Management Plan:

In the case of Ramon we are dealing with 2 different types of bone fractures:
1. Transverse tibia/fibula fracture of the right hindlimb
2. Oblique femur fracture with a transcortex fragment present in the left hind limb

The transverse tibia/fibula fracture of the right leg will be surgically managed via 
external fixation.  There are a number of reasons for opting for this surgical approach:
1. Less contamination of the fracture site by opting for closed reduction
2. Less risk of damaging the formed hematoma and blood supply to the bone.
3. They provide enough stability for the proper healing to take place.
4. These devices can be adjusted as needed to enhance proper bone alignment and 
healing without performing additional surgery.
5. External fixation is commonly used for fractures below the stifle

Surgery will be performed utilizing pins and sidebars.  Threaded pins will be used as they 
hold better, loosen slower, and result in a more stable fixation.  Each tibial bone fragment 
will have three threaded pins placed through it. The placement will be located at the end 
of each bone resulting in six cortices.  The first and last pins used in each fragment will 
be greater than or equal too 1 cm from the fracture line and as far from each other as 
possible.  Careful attention will be paid to avoid pinning muscle, tendons, and vasculature 
to the bone.  In terms of angulation of the threaded pins, they will be placed with keeping 
disturbance of the underlying structures to a minimum. A small incision will be made in 
the skin at the appropriate site for pin insertion. Holes for the pins will be predrilled in the 
cortex and screwed in by hand. 
Rigid metal sidebars will be used to maintain proper alignment of the fracture during 
radiographs and until acrylic sidebars are ready to be molded. Prior to molding 
radiographs will be taken to ensure correct alignment of the tibial bones. If the 
radiographs are deemed acceptable then the pouring of the acrylic will take place.  The 
mold will be placed ample distance (at least 1 cm) from the skin to allow for swelling, 
callus formation and cleaning. As the acrylic starts to set it produces a lot of heat, which 
facilitates removal of the softened plastic mold. After molding, the pins will be cut to 
equal lengths on either side of the leg, and 1 cm will be bent to better support the acrylic.  
This scenario is then repeated on the other side of the leg.
In regard to the fibula, it will be left to heal on its own, as there is too little bone present 
to attempt any sort of fixation.

Surgery of the oblique femur fracture will involve utilization of an internal fixation 
procedure for the following reasons:
1. Cannot be repaired via external fixation due to the mild comminution of the cortical 
area of the bone ( 1 large fragment, 2 smaller fragments)
2. Allows early return to normal function
3. Prevention of various fracture related diseases

Prior to plating of the femur, the large free cortical bone fragment must be stabilized. To 
do this three cortical screws will be placed through the free fragment into the fixed 
fragment of the bone.  Rebuilding the fracture is important to provide continuity within 
the bone and because the plate itself cannot support all of the weight on its own. Because 
there is a transcortex gap, the plate could easily bend under pressure. After the bones 
have been successfully reunited, then a neutralization plate will be placed.  This plate will 
be attached to the solid ends of the bone and will provide support so that the weight 
bearing forces will bypass the comminuted fracture site.  A plate will be used that extends 
from one metaphysis to the other utilizing three screws on either side of the cortex.  

After analyzing the clinical pathology report, it is apparent that Ramon is infection free. 
There is an increase in his blood glucose and alkaline phosphatase levels, which can be 
attributed to the recent administration of the glucocorticoid, Prednisolone Sodium 
Succinate. Some ALKP present may also be attributed to the bone fracture and 
subsequent osteogenesis. The trace occult blood in his urine could be due to blunt trauma 
as a result of HBC or maybe he suffered trauma as a result of urinary catheterization.  
Additionally, his PCV was low at 22%, which could be caused by a number of things 
including excessive fluid administration to combat the shock or possibly a reduction of 
red blood cells due to hemorrhage as a result of the bone fractures. Overall, he is in stable 
condition and most importantly is not indicating signs of any infectious processes. 

To prevent any post-op infections, Ramon will be given antibiotics.  He will also be 
prescribed analgesics for pain management. We recommend holding off on the Distemper 
and Parvo vaccinations until the fracture is completely healed, and attempt to maintain 
isolation from the ferrets and rabbit to prevent potential disease transmission to Ramon.  
In regard to nutrition, RamonŐs food should be evaluated to make sure that it contains the 
proper nutrients and correct ratios of them. He needs a proper diet to support new bone 
growth.  

Immediately after surgery Ramon will be confined to a cage or room for one week. 
Exercise will be controlled via a leash until radiographic evidence of bone healing is 
seen.  The plates will be removed 3-6 months after the bone has healed to prevent 
possible tissue rejection, plate erosion, and tissue irritation. Ramon will be scheduled for 
weekly visits until healing is complete.
RamonŐs post-op care for the external fixation will include radiographic rechecks at 6 
weeks. Additionally, complete removal of the frame will take place when bony bridging 
is seen radiographically.  After removal of the frame, exercise will be restricted for 
another week or two. RamonŐs exercise schedule will be dependent upon the healing 
progress of BOTH fractures, so his exercise regime will vary depending on which leg is 
healing the fastest.