Veterinary Practitioner Vol. 14 No.

1 June 2013

CLASSIFICATION AND CHARACTERIZATION OF COMMINUTED LONG

BONE FRACTURES IN DOGS

A.K. Bishnoi 1, M. Raghunath 2 and N.S. Saini 3

Department of Veterinary Surgery and Radiology, College of Veterinary Sciences, GADVASU, Ludhiana,
Punjab, India

ABSTRACT

Over the 2 years period, study of 42 long bone comminuted fractures in 41 dogs was done. Pre-operatively, on the basis of
radiographs, the fractures were classified according to the fracture location and configuration using the Winquist-Hansen (W-H) and
AO/ASIF classification. The records of complete history with signalment showed that the etiology of fractures in most of the cases
were automobile accidents and fall from height. Males were more affected than females and most of the animals were heavy weighed
with the average body weight of 30 kg. Femur was the most common affected long bone followed by the tibia. Concurrent injuries
including the non-comminuted fractures of other appendicular skeleton were noted in total 6 cases. According to the W-H classifica-
tion most of the fractures were found unstable with the Grade III (47.62%) and Grade IV (38.10%) fractures. According to the AO/
ASIF classification, the fractures were diaphyseal in 38 bones while distal extra-articular in the 4 cases. The severity of fractures
were B3, C1, and C3 in most of the cases. Both the fracture classification systems were found suitable for deciding the fracture
location and severity before going for internal fixation.

Key words: Dogs, long bones, comminuted fractures, classification

Introduction Small Animal Clinics, College of Veterinary Science, Ludhiana

Fracture of the long bone is a commonly encountered from the period 2010 to 2012. Complete history and signalment
orthopaedic problem in canine practice. The increasing of the cases was recorded and distribution of long bone
occurrence of high-energy traumas, in which there is comminuted fractures in the region was determined and
considerable dissipation of kinetic injury, has led to fractures distribution of fractures was carried out based on breed, sex,
that are more and more severe and difficult to treat (Pires et al., bone, limb involved, age, weight, and etiology. Any concurrent
2010). Comminuted fractures resulting from such high-energy injuries if present were also noted. The affected limbs were
trauma are not uncommon in small animals and these need radiographed in cranio-caudal and mediolateral views to
immediate surgical treatment (Reems et al., 2003). However, determine the fracture location and configuration, and fractures
repair of comminuted long bone fractures remain a challenge were classified using W inquist-Hansen (W-H) and AO/ASIF
for veterinary orthopaedic surgeons. The prognosis and classification (Miller et al., 1998), so as to plan the best treatment
surgical challenge associated with these cases is directly methodology. In Winquist- Hansen classification, grading of
related to the degree of comminution and the patient fracture was done according to degree of comminution:
signalment. For the practitioners, who refer most or all such Grade 0 – no comminution, two piece fracture.
cases to the referral hospitals, an understanding on type of Grade I – one small unimportant bone chip.
fractures commonly encountered, how they can be managed, Grade II – greater than 50% contact between major proximal
and the prognosis of such fractures can be helpful in counseling and distal fracture fragments.
clients. The orthopaedic surgeon who is equipped to manage Grade III – less than 50% contact between major proximal
these fractures surgically, the challenge is to select the and distal fracture fragments.
appropriate fixation hardware and surgical technique Grade IV – no contact between major proximal and distal
(Horstman et al., 2004; Harasen, 2003). To establish the fracture fragments.
treatment for such complex fractures, it is necessary to have Grade V – segmental fractures, no contact between major
adequate pre operative planning, with correct interpretation of proximal and distal fracture fragments.
the fracture classification, which should be simple, According to AO/ASIF classification each fracture was
reproducible, indicate prognosis, and provide a treatment described using the alpha-numeric code which designated
guideline. This paper is aimed to present the complete the bone involved, fracture location, fracture morphology and
classification and distribution of comminuted long bone its severity. In this code, the first digit identified the bone (1-
fractures in dogs presented to the clinics in the period from Humerus, 2-Radius, 3-Femur, 4-Tibia and Fibula). The second
2010 to 2012. digit identified the location of the fracture in the bone (1-
Proximal, 2-Diaphyseal, 3-Distal). The fracture morphology
Materials and Methods was described using a letter A, B, C as A- simple, B- wedge
The study included 41 cases of dogs diagnosed with fractures, and C- complex fractures. Each grade was further
comminuted long bone fractures, which were presented at grouped into three degrees of complexity (e.g. C1, C2, C3)
1
Ph.D. scholar and Corresponding author. E-mail: [email protected]
2
Assistant Professor
3
Professor cum Head of Department

