Intramedullary pinning for management of radial fracture in a capped langur.
A capped langur (Trachypithecus pileatus durga) was presented with traumatic wound and shock condition. History indicated that langur was hit by high speed vehicle. Physical examination revealed swelling and painful on palpation of left arm. Supportive care was advocated immediately.
On presentation, female Capped langur aged approximately 4 years weighing 4.5 kg, was dull and depressed. Clinical parameters observed were heart rate (108/minute), respiration rate (16/minute), low pulse rate and rectal temperature (98[degrees]F). The first aid was given at the time of rescue by topical Volinia spray along with Inj. 2 ml Tribivet (b), Inj. Dexamethasone, inj. Cefriaxone + Sulbactum and Inj. Meloxicam (b).
Clinical Examination and Diagnosis
On through clinical examination, the wound at different parts of body were found infected (Fig.1). Capped langur was immobilized with Ketamine hydrochloride @ 10 mg per kg b. wt. IM under plane of light anaesthesia. Physical examination revealed swelling over distal left arm along with feeling of crepitating sound indicating fracture of radius. The animal was subjected to radiographic examination showing complete fracture of radial bone from distal one third part. It was decided to repair the compound fracture of radial bone by open reduction using intramedullary pinning.
Surgical repair was performed three days after injury so as to allow haematoma to get organized and inflammation to subside. The primate was immobilized using the same anaesthetic induction protocol and maintenance was carried out with incremental doses of Ketamine hydrochloride as and when required. The surgical site was aseptically prepared by clipping shaving hairs and antiseptic washing with spirit and Betadinec lotion. The animal was restrained in right lateral recumbency with affected hand up followed by drapping of arm. As the complete fracture existed in medial region, surgical approach was done from medial aspect of fore arm. Incision was given in skin and under lying muscles were bluntly incised to separate and approach the site of fracture (Fig.2). Both fractured ends were reduced to bring it anatomical apposition and were held in place with bone holding clamps. The surgical wound was again washed with Betadinec lotion and installed locally with Cefriaxone + Sulbactam (562.50 mg) powder (antibiotic). Retrograde intramedullary pinning was finally done with the help of Steinmann pin 1.5 mm thickness. The distal end of proximal bone fragment was grasped with bone holding forceps and pin was inserted proximally in medullary canal. As the pin was driven proximally, an effort was made to direct it along the cranio-lateral surface of medullary cavity. The proximal bone fragment was adducted until it is parallel to surface of table and held in rotation and angulation of normal standing position as the pin penetrates the proximal bone and soft tissues. After the pin was redirected to distal fracture site by retracting the pin and seating it in dense of distal bone was thus reduced by reunion of fracture fragments by intramedullary pinning (Fig. 3). After reduction of fracture, the separated muscles were sutured in simple continuous manner followed by application of subcutaneous sutures using Relyon PGA-size 01 and skin closure in horizontal mattress pattern. Post-operatively, the whole arm was immobilized by application of thick cotton pad, Acrylic cast, Inj. Dexamethasone 1.5ml administered immediately after operation. Anaesthesia was monitored continuously via pulse oximetry and non-invasive blood pressure monitor through the 40 minutes procedure. No complication was noticed during surgery and anaesthetic recovery was uneventful. Post-operative care was under taken with Inj. Cefriaxone + Sulbactum (281.25 mg), Inj. Melonex (b) 2ml, Inj. Tribivet (b) 3ml, i.m was given daily for 7 days. Calcium supplements like Liq. Genical DS (d)--10 ml, Liq. Polybione 5ml daily orally, was also incorporated in feed to aid in fast fracture healing.
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Results and Discussion
Excellent apposition of displaced fragments was appreciable on radiograph taken immediately during post-operative period (Fig.4). Capped Langur was kept in squeeze cage for 20 days, skin wound was completely healed thus suture were removed after removal of acrylic cast and langur was kept in small cage. Intramedullary pin was removed, two months after surgery by confirmation of complete fracture healing by X-ray radiography.
