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Fsucmilogfemintures are more common in mature patients. Fractures of thefemur may be categorized as capital physeal, femoral neck,troconbepefemFewhanfraanfembilityallrepincgio

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134chanteric, subtrochanteric, diaphyseal, supracondylar, ordylar or distal physeal. Most femur fractures are closed

cause of the heavy overlying muscle, unless because of anetrating injury such as a gunshot wound. Evaluation of aur fracture is important for proper planning of treatment.

mur fractures should be assessed for location of fracture,ether open or closed, type of fracture, joint involvement,d direction of displacement of the distal fragment. Femurctures are generally not amenable to conservative repair,d some kind of internal fixation is generally required. Someoral fractures are amenable to closed reduction and sta-ization, which speeds healing and has low patient morbid-if done properly. Open reduction and stabilization is usu-y performed and is usually successful if basic principles ofair are used. Important factors in repair of femur fracturelude, appropriate surgical approach, preservation of re-nal soft tissues and their attachments to bone fragments,

Repair Techniqueand Surgical ApproachFemoral fractures can be treated using the principles of bio-logical osteosynthesis or by anatomic reduction and stabili-zation. The surgical approach will vary, depending on thetechnique selected.

Biologic OsteosynthesisBiological osteosynthesis involves minimal handling of thebone fragments. Minimally invasive surgical approaches andindirect reduction are used. Minimally invasive approachesrange from a closed approach to an open approach that islimited to the bare minimum to ensure proper placement ofthe implant (Fig. 1). Indirect reduction calls for minimalmanipulation of the fracture area. The fracture hematomadoes not need to be removed or disturbed. Comminutedfragments are not reduced anatomically and are left attachedto their soft tissue attachments (Fig. 2). The bone is distractedto length and spatial alignment is achieved. Common im-

lf Coast Veterinary Specialists, Houston, TX.ress reprint requests to Brian Beale, DVM, Diplomate ACVS, Gulf Coastrthopedic Clinical Techniqian Beale, DVM, Diplomate ACVS

Femur fractures occur commonly in cats andof the femur may be categorized as capitalchanteric, diaphyseal, supracondylar or conare closed due to the heavy overlying musclegunshot wound. Femur fractures are generasome kind of internal fixation is generally refemur fractures include bone plates, interlockand wires and external fixators. Fractures mrigid fixation or using the principles of biologparticularly effective for highly comminutedtissue attachments to bone fragments arecallus. Articular fractures should be anatomithe chance of progressive osteoarthritis.Clin Tech Small Anim Pract 19:134-150 2

KEYWORDS femur, fracture, biologic, osteosynt

emur fractures occur commonly in cats and dogs. Frac-tures of the femur usually occur after substantial traumah as with a vehicular accident. Fractures resulting fromnimal trauma may be secondary to an underlying patho-ic condition, most commonly neoplasia. Fractures of theur occur most frequently at the proximal or distal physis

immature cats and dogs. Metaphyseal and diaphyseal frac-plane

Veterinary Specialists, 1111 West Loop South #160, Houston, TX77027. E-mail: drbeale@gcvs.com

1096-2867/04/$-see front matter 2004 Elsevier Inc. All rights reserved.doi:10.1053/j.ctsap.2004.09.006s Femur Fracture Repair

following substantial trauma. Fracturesal, femoral neck, trochanteric, subtro-r distal physeal. Most femur fracturesss due to a penetrating injury such as at amenable to conservative repair, and. Implant systems suitable for repair ofils, plate-rod construct, lag screws, pinsrepaired using anatomic reduction andeosynthesis. Biologic osteosynthesis isres because vascular supply and softrved, speeding the formation of boneeduced and rigidly stabilized to reduce

sevier Inc. All rights reserved.

her anatomic or indirect reduction, adequate stabilization,propriate choice and application of implant system andper postoperative care. Gunshot fractures should be man-d especially carefully due to the higher risk of osteomy-tis and nonunion. Indirect fracture reduction and preser-ion of soft tissue attachments to fracture fragments arerticularly important in this type of fracture.nt systems used to stabilize fractures treated in this man-r include the plate-rod construct, interlocking nail, bone

