Veterinary Medical and Surgical Care Case Report
Left Radial Osteotomy Circular External Skeletal Fixation
16/08/2011
Zoe Baikie
1359539
Permission Given: Jessica Lee, VSG Student Liason
Abstract
On the 15/08/2011, 'Dave' an 8 month old dog was referred to the Veterinary Specialist Group for evaluation of left forelimb lameness. The dog had a 2-3 week history of lameness on the left forelimb, the lameness did not clear up after being prescribed non-steroidal anti inflammatory medication. Radiographs of both forelimbs were taken, these showed a large step-defect in the left forelimb which measured 1.4cm shorter than the right Radius. It was decided that the dog should have a Left Radial Osteotomy and Distraction Osteogenesis surgery to lengthen the forelimb using a Circular External Skeletal Fixation device. The Surgery went ahead as planned, this was preformed using General Anesthetic with no complications and the dog recovered well from anesthetic and a Bandage was placed around the limb and CESF. The dog had the External Fixation was removed on the 30th September. Dave was discharged on the same day as the radiograph procedure and was discharged from surgery on the 19th of August.
Initial Examination
'Dave' was arrived at the Veterinary Specialist Group at 10:07am on the 15/08/2011, and was weighed on the scales on arrival. He weighed 6.4kg and seems bright and alert with a good demeanour. When the veterinarian did the physical exam he found that his mucous membrane colour and capillary refill time were normal and on thoracic auscultation and abdominal palpation there was nothing abnormal found. When the Vet observed that the dog walked with a mild to moderate weight bearing lameness on the left forelimb on gait analysis. The vet did a flexion and extension test of the left elbow joint, which the dog found painful.
No other elbow effusion or spine pain was found, also no other orthopedic or neurological abnormalities were detected.
Name: 'Dave' Hardcastle
Colour: Black and White
Species: Canine
Breed: Jack Russell Terrier
Age: 8 Months old
Sex: Male, Neutered
Weight: 6.4kg
Date of Procedure: 16 October 2011
History
'Dave' was seen at the Veterinary Specialist Group as his referring Vet at Onewa Road Veterinary Hospital had discovered that 'Dave' was showing left foreleg lameness in the last 2-3 weeks. He was prescribed Non-steroidal Anti Inflammatory medication, he responded moderately, but the lameness did not go away. Radiographs were taken of both the left and right forelimb. The radiographs showed evidence of a step-defect in the left elbow joint. There were no other significant problems noted in his history.
Clinical Examination
When 'Dave' was physically examined in his initial consult with the veterinarian at VSG on the 15/08/2011. Overall he was bright and alert, with normal Pink Mucous membrane colour and capillary refill of <2 seconds. It was discovered that he had left foreleg lameness which had been happening for 2-3 weeks. 'Dave' was admitted to the hospital and was sedated for radiographs of both antebrachia (the area of the upper limb between the elbow and the carpals ("Antebrachial Region", 2006) and were measured. The right radius bone measured 10.0cm whilst the left radius bone measured 8.6cm. The left ulna was only 4mm shorter than the right Ulna, also there was no angulation to the carpus. The vet assessed this and concluded that this is a premature left distal radial physeal closure with a large step-defect evident at the Humero-radial joint. There was no other significant history.
Dave sitting in his kennel in the Dog Ward on the morning on his surgery.
Admission (housing)
'Dave' was admitted on the 15th of October 2011 and 10:07am. Animal details were recorded such as name, age, species, breed and sex were asked. Also client details were recorded such as appropriate contact number to reach the owner on during the day of Dave's procedure. A procedure consent form was signed by the owner for his sedation and radiographs , also the accessories that he arrived with were noted. 'Dave' was then weighed on the scales on admittance.
Dave arrived back to the hospital on the 16th of October 2011 for his operation. The owner confirmed that Dave had not eaten anything since 8pm last night and had no breakfast that morning. He was admitted to the surgery department and taken to his kennel in the Dog Ward. His kennel had a large soft fluffy (Vetbed) to sit on with newspaper underneath for him to settle down in before his surgery.