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Veterinary Practitioner Vol. 14 No. 1 June 2013

depending upon the type and extent of bone fragmentation. the fact that vehicular traffic in India is on left side. Automobile
The code used for the fracture morphology and its complexity accident was recorded as the major inciting trauma (56%
of the distal and proximal extra-articular fractures is different cases), followed by fall from height (39.02%), collision during
from that of diaphyseal fractures, as described by Miller et al. race, and abusive injuries (4.88% each). The results of study
(1998) (e.g. A1-simple, A2-wedge, A3-complex for the distal showed that long bone comminuted fractures were more
extra-articular fractures). common in German Sheperd breed (26.83 %), followed by
Labrador (19.51 %), Saint Bernard (12.20 %), Rottweiller (9.76
Results and Discussion %), Sheep dog and Hound (7.32 % each), Pakistani Bully (4.88
During the study, 41 dogs with 42 long bone comminuted %), and Dalmatian, Doberman, French Mastiff, Great Dane
fractures were presented for treatment. Different authors have and Mongrel (2.44% each). The more common involvement of
reported varying incidences of long bone comminuted fractures German Sheperd dogs may be due to the fact that it is favourite
in dogs. Duhautois (2003); Dueland et al. (1999); Raghunath breed in this part of India. The occurrence of fracture was
et al. (2007); Simon et al. (2010); Harasen (2003) and recorded in all age groups of dogs ranging from 3 months to 9
Kushwaha et al. (2011) reported a range of long bone years, but majority (70.73%) were up to the 2 years of age. The
comminuted fractures incidence with 87.60%, 76.87%, 43%, young dogs are more active than the older counterparts making
27%, 25%, and 5% cases, respectively, over the variable them more vulnerable to trauma (Raghunath et al., 2007;
periods of their study. In the present study males were affected Philips, 1979; Thilagar and Balasubramanian, 1988).
in 68% cases (n=28) and female dogs in 32% cases (n=13). The concurrent skeletal injuries with the long bone
Similar results were reported by Atri (2009); Simon et al. comminuted fractures were present in 6 cases (14.63%) which
(2010) and Raghunath et al. (2007). Maala and Celo (1975) included oblique diaphyseal tibial fracture in the contralateral
and Bains (2000) also indicated the higher incidence of limb in one case, ipsilateral oblique diaphyseal humeral
fractures in males than in females due to their higher fracture (1 case), distal 3rd diaphysial complete undisplaced
population and aggressive temperament, which makes them fracture of ipsilateral radius and ulna (1 case), overriding distal
more prone to trauma. The average body weight of the animals 3rd transverse fracture of ipsilateral radius and ulna (1 case),
was 30 kg which ranged from 15 kg to 50 kg. Such wide range impacted distal physeal fracture of contralateral radius and
of body weight in dogs treated for comminuted fractures was ulna (1 case), and pubic fracture with slight displacement of 4th
also reported by Reems et al. (2003) and Johnson et al. (1998). and 5th lumbar physis (1 case). Reems et al. (2003) and Moses
The mean body weight noted by them was 22 kg (range, 2 to et al. (2002) also noted concurrent injuries in 25.53% and
53 kg) and 30 kg (range, 13 to 56 kg), respectively. 66.67% cases of total studied comminuted fractures in small
Fractures involving femur accounted for 71.43% (n=30), animals. In one case of total 42 fractures a Grade III A open
followed by tibia (26.19%, n=11) and humerus (2.38%, n=1) of comminuted fracture of tibia bone was involved. Dudley et al.
the total fracture cases. Harasen (2003) reported that femur is (1997) reported a higher incidence (36%) of open comminuted
expected to be more resistant to comminuted fractures than fractures in tibia.
the tibia, as it is surrounded by a thick layer of muscle but The anatomical location of fractures detected according
surprisingly he also noted the higher proportion of comminuted to AO/ASIF classification was diaphyseal in 38 fractured long
fractures in the femur. Earlier, Maala and Celo (1975) accounted bones (90.48% cases), while it was distal extra-articular in the
the counteracting pulls of flexor and extensor muscles during 4 bones (9.52%). Kumar et al. (2007) also recorded higher
the high energy injuries for the common femoral fractures. In percentage of fractures in middle/distal diaphyseal region
all the cases the hind limb was involved except in one having (57%) which was followed by distal metaphyseal/epiphyseal
forelimb humeral comminuted fracture. Harasen (2003) (20%), proximal diaphyseal (12%), and proximal metaphyseal/
explained that why almost 3 of every 4 long bone fractures in epiphyseal (11%) regions. In the present study all the 4 distal
small animals occur in the hind limb. He speculated that these extra-articular comminuted fractures were present in femur
may be the patients that survived the traumatic episode and (33A3) and these were categorized as highly unstable, Grade
therefore could be presented for the surgical treatment. The III (1 case) and Grade IV (3 cases) fractures according to the
inciting trauma that is significant enough to fracture bones in W-H classification. According to Aithal and Singh (1999), and
the cranial half of the animal would more frequently cause Harasen (2003) the distal end of long bones, especially femur
lethal trauma to the head or chest, while similar trauma to the is subjected to greater stress than the proximal one during a
caudal half of the animal would be less likely to produce life- fall or an injury, thus accounting for the higher incidence of
threatening injury. He also presumed that as the animals see fractures of this anatomical location than the proximal one.
the impending trauma coming (automobiles), in their effort to According to W-H classification Grade III, IV and V comminuted
flee, they expose their hindquarters to the major force of the fractures are classified as unstable comminuted fractures, as
impact. The left side limbs were involved in 63.41% cases in such fractures there is minimal or no cortical contact between
(n=26) while the right side was involved in 36.59% cases the major proximal and distal fracture segments (Duhautois,
(n=15). These include one case in which both the hind limbs 2003; Moses et al., 2002 and Dueland et al., 1999). Of total
were affected with the comminuted fracture. Among individual forty two, 36 fractures (85.72%) were found unstable with the
bones, left femur was fractured in 60% cases and right femur incidence of 47.62% as Grade III, and 38.10% as Grade IV
in 40% cases. Among tibia, left tibia was fractured in 72.73% fractures (Table 1). There was no Grade V unstable fracture
cases while the right in 27.27% cases. Atri (2009) and recorded in this study. The higher incidence of unstable
Raghunath et al. (2007) also reported the higher incidence of comminuted fractures is ought to be related to the high energy
left limb bone fractures in dogs which could probably due to trauma as was recorded with the automobile accidents in the
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Fig. 1: Radiographs showing comminuted diaphyseal femoral fractures with the severity B3, C1, and C3

