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Evaluating the Impact of Duration of Supracondylar Femoral Fracture on Hemato-biochemical and Intra-Operative Traits in Dogs.

Introduction

Hemato-biochemical traits evaluation is a routine procedure for assessing bone metabolism and overall health of canine affected with long bone fractures. Moreover, hemato-biochemistry at various time intervals is an integral part of clinical orthopedic research studies (Mukhopadhyay et al., 2011). In referral Veterinary hospitals, the duration of fracture presentation varies which may have influence on hemato-biochemical and intra-operative results and therefore the outcome. The objective of this study was to evaluate the impact of duration of fracture on hemato-biochemical and intra-operative observations in dogs.

Materials and Methods

Twenty four dogs with twenty six supracondylar femoral fractures were included in the study. The fractures were stabilized using single end threaded intramedullary pin or cross transcortical pinning using K wires. The time since fracture till the definitive surgical intervention was defined as duration of fracture. Hematology and serum biochemistry was performed at the time of case presentation. Whole blood sample (2 mL) was collected in EDTA (Ethylene diamine tetra-acetic acid) for estimation of Hemoglobin (g/dL), total leukocyte count (total cells/[micro]L), differential (%) and absolute leukocyte count (total cells/ [micro]L). Another blood sample (3 ml) was collected in a syringe and kept undisturbed to form a clot so as to separate serum. Serum (1 ml) was collected in a vial for estimation of calcium (Ca), phosphorus (P) and alkaline phosphatase (ALP). Intra-operative observations such as ease of reduction of fracture fragments and need of bone nibbling for fracture reduction were recorded and correlated with fracture duration. The data were organized into various groups based on duration of fracture and these were subjected to statistical analysis using student's t-test to determine the level of significant difference at p<0.01 and p<0.05.

Results and Discussion

Hematology:

Hematological parameters on the day of presentation were categorized according to duration of fracture (Table 1). The total leukocyte count was found to be significantly higher (p<0.05) in dogs presented within 24 hours of fracture as compared to delayed cases presented after more than 24 hours (Table 1). It was found that leukocytosis in early presented cases might be due to pain and stress associated with trauma. Significant increase in neutrophil count and corresponding decrease in lymphocyte count was also seen in animals depending upon duration of fracture. Sastry (1998) also stated that leukocytosis may result from corticosteroid release due to stress, pain anaesthesia, trauma and surgical manipulation. The platelet count was also found to be significantly higher (p<0.05) in dogs presented within 24 hours as compared to dogs presented within 24 to 48 hours (Table 1).

Serum Biochemistry:

Serum ALP, Ca, P and Ca : P ratio on the day of presentation were categorized according to duration of fracture (Table 2). Non significantly elevated values of ALP and P and reduced values of Ca : P ratio were observed in delayed cases presented after one week as compared to cases presented within one week (Table 2). The rise in level of ALP in delayed cases of more than 1 week might be due to release of ALP from proliferating osteoblasts leading to formation of soft callus around the displaced bone fragments. Similarly initial necrosis at the ends of fractured bone fragments might have contributed to elevated levels of phosphorus (Kumar et al., 2007), therefore altering Ca : P ratio. In delayed cases, the newly formed soft callus is disturbed during definitive internal fracture fixation which nullifies the post-trauma efforts of body to stabilize fracture, thus may lead to slow fracture union. From the serum biochemical trend, it was hypothesized that decision of definitive fracture fixation, particularly in cases of supracondylar fractures, should be taken at the earliest, so as to utilize the initial efforts of body towards early fracture healing. Further studies may be required in this direction.The persistent elevated serum levels of alkaline phosphatase above the normal ranges may be explained by continuing osteoblastic activity (Mukhopadhyay et al., 2011).

Ease of reduction and nibbling of fracture fragments:

In our study, reduction of fracture fragments was easily achieved in 17 fractures but it was difficult in 9 fractures. Intra-operative findings suggested that reduction was difficult in cases which were delayed for more than one week (Table 3). It might be due to the reason that in delayed cases there was formation of soft callus and contracture of muscle which makes anatomical fracture reduction difficult. Berzon (1980) stated that anatomical reduction of Salter-Harris type I and II fractures can be difficult particularly if more than 48 hours has lapsed since the inciting trauma.