The radial fracture is very rare in langur and normally occurs due to traumatic injuries. Most of the radial fractures are known for their complexity of commination and difficulty for their because small fragments are difficult to bring under proper alignment and immobilization. However, in the present clinical situation, the fracture was simple without any signs of commination or sharp ends, soft tissue swelling palpable over forearm region could have been due to present of haematoma around fracture bone.
The techniques applicable for stabilization of radial fracture include intramedullary devices, bone plating and external skeletal fixation in small animals. Other techniques such as lag screws or cerclage wires can also be used, but only in combination with one or more of these basic fixation techniques (Gemmill, 2007). The present case was managed effectively by use of single intramedullary pin without any complications in contrast to delayed union or shortening of limb or other deformities (Johnson et al., 1998).
Post surgical complications with femoral fracture repair include implant lossening, fatigue or outright failure as a result of excessive stress on implant and subsequent bone resorption. Most of these complications are frequently encountered in large active patients as it has a negative mechanical effect on fracture healing. Other causes of implant failure in cases of commination include re-vascularized bone fragments and small fracture gaps caused by unsuccessful reduction and stabilization (Fossum et al., 1997). However in the present case no such complications were observed other than temporary decrease in range of motion of carpal joint of affected arm.
Unlike domestic animals, zoo and wild animals pose a great risk of self mutilation and very rarely keep the post-operative dressing intact especially external splintage material or devices. Jayadevappa et al. (1992) have reported combine use of intramedullary pin along with cerclage wiring for treatment of femoral fracture in a lion tailed macaque but in the present clinical case, no other implant except for single intramedullary pinning was done without any post-operative complications. In the present case, body weight of animal was less and patient was very cooperative in not meddling with intramedullary implant or suture line, which resulted in an uneventful recovery. This demonstrates that radial fracture repair in capped langur is a practical consideration despite their inability to restrict postsurgical activity. Post-operative care in these cases of wildlife are very important and can only be done by regular medication with broad-spectrum antibiotics and analgesic along with supportive therapy and restricting their motion and self mutilation by keeping them in squeeze cage.
Charles S. Farrow. Veterinary Diagnostic Imaging: Birds, Exotic Pets and Wildlife, Mosby Elsevier Inc.
Fossum T.W., Hedlund, C.S. and Hulse, D.A. (1997). Management of specific fractures. In: Small Animal Surgery, 2nd edn. Mosby, Missouri, p. 767-82.
Gary West, Rarry Heard and Nigel Caukett. Zoo Animal and Wildlife Immobilization and Anaesthesia, 1st Edn., Blackwell Publication Ltd.
Gemmill, J. (2007). Advances in management of diaphyseal fractures. In Pract. 29: 584-93.
Jayadevappa, S.M., Ranganath, L., Ranganath, B.N., Srinivas, C.L. and Madhu R.N. (1992). Surgical repair of comminuted femoral fracture in a Lion tailed monkey (Macaque silenus)--A case report. Indian Vet. J. 69: 1127-28.
Johnson, A.L., Smith, C.W. and Schaeffer, D.J. (1998). Fragment reconstruction and bone plate fixation compare with bridging plate fixation for treating highly comminuted femoral fractures in dogs: 35 cases. J. Am. Vet. Med. Assoc. 213:1157-61.
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(a)--Brand of Ranbaxy India Ltd., Delhi
(b)--Brand of Intas Animal Health, Ahmedabad
(c)--Brand of Win Medicare Ltd., Mumbai
Keshab Debnath (1), M.P. Baishya (2) and A.K. Gupta (3)
Sepahijala Zoological Park Sepahijala Agartala--799102 (Tripura)
(1.) Veterinary Officer and Corresponding author. E-mail: email@example.com
(2.) Assistant Professor, Veterinary College, Agartala
(3.) Chief Wildlife Warden, Tripura
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|Title Annotation:||Short Communication|
|Author:||Debnath, Keshab; Baishya, M.P.; Gupta, A.K.|
|Date:||Jan 1, 2016|
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