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Orthopedic clinical techniques femur fracture repair 135te, or pin and external fixator combination. Cerclage wiresuld not be used. The biological osteosynthesis techniqueideal for complex and comminuted fractures due to theid healing that occurs as a result of preservation of bloodply to the fracture fragments (Fig. 3). As early bone callus

velops, less stress is placed on the implant and more isced on the bony column.

atomic Reductionatomic reduction involves reconstruction of the bony col-n to restore stability. A traditional open surgical approachmade to the affected area of the femur. Most fracturesuire a lateral approach. The fragments of the fracture areuced and individually stabilized using pins, wires andews (Fig. 4). The entire bone is then supported using onea combination of implant systems, including bone plates,and wires, cerclage wires, adjunctive external fixators,

te-rod constructs, and interlocking nails. An effort shouldmade to preserve soft tissue attachments to bone frag-nts when using this technique, but some disruption ofse structures is common.

plant Systemsn and Wires and wire fixation is effective for stabilization of longlique and spiral fractures of the femoral shaft. Intramedul-y pins can be placed either retrograde of normograde.rmograde placement is preferred because it is easier toate the pin in a more lateral position, close to the greaterchanter and away from the femoral head (Fig. 5). Thislps avoid impingement of the sciatic nerve. The pin shouldo be cut and countersunk so that it is level with or distal totop of the greater trochanter. The distal portion of the pinuld be firmly imbedded in the metaphyseal bone. The

re 1 Minimally-invasive surgical approaches allow adequate ex-sure for placement of implants, but minimize disruption of softue structures at the fracture site.meter size of the pin should approximate the diameter ofisthmus of the mid-diaphysis of the femur. An intramed-

ostchaary pin provides excellent bending stability, but poor ro-ional and axial stability. Rotational and axial stability ofg oblique and spiral femur diaphyseal fractures can betained by appropriate placement of cerclage wires, lagews, or an adjunctive external fixator (Fig. 6).

ate-Rod Constructe combination of an intramedullary pin and a bone plates been found to be an ideal implant system for biologicalcture management of comminuted fractures in dogs ands (Fig. 7). The technique is also effective when using ana-ic reduction (Fig. 8). The addition of the intramedullary) pin to the plate significantly increases the constructfness and estimated number of cycles to fatigue failureen compared with a plate only construct. Addition of anpin to a bone plate has been shown by Hulse and cowork-to decrease strain on the plate two-fold and subsequentlyrease the fatigue life of the plate-rod construct 10-foldpared with that of the plate alone. In the canine femur,

te strain is reduced by approximately 19, 44, and 61%th the addition of an IM pin occupying 30, 40, and 50% ofmarrow cavity, respectively. The intramedullary pin is

plied first. The fracture can be assessed through a mini-lly invasive approach to help guide the tip of the pin intodistal fragment. The pin can be used to assist distractionthe fracture as it engages the distal fragment. The pinvides axial alignment and provides partial stability forplication of the plate. The surgeonmust be careful to attainational alignment before placement of the screws of thene plate. Only 2 to 3 screws are needed in the proximal and

re 2 Comminuted fragments are not reduced anatomically andleft attached to their soft tissue attachments when using biologic

eosynthesis. Cerclage wires are not used due to the increasednce of disrupting blood supply during their application.

136 B. BealeFigure 3 The biological osteosynthesis technique is ideal for complex and comminuted fractures due to the rapid healingthat occurs as a result of preservation of blood supply to the fracture fragments.

