Management Plan This Doberman pinscher has two fractures: one mid-shaft, diaphyseal, comminuted fracture of the left femur, and one diaphyseal comminuted fracture of the right tibia. Both resulted from a traumatic car accident, and surgical repair and stabilization of the fractures is necessary. There are several different options to repair the fractures, so a series of decisions and assessments were necessary to arrive at a plan of action. The fractures were first assessed using the Fracture Assessment Scale (FAS). This scale is from 1 to 9, with one being severe and nine being simple and mild. Both fractures were graded a 2 for the following reasons. First, they are complex fractures with bone fragments and multiple reattachments are required. There are multiple affected limbs, so post-op there will be constant stress placed on either of the fractures to support the dog’s hind quarters. With only one fracture, the dog could favor the affected limb and decrease stress during the early stages of healing. This also occurred from a high-velocity impact, damaging the surrounding soft tissues and increasing the time necessary for healing as well as the complexity of the surgery. Finally, the fractured will have to be fixed internally, so additional soft tissues will be cut and separated in order to realign the bones. All of these factors pull the FAS down into the 0-3 range. However, this is a young strong adult Doberman pinscher that was perfectly sound and healthy before the accident, which improves his chances for a successful recovery into the 2-3 range. The are two options for fixations with these particular fractures: external fixation and internal fixation. External fixation was considered, as there is less contamination of the fracture, less damage to the bone’s blood supply, and they provide sufficient stability for healing. Unlike plates and pins, additional surgery is not required for removal once bony union has occurred. They are also much easier to adjust without requiring additional surgery. Some disadvantages include: a bulky apparatus is more easily caught on furniture or foreign objects, they have the potential to loosen, infection is possible, and the pin tracts may cause significant scarring and alopecia to the epidermis. External fixation is recommended for fractures below the stifle and elbow, and fractures that are open and partially contaminated. This patient has a left femoral fracture above the stifle, and both fractures are closed. External fixation was considered for the tibial fracture, however due to the complex nature of the bone fragments and the possibility of a slower recovery and complications, we decided to imploy internal fixation to repair both fractures. Internal fixation with intermedullary pins in addition to orthopedic bone plates should provide the most support and stability to the comminuted fractures, and provide the best opportunity for an uncomplicated recovery and strong bony union. We believe the complex, comminuted fracture of the left femur will have the best chance of healing properly with a bone plate / intramedullary pin combination. The screws utilized with the plate are short in length, to avoid intereference with the intramedullary pin. Additional screws or the use of cerclage wire may also be required to correctly position large, loose fragments. Another option for our patient with a fracture assessment score of 2 would be a Type Ib external fixator tied in to an intramedullary pin, however, for reasons discussed above, we elected to utilize the bone plate. These fractures require rigid axial, rotational, and bending support; the bone plate and pin must carry all of the load until a biologic callus forms. With an unfavorable FAS (as in this case), there is the chance that implant failure will occur, and that the bone will not heal properly. In addition, reduction of this fracture may lead to significant soft tissue damage, which would also impair healing. Nonetheless, our assessment is that a bone plate / pin combination would provide this young animal with a fairly good chance of complete functional restoration. The diaphyseal tibial fracture on the right limb will also be managed with a combination bone plate / intramedullary pin combination. In this case, a type II or type III frame external fixator could be used, however we believe that a bone plate and screws will provide a greater stability for the tibia to heal. Once again, additional screws or cerclage wire may be necessary to reduce large fragments that have completely separated from the bone. Smaller fragments will be removed completely. The low FAS for this injury also entails the risk of implant failure due to the imposed stresses that will act on the bone plate and IM pin for extended periods of time. The post operative management for both the tibial and the femoral fractures are similar. Post-op radiographs are taken to ensure correct positioning of the bone plate, screws, IM pin, and other fragments. A soft, padded bandage should be applied for a few days to control swelling and support soft tissues. Weight-bearing on the affected limbs is expected within 2-3 weeks. Confinement is recommended until there are radiographic signs of bone union; plate removal and intramedullary pin removal are performed after the bone has healed, in approximately 8 weeks. Radiographs should be taken at 2 and 4 weeks to monitor progress. Physical therapy to maintain joint motion and enhance the use of the limbs can be performed by the owner, including gentle flexion and extension of the joints above and below the fracture, as well as gentle muscle massage. To combat infection, IV Cephazolin can be used during the surgery and while the animal is still in-hospital. Pain management is indicated after surgery, using either an opioid or an NSAID.