When it was time for Dave to have his Pre-Medication he was taken to a kennel in the surgical prep room for constant observation of him becoming sedated. He was not given a fluffy in the kennel because Dogs can sometimes vomit or defecate once sedated, and having no blankets in the kennel makes it easier to clean up.
After Dave had his surgery, he was placed on a big mattress in the surgery prep room, which was covered in many soft blankets and towels. He also had silver survival blankets wrapped over him also, with the Bair Hugger unit (Bair Hugger, 2011) turned on so that the survival blankets kept all of the warm air close to Dave's body to bring his temperature up to 38.0 Degrees C. His bed was set up like this because during surgery his body temperature had dropped from 38.0 Degrees Celsius (before surgery) to 32.5 Degrees Celsius (during surgery). While he was still unconscious, the nurse cleaned his left foreleg using a Dettol and h20 solution around the CESF apparatus (Dr. R.Jerrambangage, Vetwrap, which provides stability and protection.
Dave was monitored while he was recovering from his general anesthetic until he had woken up and could hold his head up by himself and sitting in sternal recumbancy. His recovery was from 4pm till 4:30pm.
After he had woken up he was aided back to his kennel in the Dog Ward using a sling under his abdomen. His bed was heavily padded with a mattress and many warm towels and blankets. He was encouraged to stay lying down, to avoid any excess movement which could cause extra pain or damage to tissue from the External Fixation device.
Diagnosis
Diagnostic techniques used to determine the forelimb lameness, was the use of digital Radiographs taken in the Radiology department. 'Dave' was sedated and had a series of Radiographs taken of his left and right forelimbs for measuring. Each limb had a Medio-lateral View and Cranio-Caudal view taken while Dave was sedated. The right Radius Bone measured 10.0cm in length. The Left radius was 8.6cm in length. The left Ulna was only 4mm shorter than the right bone. There happened to be no evidence of angulation of the carpus. A large step-defect was evident at the Humero-radial joint. (Dr.R.Jerram 2011)
Left radiograph Cranio-caudal view of obvious Radius shortening and step-defect at humero-radial joint.
During initial veterinarian consultation, the Vet did a full physical exam on Dave, and ruled out any spinal pain, and also no other significant orthopedic or neurological abnormalities.
The definitive diagnosis was that 'Dave' had a Left elbow incongruity, with a premature left distal radial physeal closure.
Condition
A premature left distal radial physeal closure is the result of abnormal bone growth, but may also be due to fracture malunion, joint contractor or polyarthritis. But bone abnormalitlies can also be secondary to physeal injuries, as seen in Dave's case. Conventional treatment options were used to fix Daves left radial shortening, such as a mid-diaphyseal Osteotomy and stabilizing with a conventional two ring circular external skeletal fixation. The veterinarian also discovered a large step-defect in his Humero-radial joint, where the radius does not sit against the joint completely, causing pain when moving the joint. Luckily there was no angulation to the carpus which can happen in some cases of antebrachia bone deformities. Dave's left radius measured 9.4cm while his Right Radius measured 10.0cm, this is a left radial shortening of 1.4cm. His left Ulna measured 4mm shorter than his Right radius.(Dr.R.Jerram 2011)
"It is best to treat growth deformities before irreversible joint damage occurs."
(Marcellin-Little.J.D, DEDV, 1999)
Large Step-defect seen in the mediolateral radiograph of the left antebrachia.
Normal bone anatomy seen in this mediolateral radiograph of the right antebrachia.
Circular External Radial Fixation devices have many unique concepts which make them very versatile. 1) bone fixation is provided by small -diameter wires that are under tension and connected to rings surrounding the limb/s. 2) rings connected by articulated threaded rods can be assembled in unlimited configurations; and 3) the bone can be gradually distracted after osteotomy, and bone healing will occur within the resulting gap which is also called Distraction osteogenesis (Marcellin et al., 1999).
Prognosis
The prognosis for animals that have bone deformities varies, depending on the severity of the deformity, the angulation of bones, length deficit, rotation and translation. It is important to identify and specially treat each of these components for each patient (Marcellin et al., 1999).Animals that have more severe components to their deformity need a more complicated External Fixator, and will need to come into the clinic more often for regular radiographs and distraction. Bone deformities can also be classified as Unifocal or Multifocal. Unifocal abnormalites are classified as an abnormal bone shape in one location, and Multifocal abnormalities ;having abnormal bone shape in multiple locations. Unifocal deformities are most common in dogs, and also includes premature physeal closures in the first weeks following a physeal injury (Marcellin et al., 1999), such as in Dave's case. Owners that are prepared to endure this long process will provide a much better quality of life for their companion animals, although some animals will have constantly occurring bone or joint problems.
