Case study edited by Phil Tucak
Coco is a four-month-old male entire Cavalier King Charles spaniel that presented in mid-January 2020 for an acute onset of left forelimb lameness after having a small fall. He initially presented to his primary care veterinarian who provided him with pain relief (buprenorphine 0.01mg/kg intramuscular) and localised his pain to his elbow.
Lateral and craniocaudal radiographs were taken, which revealed a fractured medial humeral condyle. This is an interesting case given that a fracture of the medial condyle is more uncommon than lateral condylar fractures. Medial condyles are relatively larger than the lateral condyles and receive less of the loading by the radial head, which makes it less likely to fracture.
Coco was referred to the surgery service at the Small Animal Specialist Hospital (SASH) for evaluation and surgical repair. Coco initially had a consultation with Dr Dan James who assessed the radiographs and performed an orthopaedic examination on Coco. He underwent surgery the same day. With the assistance of surgical resident, Dr Richard Looi, a minimally invasive approach to the repair was taken under fluoroscopic guidance. A minimally invasive approach reduces the overall morbidity of the procedure.
The fracture was closed, reduced and held in place with point-to-point bone holding forceps on the medial and lateral epicondyles. A stab incision was made over the medial epicondylar region and 0.8 mm K-wire was passed immediately cranially and distally to the epicondyle, perpendicular to the fracture gap. Placement of the wire was confirmed with intraoperative fluoroscopy. Fluoroscopy is used to ensure appropriate alignment of the fracture without having to visually assess the fracture site. This allows the procedure to be carried out through stab incisions through the skin rather than an open approach.
A 2.1 mm cannulated drill bit was passed over the K-wire. Using a 3.5mm Knight Benedikt VPC Headless Compression Screw, the transcondylar screw was placed. The Knight Benedikt VPC Headless Compression Screws work by compressing the fracture gap as the screw is placed. This compression is achieved by the variation in the length of the pitch of the screw. This screw system reduces the need for a guide hole to accomplish compression across the fracture gap. This is desirable because one of the tenets or intraarticular fracture repair is exact alignment of the fracture and no fracture gap.
A second anti-rotational K wire was passed from the medial epicondyle, through the supracondylar region and engaging the lateral humeral diaphysis. A single stitch was required to close the minimal approach. The position of the implants was confirmed with fluoroscopy and post-operative radiographs. These imaging techniques revealed appropriate alignment of the fracture.
Coco recovered well from his surgery. Overnight, his comfort levels were maintained with methadone (0.2mg/kg intravenously q4h) and meloxicam (0.1mg/kg subcutaneously post-operative, which was transitioned to per os, 24 hours later). The next morning, Coco was using the limb well, weight bearing with good range of motion and minimal discomfort.
The SASH rehabilitation team at North Ryde, consisting of Dr Naomi Boyd, Allana Langdon and Myara De Moura, assessed Coco and started him on a physiotherapy regime. His physiotherapy consisted of an active range of motion exercises including ‘puppy limbo’ and activities to increase weight bearing through the affected limb, such as three-legged standing. These active range of motion physiotherapy exercises encourage not only use of the limb, but use through a range of motions, which is beneficial for recovery. Coco continued his intensive in-hospital physiotherapy and with oral meloxicam, was discharged two days post-operative.
Coco’s owners have been diligent during his post-operative recovery—keeping him well confined and continuing his at-home physiotherapy exercises. At his two-week recheck, Coco is no longer on any medications and he is using his limb well. He will have his follow-up radiographs in the next four weeks to radiographically assess his healing.
There is a suspicion that the cause of the fracture is related to an underlying syndrome called ‘humeral intracondylar fissures (HIF)’. This syndrome has previously been known as ‘incomplete ossification of the humeral condyle (IOHC)’. The reason for the change in the nomenclature is the aetiopathogenesis is actually not fully understood, and the phrasing ‘IOHC’ implies known aetiopathogenesis. IOHC is one of the theories that is proposed to lead to humeral condylar fractures. The other predominating theory is a resultant stress fracture due to elbow incongruity. Therefore, HIF is a more appropriate term for this condition to encompass all theories of aetiopathogenesis.
HIF is a congenital syndrome in which spaniels, chondrodystrophic breeds and French bulldogs are over-represented. These patients can present as an incidental finding on survey elbow radiographs; lameness associated with a fracture from a low impact trauma, such as a small fall, like in Coco’s case or as non-fracture related lameness. Greater than 50% of these patients will present under the age of 12 months of age; however, the age range of presentation is usually between four months and five years of age. The reason the lateral condyle is the more common side is that the lateral condyle lies lateral to the axis of the humerus. This in conjunction with being relatively smaller, means that it receives the majority of the weight bearing through the radial head. It is suggested that the radial head acts like a wedge to propagate a fracture.
Dr Paul Jenkins
BVSC PGCERTVS MVS (SA PRACTICE) MANZCVS (SMALL ANIMAL SURGERY) – SURGERY RESIDENT
Dr Paul Jenkins graduated from the University of Sydney in 2010. After graduation, he moved to Tamworth and worked in mixed practice for just over three years. He then relocated to the South Tamworth Animal Hospital, which is a rural referral hospital, for two and a half years. During his time in Tamworth, he completed a postgraduate certificate and Masters in Small Animal Practice from Murdoch University in 2015.
In 2016, Dr Jenkins attained membership to the Small Animal Surgery Chapter of the Australian and New Zealand College of Veterinary Scientists. Dr Jenkins undertook a rotating internship at the Small Animal Specialist Hospital in 2017 and commenced his residency in small animal surgery in the same year.
He enjoys all aspects of surgery with a particular interest in orthopaedics and joint disease.
Prior to starting his internship, Dr Jenkins and his wife, Liz, spent time in Thailand and Malawi, Africa, participating in trap-neuter-release programs in Buddhist temples and rural villages in Africa.