DISCLAIMER

Universiteit Gent, its employees and/or students, give no warranty that the information provided in this

thesis is accurate or exhaustive, nor that the content of this thesis will not constitute or result in any

infringement of third-party rights.

Universiteit Gent, its employees and/or students do not accept any liability or responsibility for any use

which may be made of the content or information given in the thesis, nor for any reliance which may

be placed on any advice or information provided in this thesis.

GHENT UNIVERSITY

FACULTY OF VETERINARY MEDICINE

Academic year 2012-2013

THE PROGNOSIS OF FRACTURE IMMOBILISATION BY MEANS OF THE THOMAS SPLINT:

A RETROSPECTIVE STUDY OF 10 CASES

by

Lisette SMEELE

Promoter: L. Vlaminck Research topic in the context

Co-promoter: C. De Vlamynck of the Master thesis

FOREWORD

The topic for this research was not my original choice and I was initially uncertain whether I should

choose to write about it or not. It was suggested by my promoter, Professor Vlaminck and I have

thoroughly enjoyed reading about the Thomas splint and the history behind this orthopaedic device.

Some articles dated all the way back to the 1900’s and were written in such an unusual way that they

were very amusing to read.

Special thanks go out to both my promoter, Professor L. Vlaminck and co-promoter, C. De Vlamynck

for all their enthusiasm, guidance and advice during these last few months. Especially in the last

weeks before the deadline you both managed to work your way through numerous unfinished versions

of this thesis in a very short period of time. Thank you both for spending your time reading and

correcting this thesis when others might not have done so on such short notice.

Also, I would like to thank a few of my fellow students for taking over my shifts when I needed the time

to write on my thesis, and for making the telephone calls to the owners of the patients who only spoke

French and that I could not communicate with myself.

Last but not least, I would like to thank my family and friends for all the help and support they have

given me over these years. It wasn’t easy but it was definitely worth the fight.

TABLE OF CONTENTS

ABSTRACT.............................................................................................................................................. 1

1. INTRODUCTION ............................................................................................................................. 2

2. HUGH OWEN THOMAS ................................................................................................................. 3

3. THE THOMAS SPLINT ................................................................................................................... 5

3.1 AN ORTHOPAEDIC DEVICE ........................................................................................................ 5

3.2 USE AND FUNCTIONALITY ......................................................................................................... 6

3.3 TIBIAL FRACTURES ................................................................................................................... 10

3.4 RADIAL FRACTURES ................................................................................................................. 11

3.5 FEMORAL FRACTURES ............................................................................................................ 12

3.6 THE FORMATION AND PLACEMENT OF THE SPLINT ........................................................... 13

4. CANDIDATE SELECTION PRIOR APPLICATION OF THE THOMAS SPLINT........................... 17

5. FOLLOW–UP, COMPLICATIONS AND SUCCESS RATE ........................................................... 19

6. FINANCIAL ASPECTS INFLUENCING TREATMENT OPTIONS ................................................ 24

7. RETROSPECTIVE RESEARCH ................................................................................................... 25

7.1 MATERIALS AND METHODS .................................................................................................... 25

7.2 DATA COLLECTION AND ANALYSIS ........................................................................................ 33

7.3 RESULTS .................................................................................................................................... 42

7 DISCUSSION ................................................................................................................................ 45

8 CONCLUSIONS ............................................................................................................................ 50

9 REFERENCES/BIBLIOGRAPHY .................................................................................................. 51

ABSTRACT

The Thomas splint, invented by Hugh Owen Thomas, is an orthopaedic device used in veterinary

medicine for the immobilisation of a fracture site. The splint can be applied with different types of

fractures in cattle. Generally speaking the prognosis for fractures below the mid radius and tibia is

good. Tibial fractures are the most frequently treated and the most successful type of fracture treated

by means of the Thomas splint. The prognosis depends on the type of fracture, the location and the

conformation. Besides these fracture related factors the nature of the patient, the capability of the

veterinarian and the follow-up are essential for the treatment to be a success. Success rates are

generally high, because when the patient can still generate a profit by means of meat or milk

production the treatment is classified as a success and is not dependent on the fracture healing

perfectly. In the livestock sector the economical aspect is a very important factor influencing the

decision on treating the patient or not. The Thomas splint is therefore a financially relatively

inexpensive alternative for fracture immobilisation.

Keywords: Cattle – Fractures – Immobilisation – Prognosis – Thomas splint

SAMENVATTING

De Thomas spalk, ontworpen door Hugh Owen Thomas, is een orthopedisch instrument dat in de

diergeneeskunde kan worden toegepast voor de immobilisatie van een fractuur. De spalk kan gebruikt

worden bij verschillende soorten breuken bij rundvee. Over het algemeen is de prognose voor

fracturen distaal van het midden van de radius en tibia gemiddeld goed. Tibia fracturen zijn het meest

gespalkte en het meest succesvolle type fractuur wanneer deze behandeld worden door middel van

de Thomas spalk. De prognose is afhankelijk van het type fractuur, de locatie en de conformatie van

de fractuur. Buiten deze breuk gerelateerde factoren, zullen de aard van de patiënt, de bekwaamheid

van de dierenarts en de opvolging van de patiënt van essentieel belang zijn voor het succes van de

behandeling. De behandeling wordt bij veel patiënten uiteindelijk gezien als een succes. Dit kan

komen doordat de behandeling al gauw geclassificeerd wordt als een succes wanneer de patiënt nog

winstgevende is door middel van zijn/haar vlees- en/of melkproductie en niet als de breuk volledig

geheeld is. In de veehouderij is het economisch aspect een zeer belangrijke factor die zal meewegen

bij de beslissing om het dier wel of niet te behandelen met een Thomas spalk. De Thomas spalk is

dan ook financieel een relatief goedkoop alternatief voor fractuur immobilisatie.

Trefwoorden: Fracturen – Immobilisatie – Prognose – Rundvee – Thomas spalk

2

1. INTRODUCTION

Applying the right treatment and predicting a probable prognosis for a fracture may be very difficult

when working with livestock. It is often hard to find out how the fracture was obtained and how long

ago this happened. Fractures that remain unseen (Oehme & Prier, 1974), compound fractures

(Anderson & St.Jean, 2008), fractures penetrating a joint (Adams & Fessler, 1996) or comminuted

fractures, can worsen the prognosis and complicate the treatment (Gangl et al., 2006). For vets

working in the field it may be impossible to diagnose the exact type of fracture and the severity of the

situation without the use of medical imaging techniques.

Every situation should therefore be tackled individually. The type of fracture and the extent of the

damage are crucial when determining the treatment and prognosis (Adams & Fessler, 1996 ; Adams &

Fessler, 1983 ; Anderson & St.Jean, 2008). Keeping in mind that with livestock the financial aspect

remains a critical pivot point on deciding whether the animal should be treated or not (Oehme & Prier,

1974). The total value of the animal, being its current value and the profit it will generate in the future

by means of production and by future offspring, subtracted by the cost of living, must be higher than

the total cost of treatment and must be put in perspective with the possibility of failure. The owners

should not only be aware of the costs, but also of the prognosis and the labour intensity essential for

the recovery to be a success (Mudge & Bramlage, 2007). The prognosis is dependent on various

different factors. The type of fracture, the location and conformation influence the prognosis. Other

factors such as the surrounding damage, the temperament of the patient and the follow-up can also

affect the outcome (Oehme & Prier, 1974). In some cases the prognosis can be so poor that the owner

will decide to cull the patient directly without attempting to treat the patient first (Gangl et al., 2006).

The Thomas splint is an orthopaedic device used for external immobilisation. It can be applied

exclusively, with a cast or in combination with internal fixation techniques (Oehme & Prier, 1974 ;

Tomlinson, 1991). Even though the Thomas splint was one of the first constructions used for fracture

immobilisation, it is still commonly used in veterinary medicine these days. For the economically run

livestock sector the use of the Thomas splint is a good alternative due to the fact that it is relatively

inexpensive (Adams & Fessler, 1996).The influence of the Thomas splint on the prognosis of different

types of fractures is the topic of discussion for this thesis. For ten bovine patients the fracture details,

the follow-up and complications of the Thomas splint that developed during the convalescent period

are described.

3

2. HUGH OWEN THOMAS

Hugh Owen Thomas is the full name of the original designer of the “Thomas splint”, an orthopaedic

device that is still used these days (Robinson & O'Meara, 2009). Besides being recognized for his

orthopaedic qualities there are many details of his life and achievements that remain unknown to the

public. His great grandfather, a Spanish boy, was shipwrecked and adopted by a Welsh family. He

worked on the family farm where he helped the injured animals, was soon treating livestock on other

farms and ended up treating the injuries of people in the local community. In 1834 Hugh Owen

Thomas was born as the descendent of this Spanish boy and of a long family line of bonesetters that

had followed in the footsteps of their ancestor (Carter, 1991 ; Macnab, 1941).

“Bonesetters” are healers that can obtain fracture reduction in their patients. The art of orthopaedics

was traditionally passed down the family line. The capability of a bonesetter can therefore vary

incredibly and can be seen as a combination of the acquired knowledge of the family’s ancestors in

combination with personal experience. These days in western society’s bonesetters have been

replaced by orthopaedic surgeons that require a diploma and training before they practice. Traditional

bonesetters can still be found in different parts of the world (Green, 1999). Hugh Owen Thomas was

not only a bonesetter. He wrote books and articles, he invented multiple appliances for various

fractures or deformities and his area of expertise was not only limited to orthopaedics. Even though he

is well known for his creation of the Thomas splint and his orthopaedic skill, he practiced other aspects

of general medicine at the same time as a general surgeon (Kirkup, 2008 ; Macnab, 1941 ; Thomas J.

, 1916). Besides inventing the Thomas splint, he invented the “walking calliper” and the “bed knee

splint” among other devices, and even though Bier’s method is presently named after Bier, it was

initially thought of and used by Hugh Owen Thomas (Macnab, 1941 ; Thomas J. , 1917).

Hugh Owen Thomas studied in Edinburgh and London, worked with his father for a number of years

and then set up his own practice in 1859. He was a busy man that saw around 45 patients a day in his

own practice, as well as around 45 patients in their homes and with his remarkable memory he could

recall all of his patients and their medical details by heart (Macnab, 1941). In 1865 the Thomas splint

was first used and Hugh Owen Thomas incorporated the device in his book “Diseases of the hip, knee

and ankle joints, with their deformities, treated by a new and efficient method” (Thomas H. , 1875). He

believed that the body encompassed a natural capability to heal by means of rest and immobilisation

(Robinson & O'Meara, 2009). Thomas found it very important to treat his patients with “enforced,

uninterrupted and prolonged rest” (Buckwalter, 1995 ; Kirkup, 2008). In his first book he wrote that rest

“must be enforced so that the patient’s ordinary movements will not materially disturbed the joint, it

should be uninterrupted not even momentarily, and prolonged so to secure beyond any probability a

return of inflammation” (Thomas H. , 1875). The functional role that movement has on the process of

healing these days remains subject to discussion. Hugh Owen Thomas thought that complete rest was

the best way to heal, while other scientists disagree and find that a minimal amount of activity can

actually stimulate fracture healing and shorten the convalescent period (Buckwalter, 1995).

4

Thomas‘s idea’s and devices did not receive a lot of recognition whilst he was still alive and he owes

the fame he has today largely to the work of his nephew Sir Robert Jones. Hugh Owen Thomas

invented the Thomas splint with the aim of creating a device that could help patients of all financial

classes (Carter, 1991). For Thomas it was important that the splint was simple and affordable so that

all patients, whether wealthy or poor, could receive the same treatment (Robinson & O'Meara, 2009).

Thomas had a problem with the so called “enterprising surgeons” who only treated the wealthy. In

1891 Hugh Owen Thomas died at the age of 57 (Carter, 1991).

5

3. THE THOMAS SPLINT

3.1 AN ORTHOPAEDIC DEVICE

The Thomas splint is an orthopaedic device, sometimes simply named “the Thomas”. Even though the

reason for immobilisation can vary, these days the Thomas splint is most often used to fixate fractures.

It is rarely used exclusively in veterinary medicine, but always in combination with a cast and/or with

internal fixation techniques (Oehme & Prier, 1974 ; Tomlinson, 1991). The Thomas splint is the second

most applied type of external fixation, following the regular plaster cast (Oehme & Prier, 1974). When

the splint was first used in human medicine, it was not intended for the immobilisation of fractures, but

was designed for the treatment of diseases of the knee and in particular for the treatment of

tuberculosis (Robinson & O'Meara, 2009 ; Kirkup, 2008). During the time of Hugh Owen Thomas,

tuberculosis, rickets and poliomyelitis were the main diseases that resulted in crippled patients, many

of which were children. Thomas’s success started with his treatment of these crippled children,

however the Thomas splint was only really accepted when soldiers of the first world war were

successfully being cured by means of it (Carter, 1991). The Thomas splint was used massively during

the first world war and resulted in a decrease in the death rate by 60 to 80% depending on the source

(Carter, 1991 ; Macnab, 1941). Another source shows a decrease from an 80% chance of mortality

down to 15.6% when the Thomas splint was applied. Even though the exact figures remain a subject

of discussion there is no doubt that the invention of the Thomas splint had a large impact on human

medicine. Besides its original functions the Thomas splint became most commonly used for fractures

of the femur (Robinson & O'Meara, 2009).

The Thomas splint has frequently been adjusted over the years. Every splint that is different to the

original Thomas splint is therefore entitled a modified Thomas splint (Diggle, 1942). This partially

happened due to the fact that doctors and bonesetters lost the exact knowledge to remake the initial

Thomas splint, resulting in a very different success rate and outcome. People therefore tried to

improve and adjust the initial construction (Thomas J. , 1916). The Thomas splint has also been

modified to ameliorate the placement of the splint and to create the possibility of adjustment during the

convalescent period. For example, in 1969 an adjustable and detachable ring was invented for human

patients. With this system the ring could be adjusted after initial swelling had disappeared or in a case

of muscle atrophy (Ikpeme, 1969). The original Thomas splint was difficult to store because of the

shape and size of the splint and the fact that different sizes are necessary for different patients if one

does not work with custom made splints (Ord, 1936). A Thomas splint can be custom made for a

specific patient or can be premade in a certain amount of standard sizes with an adjustable sidebar for

the length of the splint. These take less time and effort to place, however they do not fit perfectly and

are less ideal than the custom made splints (Fubini & Ducharme, 2004). In 1936 an adjustable splint

was created for patients of all ages and the need for storage space decreased dramatically (Ord,

1936).

6

In humans the Thomas splint has been used in various different situations. The splint can be used as

the only form of treatment or as a device placed temporarily, for example during transport (Redden,

1973). Temporarily the splint can also be used to fixate a fracture or dislocation. Usually the placement

of a splint will encompass the entire treatment (Oehme & Prier, 1974). These days in human medicine

the Thomas splint is applied in emergencies. The version of the Thomas splint used in emergency

situations has been modified in such a way that the placement requires only a minimum amount of

time (Redden, 1973). The greatest difference between veterinary and human medicine is that a person

can be held in complete bed rest to make sure that the fracture can heal properly. The patient’s leg

can be suspended in the air by a pair of cords that make it possible to place traction on the leg. The

patient’s leg can be rotated inwards or outwards to maintain traction and prevent deviation of the leg.

Naturally, animals cannot be fixated in such a manner making the immobilisation even more important

(Maudsley, 1955).