Dave had a good prognosis, as his only bone deformity was a step-defect withing the humero-radial joint and left radial shortening. Dave had his Circular External Fixation device on his left leg for 45 days, and he has completely recovered from the Distraction process. Gradual introduction to exercise is advised for the first couple of weeks.
Treatment Options
Surgical distraction and placement of a Circular External Skeletal Fixation device is the mainstay option for treating patients with bone deformities in which one bone has become shortened. This option is most effective as it relies on unique external fixation devices and distraction osteogenesis, which no other treatment option can provide. Metal rings placed around the limb are interconnected with threaded rods (that are 1- to 1.5-mm in diameter) and are then fixed to the bone under tension of 0- 90 kg. Distraction Osteogenesis then can occur, new bone is being formed at the osteotomy site after slow distraction after surgery. (Marcellin et al., 1999). Dr. R. Jerram from the Veterinary Specialist Group has discussed and recommened this surgical treatment with the radial osteotomy and distraction osteogenesis. The owners have agreed with proceeding with surgery and It will commence on the 16th of August 2011.
Actual Treatment
The treatment plan for Dave was to have a Left Radial Osteotomy with an Imex Circular External Skeletal Fixation (CESF) ("Circular ESF System". 2010). The plan of this radial Osteotomy with the CESF is to perform a surgical treatment for left radial shortening. Dave was placed under general anesthesia and had a two ring circular external fixation device which was placed on his left radius. Both rings were secured to the radius using two IMEX Olive Stopper K-Wires ("Fixation Wire with Stopper". 2010). A mid-diaphyseal osteotomy was performed on the radius. The osteotomy site was closed using 3/0 Monocryl suture material ("Sutures- Absorbable/Monocryl Suture". 2009).
CatheterisationDave had his Intravenous catheter placed on the 16/08/2011, on the morning before his surgery.
The nurse clipped a small patch of fur using #40 blade, she then cleaned any dirt or debris off the skin using a chlorhexidine and H20 solution using a cotton wool ball, and a final wipe of the site with a cotton wool ball soaked with methylated spirits. The pink, 20ga Intravenous Catheter was placed into his Right cephalic vein. A small square of sterile swab with Betadine(Betadine n.d.) was placed on top of the catheter insertion site, this protects the insertion site from bacterial infections, which therefor increases the amount of time the catheter can stay in the leg, and reducing the amount of times the catheter has to be changed. Three strips of Hypafix (Smith et.al., n.d.) tape was used to
secure the catheter and Intravenous Fluid port in place, on Tray of equipment prepared for
the limb. The catheter was flushed through with a Sterile placing the Intravenous Catheter.
3ml syringe of sterile saline to check correct placement of
the catheter and to clear any clotted blood from the catheter stylette. The catheter site was then wrapped securely with Soffban and then covered in Vetwrap for protection, while still being able to access the injection cap.
Pre-medication
Dave was placed in his kennel in the surgery prep area and was given his pre-medication Subcutaneously at 12:15pm on the 16/8/2011.
His pre-medication of Atropine, an anticholinergic drug for analgesia, which reduces salivation and bronchal secretions, also protects the Vagus nerve and the heart by increasing the heart rate (Lane et. al. 2007. Page 513). Atropine was administered subcutaneously at the rate of 0.02-0.04mg/kg, with the total dose given at 0.21ml.
Morphine, a pure agonist drug was used to help relive preoperative pain, reducing anxiety, contributes to sedation and provides excellent analgesia during maintenance and on recovery from surgery as it lasts four hours(Lane et. al. 2007. Page 514). It was given at a concentration of 5mg, and the rate at 0.1-0.5mg/kg, a total dose of 0.51ml of Morphine (Lane et. al. 2007 Page 515).