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Orthopedic clinical techniques femur fracture repair 137tal fragment. Monocortical screws are placed if the screwnot be directed to avoid the intramedullary pin (Fig. 9).en screw holes are protected by the intramedullary pin,creasing the chance of plate breakage (Fig. 10).

terlocking Naile interlocking nail system (Innovative Animal Products,chester, MN) is another effective implant system for bio-ical or anatomic fracture management of comminutedctures in dogs and cats. The interlocking nail is a modifiedinmann pin having transverse holes designed to accom-date screws or bolts. The addition of the screws or boltsreases the ability of the pin to resist rotational and com-ssive forces at the fracture site. This type of fixation ismonly used for stabilization of fractures of the femur and

ia in people. Interlocking nails are used in dogs and cats forair of fractures of the humerus, femur and tibia. The in-locking nail system is less expensive than a bone platetem, but has similar biomechanical properties. Interlock-nails are easy to apply and are a good option for generalctitioners not wishing to invest in a bone plate system.erlocking nails can be effectively used for fractures man-

re 6 External fixators can be used to provide additional rota-nal and axial stability.re 4 Anatomic reduction involves reconstruction of the bonyumn to restore stability. The fragments of the fracture are re-ced and individually stabilized using pins and wires.

re 5 Normograde placement of intramedullary pins is preferred

d by the principles of biological osteosynthesis or ana-ic reduction (Fig. 11).

138 B. BealeFigure 7 The combination of an intramedullary pin and a bone plate has been found to be an ideal implant system forbiological fracture management of comminuted fractures in dogs and cats.

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Orthopedic clinical techniques femur fracture repair 139ternal Fixatorternal fixators are often used for biologic management ofctures, because of the lower implant cost and relative easeapplication. They can also be used effectively as an adjunctplant with pin and wire fixation. External fixators are notmonly used as the sole method of repair of femur frac-

es because of the increased morbidity associated with fix-r pins imbedded in heavy muscle surrounding the femur.ternal fixators can be used with closed or open reductionthe fracture. When applied correctly, vascular supply offracture fragments can be preserved very effectively. Lin-external fixators are most commonly used with fracturesthe femur. The disadvantage to external fixators is theater demand in the postoperative period because of ban-ge changes and pin management. External fixators can bed in a tie-in configuration. A type I external fixator isplied to the lateral surface of the femur. An intrameddularyis placed and allowed to protrude form the skin proxi-lly. The connecting bar is attached to the fixator pins andintramedullary pin using clamps. Alternatively, the fix-r pins and IM pin can be anchored using an acrylic bar.

re 8 The plate-rod construct can also be used effectively whentomically reconstructing the bony column.e tie-in configuration approximately doubles the stabilitythe repair and prevents migration or the IM pin (Fig. 12).

plapinapital Physeal Fracturecture of the capital physis can occur in growing cats andgs following moderate or severe trauma. In immature pa-nts, fracture of the physis is more likely to occur than hiplocation because of the fragile nature of the physis com-red with the stronger attachment of the ligament of theoral head. An acute onset of lameness is typically re-rted. Lameness, hip pain, and crepitus are usually ob-ved on physical examination. Radiographic examination isd to confirm a diagnosis of capital physeal fracture. Aeral and ventrodorsal view of the pelvis should be obtainedder sedation. Occasionally a frog-legged ventrodorsal viewlso needed to make a diagnosis (Fig. 13).Surgical treatment is required for capital physeal fractures.moral head ostectomy (FHO), total hip replacementR), or stabilization of the fracture are options. A cranio-

eral approach to the hip is made. Reduction of the fractured stabilization of the fracture with divergent Kirschnerres (K wires) or a lag screw is the optimal treatment indium and large dogs. The L-shaped physis should be an-mically reduced. Divergent K-wires should be used tobilize the fracture in younger patients anticipated to have

re 9 Only 2-3 screws are needed in the proximal and distalgment when using a plate-rod construct. Monocortical screws are

ced if the screw cannot be directed to avoid the intramedullary.

140 B. BealeFigure 10 Open screw holes are protected by the intramedullary pin, decreasing the chance of plate breakage.

Orthopedic clinical techniques femur fracture repair 141Figure 11 Interlocking nails can be effectively used for fractures managed by the principles of biological osteosynthesis.Complete healing of this fracture has occurred prior to 2 months.