The treatment by means of the Thomas splint has its advantages. There are no implants needed, no

surgery costs, no new trauma to the bones or soft tissue created and a smaller chance of internal

contamination of the fracture site with the possibility of developing osteomyelitis or sepsis (Shamir et

al.,1996 ; Tomlinson, 1991). The splint also does not affect the growth of the patient and does not

harm the blood supply (Weinstein & Ralphs, 2004). No anaesthesia is necessary and with the right

knowledge and skill, the Thomas splint can be placed in field settings, making it financially more

appealing (Gangl et al., 2006). Although skill is necessary, the Thomas splint can be made without the

need of specialized instruments so that it can be placed without treatment costs skyrocketing (Fubini &

Ducharme, 2004).

3.2 USE AND FUNCTIONALITY

Besides its original design for human medicine the Thomas splint has found its way into the veterinary

branch. The splint has been employed in various different animals and has been used in situations

other than fractures. Besides fractures, the Thomas splint has previously also been applied in the case

of a ruptured gastrocnemius muscle in a horse. In horses it was also found that a Thomas splint could

help to properly apposition the muscle ends in traumatic injuries, therefore preventing the excess

formation of fibrous tissue in the remaining traumatic area (Lescun et al., 1998). In small animal

medicine the Thomas splint is still sometimes used, however according to Stead (1988) the use of the

splint is gradually decreasing because skill and experience are essential in the process. Even in a

camel the splint is known to have been applied with a comminuted radial fracture (Squire & Boehm,

1991). Hereafter the focus is placed on the use of the Thomas splint for fracture immobilisation in

veterinary medicine.

With fracture immobilisation it is important to protect the fractured ends from acting forces that could

result in more damage, overriding and the opening of a closed fracture. The placement of a splint will

not only keep the fractured bones in place, but will also prevent additional damage to the surrounding

soft tissue (Mudge & Bramlage, 2007). The Thomas splint prevents the fracture site from having to

7

support any bodyweight and for the fracture fragments to collapse or override (Adams & Fessler,

1983). The Thomas splint should, when placed correctly, allow the patient to bear all their bodyweight

on the ring positioned in the inguinal or axial region and with the help of the foot piece the weight will

bypass the fractured area (Lescun et al., 1998). The Thomas splint makes it possible to keep the

bones at the fracture site in close contact with one another to promote healing (Adams & Fessler,

1996). For large cattle, external fixation or internal fixation alone might be inadequate for complete

fracture immobilisation (Trostle et al., 1995). In fact, the Thomas splint can rarely accomplish true

immobilisation. The fracture site can therefore not heal with immediate bone formation, but will form

multiple subsequently tougher and more stable tissues. This structure is called a callus and its

formation is clearly described in the paper by Adams and Fessler (1996). A callus is made up of

constantly altering types of tissue ranging from granulation tissue, to fibrocartilage, to eventually bone

formation. With increasing fracture stability bone formation will take place and the fracture site will

heal. With patients whereby adequate fracture immobility cannot be obtained, callus formation is

essential for fracture repair. Limited movement and healing can be successfully combined due to

callus formation. According to Adams and Fessler (1983) cattle can quickly form callus material

around the fractured area. The larger the callus formed, the greater the stability of the fracture site

because the diameter of the bone is increased and the possibility of the bone to bend is decreased.

Even though a large callus can take up much space in the surrounding soft tissue, in cattle this does

not seem to affect the patient’s soft tissue clinically. With young animals and sometimes in adults it is

possible to feel the callus by palpation (Adams & Fessler, 1983). Callus formation however, is not

always seen positively. The callus can cause different problems during the recovery. The callus may

put pressure on, damage or displace the surrounding soft tissue. All the problems associated with

external fixation have been classified as “fracture disease”. Even though there are many different

problems that can arise, in cattle “fracture disease” remains an infrequent phenomenon (Adams &

Fessler, 1996).

Fractures in livestock most often occur in young animals during handling or dystocia (Anderson &

St.Jean, 2008). Fractures can also occur during transport, or in the case of young calves due to the

cow injuring her calf. Most fractures however, happen when the animals are out in the meadow (Gangl

et al., 2006). Clean fractures with no complications should be able to heal in about three to six weeks

for calves under the age of one month, in six to twelve weeks for calves one to six months of age and

in twelve to sixteen weeks for older ruminants (Fubini & Ducharme, 2004). Fractures that are reduced

and that are appositioned properly have a greater chance of success (Diggle, 1942). By adequately

reducing a fracture, the chance of developing a malunion is smaller. In small animal medicine

anaesthesia is used to relax the muscles so that fracture reduction is easier to implement (Tomlinson,

1991). Besides the fracture itself, other factors influencing the prognosis of the injury are similar to, if

not more important to the healing procedure. The degree of damage to the surrounding soft tissue, the

possibility of a bacterial infection and the integrity of the blood supply all influence the prognosis of the

treatment (Oehme & Prier, 1974).

8

According to Gangl et al. (2006) the patient is brought in for treatment on an average of two days after

the fracture is established. Sometimes the owners rarely see their animals or do not notice the

lameness. This can result in delayed examination and treatment of the patient (Gangl et al., 2006).

Before any kind of treatment is carried out, veterinarians should perform a complete clinical

examination in order to decide if an animal should be treated or not, and in what manner. Not all types

of fractures can be placed in a Thomas splint. They may be too complex, the treatment too time

consuming or too expensive to carry out. Treatment failure is therefore mostly due to the

unprofessional placement and fixation of the splint and/or due to the use of the splint in situations for

which it was not created. The Thomas splint for example, can only be used as a means of external

fixation and not for fracture reduction. Previous attempts to apply continuous traction in the hope of

performing fracture reduction have not been successful (Oehme & Prier, 1974). Fractures of the

anterior limbs are more easily placed into a Thomas splint. The patients seem to have less difficulty

with an anterior splint, than one placed on a hind leg. This is partially due to the thick layer of muscles,

the udder or scrotum that can hinder the positioning of the ring of the Thomas splint, partially because

cattle rise with their hind limbs first and partially because the forelimb is placed in a straight cast that

resembles the natural posture (Adams & Fessler, 1996).

There is a general rule that can be applied when deciding on placing a splint or cast. Fractures below

the mid radius/tibia can easily be stabilised by means of a splint or cast, however proximal to this area

immobilisation should not be carried out. The reason for this limitation is that a “fulcrum effect” will be

created right at the point of the fracture site, while the purpose of a splint or cast is to diverge these

forces so that the site can heal more easily. This will result in forces exercising pressure on the

fracture site with the possibility of tissue damage, neurovascular damage and compounding of the

fracture (Anderson & St.Jean, 2008). The Thomas splint should neutralize the possible longitudinal,

transverse and anterio-posterior forces that can possibly act in on the fracture site (Thomas J. , 1917).

These forces differ per fracture. Even a small force can already cause movement in the fracture site.

The long bone fragments can function as a lever when pressure is applied at the non-fractured end.

Therefore it is very important to make sure that a perfect immobilisation is obtained with the Thomas

splint (Adams & Fessler, 1996). External fixation techniques become increasingly more ideal when the

fracture site is located in the distal area of the limb (Fubini & Ducharme, 2004).

Fractures can be considered either open or closed. A fracture whereby the skin is damaged is

classified as an “open” fracture, even if the skin damage does not reach the fractured area. This is

because the skin, providing a natural barrier against contamination and external infection, will no

longer be present (Adams & Fessler, 1996). In open fractures, the bacteria most often found in

livestock patients are Trueperella pyogenes, Streptococcus spp, Staphylococcus spp, Fusobacterium

necrophorum, Bacteroides spp and coliforms (Anderson & St.Jean, 2008). On radiographic images

gas near or in the fractured area can suggest an infection or an open fracture. When a fracture is open

it is possible to use the Thomas splint-cast combination, however open fractures are frequently

accompanied with instability, decreasing the chance of success (Adams & Fessler, 1996).

9

Splints are generally not applied with unstable fractures (Tomlinson, 1991). Closed fractures with

loose fragments can result in an open fracture when no immobilisation has been applied. Temporary

splinting or implementing another form of immobilisation is therefore very important shortly after a

fracture has developed (Oehme & Prier, 1974). Closed fractures in which there is no damage of the

blood supply tend to have a good prognosis. Open fractures have a much more limited prognosis. The

chance of success is based on the extensiveness of the soft tissue damage, the contamination and

the age of the patient. In very young patients the prognosis is worse due to the sensitivity and the

difficulty of overcoming an infection. On the other hand, mature cattle have the disadvantage that a

higher bodyweight makes immobilisation more difficult (Anderson & St.Jean, 2008).

The modified Thomas splint can be used for many different types of fractures (Adams & Fessler,

1983). Figure 1 shows the use of the Thomas splint in tibial, femoral and radial fractures in a research

performed by Gangl et al. (2006). The tibial fractures are most easily splinted. Stable fractures are

always seen as good candidates for the Thomas splint (Tomlinson, 1991). Usually the splint is used in

combination with a plaster cast to obtain greater stability and to hold the splint in place. The Thomas

splint in combination with a cast is an ideal treatment for nearly all fractures (Adams & Fessler, 1996).

The amount of different types of fractures treated by means of the Thomas splint-cast

combination

Fracture site All fracture cases Cases treated with a Thomas splint cast

combination

Tibia 57 54

Femur (distal, mid-diaphyseal) 6 4

Femur (proximal) 8 0

Radius and ulna 2 1

Fig.1 A table showing the amount of different types of fractures treated by means of the Thomas

splint-cast combination. 94.7% of the tibia fractures, 28.6% of the femur fractures and 50% of the

radial and/or ulnar fractures were treated by means of the Thomas splint-cast combination. Adapted

from Gangl et al. (2006).

With open fractures however, the wounds can no longer be checked if a cast is placed and the

possibility of infection can no longer be actively controlled (Adams & Fessler, 1996). A Thomas splint

can be applied for the treatment of fractures distal tot the elbow or stifle (Anderson & St.Jean, 2008),

and is most commonly used for fractures of the radius and tibia (Oehme & Prier, 1974). For the radial,

ulnar and tibial fractures of ruminants, the Thomas splint placed in combination with a cast is the first

choice of treatment (Gangl et al., 2006). The splint may be employed with patients suffering from a

humerus or femur fracture, however the prognosis is very limited when treatment isn’t combined with

internal fixation (Oehme & Prier, 1974). In livestock fractures of the femur and humerus should not be

treated by means of the Thomas splint as the only method of stabilisation due to the “fulcrum effect”

10

(vide supra) (Fubini & Ducharme, 2004). For more information concerning the possibilities and

prognosis of the tibial, radius and femoral fractures see 3.3, 3.4 and 3.5 respectively.

Fractures pertaining to the physis of the long bones generally heal within four weeks, while fractures

located away from the physis can take six weeks. In adult patients a fracture can heal in seven to ten

weeks, but twelve to sixteen weeks may be necessary for clinical union. At this point radiographic

imaging will often still show the fracture line. It can usually take weeks or months after clinical union for

radiographic union to be established. Radiographic union has been accomplished when the fracture

line has disappeared. The Thomas splint can be removed when clinical union has occurred and the

limb has regained its stability at the fractured site. Radiographic union is not needed, but should be

established afterwards if no complications arise in the meantime (Anderson & St.Jean, 2008). In small

animals comminuted fractures are said to be ideal candidates for splinting (Stead, 1988). In these

fractures many different forces work in on the fracture site, including forces of bending, friction,

compression and diversion. According to Weinstein and Ralphs (2004) however, comminuted

fractures don’t seem to be ideal for the placement of a Thomas splint due to these acting forces. On

the other hand when the fracture is very complex and internal fixation is not possible, the Thomas

splint seems to be the only alternative (Weinstein & Ralphs, 2004). Oblique fractures are also less

ideal candidates for a Thomas splint because they are more difficult to immobilise (Weinstein &

Ralphs, 2004) and fractures that reach a joint, on average also have a poorer prognosis (Adams &

Fessler, 1996). Splints can be used perfectly in transverse fractures. In these fractures the main force

working in on the fracture site is the same force that causes the affected bones to bend. This force will

be countered by the placement of the splint (Weinstein & Ralphs, 2004). Greenstick fractures are ideal

candidates for a Thomas splint, because the fragments will rarely override or create an open fracture if

the immobilisation is not complete. If the periosteum is still largely intact the prognosis is even better

(Tomlinson, 1991 ; Weinstein & Ralphs, 2004). In small animals fractures that are taking into account

for external fixation are transverse and short oblique fractures, however these patients will only be

splinted if the fracture site can be reduced and stabilised. When the fracture remains unstable after

reduction, other forms of treatment are usually looked into (Stead, 1988). A fracture in a more distal

part of the leg, whether front or hind, is more easily reduced and immobilised than a more proximally

located fracture (Oehme & Prier, 1974).

3.3 TIBIAL FRACTURES

The occurrence of tibial fractures varies considerably when comparing different sources. At the

veterinary clinic of Ghent University in five years’ time, of the total caseload of fractures in cattle,

41.3% were tibial fractures (Martens et al., 1998). In a different research performed by Gangl et al.

(2006) the tibial fractures made out more than 50% of all fractures in cattle. According to Anderson

and St.Jean (2008) tibia fractures accounted for only 12 to 15% of the total case-load, the percentage

calculated by Fubini and Ducharme (2004) rested at a full 12% of all long bone fractures in ruminants

and with Adams and Fessler (1996) the percentage hovered around 12 to 13.3%.

11

Fractures of the tibia can often be caused by forced extraction (Anderson & St.Jean, 2008), however

they can occur at all ages (Adams & Fessler, 1996). In cattle, fractures of the growth plates can most

frequently be noticed between the ages of three to twelve months. The growth plates, situated on the

proximal tibia, are a common location for fractures. Less frequently one can see fractures of the distal

tibia (Nap, 1986). The fractures are often oblique (Gangl et al., 2006), with in particular the fractures of

the distal part of the tibia (Oehme & Prier, 1974). Tibial fractures can frequently be more or less

comminuted (Adams & Fessler, 1996 ; Gangl et al., 2006) and displaced (Gangl et al., 2006).

In a retrospective research performed by Martens et al. (1998) it appeared that external coaptation for

tibia fractures was mainly used when the fracture was located at the proximal or distal diaphysis.

Fractures in other locations could also undergo external coaptation, however other means of treatment

were generally preferred (Martens et al., 1998). According to Anderson and St.Jean (2008) however,

when the fracture is located in the middle part of the tibia, the placement of a Thomas splint-cast

combination can also be recommended. When the tibia or radius has undergone a comminuted

fracture, the placement of a Thomas splint in combination with a cast is considered the alternative with

the biggest chance of success. Heavy patients may not be eligible for internal fixation techniques and

external fixation is often the chosen method for treatment (Adams & Fessler, 1996). Ruminants

whereby the splint cast combination is applied to a tibia and that weigh less than 500 kilograms and/or

are younger than one year old, can be given a good prognosis (Fubini & Ducharme, 2004). Tibial

fractures of patients weighing up to 775 kg have been successful in the past (Adams & Fessler, 1996),

and open tibial fractures treated with the Thomas splint can also be a success (Adams & Fessler,

1996). For tibial fractures the duration of which the splint remained in place was on average of 7.3

weeks in the experiment performed by Adams and Fessler (1983). In the paper by Adams and Fessler

(1983) the average duration was said to rest at 8.4 weeks. According to Martens et al. (1998) out of

eleven patients with a tibia fracture immobilised by a cast and/or Thomas splint, only five reached a

normal bodyweight. During the recovery period it is often necessary to adjust or replace the splint-cast

combination in tibial fractures. In the paper by Adams & Fessler (1983) two thirds of the cattle with a

Thomas splint needed to adjust or replace the splint during the convalescent period. The main reason

for adjustment or replacement was the loosening of the cast.