He became sedated from his pre-medication at 12:50pm, showing drowsiness, a lowered heart rate and respiration rate.
Induction
Dave was Induced using 0.32ml of Valium and 2.56ml of Propofol, administered very Slowly through the Intravenous catheter port to effect, and was flushed through using a 3ml syringe of sterile saline. Dave was unconscious from the effect of the Induction agents at 1:50pm. Dave was then Intubated, with an endotracheal tube which was tied in place over his nose and the cuff was inflated. The nurses listened for any leaks within the tubes, ensuring the inflated cuff provides an efficient seal around the trachea. Dave was then given his Pre Operative Anti- Biotics of Kefzol at 22mg/kg, 1.4ml Slow Intravenously into his catheter port site.
Anesthesia
Dave was connected to the Ayers T- Piece Non- rebreathing Anesthetic circuit by 1:55pm on an Isoflurane rate of 2.5% and 2L/min of oxygen when he was attached completely with the pop off valve open at 1:55pm. Dave was then wheeled into the surgery room and attached up to the anesthetic circuit in the sterile surgery room. A He was maintained during the surgery
on 2.5% initially, then was reduced gradually down to 2%, 1.8% , 16%, 1.5%, then back up to 2% fifty minutes through surgery.
Dave stayed on a smooth stable plane of anesthesia throughout
the surgical procedure (Dr.R.Jerram). He lost his pedal and palpebral reflexes once he was on a stable anesthetic plane. Dave maintained his heart rate around the 100 beats per minute mark, with his respiration rate around the 10 breaths per minute mark. His 02 saturation stayed steady around the 98-97% mark. His temperature gradually decreased from 38.0 Degrees Celsius down to 32.5 Degrees Celsius during the surgery. Dave was lying on a surgical warm blanket, with surgical drapes covering his body and the Bair Hugger turned on with the tubes lying next to his body, so we can try to keep his temperature from falling past a severe point.
Dave was turned taken off the anesthetic circuit seventy minutes after being in the sterile surgery room for his operation at 4pm. He was taken out of the surgery room into the surgical prep room to recover from his anesthetic.
Dave attached to the anesthetic circuit, with his left leg being cleaned and prepared for surgery.
Post operative care
Once Dave was out of surgery (3;30pm), he was taken over to the Radiology Department to take some radiographs of his left forelimb. Radiographs are necessary to check that the pins have been placed correctly and the Osteotomy has been adequate for distraction to start.
After a series of radiographs, Dave was taken over to the surgery prep area where the nurse gently cleaned the operated limb with a Dettol and H20 solution using cotton wool balls to remove blood and any bacteria from the surface of the skin. The limb was dried thoroughly and was wrapped securely using plenty of Soffban to protect the CESF and limb from swelling and any damage once recovered. The bandage was then covered in vetwrap to protect the bandage and provide support.
Once Dave started to show signs of anesthetic recovery (swallow and cough reflex, palpebral and pedal reflex, increasing respiratory rate and heart rate), he was extubated and was wrapped with survival blankets with the Bair Hugger (Bair Hugger, 2011) turned on to slowing increase his temperature back up to 38.0 Degrees Celsius. Recovery took 30minutes.
Dave was administered Post Operative Analgesia of 5mg Morphine at 0.8mg/kg 1ml subcutaneously. It needs to be given 4-6 hourly as needed.
He was also administered Post Operative Anti-Biotics of Kefzol 22mg/kg Slow Intravenously 8 hourly, this drug is used to prevent an infection in the pins which have been placed into the bones.
Dave, having his left limb cleaned using a Dettol solution before placing the bandage.
Dave recovering after surgery, still with his endotracheal tube tied in and monitoring equipment attached.
Dave has recovered much more, he is panting and is moving his head and limbs.
Fluid/ Pain Management
Fluid Therapy
On the 16th of August 2011, Dave was having a procedure in the surgery department.
He was placed on Intravenous Fluids during the surgical procedure using Lactated Ringers Solution and fluid pump with an 86cm extension set. Fluids were administered once Dave was in the sterile surgical room and was kept on this rate for the whole surgery.