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142 B. Bealestantial additional growth, because a lag screw placedoss the fracture will lead to quick closure of the physis andested growth. Divergent wires can be placed in normo-de or antegrade fashion. Maximal purchase of the femoralad should be achieved, but care should be taken to avoidnetration of the articular surface of the femoral head by thewire (Fig. 14). This technique can also be used effectivelysmall dogs and cats, but FHO is also used frequently in thise patient because of the decreased cost and high successe. Vascular damage to the lateral or medial circumflexoral, or caudal gluteal arteries can occur as a result of thisury, leading to secondary aseptic necrosis of the femoralad or neck (Fig. 15). Owners should be cautioned aboutpossibility of this occurring before agreeing to surgicaluction and fixation. Some patients may also develop os-arthritis after repair of the capital physeal fracture Becausethe possibility of avascular necrosis occurring in the weekser surgery, some owners opt for FHO or THR, to eliminate

re 12 External fixators are often used for biologic managementfractures, due to the lower implant cost and relative ease of ap-cation. They can also be used effectively as an adjunct implanth pin and wire fixation. The tie-in configuration approximatelyubles the stability of the repair and prevents migration of the IM.possibility of needing a second surgery. Postoperatively,tients should be confined and restricted to short leashed

legfralks. Follow-up radiographs should be obtained in 6 to 8eks.

moral Neck Fracturesmoral neck fractures occur in dogs and cats of all ages afterstantial trauma. An acute onset of lameness is seen. Lame-ss, hip pain, and crepitus are usually observed on physicalmination. Radiographic examination is used to confirm agnosis of femoral neck fracture. A lateral and ventrodorsalw of the pelvis should be obtained under sedation oresthesia.

re 13 Radiographic examination is used to confirm a diagnosiscapital physeal fracture. A lateral and ventrodorsal view of thevis should be obtained under sedation. Occasionally a frog-

ged ventrodorsal view is also needed to see displacement of thegment and make a diagnosis (B).

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Orthopedic clinical techniques femur fracture repair 143Surgical treatment is required for femoral neck fractures.O, THR, or stabilization of the fracture are options. Aniolateral approach to the hip combined with a lateral

re 14 Divergent K-wires should be used to stabilize the fractureyounger patients because a lag screw placed across the fracturel lead to quick closure of the physis and arrested growth. Maxi-l purchase of the femoral head should be achieved, but careuld be taken to avoid penetration of the articular surface by theires.

re 15 Vascular damage to the lateral or medial circumflex fem-

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l, or caudal gluteal arteries can occur as a result of this injury,ding to secondary aseptic necrosis of the femoral head or neck.proach to the proximal femur is used to gain access to thecture. Reduction of the fracture and stabilization of thecture with divergent K-wires or a lag screw is the optimalatment in medium and large dogs (Fig. 16). Femoral neckctures can be difficult to repair and are often found inbination with subtrochanteric femur fractures. Occa-

nally, fractures of the femoral neck will extend up throughfemoral head creating an articular component to the frac-e. Repair of this type of fracture requires accurate ana-ic reduction of the articular surface to avoid significanteoarthritis. Divergent K-wires should be used to stabilizefracture in younger patients anticipated to have substan-

l additional growth, because a lag screw placed across theital physis will lead to quick closure of the physis andested growth. Divergent wires can be placed in normo-de or antegrade fashion. Maximal purchase of the femoralad should be achieved, but care should be taken to avoidnetration of the articular surface of the femoral head by thewire. This technique can also be used effectively in smallgs and cats, but FHO is also used frequently in this sizetient because of the decreased cost and high success rate.scular damage can occur as a result of this injury, leadingsecondary aseptic necrosis and nonunion of the femoralck. Owners should be cautioned about the possibility ofs occurring before agreeing to surgical reduction and fix-

re 16 Reduction and stabilization of a femoral neck fracture withergent K-wires or a lag screw is the optimal treatment in mediumlarge dogs.on. Because of the possibility of avascular necrosis occur-g in the weeks after surgery, some owners opt for FHO or