3.4 RADIAL FRACTURES

Just like the tibia, the prevalence of radial fractures varies with different researches. Fractures of the

radius accounted for 7% of all long bone fractures in ruminants according to Fubini and Ducharme

(2004) and fractures of the radius and ulna combined also accounted for 7% of the total case-load

according to Anderson and St.Jean (2008). Adams and Fessler (1996) stated that in experimental

settings the value found for the percentage of radial-ulnar fractures was 8.3%, while withTrostle et al.

(1995) the radial fractures accounted for 4 to 7% of all long bones.

Patients with a radial fracture whereby the Thomas splint cast-combination is applied, that weigh less

than 500 kilograms and/or are younger than one year old, can usually be given a good prognosis

(Fubini & Ducharme, 2004). For cattle weighing over 500 kg, the treatment of the radius with a cast is

12

difficult because complete immobilisation is near impossible. This is because the cast cannot reach a

position more proximal than the elbow joint, making it very challenging to perfectly fixate a radial

fracture (Trostle et al., 1995). Heavy patients may not be eligible for internal fixation techniques,

therefore external fixation is frequently chosen as the method of treatment. Radial fractures treated

with patients weighing up to 545kg have been successful (Adams & Fessler, 1996).In an experiment a

bull weighing 823 kilograms with a closed, comminuted, spiral fracture of the radius, was placed in a

Thomas splint in combination with internal fixation. The treatment was a success because once the

bull had fully recovered it was even able to mount a phantom. Although the treatment of patients with

a bodyweight comparable to this bull have rarely been reported as a success, this patient can be

considered as an exception (Trostle et al., 1995). The placement of a Thomas splint was also

attempted with a twelve months old camel with a comminuted radial fracture. Even though the camel

limps with its leg, the owners were pleased and the recovery can be seen as successful (Squire &

Boehm, 1991).

Radial fractures can occur at all ages and usually remain closed. Radial fractures are often

comminuted and when this is the case the placement of a Thomas splint-cast combination is

considered the alternative with the biggest chance of success (Adams & Fessler, 1996). Fractures

located at the height of the mid radius or ulna are good candidates for the placement of a Thomas

splint-cast combination (Anderson & St.Jean, 2008). Oblique fractures are also frequently seen and

are most common in the distal part of the radius (Oehme & Prier, 1974). The average duration for the

treatment of a radial fracture was 5.5 weeks in the study by Adams and Fessler (1996). The length can

vary from three to thirteen weeks depending on the patient, the need for adjustments and the type and

location of the fracture (Adams & Fessler, 1983). During the recovery period it is often necessary to

adjust or replace the splint-cast combination in radial fractures. In the paper by Adams & Fessler

(1983) two thirds of the cattle in a Thomas splint needed to adjust or replace the splint during the

convalescent period. The main reason for adjustment or replacement was a loosening of the cast. In

comparison to other affected bones, the patient’s survival rate was the highest for fractures of the

radius, with a percentage of 86%.

3.5 FEMORAL FRACTURES

The percentage of femoral fractures varies greatly with the source of information. In a study performed

by Crawford and Fretz (1985), out of 213 bovine fractures, the bone that was most commonly affected

was the femur. According to Gangl et al. (2006) femur fractures accounted for around 15 to 32% of the

total amount of fractures in cattle, while according to Anderson and St.Jean (2008) fractures of the

femur accounted for 32% of all the fractures in cattle. Femoral fractures in calves can be due to

dystocia or due to trauma, such as the dam falling or stepping on her calf (St-Jean et al., 1992).

Fractures of the diaphyseal femur are often the result of extraction in the case of dystocia. In a

research by Nichols et al. (2010) 60% of the calves brought in for treatment with a diaphyseal femur

fracture had established the fracture because of dystocia. The femur may also fracture during dystocia

when the stifle enters the birth canal at the same time as the pelvis of the calf. This situation is called a

13

hip-lock (Ewoldt et al., 2003 ; Nichols et al., 2010). Femur fractures are also found in adult cattle. Older

cattle are most often treated conservatively or are sent to the abattoir (Nichols et al., 2010). Due to the

tension induced by the musculature, the forces exerted on the bone fragments are often enough to

make the fragments override (Oehme & Prier, 1974).

Femur fractures can be treated in different ways. Femur fractures are very difficult to immobilise with

only external fixation. Research shows that the Thomas splint can be used in combination with internal

fixation, however that the results appear to be similar in success rate when the calves are only treated

with internal fixation. The use of the Thomas splint can therefore not be seen as a good alternative for

fracture immobilisation (Ames, 1981). According to Mudge and Bramlage (2007) femur fractures in

horses are never splinted because an accurate immobilisation cannot be obtained (Mudge &

Bramlage, 2007). In a study performed by Gangl et al. (2006) four bovine patients with middle or distal

diaphyseal fractures were placed in a Thomas splint. Neither of the four was a success. However any

conclusion reported from this result would be biased, because three of these patients were younger

than three days old and died of secondary infections, whilst the 4th patients weighed more than 300kg

(Gangl et al., 2006). Conservative treatment may also be an option, however many complications can

arise in the convalescent period. Conservative treatment can be chosen when the patient is still

mobile, but the possibility that the patient may develop severe complications is realistic. Conservative

treatment is usually accompanied with a lot of work for the owners (Nichols et al., 2010).

3.6 THE FORMATION AND PLACEMENT OF THE SPLINT

Even though the Thomas splint still used in veterinary medicine these days is comparable with the

original Thomas splint, this device can be seen as a modified version of its original. Without further

explanation of the original splint and its historical and present use in human medicine, hereunder the

explanation will solely refer to the placement of the splint and the methods used in veterinary medicine

and will refer specifically to cattle.

The placement of a cast is not as simple as it may seem and in order for the splint to function correctly

experience and practice is necessary to obtain good results (Tomlinson, 1991). According to Adams

and Fessler (1996) the placement of a Thomas splint is not as challenging as was mentioned before.

They suggest that experience helps, but that training is not essential for the placement to be

considered a success. The perfect splint is a sturdy, long-lasting, light-weight and easily positioned

device (Mudge & Bramlage, 2007). It is important that when placing a splint and/or cast, that the joints

proximal and distal to the fracture site are stabilized in order to obtain adequate immobilisation

(Crawford & Fretz, 1985 ; Fubini & Ducharme, 2004 ; Tomlinson, 1991 ; Weinstein & Ralphs, 2004).

This insinuates that fractures of the femur or humerus cannot be properly immobilised (Tomlinson,

1991). In general for all animals it is better to apply a custom made splint then to adjust a premade

splint that will not fit perfectly (Weinstein & Ralphs, 2004). After a leg is fractured, no matter which

bones are affected, it is important to immobilise the limb as quickly as possible so that a minimum of

additional damage presents itself (Adams & Fessler, 1996). If reduction of the fracture is attempted

14

this should be done within 48 hours, because when time passes muscle contraction will make

reduction much more difficult. In small animals they will use general anaesthesia so that muscle

relaxation can be obtained (Weinstein & Ralphs, 2004). When the fractured leg is still swollen, a splint

should never be put in place (Tomlinson, 1991). Robert Jones bandages can be used to reduce the

swelling (Tomlinson, 1991 ; Weinstein & Ralphs, 2004) and may also be used before fracture

reduction is attempted (Tomlinson, 1991).

The material needed for the Thomas splint can vary (Adams & Fessler, 1996). The original Thomas

splint used in human medicine had a fixed upper ring and iron sidebars (Diggle, 1942). Aluminium rods

or pipes as well as iron can also be used as sidebars these days when applied to cattle (Oehme &

Prier, 1974) and the use of steel is another possibility (Fubini & Ducharme, 2004). The weight of the

splint used is based on the weight and size of the patient (Oehme & Prier, 1974). Is the patient’s

bodyweight high, than caution must be taken into creating a sturdy splint so that breakage can be

prevented. On the other hand, the splint and cast must not be too heavy, because the patient may not

be able to stand up and use the leg with the splint in place (Tomlinson, 1991). Combining a light-

weight splint with a medium-weight plaster cast seems the ideal combination (Oehme & Prier, 1974).

The rods used to create the supporting structures of the Thomas splint can vary in size according to

the weight of the patient. Ruminants weighing less than 140 kg, weighing between 140 and 500 kg

and patients outweighing 500 kg, can be placed in a splint made up of metal rods with a diameter of

6.35 mm (quarter of an inch), 12.7mm (half an inch) and 2.5 cm (one inch) respectively (Fubini &

Ducharme, 2004).

For the placement of a cast different types of material can be used. Synthetic casting material is most

often used in comparison with natural plaster of Paris. Synthetic material is more sturdy and long-

lasting and the patient can bear weight on the fractured leg already thirty minutes after application.

They are light, not affected by moisture and radiographs can be taken with the cast in place (Adams &

Fessler, 1996). With some casting material radiographic images can be taken. Natural plaster of Paris

is the least radiolucent, while synthetic casting material, with in particular the Delta Cast (Deltacast

conformable®, BSN-medical), is much more radiolucent (Stead, 1988). When placing a cast, the

thickness should also be related to the weight of the patient and to the location of the fracture. Calves

with a body weight under 150kg can be placed in a synthetic cast made up of six to eight layers in

thickness, while in adult patients the synthetic cast should consist up of twelve to sixteen layers of

casting material (Anderson & St.Jean, 2008). In the book by Fubini and Ducharme (2004), the

synthetic cast for ruminants weighing less than 150 kg was said to be strong enough when composed

of four to six layers, however when the weight exceeded 150kg, depending on the weight of the

patient, the cast could be eight to twelve layers thick. Cast’s for hind legs are generally thicker due to

the angle of the hock, the cast carries a larger stress load (Adams & Fessler, 1996) and because the

hind limbs support a greater percentage of the patient’s bodyweight (Fubini & Ducharme, 2004).

To obtain measurements for the splint, the patient should be standing and the measurements should

be taken from the contralateral uninjured limb (Anderson & St.Jean, 2008). The patient is placed in

15

lateral recumbence with the fractured leg on top (Fubini & Ducharme, 2004 ; Gangl et al., 2006). The

patient is given Xylazine and sometimes an epidural when needed (Gangl et al., 2006). The patient

can be restrained, sedated and/or anesthetized during the positioning of the splint. First the fracture

needs to be reduced to optimize the alignment of the fracture (Anderson & St.Jean, 2008 ; Fubini &

Ducharme, 2004). One can also use rope to ameliorate the placement of the cast (Fubini & Ducharme,

2004).

The first step in the construction of the splint is the fitting of the ring. To place a splint you need the

circumference of the axillary region or femoral region of the front or hind limb respectively. The splint is

composed of a medial ring and a dorsolateral ring. The medial ring should be tightly placed around the

limb and should fit like a “glove” (Fubini & Ducharme, 2004). The ring should fit around the limb in

between the thighs or in between the chest wall and the front limb, depending on which fracture needs

splinting (Oehme & Prier, 1974). The axial or inguinal area of the body is therefore the area where the

body weight will be supported by the Thomas splint (Gangl et al., 2006). The proximal ring structure of

the splint will function as the fulcrum of the Thomas splint. The splint should not be able to brush

against the tuber coxae, the great trochanter, the tuber ischia or the shoulder, causing unnecessary

friction and eventually skin damage (Adams & Fessler, 1996 ; Gangl et al., 2006 ; Oehme & Prier,

1974). The dorsolateral ring must reach above the greater tubercle of the humerus or the great

trochanter of the femur. Prior to construction and after the ring has been fitted, one can use tape to

level the ring and to recognize the location where the cranial and caudal splint connect with the ring

(Fubini & Ducharme, 2004). The ring made for a front leg is round, while the ring for a hind leg is

usually oval. The rods are shaped to the curves of the legs. The rods for a splint applied to the front

leg remain straight, but the rods are bent for the hind legs (Adams & Fessler, 1996 ; Fubini &

Ducharme, 2004 ; Oehme & Prier, 1974). The curves are made to imitate the natural posture and to

stimulate ambulation. This cannot be obtained when the hind leg is fixated in extension (Oehme &

Prier, 1974). External devices must always reach all the way to the ground in order for the device to be

functional (Anderson & St.Jean, 2008 ; Fubini & Ducharme, 2004).

To form the Thomas splint, a long rod is bent starting in the middle creating the medial circle for the

splint and the side bars (Fubini & Ducharme, 2004). The rod is bent over 540 degrees (Adams &

Fessler, 1996 ; Fubini & Ducharme, 2004), or over 630 degrees to obtain the foundation for the splint

(Fubini & Ducharme, 2004). The sidebars are bent by forty degrees in relation to the position of the

ring (Adams & Fessler, 1996). The sidebars exceed the length of the limb by two centimetres (Gangl

et al., 2006). In order to apply traction the splint needs to be longer than the limb resulting in a

decrease in the mobility of the patient (Fubini & Ducharme, 2004 ; Oehme & Prier, 1974). To avoid

ulceration the ring should be well padded with cotton-wool and tape, however this should not be

overdone due to the possibility of the splint loosening from the upper limb (Fubini & Ducharme, 2004).

The leg is cleaned and placed into a stockinet or bandage before the splint is slided onto the leg later

on. The splint can also be padded with foam rubber pipe insulation instead (Gangl et al., 2006). After

the padding of the splint the fractured leg will be padded as well. Thick padding is not good for the

prognosis because the leg may be able to move in the cast afterwards and the appositioned bones at

16

the fracture site will no longer be fixated in place (Fubini & Ducharme, 2004 ; Weinstein & Ralphs,

2004). There are however a couple of bony prominences that should be padded with an extra layer.

The accessory carpal bone, the styloid process of the ulna, the calcaneus and the medial and lateral

malleolus of the tibia should be protected with extra padding (Fubini & Ducharme, 2004).The

dewclaws may also receive some extra padding (Adams & Fessler, 1996). In small animal medicine

the padding is layered with a 50% overlap on the previous layer. Excess padding will have the

tendency to move up or down and to bunch up, therefore creating an area under pressure where

sores can more easily develop (Tomlinson, 1991). To prevent this, one can use multiple layers of

stockinet’s instead (Adams & Fessler, 1996 ; Tomlinson, 1991). The claws of the fracture leg can be

held apart by placing some cotton-wool or gauge padding in the interdigital space (Adams & Fessler,

1996).

A foot piece is made by welding the two ends of the sidebars together onto for example a steel plate

(Gangl et al., 2006). Another possibility is that a foot piece is made by placing another rod with a

smaller diameter into the side bars. By making holes in the supporting side bars at every 2,5 cm, the

splint becomes adjustable (Fubini & Ducharme, 2004). Holes will also be drilled through each claw. By

drilling holes in the walls of the claws, the wires can be attached to the splint (Adams & Fessler, 1996 ;

Fubini & Ducharme, 2004).To prevent failure due to wire breakage, two or three strands of wire are

used to fixate each digit. Afterwards the distal wire is covered by methyl methacrylate to protect

against abrasion (Fubini & Ducharme, 2004). Tension can be created by applying traction to the wires

(Fubini & Ducharme, 2004).The traction exercised by the fixation technique should be sufficient to

keep the fracture site properly appositioned to allow for callus formation (Gangl et al., 2006).

Underneath the claws of the splinted and contralateral leg a similar sized foot piece is placed. The

supporting rods that are attached to the foot piece allow the patient to lean on the fractured leg with its

bodyweight being supported only by the ring and the foot piece of the splint (Oehme & Prier, 1974).