Fig. 2: Radiographs showing comminuted diaphyseal tibial fractures with the severity B3, C1, and C3.

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maximum number of cases in this study. Besides, the heavy and Fig 2) were found in the maximum number of total cases
body weight of the animals, as found in this study, resulted in with the percentage of 28.57%, 28.57%, and 21.43%,
the maximal load on the long bones when encountered with respectively (Table 2). Also, the overall incidence of these
the stronger ground reaction force as in the cases of fall from grades of fractures were found much higher in femur (54.76%)
the height. Thus, under conditions of high loading rate, the than in tibia (23.81%). Prevalance of complications and
stored energy in the structure (bone) exceeds that which can unacceptable limb function after internal fixation of comminuted
be dissipated via the formation of one crack, thus resulting in fractures is directly related to the severity of the comminution
the formation of multiple cracks which initiates the beginning (Sarmiento et al., 1995), which should be kept in mind when
of energetically less favourable fracture mechanisms. This comparing the success rate between the different modes of
situation results clinically in fracture comminution. Thus, mass fracture treatment. Moreover, the preoperative availability of
and velocity plays the role in determining the ultimate fracture proper classification of such complex fractures gives idea to
and fracture potential (Smith, 1985). In the individual bones, the referral surgeon as what type of forces had played in the
the percentage of Grade III and Grade IV unstable comminuted creation of such fractures and to counteract them what type of
fractures was recorded higher in femur than those of tibia. implant can be used that can combat these forces during intra-
Similar higher percentage of unstable comminuted fractures and post- operative period till the complete fracture healing. In
in femur and in the total long bone fractures was recorded by our present study both the Winquist-Hansen and AO/ASIF
Dueland et al. (1999). They recorded total 86% (103 out of fracture classification systems were combinedly found suitable
120) comminuted fractures of which 68% (70 out of 103) were for deciding the fracture location and severity before going for
classified as unstable. According to the AO/ASIF classification internal fixation.
the fractures with the severity grade of B3, C1, and C3 (Fig 1
Table 1: Winquist-Hansen classification of long bone comminuted fractures
Grade Grade I Grade II Grade III Grade IV Grade V
Bone
Femur 0 3 (7.14%) 16 (38.10%) 11 (26.20%) 0
Tibia 0 3 (7.14%) 3 (7.14%) 5 (11.90%) 0
Humerus 0 0 (0.00%) 1 (2.38%) 0 (0.00%) 0
Total 0 6 (14.28%) 20 (47.62%) 16 (38.10%) 0
Percentage is of the total 42 fractures
Table 2: AO/ASIF classification of long bone comminuted fractures
Number of diaphyseal fractures with different severities
Bone 2B1 2B2 2B3 2C1 2C2 2C3
Femur (3_) 1 2 9 7 0 7
Tibia (4_) 0 0 3 5 1 2
Humerus (1_) 0 1 0 0 0 0
Total 1 3 12 12 1 9
( _ represents the rest of the alphanumeric code e.g. 2B1, 2B2, 2B3 for each type of long bone fracture designating fracture location,
fracture morphology and its severity)

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