Capital Physeal Fractures of the Femur Bone

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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Animal Surgical Center of Michigan

5045 Miller Road

Flint, MI 48507

www.animalsurgicalcenter.com

Phone: 810-671-0088

Key Points

Fractures of the hip occur in immature cats and dogs

Surgery is the best option to repair hip fractures

The prognosis is fair to good with this type of surgery


Anatomy

Puppies have growth plates at the ends of the femur bones from which the bone grows. Growth plates are susceptible to developing fractures in immature animals. One such growth plate is called the capital physis or growth plate of the head of the femur bone. This head forms the so-called ball of the hip joint.

 

Cause of fracture

A fracture is synonymous with a broken bone. When a fracture occurs through this growth plate the cap of the head of the femur slips off, hence this fracture is referred to as a “slipped cap”. This type of fracture only occurs in dogs that are less than one year of age and cats that are just under 2 years of age. The most common cause of a femoral fracture is trauma such as being struck by a motorized vehicle or taking a fall.

 

Signs

Sudden onset of severe to nonweight-bearing lameness is common in patients sustaining a slipped capital physeal fracture. Palpation of the hip will elicit pain and a grating or clicking sensation may be felt when moving the hip joint.

 

Diagnosis

The diagnosis of a slipped capital physeal fracture requires x-rays; typical x-ray views include the hip extended, frog-leg, and lateral views. A misdiagnosis of a slipped cap can be made on the typical hip extended x-ray of the pelvis - the hip may actually look fairly normal (see x-ray right). Therefore, a frog-leg view (limbs splayed apart) should be used to assess the hip joint (put your cursor over image to see the frog-leg view). Other testing that may be recommended prior to anesthesia includes a complete blood count and chemistry profile to ensure that the pet is healthy. If the fracture was due to trauma such as being hit by a motor vehicle, chest x-rays should be made to rule out lung and chest trauma.

 

 

Surgery

Slipped cap fractures always require surgery for a successful outcome. The surgery should be done as soon as possible so that broken end of the bone does not get worn down, thus preventing the fracture from fitting together properly. In small dogs and cats a simple procedure called a femoral head and neck excision is an acceptable treatment. This involves removing the broken fragment and the neck of the femur bone in order that a false joint will form. In medium to large dogs, primary repair of the fracture is always recommended. Generally two pins are inserted in the bone to stabilize the fracture (see photo below right - put cursor over photos to enlarge).

 

Aftercare

After surgery, you can continue to give your pet a prescribed pain reliever to minimize discomfort. It’s also extremely important to limit your dog’s activity and exercise level during this post-operative period. A sling will be placed on your companion’s hind limb to prevent weight-bearing during the first 10-14 days after surgery. Rehabilitation exercises can be done at your home or if you choose, by professionally trained therapists at an animal rehabilitation center. Rehabilitation therapy should be continued until your dog is bearing weight well on the operated limb (typically 2 - 4 weeks after surgery). Detailed instructions will be given to you after the surgery. The surgeon will monitor the healing process with two follow-up exams. The first is scheduled at two weeks after the surgery and the second is at eight weeks after the surgery. By 8 to 10 weeks after surgery, most dogs are fully weight-bearing on the operated limb, although exercise should be limited during the first three months after the procedure.

 

Prognosis

Surgery usually gives an acceptable outcome; however, it is possible that the dog may not be a good athlete (such as a hunting dog). Dogs that are 4 months and younger tend to develop much more arthritis than older dogs with the same fracture. Uncommon complications include infection, breakage of the pins, and sciatic nerve damage. In general most small dogs and cats that receive a femoral head and neck excision surgery regain very good function on the limb. Primary repair of the fracture has been reported to be successful in 80% of the cases, whereas, no surgery will result in persistent lameness and hip pai

 

References

  1. Gilson KL, vanEe RT, Pechman RD femoral capital physeal fractures in dogs: 34 cases. J Am Vet Med Assoc. 1991, 198(5):886-90.
  2. DeCamp CE, Probst CW and Thomas MW. Internal fixation of femoral capital physieal injuries in dogs: 40 cases (1979 to 1987). J Am Vet Med Assoc 1989;12 :194(12)1750-4.
  3. McNicholas WT, Wilkens BE, Blevins WE, et al. Spontaneous femoral capital physeal fractures in adult cats: 26 cases (1996–2001). J Am Vet Med Assoc 2002;221:1731–6.
  4. Fischer HR, Norton J, Kobluk CN, et al. Surgical reduction and stabilization for repair of femoral capital physeal fractures in cats: 13 cases (1998–2002). J Am Vet Med Assoc 2004;224:1478–82.

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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