Finally the splint and cast are strapped together to optimize fixation. First the limb is casted, with the

length and position of the cast depending on the fracture site, followed by the placement of the splint

itself. An assistant or student should hold the limb in place while the cast is made (Fubini & Ducharme,

2004). The splint should always be completely surrounded by the plaster cast (Adams & Fessler,

1996) in order to prevent bending and to prevent the other legs from getting stuck in the splint (Oehme

& Prier, 1974). In the paper by Gangl et al. (2006) the authors clearly disagree with Oehme and Prier

(1974) and state that with the placement of a Thomas splint-cast combination the fractured leg is

attached to the caudal supporting rod from the foot until the hock, the hock is attached to both the

cranial and caudal supporting rods of the splint and from the hock upwards the leg is attached solely

to the cranial supporting rod. The cast and splint are usually removed with the use of an oscillating

saw. It is advised to place another temporary splint or bandage the leg after removal of the splint-cast

combination (Adams & Fessler, 1996).

17

4. CANDIDATE SELECTION PRIOR APPLICATION OF THE THOMAS SPLINT

When deciding on treating the patient or not, the average owner will consider the following: the total

cost, the success rate, the economic and genetic value of the patient and the type and severity of the

fracture. Cheap and successful treatment can be seen as the best combination, however when the

patient is of high value, costly treatment even with a minimal success rate will sometimes be

attempted (Anderson & St.Jean, 2008). For the treatment to be a success a patient should be

analysed beforehand and the owner should be made aware of all the implications associated with the

treatment, such as the prognosis, the labour intensity and the costs (Mudge & Bramlage, 2007). On

top of all this, a good communication between the farmer and the veterinarian is essential for the

treatment to be a successful (Tomlinson, 1991).

There are many different types of trauma and fractures possible in livestock and for these different

situations the severity of the injury can also vary greatly. Due to all these different situations, various

techniques for treatment should be considered. The decision on which treatment to use can be based

on the location and the type of fracture, the severity and configuration of the fracture, the surrounding

damage, the presence of an infection, the behaviour of the patient, the proficiency of the veterinarian,

the motivation of the owner and the possibility for follow-up and after-treatment if needed (Anderson &

St.Jean, 2008 ; Adams & Fessler, 1996 ; Adams & Fessler, 1983 ; Tomlinson, 1991). It is sometimes

very difficult to be sure how an animal will behave in the convalescent period (Adams & Fessler,

1996). In some cases the prognosis can be so inadequate that treatment is not even considered

(Gangl et al., 2006). According to Oehme and Prier (1974), even though a patient may be a poor

candidate for surgery, if it is worth a lot, the owner may choose to carry-out the surgery anyhow. On

the other hand, ideal candidates for surgery, with a good prognosis, but that are financially not very

worthy, may be euthanized. Sometimes the recovery period is so long or the chance of success is so

slim, that treatment is not recommended. Ten to twelve weeks is de average maximum that livestock

can benefit from an orthopaedic device such as the Thomas splint. Time is also an essential factor for

the success of the treatment or the lack of success. The sooner the splint is placed, the faster the

immobilisation, the smaller the damage to the vitality of the surrounding soft tissue and the quicker the

recovery.

Cows are generally ideal candidates for the placement of a splint. They tend to lie down a great deal

of the time, giving the fracture a fair chance of healing (Oehme & Prier, 1974 ; Trostle et al., 1995).

Cattle are more resistant to fatigue or acquired trauma of the contralateral limb, and are less prone to

develop laminitis than other species (Anderson & St.Jean, 2008). They rarely develop actual

complications of the contralateral limb (Trostle et al., 1995). Cattle are usually well able to endure the

splint (Anderson & St.Jean, 2008) and should get used to it after a couple of days (Fubini &

Ducharme, 2004). Cattle that manage to stand up with a splint in place, more easily avoid decubitus

sores and ulceration (Oehme & Prier, 1974). Heavier patients are less ideal and more difficult to

handle. At the start of the convalescent period the heavier patients have more trouble standing up with

the splint in place and are also much more difficult to help due to their weight (Adams & Fessler,

18

1983). When the weight of the patient exceeds 300 kilograms, treatment is uncommon (Gangl et al.,

2006). In the study performed by Gangl et al. (2006) there was no influence of bodyweight on the

prognosis. This conclusion however cannot be accurate because most of the patients with a weight

exceeding 300kg were not treated. This was advised due to previous studies that showed a negative

relationship between an increase in weight and success (Gangl et al., 2006).

Furthermore the location of the injury is relevant to the prognosis. Because the front limb is

immobilised in a straight position, it is easier to splint and fixate the front limb. For the hind legs the

splint needs to be bent and adjusted to maintain the natural position of the leg (Oehme & Prier, 1974).

Temperament is also a factor that should be evaluated. Cows are preferable candidates to bulls due to

their temperament and the danger involved for the veterinarian and associates. Before surgery the

animal should be analysed as to how he/she reacts to stress and pain so that the veterinarian can

decide whether it is wise to continue with the placement. The temperament can vary with gender,

breed and every individual. Calm and domesticated animals are the ideal candidates for the placement

of a Thomas splint (Oehme & Prier, 1974). Age can be a contributing factor in choosing the most ideal

treatment. Very young and very heavy animals are not the ideal target group for the Thomas splint

(Gangl et al., 2006) and the prognosis for cattle will decrease with weight and age (Trostle et al.,

1995). There are multiple reasons why younger animals are better candidates for the treatment with a

Thomas splint: the fracture site heals more quickly, the patients weigh less, therefore they place less

pressure on the fracture site, they‘re easier to manipulate, they are more quickly accustomed to

human contact and are therefore less prone to stress and accidental self-mutilation (Oehme & Prier,

1974). A disadvantage however is that neonatal patients of three days and younger and with a

bodyweight less than 80kg were more susceptible to death caused by secondary infection (Gangl et

al., 2006).

19

5. FOLLOW–UP, COMPLICATIONS AND SUCCESS RATE

It is necessary that a patient with a Thomas splint is checked daily, or more often and preferably on a

regular basis (Corea et al., 1992 ; Gangl et al., 2006).The patients’ health and appetite should be

checked, as well as the possibility of ambulation and the condition of the splint and cast. The splint

and/or cast can be damaged, can become moist, instable and may even break completely (Fubini &

Ducharme, 2004). Because the front limb cast is straight, the possibility to break is much smaller than

for the hind legs (Adams & Fessler, 1996). Even though it may be necessary it is difficult to repair a

splint in field settings and many veterinarians do not have the knowledge or skill to successfully carry

out this task (Gangl et al., 2006). The prognosis of the treatment is directly related to the aftercare

carried out by the owner or clinic, depending on where the patient resides. The owner should place the

patient in an individual box or stable for the weeks during which the patient is splinted (Fubini &

Ducharme, 2004).

When a cast is placed and the patient is younger than one month old, the cast should be renewed

every three weeks due to possible growth impairment. If the calf is between the age of one and six

months, it is advised to renew the cast every four weeks and when the ruminant is a yearling or older,

the cast will remain in place for an average of six to eight weeks (Adams & Fessler, 1996 ; Fubini &

Ducharme, 2004). According to the paper by Fubini and Ducharme (2004) the Thomas splint-cast

combination should be kept in place for six to ten weeks, while Gangl et al. (2006) suggest a more

narrow range of duration and state that the splint should remain in place for seven to eight weeks.

After removal of the splint the confinement of the patient for at least another two weeks (Fubini &

Ducharme, 2004), if not a month or more combined with limited movement, is advised (Adams &

Fessler, 1983 ; Tomlinson, 1991 ; Weinstein & Ralphs, 2004).

After placement of the splint-cast combination the patient should be allowed to rest in a stable with

preferably dry bedding and not too deep. If the bedding is too deep ambulation is made more difficult

(Adams & Fessler, 1996). Heavier animals have more problems with ambulation with the splint in

place and tend to lie down more frequently (Gangl et al., 2006). It is important that the patient can

stand up, because on-going recumbence will eventually result in sores and ulceration (Adams &

Fessler, 1996). The patient should be helped up when this is doable for the owner and when this is

necessary for the patient (Adams & Fessler, 1996 ; Gangl et al., 2006). When the patient is lying down

the splinted limb should always be the topmost. If this is not the case the patient will never be able to

stand up and when the patient cannot regain an upright sternal position, bloating can take place

(Fubini & Ducharme, 2004). Cattle generally quickly learn how to rise with the splint in place. Calves

manage to stand and walk around within two days, while adult cattle may require four to five days

(Adams & Fessler, 1996). According to Fubini and Ducharme (2004) most patients are accustomed to

the splint after two or three days and Anderson and St.Jean (2008) advise assistance to the patients

for the first three to five days, or until they are able to rise up by themselves. Chronic recumbency is a

complication that can occur, especially with older heavier animals (Adams & Fessler, 1996).

20

Failure can result from the lack of monitoring and follow-up of the patient. This is often the case when

the choice is made not to hospitalize the patient, but to take him/her home (Gangl et al., (2006). The

splint can be built and used without any complications arising, however most of the time minor

complications cannot be avoided (Oehme & Prier, 1974). All complications possible are either due to a

lack of adequate patient selection, the incorrect construction or placement of the splint or the follow-up

of the patient (Tomlinson, 1991). There are many different possible complications that may arise

during the time that the patient is splinted and during the rest of the recovery period (Fubini &

Ducharme, 2004). The first possible complication involves the presence of post-traumatic swelling

(Adams & Fessler, 1996). It is often seen that a fracture can cause acute swelling which decreases

after a couple of days, leading to the possibility of the splint loosening (Fubini & Ducharme, 2004). A

slipping splint will more quickly be noticed in a hospital environment (Gangl et al., 2006). In such a

case it may be necessary to adjust or replace the splint-cast combination after four to seven days to

avoid any further complications (Adams & Fessler, 1996). The Thomas splint can slip when the

fracture hematoma reduces in size and the circumference of the upper limb decreases (Gangl et al.,

2006). A cast can loosen for different reasons. The placement may not have been carried out properly

(Stead, 1988), or the leg may have decreased in circumference as a result of muscle atrophy (Stead,

1988 ; Tomlinson, 1991). It is important that the patient therefore remains ambulatory (Stead, 1988).

According to research in human medicine, the placement of a cast will always cause muscle atrophy.

The extent of this atrophy depends on the duration of the cast immobilisation. Muscle atrophy will not

only effect the strength of the leg after cast removal, but can result in a long term decrease in the

possible force exerted by the effected musculature (Khalid et al., 2006).

When the cast becomes wet due to urine, rain or wet bedding, the skin can become damaged,

possibly resulting in dermatitis. If this situation arises, the splint should be removed and the skin

should be given the time to dry completely before a new splint and cast are placed (Tomlinson, 1991).

Even though ruminants have a thick skin and are less prone to cast sores, injuries of the skin are the

most common complication seen (Fubini & Ducharme, 2004). Pressure sores and erosions can remain

superficial or may develop into deep ulcers (Corea et al., 1992). Even though the ulcers can become

quite extravagant, most of the time the ulcers heal easily after removal of the splint (Adams & Fessler,

1983). There are a few typical points at which sores and ulceration are most frequently encountered.

These include the area distal to the dewclaws, the palmar/plantar side of the fetlock, the area

surrounding the accessory carpal bone, the area surrounding the calcaneus, the proximal edge of the

cast and under the supporting ring (Adams & Fessler, 1996). A splint-cast combination that has

loosened will much more easily cause sores at the top of the splint, or on the inside of the cast

(Tomlinson, 1991).

When the patient is placed in a splint and the duration of the immobilisation is too long at some point

the bone will start deteriorating because bone resorption will be greater than bone formation. If the

patient cannot stand and bears no weight on the fractured limb, the mass of the bone can decrease to

less than 50% within twelve weeks. It appears that occasional weight bearing can stimulate bone

healing (Buckwalter, 1995). Osteoporosis can finally be the result of prolonged immobilisation (Fubini

21

& Ducharme, 2004). After removing the cast and splint it is always encouraged to make another x-ray.

Usually surrounding the fracture site there will be extensive periosteal bone growth (Fubini &

Ducharme, 2004). Fracture lines can still be visible on radiographic images after removal of the splint,

even though callus formation has already clinically stabilized the fracture (Adams & Fessler, 1983). It

is not essential to pursue the immobilisation until fracture lines are no longer visible on the

radiographic images taken. The splint may be removed if the callus is well formed and the leg is

clinically stable (Adams & Fessler, 1996). After removal of the splint the affected bones may not yet be

adequately aligned, however in time the alignment can remodel and obtain its natural position.

According to Adams and Fessler (1983) a malposition of the fractured bones should therefore not be a

reason to avoid the use of the Thomas splint. Remodelling of the leg into a more physiological position

can evolve in the following half to 1.5 years (Adams & Fessler, 1996). Only after the fracture site has

remodelled and the fracture lines have disappeared from the radiographic images taken, can one be

certain that the fracture is fully healed and that the leg can withstand the bodyweight and the normal

activity of the patient (Tomlinson, 1991).

Delayed union or non-union can occur when the fracture site has not been stabilized correctly (Adams

& Fessler, 1983 ; Anderson & St.Jean, 2008 ; Tomlinson, 1991) or when the bones do not apposition

properly (Adams & Fessler, 1983). Due to inadequate fixation and apposition, non-union of the bones

in the fracture site can occur and an open fracture can form (Adams & Fessler, 1983 ; Fubini &

Ducharme, 2004). When the fracture is open it is recommended to give antibiotics for one or two

weeks (Gangl et al., 2006). In the paper by Gangl et al. (2006) there was no relationship found

between the fracture being open or closed and the success of the treatment. Due to inadequate

immobilisation and due to the fact that the splinted leg is extended slightly passed its natural length,

cattle can experience abduction of the leg after recovery (Maudsley, 1955). The patient can end up

with a persistent deformity of the leg, a lateral deviation of the limb and/or an outward rotation of the

leg. Younger patients can more easily compensate for these complications due to their remaining

growth potential (Adams & Fessler, 1983). In radial and tibial fractures the most common complication

with the placement of a Thomas splint is a deviation of the affected bones. The extent of the deviation

however, can decrease over time (Adams & Fessler, 1983). Chronic lameness can be the result

(Adams & Fessler, 1996).

After removal of the Thomas splint it is always possible that the fracture reoccurs (Tomlinson, 1991).

With the patients where the splint had slipped, re-fractures are more commonly seen (Gangl et al.,

2006). After removal of the splint the patient might have more difficulty getting around than whilst the

splint remained in place. This can be because the joints may have stiffened and due to muscle

atrophy. With the original Thomas splint in human medicine, people could have a completely stiff knee

after the initial removal of the splint (Diggle, 1942). The mobility of the joint could thereafter regain full

movement or remain restricted to a certain angle (The Lancet, 1942). In human medicine the most

common complication of a femur fracture treated by means of the Thomas splint is the instability of the

knee and the disability to bend and move it naturally after removal of the splint. This complication can

decrease in time and even resolve completely, but the acquired loss of knee function can also sustain

22

(Thomas & Meggitt, 1981). In cattle, after the removal of the splint, joint laxity or stiffness are both

possible. The elbow and stifle are the two joints that are most likely to be stiff after removal of the

splint. The chance of developing joint stiffness is inversely related to the distance of the fracture site to

the nearest joint. The shorter the distance, the greater the chance of developing joint stiffness. It is

important that the leg is immobilised in a physiological position and after removal of the splint and cast

the joint should be subjected to both flexional and extensional movement in order to diminish any joint

rigidity present (Tomlinson, 1991). After removal of the splint the patients affected leg can also show a

certain amount of laxity. With movement and time the laxity will usually disappear (Adams & Fessler,

1983). When there is instability of a joint due to ineffective fracture immobilisation, it is possible for a

patient to develop degenerative joint disease (Tomlinson, 1991 ; Trostle et al.,1995). If the fracture is

located outside of the joint and there is a congruency of the bone fragments at the fracture site,

degenerative joint disease is less likely but can still arise if the joint remains unstable (Trostle et al.,

1995). Besides the fractured leg, treatment by means of the Thomas splint can also result in injury of

the contralateral limb due to excess weight bearing (Anderson & St.Jean, 2008).

