface of right pelvic limb, hanging toe touches, land treadmill variations, 3-legged stands/hemi-standing over physio, slow walking), but nada. He is terribly resistant (unable?) to bear weight and I am puzzled about why.
I feel like I am missing something here that is resulting in Banjo’s current status:
1) Osteomyelitis? Previous rads not indicative, skin around site looks great, and never any indications of fever/malaise.
2) Migrating Hardware or Pin Impingement? No significant shift change on serial radiographs and I suspect Banjo would be more painful when attempting to bear weight on his left hind.
3) Though soft tissues are restrictive, I feel like we made decent progress in relieving trigger points, gaining extension, and increasing overall mobility.
Any ideas about underlying causes and/or other techniques (besides the ones in your videos) to deal with non-weight bearing dogs?
Mahalo!
J
https://youtu.be/oi06iUxvIXA
https://youtu.be/FThMaSM347k
I hope you are well
Stumped about a case and was wondering if I could get your input:
Banjo is a 12 yr old MC Australian Shepherd who initially presented to me 6-weeks post-op for continued non-weigh- bearing lameness after repair of a long oblique comminuted fracture of the proximal 1/3 and distal 1/3 of left femoral diaphysis, with a minimally displaced fracture of the left femoral neck (he had a bit of a run-in with a tractor).
No complications intra-op or immediately post-op. The owners report that after the surgery, Banjo was intermittently toe-touching lame (never fully weight-bearing), but about two weeks ago, the owner came home and Banjo was completely non-weight bearing. He subsequently went to his primary vet, where a small (<4mm) superficial puncture was present at the top of the suture line that had a mild amount of purulent discharge present (no draining tract) – a C&S was performed revealing a rather resistant bacteria (Pseudomonas). In the time it took to get the culture results, the puncture healed without any antibiotic intervention
On initial presentation to me, Banjo was off all pain medications. He was 5/5 lame on LH standing and walking, with decreased CF extension (20 degrees less than contralateral limb) and empty end feel. His SIJ lacked any mobility and had left sarcotuberous ligament/lumbar discomfort. Trigger points associated with left sartorius and quad (and traps, latissimus), with mild tenderness at left iliposaos and QL. Adductors/pectineus tender, but not overtly painful. No discomfort on actual palpation of left femur and skin over incision site looked great. Diffuse (disuse) muscle atrophy all throughout the left pelvic limb.
Neurologically, delayed/normal CPs on left hindlimb. Normal patella/sciatic reflex, with mild decrease in hock flexion during withdrawal. Superficial dermatomes seemed normal.
I did manual therapy on the hip and SIJ, acupuncture, electroacupuncture, and laser therapy. We did some initial ther-ex, but nothing too heavy as I was thinking pain/soft tissue restrictions were a large part of his symptoms.
After the initial appointment, I recommended some exercises to gain more CF ROM (tummy tickles), some weight displacement exercises, and techniques to improve afferent nerve sensation (in case of a neuropathy). I also started gabapentin and an NSAID to help rule-out the possibility of pain contributing to his symptoms.
In the time between my second appointment (about 4-5 days later), the owner reports Banjo appeared "happier", but weight-bearing status did not change. My PE showed better hip extension (left hip improved by about 8 degrees) and with less myofascial trigger points. His degree of hock flexion during withdrawals was normal, too. During Cavalettis, his demonstrated good hip flexion/extension, but stops hip extension when he is about to place the left hindlimb. Otherwise my PE didn’t change much and he was still 5/5 lame.
Thinking that we were making headway in pain, trigger point mitigation, and hip mobility, I tried to encourage weight-bearing with a variety of techniques: different irritants on pedal surface of right pelvic limb, hanging toe touches, land treadmill variations, 3-legged stands/hemi-standing over physio, slow walking), but nada. He is terribly resistant (unable?) to bear weight and I am puzzled about why.
I feel like I am missing something here that is resulting in Banjo’s current status:
1) Osteomyelitis? Previous rads not indicative, skin around site looks great, and never any indications of fever/malaise.
2) Migrating Hardware or Pin Impingement? No significant shift change on serial radiographs and I suspect Banjo would be more painful when attempting to bear weight on his left hind.
3) Though soft tissues are restrictive, I feel like we made decent progress in relieving trigger points, gaining extension, and increasing overall mobility.
Any ideas about underlying causes and/or other techniques (besides the ones in your videos) to deal with non-weight bearing dogs?
Mahalo!
J
https://youtu.be/oi06iUxvIXA
https://youtu.be/FThMaSM347k