Surgical Fluids Calculation : 10mg X Weight in KG (6.4kg) =640ml
640ml / 12 = 53.3ml/per hour
Dave did not have a fluid deficit as he was not dehydrated and also has not experienced any vomiting or diarrhea in the past 24 hours.
Once surgery was finished, Dave was taken off surgical fluids and was monitored while he was recovering.
Pain Management
On the 16th of August 2011, before Dave had his surgery he was given Pre-medication of 0.21ml Atropine and 5mg Morphine, 0.51ml Subcutaneous prior to surgery. He was also given a Brachial Plexus Block using 2.5ml of Marcain. Dave was given a Brachial Plexus Block as it provides long-lasting analgesia and a valuable tool for the management of pain in the forearm ("Brachial Plexus Block in dogs", 2002).
Dave was given one dose of 5mg Morphine at 3pm during his surgical operation of 1ml Subcutaneous .
Post Operative Pain relief was given once he was out of surgery and was recovering. He was given 5mg Morphine, at 0.8/kg, 1ml subcutaneous. The rate between doses is 4-6 hourly. He was being assessed for pain at 8pm, 1am, 6am.
He was also given another dose of his Antibiotic Kefzol of 1.4ml Slow IV at 9pm that evening.
Morphine is a commonly used drug as it is an excellent pain blocker which last up to 6 hours. It also has anti- emetic properties which helps animals feel encouraged to eat food after surgical procedures (Dr. R .Jerram 2011).
Nursing Care
During Surgery, Dave was constantly monitored every 5 minutes with his Capillary Refill Time, Mucous Membrane Colour, Eye Position, Temperature, Heart Rate, Respiration Rate, CO2/02, 02 Saturation and Anesthetic gas % , being monitored. There were no complications with the anesthetic and Dave was closely monitored while he was recovering from anesthetic. He was regularly being visited and assessed by staff. His hospital charts showed his daily data including his Heart rate, Respiration rate, Temperature and Mucous Membranes. Urination and defecation is also charted on the hospital sheets. Food and instructions are also written on the sheets so all nurses know what they can and cannot feed to patients.
Prior to surgery, Dave was administered a Pre-medication of 0.21ml Atropine and 5mg Morphine at 0.51ml. These were given as a sedative to gently make him feel drowsy and to create pain blocking within the nerves before the surgery started. A small pink 20ga Intravenous Catheter was then placed and a T-Port was attached, then flushed through with sterile saline. Once he was Induced, using Propofol 2.56ml and Valium 0.32ml, he was attached to the Anesthetic circuit with an endotracheal tube placed and the cuff inflated. Dave was also given a Brachial Plexus Block using 2.5ml of Marcain to help with the pain management occurring during and after surgery.
Post Operative care included continuous monitoring of his vital signs such as temperature, Heart Rate, respiration rate and oxygen saturation. Dave recovered well from the anesthetic and was moving his head and arms within half an hour of recovery, so therefore didn't need any other treatment of extra pain medication.
Dave did need a sling to aid him when he walked outside for toileting, and his bandage needed to be covered in a plastic wrap to prevent it from getting wet as it could cause an infection within the pins which were placed into the bone.
On the 17th of August 2011, Dave was given 1/2 Clavulox tablets 250mg at 4pm, instead of his Kefzol injections. He also was given Temgesic as a pain relief at 0.32ml Subcutaneous every 6-8 hours.
Dave was also given a Non- Steroidal Anti Inflammatory Drug, Metacam oral suspension 10ml 1 Using the calibrated syringe provided please give a 6.4kg dose orally once daily.
AM / PM.
The AEC nurses noted on the hospital charts that overnight, he had started to chew at his bandages and fixator, so an Elizabethan collar was fitted on him. He was still eating and drinking very well, as well as taking oral medications with his food.
Discharge, After Care and Follow Up Care
Dave was discharged after his operation on the 19th of August 2011, following the instructions given on performing the distraction process on the CESF apparatus. He had no problems overnight and is still eating and drinking well, with normal toileting.
Discharge and Aftercare Information
Dave has had surgery to lengthen the radius bone of his left front leg. The shortened bone was causing incongruity and potential arthritis in the elbow. A circular external skeletal fixation device has been placed on the radius bone. The radius bone has been cut. The fixation device includes 2 distractor devices to enable the bone to be lengthened gradually as it heals. Further x-rays will need to be taken during the healing process to ensure that the distraction is proceeding appropriately.