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144 B. BealeR, to eliminate the possibility of needing a second surgery.stoperatively, patients should be confined and restricted tort leashed walks. Follow-up radiographs should be ob-ned 8 weeks after surgery.

rochanteric Fracturesctures of the greater trochanter will occasionally occur asisolated fracture or combined with other fractures of theur or pelvis. The fragment displaces cranially and proxi-lly because of the pull of the attached middle gluteal mus-. This fracture should be repaired with a technique thatll withstand the distractive gluteal force that occurs duringightbearing. Acceptable techniques of repair include a pind tension band, lag screw or a bone plate (Fig. 17). If usingin and tension band, 2 K-wires or pins are directed acrossgreater trochanter from lateral to medial, exiting the me-l cortex of the proximal femur. A figure-of-eight stainlessel band is placed on the lateral surface of the femur. Thest common size of pins used vary from 0.045 to 5/64,pending on patient size. The size of wire varies from 0.8 to5 mm, depending on the size of patient. A traditionaleral approach to the proximal femur is used.

ubtrochanteric Fracturesbtrochanteric fractures involve the proximal metaphysealion of the femur and can occur as an isolated fracture ory be found in association with a femoral neck or diaphy-l fracture. Fractures of this type are often highly commi-ted. This type of fracture can be difficult to anatomicallyuce and stabilize adequately. Minimal dissection shouldperformed to decrease the chance of damaging regionalod supply to the fragments, which are important for earlyne healing. These types of fractures can be anatomicallyuced and stabilized or can be indirectly reduced andated by biological osteosynthesis using minimally invasivehnique (Fig. 18). Implant systems that are commonly usedlude, pin and wire, lag screws, bone plate, interlockingil, and plate-rod fixation. External fixators can also be ap-ed adjunctively, but their use in the femur is less desirablecause of the large amount of soft tissue overlying the bone,ich increases patient morbidity.

actures of the Femoral Shaftmoral shaft fractures occur secondary to substantialuma. Femoral shaft fractures vary greatly in their complex-. Common fracture types include transverse, oblique, spi-, and comminuted. Fractures that occur followingminimaluma should be carefully evaluated for underlying disease,ecially neoplasia, which is a common cause of pathologicctures. A lateral approach to the femur is made to reduced stabilize all of these fracture types.Long oblique and spiral fractures can be repaired successfullymany healthy patients using pin andwire technique (Fig. 19).pair of these types of fractures are ideal for the novice ortho-ic surgeon or general practitioner. It is important to size theplants appropriately. The intramedullary pin diameter

uldbe slightly smaller than thediameter of the isthmusof theur. The pin should be cut short and countersunk proximallyre 17 Fractures of the greater trochanter should be repaired withechnique that will withstand the distractive gluteal force thaturs during weightbearing. Acceptable techniques of repair in-de a pin and tension band, lag screw or a bone plate.

Orthopedic clinical techniques femur fracture repair 145Figure 18 A highly comminuted subtrochanteric fracture of the femur in a cat is treated successfully using a plate-rodconstruct. The fracture is healed at the 2 month recheck exam.

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146re 19 Long oblique and spiral fractures can be repaired success-ly in many healthy patients using pin and wire technique.B. BealeFigure 20 Short oblique fractures and transverse fractures can bconstruct or interlocking nails.re 21 Complex comminuted and open fractures are best treated usinglogical osteosynthesis. This proximal femur fracture would be difficulteduce anatomically without devitalizing the comminuted fragments.e repaired successfully with bone plates, plate-rod

Orthopedic clinical techniques femur fracture repair 147Figure 22 Supracondylar fractures can be highly comminuted and may involve the articular surface. This patient wastreated effectively by placing a lag screw across the intercondylar fracture and stabilizing the supracondylar componentwith an interlocking nail using the principle of biological osteosynthesis.