Besides the most common complications discussed above there are many other possible

complications that can be seen less frequently. Nerve and vessel damage can occur, but may be

prevented by adequate fracture stabilization. Sepsis is a possible complication, but will less likely

develop when the fracture site is thoroughly cleaned and curetted before a cast and splint is placed

(Anderson & St.Jean, 2008). Osteomyelitis is a complication that can develop more easily in patients

with an open fracture (Oehme & Prier, 1974) and according to Anderson and St.Jean (2008) muscle

contracture, ligament contracture and decreased quality of articular cartilage can also be seen as a

complication even though other papers have not discussed these complications any further.

In a retrospective study by Gangl et al. (2006), treatment with a Thomas splint was classified as either

a complete success, when the productivity of the patient returned to its original level, a partial success,

when the productivity decreased, or as a failure, when the patient died or was euthanized. 52.6% of

the patients treated with the Thomas splint-cast combination where seen as a complete success,

18.4% was ranked as partially successful, 25% was seen as a failure and of the remaining 4%, no

information was obtained. According to Gangl et al. (2006), there was an overall success rate of 71%

for the treatment with the Thomas splint. This success rate varies with different researches. In one

study by Anderson et al. (1994) of all the patients with a tibial fracture placed in a Thomas splint 80%

of the patients was considered successfully treated. The numbers instead of the percentages of

failure, partial or complete success in the research performed by Gangl et al. (2006) are shown in

figure 2.

Another similar experiment was performed by Adams and Fessler (1983) whereby 93% of the patients

that were splinted could be seen as a success and 87% of these patients could still be used for

breeding or milking without a decrease in the level of production in these areas. According to the study

performed by Anderson and St.Jean (2008) the survival rate of the treatment by means of the Thomas

splint of different bone fractures did not seem to vary significantly. There was also no significant

23

difference between the weight of the patients, the survival rate of all the patients with a specific

fracture and the success of the patients treated by means of the Thomas splint-cast combination. The

biggest success with the Thomas splint was for cattle with radial fractures, which had a 100% success.

After 1 year of age the patient survival rate decreases, however this may be due to the fact that the

animals have or are close to reaching their slaughter weight, therefore increasing the difficulty to stand

up and bear weight on the affected leg (Crawford & Fretz, 1985). In the study by Gangl et al. (2006)

there was no relationship between the age, sex, body weight, the fact that a fracture was open or

closed, and the success rate of the treatment.

The patients treated by means of the Thomas splint are classified as a failure, a partial success

or a complete success.

Fig.2 The success of the treatment by means of the Thomas splint-cast combination with different

types of fractures. Treatment was considered a success when the patient returned to its initial level of

production, a partial success when the initial level of production was not fully achieved and a failure

when the patient was culled or died. Adapted from Gangl et al. (2006).

24

6. FINANCIAL ASPECTS INFLUENCING TREATMENT OPTIONS

With livestock, economic value is probably one, if not the most important factor influencing the

decision to treat an animal or not. The owner will want to know how much the placement and the

follow-up treatment will cost and will want to compare this to the prognosis of the fracture and the

possibility of complications that may follow. For livestock the sentimental value is often minimal and

will therefore rarely weigh up to the previous factors upon deciding on further treatment (Oehme &

Prier, 1974). In comparison to other species, cattle will usually only be treated if the procedure is

financially worthwhile. The Thomas splint is frequently chosen as a means of treatment because it is

inexpensive in comparison to other immobilisation techniques and can therefore be applied to patients

raised purely for their economic value (Adams & Fessler, 1996). Financially the best alternative for

fracture immobilisation is the placement of a cast (Adams & Fessler, 1996 ; Fubini & Ducharme,

2004), besides treating the patient conservatively. From the total amount of cattle lost on a yearly

basis, fractured limbs account for around 10%. However the total caseload of cattle presented at

veterinary medical schools will stagnate at around 1 or 2%, suggesting that the financial and/or

prognostic prospects of choosing treatment over culling, is lacking in appeal (Gangl et al., 2006). The

aim of fracture repair for commercial cattle is different than for hobby cattle or other species. When the

patient can still carry out its economic function, the treatment can be considered a success. As long as

they remain generating a profit by means of milk production or growth, a perfect recovery is ideal but

not necessary. This means that even if the patient remains partially lame or the affected leg has

become deviated or rotated in morphology after removal of the splint, the treatment can still be worth it

(Adams & Fessler, 1996). Sometimes is may be a better alternative to cull the patient without

attempting treatment, than risking the chance of having to cull the animal later on due to the

inadequate speed or lack of recovery and/or due to excessive treatment costs (Oehme & Prier, 1974).

At the veterinary clinic of Ghent University, the price given for treatment by means of the Thomas

splint varies with the size of the patient. The more material is needed to create the splint, the more

expensive the procedure. On average the costs varied between 250 and 400 euro’s per patient.

Included in these costs are the placement and the costs of radiography. The placement of the Thomas

splint should, when success is obtained, be limited to this one payment. However if complications

arise the costs can rise or result in a failure of treatment. This is financially speaking the worst situation

possible because in this situation the patient would have generated a better profit if it had been culled

without treatment. In 2012 the average new born calf in The Netherlands was worth around 200

euro’s. For calf breeds used for meat production this value rested a little higher at 294 euro’s on

average and for milk breeds the value per new born calf was averaged at 156 euro’s (Beekman,

2012). Most patients are financially good candidates. A few exceptions are the male calves of milk

breeds culled at an age ranging between 100 and 250 days and with a weight ranging between 90 and

250 kg’s, are the adult cows having undergone multiple lactations and are the meat breeds

approaching culling weight (CRV, 2012). Even though the livestock sector is a finally stimulated and

driven sector, in some cases the choice is made to refuse treatment. This can be determined by other

factors such as the prognosis and the labour-intensity of the treatment.

25

7. RETROSPECTIVE RESEARCH

7.1 MATERIALS AND METHODS

At the veterinary clinic of the University of Ghent ten patients with either a tibia or radius fracture were

treated by means of the Thomas splint between 2008 and 2013. From these ten patients nine had a

tibial fracture and only one had a radial fracture. Figure three shows the details of the ten patients. The

patients treated were all under one year of age, with the exception of patient number 10 of which the

age is unknown. This patient weighs 450 kg and can therefore be classified as the only adult patient in

this research. With patient ten being the heaviest patient, the weight of the other patients ranged from

65 to 380 kg. Two patients were not weighed at the clinic. Of these two patients, the first had not

reached the age of two months and the second was only two days old. The weight of the first patient

will most probably also be in the range of 65 to 450kg. The second patient, being the youngest of the

group, may have a weight in the same range as the others, or may weigh less. The Belgian Blue breed

made out the highest percentage of the patients treated. This value of 80% was followed by the

remaining patients that all belonged to the Holstein-Friesian breed. The gender of the patients was

equally divided in this research. In comparison to the females, the males treated were generally

younger.

Informative details on the ten patients analysed in this retrospective research

Patient Age Breed Gender Weight

1 0Y, 1M, 24D Holstein-Friesian Female Unknown

2 0Y, 0M, 2D Belgian blue Male Unknown

3 0Y, 10M, 13D Belgian blue Female 380 kg

4 0Y, 1M, 22D Belgian blue Male 65 kg

5 0Y, 1M, 0D Belgian blue Male 165 kg

6 0Y, 6M, 4D Belgian blue Male 240 kg

7 0Y, 2M, 28D Belgian blue Female 167 kg

8 0Y, 0M, 1D Belgian blue Male 78 kg

9 0Y, 7M, 23D Belgian blue Female 270 kg

10 Unknown Holstein-Friesian Female 450 kg

Fig. 3 Showing age, breed, gender and weight of the ten patients

In these six years there were also two patients with a femur fracture, however neither of the two was

considered eligible for splinting. The first patient had a proximal femoral fracture of which the distal

fragment was displaced in a caudodorsal direction. This patient was treated conservatively. The

second patient obtained a transverse, spiral fracture at the level of the mid femur and the distal

fragment was also displaced in a caudodorsal direction. This patient was euthanized. These two

patients will not be discussed furthermore.

26

Of these ten patients the anamnesis was taken and the patient was clinically examined. The

anamnesis was often incomplete and it was decided that one of the questions in the questionnaire for

the owners should aim for a more detailed anamnesis. During the clinical examination it was noted

that four patients showed moderate tissue swelling at the fracture site, two showed severe swelling,

one patient had a large oedematous bump at the fracture site and in four patients crepitation was

audible. Patient two had a moist and swollen navel besides its fractured leg.

After the clinical examination the patients were taken to the medical imaging department for

radiography. In patient number ten no x-rays were taking due to practical reasons. For the remaining

nine patients, that all had a tibia fracture, the same two projections were used. A craniocaudal and a

dorsolateral projection were taken. In figure 4 the details related to the radiography performed on each

patient are shown. Of the ten fractures, six fractures were on the right leg and the remaining four were

located on the left leg. All ten fractures were closed. Of the ten fractures four were mildly displaced

and three were displaced to a greater extent. Four fractures were complete, three were transverse,

four were comminuted, three were oblique, one was spiral and two fractures were classified as type II

Salter Harris fractures. Of the two Salter Harris fractures, the first fracture (patient two) communicated

with the proximal femorotibial joint, while the fracture of the second patient (number five) affected the

distal metaphysis of the tibia and the tibiotarsal joint. Three fractures were located on the mid

diaphysis of the tibia, three fractures had been established on the proximal diaphysis of the tibia and

one patient had a fracture from the middle to the proximal third of the tibial diaphysis.

Fracture details of the ten patients

Patient Fractured bone

Left/right leg

effected

Fracture details and confirmation

1 Tibia Left Closed, complete, mildly displaced, spiral fracture of the mid diaphysis

2 Tibia Left Closed, mildly displaced, Salter Harris type II fracture of the tibia involving the tuberositas tibiae apophysis

3 Tibia Right Closed, displaced, transverse, mid diaphyseal fracture with laterally a triangular butterfly fragment

4 Tibia Left Closed, displaced, comminuted, oblique fracture of the distal metaphysis. No contact with the joint

5 Tibia Right Closed, Salter Harris type II fracture of the proximal tibia

6 Tibia Left Closed, complete, transverse fracture of the mid diaphysis

7 Tibia Right Closed, complete, comminuted, displaced, transverse fracture of the proximal third of the tibia and fibula. At least two fragments present

8 Tibia Right Closed, complete, mildly displaced, short oblique fracture of the proximal diaphysis. At least to fragments present

9 Tibia Right Closed, mildly displaced, oblique fracture of the mid to proximal third of the tibial diaphysis. At least 3 fragments

10 Radius Right No x-rays taken

Fig. 4 Showing the prevalence of radial and tibial fractures, which leg was affected and further details

on the radiography of the ten patients in this retrospective study

27

Out of the ten patients, four where seen at the veterinary clinic for a second visit. Patient two arrived at

the clinic for a second consult because the owner wanted a check-up on their patient. The splint was

adjusted and the areas on the skin that were damaged were treated with tetracycline spray. Patient

four also arrived for a second consult. With patient four the splint had loosened and was adjusted and

replaced. Patient five was brought in for another reason. The medial ring of the splint had caused

abrasions and wounds had formed in the thigh area. The owners had removed the medial part of the

ring and the splint was thereafter no longer stable. The wound was curetted, cleaned, covered in

honey ointment and finally bandaged. Patient seven is the only patient for which two sets of x-rays

were taken. Patient seven came in for a check-up after one month and for wound care. The patient

was once again taken to radiography and the original photos were compared to the new ones taken.

Figure five shows the fracture before the leg was splinted and four weeks into recovery. The skin

damage of patient seven was cleaned, covered with honey ointment and bandaged.

Radiography of the tibial fracture of patient number seven, prior application of the splint and

after a month of recovery

Fig 5. The left image shows a complete, transverse fracture of the tibia and fibula. The distal fracture

line is in a V-shape and there is a fissure visible pointing to the proximocaudal direction. The right

image shows the affected leg in the splint four weeks into the convalescent period. The fracture lines

are no longer visible, the fracture site is not properly appositioned and the entire leg has shortened.

The radiolucent area shows new bone formation at the fracture site. The fracture is healing.

28

The instructions for the follow-up of the patients and the advice given to the owners about the

convalescent period are generally always the same. The instructions are shown underneath:

Place the patient in a small box on a thin layer of straw. Help the patient to get up when needed and

until he/she can do so individually. The splint will be removed after eight or ten weeks. After four

weeks the Thomas splint-cast combination should be checked and possibly adjusted and replaced.

Make sure that the patient can stand up, will drink and does not develop a fever. If this is the case, an

extra appointment to check the cast is advised. Regularly examine the cast and splint for sores and

ulceration and disinfect these areas when needed.

The method used for splinting a patient at the veterinary clinic of the University of Ghent can be

described as follows. The method explains the placement of a splint in the case of a tibia fracture. The

construction is easier for a patient with a radial fracture because the supporting side bars of the splint

can remain straight.

In the veterinary clinic for large animals at the University of Ghent, the placement of a Thomas splint is

generally always performed in the same manner and is an achievement obtained by the teamwork of

the veterinary surgeon and the farrier. Once the placement of a Thomas splint as a means of therapy

has been chosen, the patient will at first see the farrier. The farrier will measure the length of the

patient’s fractured hind leg (length and width) and create the foundation for the splint. The shape of

this foundation can be described as resembling that of a “keyhole” (see fig.6).

The “keyhole” shaped foundation of the Thomas splint with and without padding

Fig.6 The left side of the image shows the welded foundation of the Thomas splint tailor-made for

patient 9, and the right side of the image is the same foundation padded and ready for use.

29

The thickness of the metal used for the construction of the splint can vary and is thus dependent on

the size and weight of the patient. The foundation is made with a purely iron rod of at least three times

the length of the injured leg and with a diameter ranging from twelve to eighteen millimetres. The rod is

carefully bent into shape and the progress is regularly checked by comparing the shape of the splint to

the shape of the fractured leg. Thereafter the inner part of the ring which will co-function with the

lateral side of the ring as the fulcrum of the splint, is welded onto the foundation (see fig.7).

The welding of the foundation of the Thomas splint in progress

Fig.7 The welding of the medial side of the supporting ring to the outer foundation of the splint.

Patient 9.

The animal is sedated (XYL-M®, VMD, 0.05-0.3 mg/kg) and after being shaved at the base of the tail,

is given an epidural (procaine 4% without adrenaline, VMD, 1ml/5kg bodyweight). The patient is

placed in lateral recumbancy with the fractured leg on top. The patient can remain in the stable with a

plastic canvas draped underneath the fractured leg to shield it from any straw or dirt, or can be placed

on the operating table.

The claws and dewclaws are superficially grated to roughen and straighten the surface and to enlarge

the surface area. Hoof knives can be used if necessary. The claws are thereafter wiped and cleaned

with cotton-wool drenched in ether. In each claw a hole with two millimetres in diameter is drilled using

a manual drill. A foot piece is created for the fractured leg to attach the foot to the splint. The structure

used for the foot piece is a wooden block, normally used for orthopaedic shoeing in cattle. The size of

the block is adapted to the size of the claws and similar sized holes are drilled through the foot piece

as well.