In our study, nibbling of fractured bone fragments was required in 5 out of 26 fracture so as to properly align the fractured bone fragments (Table 3). Excessive dissection and bone nibbling was required in more number of dogs that were presented after one week (Table 3).

Despite a huge research, the optimal timing of definitive surgical stabilization is controversial. In Veterinary medicine, there is lack of guidelines with respect to timing of fracture management, therefore the orthopedic surgeons are left to rely on their own experience or whenever the patient has sufficiently stable general anesthesia (Peterson et al., 2015). General concerns related to timing of fracture care include presence of soft tissue injury and open fractures (Wagner et al., 1979). Ideally, patients should be operated as soon as possible after they have been thoroughly evaluated and appropriately stabilized. Surgical repair with either open or closed reduction is recommended within 24 to 72 hours (Herron, 1975; Jackson, 1990).

In conclusions, duration of fracture alters the hematobiochemical profile which might have implications on the outcome of fracture in Veterinary and Medical practice.

Acknowledgement

Authors are thankful to Indian Council of Agricultural Research (ICAR), New Delhi for financial support to conduct this study under 'All India Network Program on Diagnostic Imaging and Management of Surgical Conditions in Animals'.

References

Berzon, J. (1980). The classification and management of epiphyseal plate fractures. J. Am. Anim. Hosp. Assoc. 16: 651.

Herron, M.R. (1975). Lateral condylar fractures of |the humerus: A method of closed repair. Canine Prac. 2: 30-35.

Jackson, D.A. (1990). Management of humeral fractures, In: Bojrab, M.J. (Ed.) Current Techniques in Small Animal Surgery, 3rd Edn. Philadelphia, PA, Lea and Febiger, p. 766-69.

Kumar, A., Sharma, V.K. and Agarwal, D.K. (2007). Evaluation of parijat (Nyctanthesarbortristis) and Masipachi (Artemisia parviflora) herbs as Osteoinducers in canine fracture healing. Indian J. Anim. Sci. 77: 870-73.

Mukhopadhyay, M., Sinha, R., Pal, M., Bhattacharyya, S., Dan, A. and Roy, M.M. (2011). Role of Common Biochemical Markers for the Assessment of Fracture Union. Indian J. Clin. Biochem. 26: 274-78.

Peterson, N.W., Buote, N.J. and Barr, J.W. (2015). The impact of surgical timing and intervention on outcome in traumatized dogs and cats. J. Vet. Emerg. Critical Care 25: 63-75.

Sastry, G.A. (1998). Veterinary Clinical Pathology. CBS Publisher and Distributors Pvt. Ltd., Delhi. p. 1025.

Wagner, W.F., Neal, D.C. and Alpert, B. (1979). Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg. 37: 97-100.

Kirandeep Kaur Gill (1), Ashwani Kumar (2), Varinder Uppal (3) and Siddharath Deshmukh (4)

Department of Veterinary Surgery and Radiology College of Veterinary Sciences Guru Angad Dev Veterinary and Animal Sciences University (GADVASU) Ludhiana - 141004 (Punjab)

(1.) Research Fellow

(2.) Associate Professor and Corresponding author. E-mail: drashwanikumar@rediffmail.com

(3.) Professor, Department of Veterinary Anatomy

(4.) Assistant Veterinary Pathologist, Department of Veterinary Pathology
Table 1: Correlation of time of presentation and hematological
parameters in dogs affected with supracondylar fractures

Duration of     Hemo-             TLC/           Neutrophils
fracture      globin (%)      (per [micro]L)         (%)
(in hours)