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148 B. Bealeavoid interference with the sciatic nerve. Cerclage wiresuld be of adequate size to provide rotational and axial stabil-. Wires should be applied very tightly and the security of thee checkedbefore closure. Loosewires lead to delayedhealingause of disruption of blood supply. If a loose wire is found, ituld be replaced with a tight one.Short oblique fractures and transverse fractures can beaired successfully with bone plates, plate-rod construct,interlocking nails (Fig. 20). Pin and wire fixation can leadhealing, but also has a higher risk of delayed or nonunione to a decreased ability to provide rotational and axialbility. Stack pinning does not significantly increase theistance to rotational stability when compared with a singleramedullary pin. When repairing short oblique or trans-se fractures with pins and wire, an adjunct external fixatoruld be considered for 4 to 6 weeks.Simple comminuted fractures can be treated using thenciples of biological osteosynthesis or anatomic reductiond stabilization. Complex comminuted and open fracturesbest treated using biological osteosynthesis (Fig. 21).

mminuted fractures are best repaired with more stableplant configurations, including bone plates, plate-rod con-uct or interlocking nail. If using pins and wires, an adjunc-e external fixator is strongly advised.

upracondylar andistal Physeal Fracturespracondylar fractures are most common in mature pa-nts. They involve the distal metaphyseal region of the fe-r and can occur as an isolated fracture or may be found inociation with femoral shaft or condylar fractures. Frac-es of this type may be highly comminuted (Fig. 22). Thise of fracture can be difficult to anatomically reduce andbilize adequately because of the pull of muscles and distalture of the fracture. Minimal dissection should be per-med to decrease the chance of damaging regional bloodply to the fragments, which are important for early bone

aling. These types of fractures can be anatomically reducedd stabilized or can be indirectly reduced and treated bylogical osteosynthesis using minimally invasive tech-ue. Implant systems that are commonly used include, pind wire, lag screws, bone plate, interlocking nail, and plate-fixation. External fixators can also be applied adjunc-

ely, but their use in the femur is less desirable because oflarge amount of soft tissue overlying the bone, whichreases patient morbidity.Distal physeal fractures occur in immature patients. A typealter-Harris fracture is most common. The distal metaph-s of the immature dog and cat has four pegs that align withr recessed regions in the distal epiphysis. This anatomicture can be used to help align the fracture and providese rotational stability during surgical repair. Distal physeal

ctures are usually repaired with pins and an attempt isde to avoid any configuration that would place compres-n across the physis. Cross pins or a single IM pin and cross

are common methods of repair (Fig 23). Lag screw fixa-

n should be used for the condylar portion of a type IVturanter-Harris fracture. Damage to the physis can lead to limbrtening or angular limb deformity.Divergent pins directed from the medial and lateral con-les, across the fracture line can be deflected off the oppositetex of the diaphysis and seated in the proximal metaphysisg 24). This method of pin placement is commonly referredas the rush-pin technique. This technique works well inatively simple supracondylar or distal diaphyseal fractures.

ondylar Fracturesndylar fractures involving the articular surface must beated using open reduction. Repair of condylar fracture cancomplex and more difficult than might be anticipatedm review of the preoperative radiographs. A lateral ap-ach to the distal femur is used in combination with aeral parapatellar approach to the stifle. It is essential toain accurate anatomic reduction of the articular surface toer the chance of developing osteoarthritis. Condylar frac-

re 23 Distal physeal fractures occur in immature patients. Thister 2 fracture was repaired using a cross pin technique. Earlyoval of the pins following healing may decrease the chance ofmature closure of the physis.es should be repaired rigidly using one or more lag screwsd antirotational wires where appropriate (Fig. 25).