Please follow these instructions to ensure that Dave has a complete recovery from this surgery.
1. NO RUNNING, JUMPING, OR STAIRS FOR SIX WEEKS. Your dog should be confined to a small room or kennel during this time. Take your dog on a lead for urination and defecation.
2. The bandage has been placed to reduce swelling around the bone. This bandage needs to be changed regularly. This should be done at our hospital to enable assessment of the limb.
3. Sutures need to be removed 10-14 days following the surgery. Please call if there is any swelling, discharge, or redness around the suture line.
4. Give the medications as prescribed.
5. The distractor devices need to be turned ½ turn twice daily beginning on 19/08/11. X-rays should be taken on 22/08/11 to evaluate the bone length.
6. Once distraction has stopped the fixation device must remain in place for a minimum of 4 weeks. Further Xrays will need to be taken to determine whether complete bone healing has occurred.
7. Please don't hesitate to call if you have any questions or concerns.
Dr. Richard Jerram, BVSc, Dipl ACVS.
Registered specialist, Small animal surgery.Jessica Lee
Veterinary Surgical Consultants.
97 Carrington rd
Mt Albert
22-08-2011 12:54pm
Dave was admitted for radiographs and bandage change today. Extra sedative needed. Sedated with Domitor 0.33ml and Butorphic 0.12ml. Reversed with Antisedan 0.33ml. Distraction was performed with owner this morning.
Dr. R.Jerram wants to slow down distraction will only distract one quarter turn each day. This will be pink nail polish to black, next day black to pink, next day pink to black. Will be back on Thursday for radiographs and bandage change.
25-08-2011 6:06pm
Dave returned to our hospital on 22/08/11 and 25/08/11. The dog was sedated and radiographs confirmed excellent distraction of the radial osteotomy site was evidence of new bone formation within the osteotomy gap.
On 25/08/11, it was evident that normal congruity of the elbow joint had been restored. The dog has been discharged with instructions for no further distraction and maintenance of the CESF apparatus until adequate bone consolidation has occurred.
On 25/08/11, it was evident that normal congruity of the elbow joint had been restored. The dog has been discharged with instructions for no further distraction and maintenance of the CESF apparatus until adequate bone consolidation has occurred.
The dog should return to our hospital weekly for bandage changing and further radiographs will be taken in three weeks time. I will keep you informed on this dog's progress.
Thank you for your referral and please don't hesitate to contact me if you have any questions or concerns.
Sincerely
Dr. Richard Jerram, BVSc, Diplomate ACVS
Registered Specialist, Small Animal Surgery
15-09-2011 6:14pm
Dave returned to our hospital on 15/09/11 for reevaluation four weeks following right distraction osteogenesis of the radius. The dog was sedated and radiographs confirmed almost complete bony healing with a radiolucent gap still present at the site of the radial distraction. The CESF apparatus has been re-bandaged and I have recommended further radiographs and evaluation in two weeks time before removal of the apparatus. I will keep you informed on this dog's progress.
Sincerely
Dr. Richard Jerram, BVSc, Diplomate ACVS
Registered Specialist, Small Animal Surgery
30-09-2011 2:57pm
Dave returned to our hospital and 30/09/11 for further evaluation of left radial distraction osteogenesis. The dog was sedated and radiographs confirmed almost complete bony healing of the radial osteotomy and normal elbow congruity. The entire circular ESF apparatus was removed. The dog has been discharged with instructions for a gradual return to normal activity over the next 4-6 weeks. Some nonsteroidal antiinflammatory medication was dispensed for pain relief for the next few days.
Thank you for your referral and please don't hesitate to contact me if you have any questions or concerns.
Sincerely
Dr. Richard Jerram, BVSc, Diplomate ACVS
Registered Specialist, Small Animal Surgery
Discussion
The option that were discussed with the owners were very limited and the Vet at VSG recommended going ahead with the Circular ESF apparatus and Ostetomy operation.