<24 (n=4)     10.40[+ or -]   22175.00[+ or -]   88.50[+ or -]
               0.84             969.48 (abc)      3.40 (ab)
>24 to 48     11.18[+ or -]   17876.67[+ or -]   83.00[+ or -]
(n=6)          0.80            1364.43 (a)        4.54
 48 to 72     10.00[+ or -]   20330[+ or -]      84.00[+ or -]
(n=4)          0.88            3624.93            2.16 (cd)
 72 to 168    10.26[+ or -]   15908.33[+ or -]   70.00[+ or -]
(n=6)          0.62            2327.86 (b)        5.65 (ac)
 <1 week      10.57[+ or -]   14677.50[+ or -]   77.00[+ or -]
(n=4)          1.47            2363.23 (c)        2.38 (bd)

Duration of   Neutrophils                        Lymphocytes
fracture      per [micro]L          (%)          per [micro]L
(in hours)

<24 (n=4)     19710.6[+ or -]    11.50[+ or -]   2464.47[+ or -]
               1616.27 (*ab)      3.40 (ab)       713.93
>24 to 48     14893.33[+ or -]   15.66[+ or -]   2756.07[+ or -]
(n=6)          1565.15 (a)        4.73            792.78
 48 to 72     17059.7[+ or -]    14.00[+ or -]   2793.7[+ or -]
(n=4)          2991.89            1.41            507.17
 72 to 168    11729.53[+ or -]   21.33[+ or -]   2822.37[+ or -]
(n=6)          2286.99 (b)        5.52 (a)        528.39
 <1 week      11348[+ or -]      21.00[+ or -]   3041.4[+ or -]
(n=4)          1863.97 (*)        1.29 (b)        484.37

Duration of   Eosinophils    Platelets
fracture      (%)            ([10.sup.3]/[micro]L)
(in hours)

<24 (n=4)     0 (*)          352.50[+ or -]
                              21.5 (a)
>24 to 48     1.33[+ or -]   250.83 [+ or -]
(n=6)         0.66 (a)        30.23 (a)
 48 to 72     2.00[+ or -]   283.00[+ or -]
(n=4)         1.15 (b)        42.58
 72 to 168    8.33[+ or -]   320.33[+ or -]
(n=6)         2.28 (*abc)     24.20 (*)
 <1 week      1.50[+ or -]   394.00[+ or -]
(n=4)         0.95 (c)        84.34

(*) Differ significantly (P<0.01) between groups
(a,b,c,d) Differ significantly (P<0.05) between groups

Table 2: Correlation of time of presentation and bio-chemical traits in
dogs affected with supracondylar fractures

Time since        Alkaline             Calcium           Phosphorus
fractures     phosphatase (IU/L)       (mg/dL)            (mg/dL)
(in hours)

< 24 (n=4)    158.25[+ or -]2.75    9.82[+ or -]0.59  5.92[+ or -]0.89
  24 to 48    161.00[+ or -]27.32  10.60[+ or -]0.49  5.78[+ or -]0.48
(n=6)
  48 to 72    145.00[+ or -]6.74   10.50[+ or -]0.38  5.82[+ or -]0.50
(n=4)
  72 to 168   145.50[+ or -]13.71   9.41[+ or -]0.60  5.66[+ or -]0.65
(n=6)
  >1 week     187.25[+ or -]18.86  10.82[+ or -]0.50  7.22[+ or -]0.64
(n=4)

Time since     Ca : P ratio
fractures
(in hours)

< 24 (n=4)    1.70[+ or -]0.22
  24 to 48    1.86[+ or -]0.14
(n=6)
  48 to 72    1.82[+ or -]0.12
(n=4)
  72 to 168   1.76[+ or -]0.22
(n=6)
  >1 week     1.52[+ or -]0.11
(n=4)

Table 3: Effect of duration of fracture on ease of fracture reduction
and bone nibbling

Time since           Ease of               Bone
fractures           reduction            nibbling
(in hours)        Easy  Difficult    Done   Not required

< 24 (n=5)          5      0           1         4
  24 to 48 (n=6)    5      1           1         5
  48 to 72 (n=4)    3      1           0         4
  72 to 168         4      2           1         5
(n=6)
  >1 week (n=5)     0      5           2         3
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Title Annotation:Clinical Article
Author:Gill, Kirandeep Kaur; Kumar, Ashwani; Uppal, Varinder; Deshmukh, Siddharath
Publication:Intas Polivet
Date:Jul 1, 2018
Words:1839
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