The fractured leg is padded as high up as possible with cotton-wool, followed by a layer of permanent

elastic bandages (Idealflex®, Hartmann). The splint is also completely covered to avoid pressure

wounds. First with cotton-wool and afterwards with bandaging tape (Wrapz® , Millpledge).

Metal wires are passed through the holes in the claws and foot piece, and are fixated to the splint later

on in the procedure. The foot piece is glued to the claws with a special type of glue often used by the

30

farrier (Superfast®,Vettec). The glue is carefully placed in between the claws and the foot piece, and

is smeared around the edges for extra stability.

The attachment of the fractured leg to the base of the splint

Fig.8 The attachment of the metal wiring coming from the foot piece and going to the base of the

Thomas splint. Patient 9.

The splint is slipped onto the fractured leg and the metal wires of the claws are attached to the base of

the splint (see fig.8). The leg is stretched while doing so, however a natural configuration of the leg

should always remain. Once the leg is fixated to the splint, the plastering work can be started (see

fig.9). The casting material used for the leg and splint is a combination of different types of plaster.

Natural (Cellona®, Lohmann-Rauscher) plaster bandaging is used under the claws to stabilize the foot

piece and is used around the leg as proximal as possible, above the bandaged area, directly onto the

skin. For the rest of the splint synthetic (Deltacast conformable®, BSN-medical) plastering material is

used. At first the plastering material is placed solely around the leg itself to secure the cast. From here

onwards most of the splint, with the exception of the supporting ring, will be covered with plaster

bandaging. Starting out with the fixation of the leg to the nearest supporting rod, the fixation of the leg

to the other rod will follow and finally the leg is fully bandaged.

After the plaster is dry, the patient remains at the clinic for a day to check if the splint remains sturdy

and stable. After placement of the splint the patient is treated with an NSAID, such as Emdofluxin®

(Flunixine meglumine,1.1-2.2mg/kg per day) for three days in a row. The cast and splint will be

checked after four to five weeks and is possibly adjusted or replaced. In total the cast and splint should

remain in position for eight to ten weeks.

31

The Thomas splint positioned and partially plastered

Fig.9 The Thomas splint is in its final position and is partially plastered at the base of the splint. The

foot is plastered to the posterior supporting rod of the splint. Both the anterior and posterior strut will

be completely covered thereby fixating the leg to the splint. Patient 9.

The data for each patient was found in the computer files of the veterinary clinic of Ghent University.

The data was recorded and the owners were called by telephone to answer general questions about

the patients and some questions about the follow-up. All owners were willing to cooperate with the

research.

Hereunder is a list of questions used as a guideline for the telephone conversations to make sure that

no important details were forgotten.

1. How did the patient fracture their tibia or radius? Did the owner see it happen or did he/she

find the patient recumbent? Is the owner aware of the amount of time that has passed

between the moment the fracture was established and the time the patient was brought in for

clinical examination?

2. Why did the owner decide on treating the patient by means of a Thomas splint? What were

the other alternatives? Internal fixation? Conservative treatment? Euthanasia?

3. Was this the first time that the owner chose to treat a patient with a Thomas splint-cast

combination? If not, how did the treatment of the other patient(s) evolve?

4. How did the patient behave with the splint in place?

a. Did the patient experience any complications during the convalescent period?

i. Did the splint remain in place? Did the splint loosen? Break?

ii. Was it necessary to return back to the veterinary clinic of the University of

Ghent or to a local clinic? If so, what was the reason? Loosening of the splint?

Infection? Pain?

iii. Did the patient experience any pressure sores and/or ulceration?

b. Could the patient ambulate with the splint in place? How long did it take for the patient

to stand up and lie down without any help?

32

c. Did the patient experience any form of illness or discomfort? Anorexia? Diarrhoea?

Fever? Tympania?

5. How often did the owner check the patient during its recovery? What exactly did the owner

check?

6. Where was the patient placed? How large was the recovery box and what was used as

bedding material?

7. How did the patient react when the splint and cast were removed?

a. Could the patient bear any weight on the effected leg? How did this evolve?

b. Was the effected leg stiff or unstable?

8. Did the owner see any progress in the effected leg? How fast did this happen?

9. Does the owner think the procedure was a success? Was the procedure financially

worthwhile? Was the procedure labour-intensive?

10. In the future would the owner choose for the Thomas splint once again if a similar situation

arose?

33

7.2 DATA COLLECTION AND ANALYSIS

The data collected by means of the telephone conversations with the owners, is written out per patient

below. Some of the owners did not remember all the details of the patient during the oral

questionnaire. The numbers and questions that correspond with one another are shown on page 32-

33, and have not been repeated with every patient.

TIBIAL FRACTURES

PATIENT 1:

1. The fracture was presumably caused by the calf jumping over de box wall, however the owner

did not see it happen. The calf was in a lot of pain and the leg was bent in a right angle. The

owner twisted the leg a quarter of a turn and pushed the leg inwards until it clicked back into

place. The calf was brought in at the veterinary clinic that same day.

2. Treatment with a Thomas splint seemed to be the better alternative because surgery wasn’t

an option.

3. This was the first time that a calf of the owner had been splinted.

4. The calf lay down most of the time and could easily get up by herself from day one. She ate

and drank well. She was given penicillin and painkillers for two weeks.

5. She was checked at least three times a day and given extra milk when needed.

6. After placement of the splint the calf was brought home and placed in a very small box bedded

with a large amount of straw. The size of the box was so small that the calf could not turn

around. Six weeks later the calf was given more space.

7. After removal of the splint she could quickly put her weight on the affected leg. After three

months there was no atrophy visible anymore and the leg looked no different from the

contralateral leg. She is now still doing very well as a dairy cow and has a lactation value of

116.

8. There was definitely progress visible, but how fast this occurred the owner cannot recall.

9. The owner did not think the treatment was a lot work necessarily because the other calves in

the stable had to be checked during the day as well. The patient was independent and in no

need of help. The treatment was a success.

10. Yes.

PATIENT 2:

1. The fracture was caused during/after the caesarean section and the calf was brought in at the

university 2 days after birth.

2. There were not many alternatives, the patient was still young and the prognosis seemed

adequate.

34

3. This was the first time an animal had a splint on the farm.

4. The calf could easily get up and move with the Thomas splint. He ate well and needed no

help in getting up. There were no complications that the owner could remember.

5. Regularly. No further detail.

6. He was placed in a small stable (+/-6m2) with straw bedding.

7. After the splint was removed there was a lot of muscle atrophy and the owner was worried of

the fracture reoccurring. However, after removal the calf could bear weight on the affected leg.

The calf could walk around normally with the splint and once the atrophy was restored the leg

looked very similar although slightly smaller than the contralateral leg. In 22 months the calf

weighed 803 kilograms.

8. The owner saw the patient become progressively more mobile and could see the fractured leg

slowly restoring in size after removal of the splint.

9. A success according to the owner.

10. Yes.

PATIENT 3:

1. The stable works with a system of different heights between the floor and the beds. The

patient must have slipped or could have been pushed by the others, but the exact cause of the

fracture remains unknown. The fracture must have been established in the morning or early

afternoon, because the patient was found by the owner in the afternoon and was brought in at

the veterinary clinic the next morning.

2. The patient still had a certain commercial value and the owner wanted to try the treatment.

3. This was the first animal treated by means of the Thomas splint at the farm.

4. The splint could not hold the weight of the patient properly. The splint moved easily and the

patient tried to get up but never managed to do this alone. If no help was given the patient

could rise with its hind legs, but not with its front legs. After two or three days the local

veterinarian removed the splint and saw that the leg was infected. The patient received

antibiotics, the splint was slipped back onto the leg and the leg was re-plastered. This time the

splint could not hold the bodyweight of the patient and the splint broke. Five days later the

veterinarian returned, removed the splint again and noted areas of gangrene. The patient was

euthanized thereafter. During these few days the patient ate well, but less than usual and lost

a bit of weight as a result.

5. Two or three times a day.

6. The patient was placed in a small straw filled box.

7. Question not relevant for this patient.

8. Question not relevant for this patient.

9. The procedure was not a success in this patient and financially not worthwhile. The procedure

could have been labour-intensive, however because the splint was already removed after a

few days, the labour remained limited. If a similar situation was presented, the patient would

be culled on the farm.

35

10. In the future the owner will not choose for the Thomas splint as a means of treatment if the

patient is similar to the animal in question. However, because the owner was forewarned that

the prognosis of this patient was guarded due to the bodyweight, he/she would consider the

treatment in a different case.

PATIENT 4 & 6:

Patient 4 and 6 are described together. These calves belong to the same owner. Because there have

been numerous fractures on the owners farm in the past decade, the owner can no longer recall which

calf obtained which fracture and how they had occurred. The owner vaguely remembered the two

calves placed in a Thomas splint and was very positive about the treatment.

1. The owner did not see how either of the fractures were obtained with the two calves. The

owner regularly checked the calves and would quickly have noticed the individuals with a

fracture. The owner would probably have brought the calves in at the veterinary clinic on the

same day or as soon as possible.

2. According to the owner, fifteen to twenty calves had already been treated at the veterinary

clinic of Ghent University in the past and they had always been successful. The veterinarian

had advised to treat the calves with a Thomas splint and the owner had approved without a

doubt.

3. Patient number 4 was the first calf placed in a Thomas splint.

4. The patients experienced no complications that the owner could recollect. The calves could

stand up individually after a day or two and did not need any further help. The splint could hold

the patients easily and remained sturdy throughout the convalescent period. The patients

never had a fever. The patients drank well. The patients were generally leaner than the other

healthy calves in their age group.

5. The owner checks the calves multiple times a day. When the owner came to feed the calves,

they would easily stand up.

6. The patients are always placed in individual boxes with straw bedding. The size of the box is

just enough for the patients to stand up and to take a few steps.

7. After removal of the splint the patients could bear weight on the leg and ambulate with it. The

leg was thinner than the contralateral leg.

8. The progress was quick and the patients were cured in 2 to 2,5 months.

9. The owner was incredibly enthusiastic of the treatment procedure, the success rate and the

veterinary clinic of Ghent University in general.

10. Yes.

PATIENT 5:

1. The cause of the tibial fracture is unknown. The owner found the calf in lateral recumbence.

The patient possibly slipped or the dam may have harmed her calf accidentally.

2. The owner is a veterinarian and decided on treating the calf by means of a Thomas splint.

36

3. This was the first time that the owner chose to treat a patient with a Thomas splint-cast

combination.

4. The patient could stand up with the splint in place, however did not use it for support and

dragged it along the ground. On the 4th of February 2011 the medial part of the splint was

removed. The splint was loosening and there were pressure sores on the skin where the

inside of the splint had been rubbing against the skin. The flesh was exposed and had a

strong odour. The patient received antibiotics for two days and painkillers. On the 9th

the

patient was brought in at the clinic, the wounds were treated and the splint adjusted. In the

beginning of the convalescent period the patient could stand up quite easily, however because

of the pressure sores the calf had more trouble later on in the procedure.

5. The patient was checked at least twice a day.

6. The patient remained with the dam in a stable with straw where the calf was free to walk

around.

7. After removal of the splint the effected leg had clearly undergone muscle atrophy. A callus

could be felt, but the patient did not bear any weight on the leg.

8. The patient drank and ate well and the patient reached its target bodyweight before it was sent

to the abattoir. On the other hand there was barely any progress concerning the fractured leg.

The patient never supported any weight on the fractured leg.

9. The owner does not think the treatment was a success, however was not disappointed

because the calf could still reach its target weight. It was financially worth it in the end.

10. The owner seems quite pessimistic about the Thomas splint. Whether the owner would

consider choosing this type of treatment again, depends on whether the situation has a good

prognosis or not.

PATIENT 7:

1. The patient was most probably jumped on by a cow in heat and was found lying down in the

field. The same day she was brought in at the veterinary clinic.

2. Question not answered.

3. This was the first time that a Thomas splint-cast combination as a means of treatment was

used at the farm.

4. The patient always ate well and after a few days could stand up with the splint in place without

any help. There was a block underneath the affected leg which made her slip and the leg

would move outward with every step. The contralateral leg was therefore overloaded with

weight and she started sagging through this leg. She returned to the clinic one month later

because there were abrasions in between the legs and the splint was removed one week

beforehand because the lateral part of the ring was rubbing againsr the leg so badly that it

was nearly penetrating a joint. She had a fever at the same time as she had the wounds and

was given antibiotics. The lateral part was removed by the owner and the patient was brought

to the clinic for evaluation. The patient was sent home and the local veterinarian removed the

37

splint. This was quite difficult and the leg was harmed distally. The patient was given

antibiotics again.

5. Regularly.

6. At the farm she was placed in a small individual box with straw for one month.

7. In the beginning of January she was still dragging her leg when walking and by February she

was outside with the other cows. There is practically nothing to see on the affected leg

besides that it is slightly larger at the fractured site. She is walking and running outside these

days.

8. There was an abduction of the affected leg but with the growth of the animal the posture

improved and the abduction is no longer visible. There progression was slow and steady.

9. The owner thinks that the treatment was a success. The amount of time that was needed to

help and check the patient was reasonable.

10. Yes.

PATIENT 8:

1. The cause of the fracture is unknown.

2. The owner decided to treat the patient by means of a Thomas splint because the fracture was

too close to the joint to be able to perform surgery and euthanasia was not an option for the

owner.

3. This was the first patient placed in a Thomas splint on the farm.

4. The patient had a good appetite during the convalescent period and no general problems such

as diarrhoea. The patient could stand up quite soon after placement of the splint, however the

patient quickly developed pressure sores on the front legs at the level of the fetlock and

carpus. The patient had increasingly more difficulty to stand up and needed help with this. The

wounds on the front leg became quite extravagant and were cleaned and bandaged. The

patient was given antibiotics and NSAID’s. On the second of April, after around 1,5 months,

the splint was removed, however part of the plasterwork still remains connected to the leg.

There are no pressure sores or other complications visible on the fractured leg.

5. The patient was checked and helped when needed multiple times a day.

6. The patient was placed alone in a small box with straw. The box was about 6m2 in size.

7. After removal of the splint the patient could stand up more easily, however the patient still has

trouble standing up with its front legs. If no help is given the patient often remains dangling in

the air, standing only on its hind legs until fatigue causes the patient to lie down again.

8. Once the front legs were damaged by pressure sores the patient seemed to be getting worse.

The patient had more difficulty standing up and would have lost a lot of weight had the owner

not cared for the patient on a regular basis. After removal of the splint the patient immediately

seemed more comfortable. The owner now hopes that the fracture site will remain stable, that

there will be no further complications and that the wounds on the front legs will heal quickly.

9. The owner cannot decide whether the treatment was a success just yet, because this was the

first patient treated by means of the Thomas splint and because the convalescent period of

38

the patient is not completely over. The patient is still recovering from the fracture. The owner

would be able to say more in a month or so, however due to fact that the extent of this

research was limited by a lack of time, further details could not be obtained.

10. Possibly.

PATIENT 9:

1. In the evening of the first of April when the calves were moved indoors, the patient was found

with a broken right hind leg. How the fractured occurred exactly remains unknown. The patient

broke her leg at around 18:00 hours on the first of April en was brought in at the veterinary

clinic the next day.

2. The fracture was so complex that surgery wasn’t an option. The owners decided to try the

Thomas splint in the hope that the patient did not have to be culled.

3. This was the first time that the owner chose to treat a patient with a Thomas splint-cast

combination.

