3039. A 9-year-old Westie fell and broke his right hind leg - tibia and fibula. Skin disease

Feb 26, 2017

Chronic skin disease
Old dog with poor immune status
Under new drug for skin disease for the past 2 weeks

Seen by Vet 1 on Feb 26, 2017
X-rays  Spiral fracture of tibia and fracture of fibula - Right hind.

Seen by Toa Payoh Vets on Feb 28, 2017.
Proximal tibial fracture from fall
Closed fracture

TIBIAL SHAFT FRACTURES
Haematoma
Blood supply to diaphysis.

Open fractures are surgical emergencies.
Debridement of necrotic tissues and irrigation to remove bacteria and prophylactic IV antibiotics to be done within 6 hours of open fractures to decrease infection rates.


1.  Cast treatment is non-operative method. Most closed tibial fractures can be treated without surgery with good results. Wait 3 days to let swelling go down. 6 weeks. X-rays.  Non-displaced fractured tibial shaft ideal.

2.  Surgery.  Open reduction and internal fixation (ORIF) e.g. intramedullary nailing, external fixation, plating
and in some cases, amputation.
3. Intramedullary rod therapy.

Cast treatment has fewer infections than ORIF
ORIF has a higher union rate as there is more fracture stability.

Fracture stability and infection risk must be considered..

Surgical fixation is required when fractures are unstable.
Cast treatment isbest in a young patient with a non-displaced fracture.


OPEN FRACTURES
Outcome
No union
Mal union

Intramedullary nailing is generally used to treat many types of tibial shaft fractures.
Infections


IN THIS CASE
This Westie has chronic dermatitis for many years with no resolution when given steroids and coconut oil. However, in the last 2 weeks, he was given Oclacitinib (Apoquel by Zoetis) 16 mg divided into 4 parts. For the first 2 weeks, he took 1/4 tablet twice a day. He will be taking 1/4 tablet once per week for the next 2 weeks.

The owner was happy that the Westie responded very well with no itchy scratching just within the 2 weeks of Oclaitinib.

Oclacitinib, an immune suppressant drug is used for the control of pruritus associated with allergic dermatitis. The healing of the fractured tibial shaft fractures will be adversely affected if this drug is to be used  as it suppresses the immune system.

Owner warned that open reduction will result in bacteria from skin infections getting into the fractured bones resulting in osteomyelitis, pain and possible loss of leg via amputation. Also the
 high financial costs and worries if infections occur after open reduction using intramedullary nailing surgery.

The dog is old and his immune system is poorer than a young one. He had been on Oclacitinib for the past 2 weeks and this further depress his immune system.

Cast treatment is advised as the proximal tibial shaft fractures are minimally displaced and look stable on X-rays. Wait another 2 days for the swelling to go down. Antibiotics are given. No more Oclacitinib for the next 6 weeks when on cast. The dog may feel itchy and scratch again, including the right hind leg skin!    


UPDATE ON JAN 22, 2019
The Westie came in as he had a gigantic lick wound above his right elbow. Pus and raw flesh and fat were seen. Blood test showed high total white cell count indicating bacteraemia. The dog is an inpatient for 7 days to get the infection under control and cleaning of the wound. He was clipped bald and given anti-inflammatory injection of pred. He need apoquel 3.6 mg two times per day for 14 days and then 1 time per day for another 28 days, together with antibiotics. Not possible to close the wound.