This seemed to be the only surgery that could have corrected the bone deformity, and the operation was very successful. Dave was operated on as very soon after he was referred to the specialist clinic which was best as it is important to treat growth deformities before they become irreversible (Marcellin et al., 1999), and Dave was still young at only 8 Months old, so it was ideal time for surgical intervention. Nursing care provided for Dave was the best as he was enthusiastic for food and water once he was recovered from anesthesia, as he woke up feeling secure and with pain relief on-board, he did not feel anxious to eat or drink. Dave recovered from his operation smoothly and the outcome for him was very good, he now has no Circular ESF apparatus on his limb and he is being slowly introduced back into walking on lead.
Referencing and Bibliography
Antebrachial Region. (2006). In Medilexicon Online Dictionary.
Retrieved From: http://www.medilexicon.com/medicaldictionary.php?t=77118
In-text citation: ("Antebrachial Region", 2006)
Bair Hugger Therapy , Warming Units and Accessories (2011)
Retrieved from: http://www.arizant.com/us/bairhuggertherapy/warmingunits
In - text citation: (Bair Hugger, 2011)
Betadine Antiseptic Ointment Tube (n.d.)
Retrieved from: http://store.pharmacy-nz.com/betadine_antisep_liq_15ml.html
In-text Citation: (Betadine n.d.)
Brachial Plexus Block in dogs- A new technique. (2002).
Retrieved from: http://www.vetcontact.com/en/art.php?a=104
In- text citation: ("Brachial Plexus Block in dogs", 2002)
Circular ESF System. (2010).
Retrieved from: http://www.imexvet.com/products/external-skeletal-fixation/circular-esf-system
In-text citation: ("Circular ESF System". 2010)
D.R Lane and B. Cooper and L.Turner, (2007) BSAVA textbook of veterinary nursing 4th edition
In-text Citation: (Lane et. al. 2007)
Dr. Richard Jerram, BVSc, Diplomate ACVS
Registered Specialist, Small Animal Surgery
Fixation Wire with Stopper. (2010).
Retrieved From: http://www.imexvet.com/products/external-skeletal-fixation/circular-esf-system/fixation-wires/368-fixation-wire-with-stopper
In-text citation: ("Fixation Wire with Stopper". 2010)
Small Animal/ Exotics, 20th Anniversary, Compendium June 1999, Volume 21 No.6.
Retrievef From: http://www.scribd.com/doc/23752606/Treating-Bone-Deformities-With-Circular-External-Skeletal-Fixation
First In-text citation: (Marcellin-Little.J.D, DEDV, 1999)
Subsequent In-text citation: (Marcellin et al., 1999)
Retrieved From: http://wound.smith-nephew.com/nz/Product.asp?NodeId=490
In-text citation: (Smith et.al., n.d.)
Sutures- Absorbable/ Monocryl Suture. (2009).
Retrieved From: http://www.ecatalog.ethicon.com/sutures-absorbable/view/monocryl-suture
In-text citation: ("Sutures- Absorbable/Monocryl Suture". 2009)
Acknowledgements
I would like to thank Jessia Lee, from the Surgery department at VSG for helping me with information and Diagnostic reports to complete my Case Report.
I would also like to thank Tracey Griffin from the Radiology Department at VSG for providing me the Radiographs of Dave Hardcastle on the 16/8/2011 till the 25/09/2011.
Appendix
Additional Information (e.g. Surgical Charts and Diagnostic Sheets) are included in My Pages found on the top right hand side of my Blog, some information could not be put online but has been handed in with a physical copy of the case report.
Atropine – Atropine sulphate, decreases bronchial and salivary secretions
Bair Hugger- A Therapeutic Warmer used during and after surgical procedures.
ET – Endotracheal tube, breathing tube used in anesthesia
Hypafix- Low allergy adhesive, non woven dressing retention sheet
IV – Intravenous route of administering a drug
LRS – Lactated Ringers solution, crystalloid fluid solution
Morphine – Opioid, used for pain relief and pre medication
NSAID – Metacam - Non-steroidal anti-inflammatory drug used for pain relief
Propofol- Short- acting Induction agent, for anesthesia
SQ – Subcutaneous route of administrating a drug
Temgesic - Buprenorphine, a pain relief
Valium - Diazepam, used for muscle relaxation and amnesia