4. Ten days after the placement the patient is still not able to stand up with the splint. She is

making attempts however cannot lift herself of the ground. With help she cannot be lifted

either due to her weight. She eats/drinks well, experienced no fever or diarrhoea up till now

and seems quite calm. Even though she cannot stand she can crawl around and rest in

different parts of the stable. At the right front leg the skin on the medial sides of the carpus is

developing abrasions.

5. The owners check the patient at least once a day to see if she is standing, if she hurt herself, if

the splint is still in place etc.

6. The patient is placed in a stable of about 10m2 and with a thick layer of straw bedding.

7. Question not applicable for this patient.

8. The owners for now see little progression.

9. The owners think that the treatment is time consuming, however remain hopeful that it will be

successful.

10. Question not applicable for this patient.

RADIAL FRACTURE

PATIENT 10:

1. The cause of the fracture remains unknown. The heifer stable was overfull and presumably

the fracture was caused by the patient becoming stuck somewhere or tripping. The fracture

was noticed on the same day and the patient was transferred to the veterinary clinic of the

University of Ghent.

2. The heifer was treated by means of the Thomas splint because she was pregnant and

therefore had a certain potential economic value.

39

3. This was the first time an animal was splinted on the farm.

4. The patient never had trouble getting on her feet, she was never ill or had noticeable changes

in her appetite. Near the end of the convalescent period she had some skin abrasions, but

nothing serious. There were no further complications, but the heifer was culled two weeks

days after she calved of a bull calf.

5. She was checked multiple times a day but was never in need of extra care.

6. The heifer was placed in a stable filled with straw.

7. After removal of the splint she could bear weight on the affected limb but walked with a limp.

The leg made a “mowing” movement when she was walking. Besides the fact that the leg was

a little bigger due to callus formation, the leg looked reasonably similar to the contralateral leg.

8. Besides the first week when the heifer learned how to stand up individually and when the

progress was obvious, no further progress was noticed in the rest of the convalescent period.

9. It cost the owner around 400 euro’s and the owner will not make the same decision if a

comparable situation arises. It might have been financially worth it had the calf been a female.

10. No.

Here below are the main results schematically arranged in charts, comparing the results of the

different patients.

Fig.10 A pie chart showing the number of complications present during the convalescent period for

each of the patients. Excluded from the possible complications are the presence of muscle atrophy,

difficulty in standing up for the first couple of days after placement of the splint and instability right after

removal of the splint, because these can be seen as normal and expected for this treatment.

50%

40%

The presence and number of complications during the convalescent period

Yes, one type of complication

Yes, more than one type ofcomplication

No complications

40

Fig.11 A pie chart showing the percentages of the different possible complications with which the 10

patients were affected during the convalescent period. Other complications such as a permanent

deviation of the effected leg or a re-establishment of the initial fracture can also occur, but were not

seen in these 10 patients.

Fig.12 A pie chart showing the size of the housing arrangements in which the patients stayed during

the entire convalescent period.

Possible complications during the convalescent period

Damaging or breaking of thesplint (8.3%)

Pressure sores / ulceration ofthe skin (33.3%)

Infection / gangrene of the skin(8.3%)

Unable to stand up with thesplint in place (16.7%)

No support on the effected leg(16.7%)

Contralateral leg overload(8.3%)

Permanent limp (8.3%)

Individual box: Limited space for

ambulation 50%

Individual stable: sufficient space for

ambulation 30%

Shared stable 10%

Housing size of the patients

41

Fig.13 A pie chart showing the success of the treatment according to the owners. The 20% of which

the choice was “other” included patients number eight and nine. The convalescent period for these two

patients could only partially be followed up due to a lack of time.

Fig.14 A pie chart showing the most likely decision that the owners would make in the future on

repeating the treatment by means of a Thomas splint, if another situation would present itself with a

patient in need of similar treatment. The 20% for which the choice was “unknown” encompass the two

patients (number eight and nine) of which the recovery period could only partially be followed up due

to a lack of time.

Succesful 50% Unsuccessfull

30%

Other 20%

The succes of the treatment according to the owner

Yes 50%

No 10%

Only in the case of a good prognosis

20%

Unknown 20%

Would the owner choose for the Thomas splint once again

42

7.3 RESULTS

From the ten patients that formed the basis of this research, for nine of the patients the cause of the

fracture can only be guessed and with only one of the patients the owner was sure that the fracture

had been established during the caesarean section. Even in this last patient the exact moment that the

fracture was established remains unknown. Due to the lack of knowledge about the development of

the fractures, it is impossible to calculate how much time had passed exactly before each patient was

brought in for examination and splinted as a result. Each patient however, was said to have been

found or noticed within a day because the animals are checked and cared for at least once a day

depending on the farm.

On average the owners did not accurately describe why they had chosen the treatment by means of a

Thomas splint. Euthanasia or conservative treatment where rarely or never mentioned respectively.

Most owners made their decision based on the fact that surgery with internal fixation wasn’t an option

and because the treatment had been advised by the veterinary surgeon. The choice was generally

more easily made with a young light patient with a good prognosis than with an older heavier patient.

The owners of patient three even mentioned that if a similar situation came along, the adult patient

would have been culled on the farm. Besides patient number six, all the other nine patients were the

first animals of the owners to have been treated with the Thomas splint-cast combination. Without an

ideal alternative and with no previous negative association with the splint, the fact that the Thomas

splint was new to the owners could have provoked them into choosing it.

The patients all experienced minor complications during the time that the splint remained in place,

such as the presence of muscle atrophy, difficulty in standing up for the first couple of days after

placement of the splint and instability right after removal of the splint. These complications can be

seen as normal and expected for this treatment. Furthermore five of the patients experienced no

actual noteworthy complications at all, one patient developed one complication and four patients

developed more than one different type. Of the total prevalence of the different complications,

pressure sores and ulceration made out 33.3%, the inability to stand up with the splint in place and the

lack of support on the splinted leg both made out 16.7% and the damage or breakage to the splint, the

presence of infection and gangrene, contralateral limb overload and lastly a permanent limp, each

made out 8.3%.of the total prevalence. 40% of the patients returned to the clinic for a second visit. Of

these patients only one (25%) of the patients had a loosened splint that needed adjusting and

replacing, in one patient (25%) the owner had removed the medial ring creating instability and in three

patients (75%) wound care was needed to a greater or lesser extent. Of the remaining patients that did

not return to the veterinary clinic of Ghent University, one patient was seen by the local veterinarian

because the splint had loosened. This increases the amount of patients of which the splint had

loosened to 20%.

Most patients had little trouble getting on their feet. Seven of the ten patients were seen on their feet

within a couple of days after placement of the splint. Even patient number ten with a bodyweight of

43

450kg never had problems getting to her feet. The other patients that showed more difficulty always

seemed to have a reason for this incapability. Patient three could not stand up individually with the

splint in place. This patient however had a gradually loosening splint and an infection that later

developed into gangrene. Patient five could stand up after a few days, but never placed any weight on

the splinted leg. The patient had increasingly more trouble getting up further into the convalescent

period due to the pressure sores and ulceration that were becoming worse and worse. Patient nine

cannot rise up with the splint in place, however since the last information was received from the owner

after only ten days in recovery, no conclusions can be made from this patient.

70% of the patients did not experience any form of illness during the convalescent period. Patient

three experienced a fever due to the infection and gangrene that developed and patient seven also

developed a fever due to the extensive abrasions of the skin. All of the patients were checked on a

regular basis. One patient was checked at least once a day, three patients were checked twice, thrice

or two or three times a day respectively, and the remaining four patients were said to have been

checked multiple times a day. All patients were placed in a box filled with straw, 10% of the patient

shared the stable with others, 50% of the patients were placed in a box where limited movement was

possible and 30% of the patients were individually placed in a larger stable.

After removal of the splint four patients could easily bear weight on the affected limb. The leg was

often thinner than the contralateral leg and the owners were concerned that the fracture would

reoccur. This was never the case. These five patients all showed progression and within three months

the owners stated that the patients had completely recovered. Patient five supported no weight on the

fractured limb with or without the splint in place. The patient grew up to culling weight, however there

was no progression seen for the fractured limb. Patient eight appeared more comfortable after removal

of the splint because the pressure on the wounds of the front legs was taken away. The total

progression of patient eight and nine remain unknown due to a lack of time for observation. Patient ten

had a limp after removal of the splint and walked with a “mowing” movement of the leg. There was no

further progression. Patient three was euthanized and beforehand there was also no progression

seen.

According to the owners 50% said that the treatment was a success, 30% disagreed and for the

remaining 20% the success remained undecided because the convalescent period was still running. In

the future, if a similar situation did arise, 50% of the owners would choose for the Thomas splint once

again, 30% would not and 20% would choose for the treatment only if the prognosis is fair. The

remaining two owners were indecisive because the treatment had not yet been fully completed for

their patient.

The data was acquired by means of a telephone conversation with each of the owners and had to its

advantage that it was a fast and direct method of obtaining results. Furthermore the opinion of the

owner was more easily understood than if it had been received in writing. The questions, however,

were frequently only partially answered. The owners were often eager to hang up as soon as possible,

44

even if they have been asked if they had the time or when they were called back at a moment they

had personally suggested. Not all the owners were easily understandable or had difficulty

understanding the caller and some of the details of the patients had already been forgotten by the time

the owners were called.

Looking back at the research if might have been a better alternative to call the owners, ask for an

email address and mail them the questionnaire. This would have given the owners more time to think

about the answers, to ask a family member or a friend about the forgotten details of the patient and

could have resulted in more detailed and accurate result.

45

7 DISCUSSION

The information found on the Thomas splint and the results obtained in this retrospective study have

many points that overlap and show similarities. These will not be the focal point of this discussion and

besides a few examples, will not be actively discussed any further. The differences however, will be

emphasized in this section and comparisons will be made regarding the information found in the

literature versus the results obtained in this research.

According to Lescun et al. (1998) the Thomas splint can be used to properly apposition traumatic

muscle ends in preventing excess formation of fibrous tissue. In this retrospective study however, the

function of the Thomas splint was solely used to immobilise the fractures of different bones. Fractures

in livestock are described in the literature as most often occurring in young animals during dystocia or

during handling of the patients (Anderson & St.Jean, 2008). Most fractures however, whether in adult

cattle or calves, occur when the patients are out in the meadow (Gangl et al., 2006). In this research

the exact cause of the fractures often remained unknown, however since the owners did not cause the

fracture during handling, with possibly the exception of patient nine, all the patients were found in the

field or stable. According to Gangl et al. (2006) the patient is usually easily noticed and is, on average,

examined in two days after the fracture is established. Each of the ten patients in this research was

said to have been found within a day and brought in at the veterinary clinic soon thereafter.

The prognosis for the placement of the Thomas splint is influenced by many factors, According to

Oehme and Prier (1974) the surrounding soft tissue damage, the possibility of an infection and the

integrity of the blood supply influence the prognosis. In patient number three the loosening of the splint

caused skin damage, infection and eventually gangrene to develop. The prognosis became so poor

that the patient was culled. In the paper by Anderson and St.Jean (2008) it stated that fractures below

the mid radius/tibia were good candidates for splinting, however that proximal to this area

immobilisation should not be attempted. Of the five patients with a tibia fracture in this study that were

classified as a success, two patients had a fracture located in the proximal tibia. The third and last

patient in this research had a proximal tibia fracture, however the treatment was a failure. Of the other

three successes, two had a fracture located in the mid diaphysis of the tibia and one in the distal part

of the tibia. Furthermore one of the fractures at the height of the mid tibia also failed to heal. In the

paper by Tomlinson (1991) it said that splints are usually not applied with unstable fractures. Since

seven of the patients treated by means of the Thomas splint had a fracture that was more or less

displaced, this guideline is clearly not applied at the veterinary clinic of Ghent University.

Anderson and St.Jean (2008) wrote that the prognosis for treatment by means of the Thomas splint is

worse for young patients because they are more sensitive to infection and sepsis. Patient number two,

being the youngest of all, however, experienced no complications. Patient three was a bit more than

ten months of age and developed an infection and gangrene. In the same paper by Anderson and

St.Jean (2008) older patients are said to have the disadvantage of the higher bodyweight making

ambulation more difficult. This is not clearly seen in this research. The heaviest patients were: patient

ten with a weight of 450kg, patient three with a weight of 380kg, patient nine with a weight of 270 kg

46

and patient six with a weight of 240kg. Patient ten, the heaviest patient, was clinically seen as a

success. However the treatment was not financially worthwhile for the owner and the owner did not

speak of the treatment as being successful. Patient three was euthanized, patient nine is still in the

convalescent period and patient six was a complete success. In the paper by Fubini and Ducharme

(2004) the treatment by means of the splint cast combination in patients weighing less than 500 kg

and less than one year of age can be given a good prognosis. In this research all nine patients with a

tibia fracture were under the age of one. The treatment was successful for five patients, for two

patients the treatment was not and for the last two the end result will remain unknown.

In the paper by Gangl et al. (2006) it says that for radial and tibial fractures, the treatment by means of

a Thomas splint-cast combination is the first choice. In this study the emphasis is not placed on the

reason why the treatment was performed, but is placed on the prognosis of the treatment itself. Most

of the owners in this research based their final decision on the fact that surgery with internal fixation

wasn’t an option and because the treatment had been advised by the veterinary surgeon. The first

choice of treatment for the tibial and radial fractures might therefore have consisted of an internal

fixation technique had this been an option. Besides splinting radial and tibial fractures, Oehme and

Prier (1974) mention that the splint can also be employed with femoral fractures, however that the

prognosis is very limited if treatment isn’t combined with an internal fixation technique. Between 2008

and 2013 only two femoral fractures were presented at the veterinary clinic of the University of Ghent.

Neither of these two patients was placed in a Thomas splint because the prognosis was so poor that

treatment was not advised. According to Mudge and Bramlage (2007) femur fractures cannot obtain

an accurate immobilisation and in the research by Gangl et al. (2006) four patients with a femoral

fracture were placed in a Thomas splint. None of the patients was successfully treated.

According to Anderson and St.Jean (2008) fractures of the physis of any long bone can heal within

two weeks and fractures away from the physis will take six weeks. In this study the splint remained in

place for eight to ten weeks. This should therefore be enough time for the bones to heal when no

complications arise. In the same paper it states that in adult patients a fracture can heal in eight to ten

weeks, but that twelve to sixteen weeks may be necessary to achieve clinical union.

Stead (1988) states that comminuted fractures are ideal for splinting, Weinstein and Ralphs (2004)

however disagree with this, but mention that when internal fixation is not possible, the Thomas splint is

the only good alternative. All ten patients had complex fractures, and due to this complexity internal

fixation was not an option. Many fractures were comminuted and/or very unstable and could therefore

only be treated by means of the Thomas splint. Weinstein and Ralphs say that oblique fractures are

not ideal candidates for splinting due to the difficulty of immobilisation. In this research, patient four,

eight and nine had established an oblique fracture and patient one had a spiral fracture. Patient four

and one were successful, but patients eight and nine remain unknown. According to Adams and

Fessler (1996) the prognosis is also poorer when the fracture reaches a joint. Two patients in this

research were classified as type II Salter Harris fractures. One patient was a complete success; the

other never placed any weight on the fractured leg and could be considered a failure even though the

patient eventually reached its culling weight. Weinstein and Ralphs (2004) mention that transverse

47

fractures are ideal candidates for splinting because the main force working in on the fracture site is the

same force that will be countered by the placement of the splint. In this retrospective study patient

number three, six and seven had a transverse fracture. Respectively the treatment of the patients was

considered as a failure, a complete success and as another success. In the paper by Adams and

Fessler (1983) the main reason for adjustment or replacement of the splint was due to the loosening of

the cast. Out of the ten patients in this study in two patients the splint had loosened and with another

two patients the splint was adjusted or removed due to excessive skin damage. Even though a splint

loosening is a complication seen in this research, its prevalence is not by far the greatest.