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Orthopedic clinical techniques femur fracture repairomplications andostoperative Periodmplications include pin migration, sciatic nerve entrap-nt, infection, nonunion, delayed union, implant fail-e, quadriceps tie-down, and premature physeal closureding to limb shortening or angular deformity (Fig. 26).st of these complications can be avoided by good sur-al planning, appropriate implant selection, good surgi-technique and proper postoperative management.

acture healing may vary from 4 to 16 weeks, dependingthe age of the patient, type of fracture, method of re-ir, surgical approach used, compliance of the owner,d compliance of the patient. Bandages are generally noted after repair of femur fractures. Weight bearing shouldencouraged immediately after surgery in adequatelybilized fractures. The hip, stifle and tarsus should benipulated using range of motion or walking exercise.rly return to function reduces the chance of fractureease and encourages early callus formation. Quadriceps-down is perhaps one exception to the typical postop-tive protocol. Immature dogs having femoral shaft, su-acondylar, or distal physeal fractures are susceptible toorporation of the quadriceps muscle in the extensiveny callus of the healing fracture. The quadriceps isked into position and the stifle remains in an extendedsition. This condition is best prevented, rather thanated. Placement of the stifle at a 90 angle suing a figure-eight flexion bandage for 1 week generally will helpevent this severely debilitating condition. After removal

Figure 24 Divergent pins directed from the medial and lateropposite cortex of the diaphysis and seated in the proximathe bandage, the stifle should be treated with range oftion exercise several times a day. Figu

modyles, across the fracture line can be deflected off thephysis.

149re 25 Condylar fractures should be repaired rigidly using one orre lag screws and anti-rotational wires where appropriate.

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150 B. BealeferencesBardet JF, Vanini R: Fractures of the femur, in Brinker WO, OlmsteadML, Sumner-Smith G, et al. (eds): Manual of internal fixation in smallanimals. Berlin, Springer-Verlag, 1998, pp 155-162Dueland RT, Berglund L, Vanderby R, et al: Structural properties ofinterlocking nails, canine femora, and femur-interlocking nail con-structs. Vet Surg 25:386-396, 1996Horstman CL, Beale BS, Conzemius MG, et al: Biological osteosynthesisversus traditional anatomic reconstruction of 20 long-bone fracturesusing an interlocking nail: 1994-2001. Vet Surg 33:232-237, 2004Hulse D, Hyman W, Nori M, et al: Reduction in plate strain by additionof an intramedullary pin. Vet Surg 26:451-459, 1997Hulse D, Ferry K, Fawcett A, et al: Effect of intramedullary pin size on

Figure 26 Plate failure occurred in this fracture treated by aA medial buttress defect led to cyclic strain of the plate careducing bone plate strain. Vet Comp Orthop Traumatol 13:185-190,2000Johnson AL, Egger EL, Eurell JC, et al: Biomechanics and biology offracture healing with external skeletal fixation. Compend Contin EducPract Vet 20:487-502, 1998Johnson AL, Seitz SE, Smith CW, et al: Closed reduction and type-IIexternal fixation of comminuted fractures of the radius and tibia in dogs:23 cases (1990-1994). JAVMA 209:1445-1448, 1996Palmer RH: Biological osteosynthesis. Vet Clin North Am Small AnimPract 29:1171-1185, 1999Reems MR, Beale BS, Hulse DA: Use of a plate-rod construct and prin-ciples of biological osteosynthesis for repair of diaphyseal fractures indogs and cats: 47 cases (1994-2001). J Am Vet Med Assoc 223:330-335,2003

c reconstruction and a traditional surgical approach.t to fail.6.

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Orthopedic Clinical Techniques Femur Fracture RepairRepair Technique and Surgical ApproachBiologic OsteosynthesisAnatomic Reduction

Implant SystemsPin and WirePlate-Rod ConstructInterlocking NailExternal Fixator

Capital Physeal FractureFemoral Neck FracturesTrochanteric FracturesSubtrochanteric FracturesFractures of the Femoral ShaftSupracondylar and Distal Physeal FracturesCondylar FracturesComplications and Postoperative PeriodReferences