The method for the creation and application of the Thomas splint at the veterinary clinic of the

University of Ghent holds many similarities with the methods explained in different scientific articles.

According to Weinstein and Ralphs (2004) it is best to construct a custom made splint for each patient.

The ten splints constructed at the veterinary clinic of Ghent University were all custom made.

Sometimes a fractured leg is swollen when the patient arrives at the clinic. A splint should never be

placed if this is the case, states Tomlinson (1991). According to Weinstein and Ralphs (2004) Robert

Jones bandaging can be used to reduce the swelling. In this research at least six of the patients

showing moderate or severe swelling of the fracture limb. None of the patients was bandaged with a

Robert Jones bandage and for none of the patients the treatment was adjourned until the swelling had

subsided. For the placement of the splint iron, aluminium (Oehme & Prier, 1974), or steel can be used

to create the sidebars (Fubini & Ducharme, 2004). According to Oehme and Prier (1974) the weight of

the splint should be adapted to the weight and size of the patient. This was also applied at the

veterinary clinic of Ghent University, where the diameter of the iron rods use ranged from twelve to

eighteen millimetres depending on the patient in need of splinting. Besides the weight of the splint, the

thickness of the cast should also be related to the weight of the patient. In a paper by Anderson and

St.Jean (2008) it is suggested to place a cast with six to eight layers of synthetic plaster when the

patient weighed under 150kg. Fubini and Ducharme (2004) suggest four to six layers in casting

thickness when the patient weighs under 150kg and eight to twelve when the patients is heavier. The

patients in this study were not plastered with a specific amount of layers. The veterinarian applied the

plaster until it seemed thick enough to withstand the weight and movement of the patient. The

veterinary clinic of Ghent University and Stead (1988) agree with each other that with some casting

material radiographic images can be taken. Deltacast (Deltacast conformable®, BSN-medical) casting

material, is the most radiolucent product on the market and is always used at the clinic.

According to Anderson and St.Jean (2008) the measurements needed to build the splint should be

taken from the contralateral uninjured limb. The injured leg as opposed to the contralateral leg is

always measured at the clinic. In the same paper by Anderson and St.Jean (2008) the fracture should

first be reduced to optimize the alignment of the fracture. This was also not performed in this research.

The tension placed on the fractured leg when the splint is attached to the leg should partially reduce

the fracture and allow for the fracture ends to align more properly. In the paper by Gangl et al. (2006)

the sidebars exceed the length of the splint by two centimetres. The splint is padded before use to

minimise the chance of skin damage. The padding can consist of cotton-wool and bandaging tape, as

48

applied in this research, while according to Gang et al. (2006) foam rubber insulation can also be

used. To make the splint more adjustable, Fubini and Ducharme (2004) state that holes can be made

in the side bars at every 2.5 cm. The splints at the veterinary clinic were all custom made, without

these holes for adjustment. Adjustment could be obtained after removal of the splint. In contrast to the

method at Ghent University, Oehme and Prier (1974) advise the placement of a similar sized foot

piece underneath both the claws of the splinted and contralateral leg. At Ghent University the

contralateral leg was never given a foot piece. Furthermore it was stated that the splint should be

completely surrounded by the plaster cast (Adams & Fessler, 1996). Gangl et al. (2006) showed a

different technique to plaster the splinted leg. With this technique the leg is attached to the caudal

supporting rod from the foot upwards till the hock, the hock is attached to both the cranial and caudal

supporting rods of the splint and from the hock upwards the leg is attached solely to the cranial

supporting rod. At the veterinary clinic the splint of the ten patients in this research was splinted

completely. Adams and Fessler (1996) advise a cast change every three weeks when the patient is

younger than a month, every four weeks when the patient is between the age of one and six months

and every six to eight weeks when the patient is older. Gangl et al. advises the splint to remain in

place for seven to eight weeks. At Ghent University the patients are checked after four to five weeks

and the cast is removed after eight to ten weeks.

Cattle are resistant to injury of the contralateral limb and are less prone to develop laminitis than other

species (Anderson & St.Jean, 2008). Of the ten patients in this research, only one patient developed

an injury of the contralateral leg. The block underneath the affected leg made the patient slip and

moves the leg outwards with every step. The contralateral leg became overloaded and resulted in the

patient sagging through the contralateral leg. According to Anderson and St.Jean (2008) cattle are

usually well able to endure the splint. After a couple of days the patient should be accustomed to the

splint (Fubini & Ducharme, 2004). In this research eight of the ten patients could stand up individually

after a few days. In the book by Oehme and Prier (1974) it says that the splint is usually tolerated

better on the front limb because when the patients stand up they lean on their hind legs first before

placing their front legs in an upright position. This might be the reason why the heaviest patient in this

research, number ten with a weight of 450kg, could easily get back on her feet.

After removal of the splint Fubini and Ducharme (2004) suggest another two weeks in confinement,

while Adams and Fessler (1983), Tomlinson (1991) and Weinstein and Ralphs (2004) advise a month

of confinement. The University of Ghent agrees with the last point of view and instructs the owners to

allow the patient another months’ worth of rest. After removing the cast and splint the owners are

encouraged to make another x-ray to see if the fracture lines remain visible, and to check whether the

fracture is healing at all by means of callus formation (Fubini & Ducharme, 2004). This check-up was

not performed at Ghent University. In one patient a radiographic check-up was taken when the splint

still remained in place (see fig. 5). After the recovery period the patient may end up with a persistent

deformity, deviation or rotation of the leg. Hereafter the leg can remodel and growth can allow the

patient to compensate for the complication. The younger the patient the greater the chances for

recovery (Adams & Fessler, 1983). Patient seven had a deviation of the leg and dragged the leg along

49

after the splint was removed. Afterwards the patient progressed incredibly and the patient was able to

run outside without any visible defect on the originally fractured leg. Furthermore four patients had an

atrophic leg after removal of the splint. With all these patients the leg returned to its original size later

on in the convalescent period. Patient ten had a constant limp and walked with a “mowing” movement.

Whether this defect could have been resolved in time will remain unknown because the patient was

culled soon after the partus. After removal of the splint the patient may possibly experience trouble

with ambulation. This can be caused by stiffened joints and/or due to muscle atrophy (Diggle, 1942). In

this study the patients may or may not have experienced problems with ambulation after the splint was

removed, however if this was the case, the problems were very limited because none of the owners

took note of it. On the contrary, some of the patients, such as patient eight, seemed more at ease after

the removal of the splint.

The success of the Thomas splint varies in different researches. In the research performed by Gangl

et al. 71% of the patient treated by means of the Thomas splint-cast combination were successful. Of

all the patients 52.6% was seen as a complete success and 25% was a failure. In the study by

Anderson et al. 80% of the treated patients were also classified as a complete success. The study by

Adams and Fessler (1983) described the treatment for 93% of the patients to be a complete success.

In this retrospective study the treatment of 50% of the patients was a complete success. 20% of the

patients recovered partially and can be classified as a partial success. One patient was euthanized

and for the remaining two patients the treatment success has not yet been evaluated. According to

Crawford and Fretz (1985) the bone with the biggest treatment success rate was for cattle with radial

fractures. In this research 100% of the patients were treated with a partial success. At the veterinary

clinic of the University of Ghent of the seven tibial fractures that could be followed up till the end of the

convalescent period, five were completely successful, one was a partial success and the last patient

was classified as a treatment failure.

50

8 CONCLUSIONS

The prognosis of fracture immobilisation by means of the Thomas splint is difficult to predict. The

prognosis is influenced by many factors at the same time, some of which cannot be controlled by the

veterinarian and/or the owner. The type of fracture, the location, the confirmation and the surrounding

soft tissue damage primarily affect the prognosis. Below the mid radius or tibia fractures are said to

have a fair prognosis and it is advised that the fractures located proximal to this location should not be

attempted. From this retrospective research however, one can conclude that fractures proximal to this

position have been successful and that on the other hand fractures located more distally have in this

study been classified as a failure even though the initial prognosis was fair. Age was seen as an

important contributing factor for the prognosis, however the oldest and heaviest patient in this study

was categorised as a partial success, while with one of the younger and lighter patients the treatment

failed due to infection and gangrene. Age was also shown to have an influence on the possibility to

recover from a complication during the remodelling phase of the convalescent period. In this study

patients with unstable factures were also seen to be treated successfully. Even though the splint was

not a success in all patients, comminuted, oblique, spiral and transverse fractures and even fractures

communicating with a joint could all be successfully treated in this research. This research was limited

to only ten patients, therefore, besides being able to conclude that different types of fractures can be

successfully treated, there were not enough patients with a specific type of fracture to be able to

significantly estimate the nature of the prognosis, and to form a more precise conclusion on this

matter. In this retrospective study out of the ten patients examined and treated by means of the

Thomas splint, 50% was seen as a complete success, 20% was seen as a partial success and with

only 10% of the patients the treatment failed. This percentage of success could have even been

higher because for the last two patients it was too early to make a conclusion of the success of the

treatment. The prognosis for the treatment of a fracture by means of the Thomas splint is generally

good in comparison to other methods of immobilisation The placement is relatively inexpensive, which

is why the device is still presently in use for the treatment of fractures in livestock.

51

9 REFERENCES/BIBLIOGRAPHY

Adams, S., & Fessler, J. (1983). Treatment of radial-ulnar and tibial fractures in cattle, using a

modified Thomas splint-cast combination. Journal of the American Veterinary Medical

Association(183), 430-433.

Adams, S., & Fessler, J. (1996). Treatment of fractures of the tibia and radius-ulna by external

coaptation. Veterinary clinics of North America: food animal practice(12), 181-198.

Ames, N. (1981). Comparison of methods for femoral fracture repair in young calves. Journal of the

American Veterinary Medical Association(179), 458-459.

Anderson, D., & St.Jean, G. (2008). Management of fractures in field settings. Veterinary clinics of

north america: food animal practice(24), 567-582.

Beekman, J. (2012, Juni 5). Nuka's gaan beter renderen dan starters. Boerderij, 32-34.

Buckwalter, J. (1995). Activity vs. rest in the treatment of bone, soft tissue and joint injuries. The Iowa

Orthopaedic Journal(15), 29-42.

Carter, A. (1991). Hugh Owen Thomas: the cripple's champion. British Medical Journal(303), 1578-

1581.

Corea, J., Ibrahim, A., & Hegazi, M. (1992). The Thomas splint causing urethral injury. The British

Journal of Accident Surgery(23), 340-341.

Crawford, W., & Fretz, P. (1985). Long bone fractures in large animals. A retrospective study.

Veterinary surgery(4), 295-302.

CRV. (2012). Kengetallen E-22 vleesindex. CRV.

Diggle, W. (1942). The Thomas Splint in the treatment of fractured femur. The Lancet(240), 355-357.

Ewoldt, J., Hull, B., & Ayars, W. (2003). Repair of femoral capital physeal fractures in 12 cattle.

Veterinary surgery(32), 30-36.

Fubini, S., & Ducharme, N. (2004). Farm animal surgery. St. Louis: Saunders.

Gangl, M., Grulke, S., Serteyn, D., & Touati, K. (2006). Retrospective study of 99 cases of bone

fractures in cattle treated by external coaptation or confinement. Veterinary record(158), 264 -

268.

Green, S. (1999). Orthopaedic surgeons. Inheritors of tradition. Clinical orthopaedics and related

research(363), 258-263.

Ikpeme, J. O. (1969). Adjustable and detachable ring for Thomas's Splint. British Medical Journal(3),

49-50.

Khalid, M., Brannigan, A., & Burke, T. (2006). Calf muscle wasting after tibial shaft fracture. British

Journal of Sports Medicine(40), 552-553.

Kirkup, J. (2008). Who made what? Thomas's splint. Journal of medical biography, 104-104.

Lescun, T., Hawkins, J., & Siems, J. (1998). Management of rupture of the gastrocnemius and

superficial digital flexor muscles with a modified Thomas splint-cast combination in a horse.

Journal of the American Veterinary Medical Association(213), 1457-1459.

52

Macnab, D. (1941). Hugh Owen Thomas (1834-1891) The founder of Orthopaedic Surgery. The

Canadian Medical Association Journal(45), 448-452.

Martens, A., Steenhout, M., Gasthuys, F., De Cupere, C., De Moor, A., & Verschooten, F. (1998).

Conservative and surgical treatment of tibial fractures in cattle. The Veterinary Record(143),

12-16.

Maudsley, R. H. (1955). A versatile Thomas splint for sliding traction. The Lancet(269), 597-597.

Mudge, M., & Bramlage, L. (2007). Field fracture management. The Veterinary clinics of North

America. Equine practice(23), 117-133.

Nap, R. (1986). Behandeling van een groeischrijf fractuur van de distale tibia bij een kalf. Tijdschrift

voor diergeneeskunde(111), 1249-1252.

Nichols, S., Anderson, D., Miesner, M., & Newman, K. (2010). Femoral diaphysis fractures in cattle: 26

cases (1994-2005). Australian Veterinary Journal(88), 39-44.

Oehme, F., & Prier, J. (1974). Textbook of large animal surgery. Baltimore: The Williams & Wilkins

Company.

Ord, A. (1936). A universal splint. The Lancet(228), 1338-1338.

Redden, J. F. (1973). The Thomas splint: a quick method of application. The British Journal of

Accident Surgery(5), 165-166.

Robinson, P., & O'Meara, M. (2009). The thomas splint. The journal of bone and joint surgery(4), 540-

543.

Shamir, M., Shahar, R., & Johnston, D. (1996). Semirigid external fixation for repair of fractures in

young animals. Journal of the American Animal Hospital Association(32), 521-526.

Squire, K., & Boehm, P. (1991). External fixation repair of a displaced comminuted radial fracture in a

juvenile camel. Journal of the american veterinary medical association(6), 769-771.

Stead, C. (1988). External support for small animals. In practice(10), 139-149.

St-Jean, G., DeBowes, R., Rashmir, A., & Engelken, T. (1992). Repair of a proximal diaphyseal

femoral fracture in a calf, using intramedullary pinning, cerclage wiring, and external fixation.

Journal of the American Veterinary Medical Association(200), 1701-1703.

The Lancet. (1942). The Thomas Splint. The Lancet(240), 371-371.

Thomas, H. (1875). Diseases of the hip, knee and ankle joints, with their deformities, treated by a new

and efficient method. London.

Thomas, J. (1916). A reconsideration of the principles and methods of Hugh Owen Thomas. I. Some

reflections on Thomas's splints. The British Medical Journal(2), 71-72.

Thomas, J. (1917). A reconsideration of the principles and methods of Hugh Owen Thomas. II. Some

reflections on Thomas's splints and practice. The British Medical Journal(2), 175-179.

Thomas, T., & Meggitt, B. (1981). A comparitive study of methods for treating fractures of the distal

half of the femur. The Journal of bone and joint surgery. Britsh volume(63-B), 3-6.

Tomlinson, J. (1991). Complications of fractures repaired with casts and splints. Veterinary clinics of

North America: small animal practice(21), 735-744.

53

Trostle, S., Wilson, D., Hanson, P., & Brown, C. (1995). Management of a radial fracture in an adult

bull. Journal of american veterinary medical association(12), 1917-1919.

Weinstein, J., & Ralphs, S. (2004). External coaptation. Clinical techniques in small animal

practice(19), 98-104.