Treatment Plan:

Initially, we would like to determine the cause of the anemia (low hematocrit) through 
additional diagnostic testing such as additional bloodwork and thoracic and abdominal 
radiographs.  Blood transfusion or administration of Oxyglobin may be indicated.  If 
internal hemorrhage is suspected, exploratory laporotomy may be necessary.  After 
diagnosis of the severely low hematocrit and supportive treatment, we will turn our 
attention to the less life threatening fracture repair.

For the mid diaphyseal fracture of the left femur with nonreducable wedges, we will offer 
the client a couple of options.  Closed reduction and limb splintage would be the most 
inexpensive for the client, and has its advantages by maximizing the biological bridging 
osteosynthesis.  Closed reduction will minimize disruption of the already formed 
hematoma and the current blood supply to the bone fragments.  This depends on the 
clientÕs intention for the animal.  Complete return to normal function may not be 
expected if this animal is involved in any type of strenuous activity.  Even if the closed 
reduction is done well, the bone may still heal slightly abnormally.  Also this method will 
not allow the animal use of the limb as quickly, decreasing muscle and joint use and 
increasing the time for return to function.      

Application of a bone plate may improve the normal shape bone growth by fixing the 
shape and holding the bone there in a more permanent fixture.  The main goal for internal 
fixation is to provide a rigid support that allows a faster return to normal function.  
Although a much larger exposure is needed to apply the plate, it should work well if 
proper care is taken to prevent infection, decreased blood supply or neurological damage.  
Application of a bridging plate is performed by contouring the plate from the 
craniocaudal radiograph of the opposite femur and attached proximally and distally 
without handling or reduction of the fragments, which will tend to be pulled into the 
fracture gap by muscular forces.   It is important to restore bone length as accurately as 
possible.  Four plate screws (going through 8 cortices) will be placed both proximal and 
distal to the fracture site.   

For the mid diaphyseal fracture of the right tibia and fibula, with nonreducable wedges in 
the tibia, we will again offer two options to the client.  Closed reduction and limb 
splintage is the least expensive and may be advantageous for the same reasons as listed 
above.  It also has the same disadvantages.  

External fixation after closed reduction or minimal open reduction may be the best option 
in this case.   This works well since the lower limb has minimal soft tissue.  A minimum 
of six fixation pins, three proximal and three distal to the fracture site will be used.  If a 
closed reduction is used, the smaller fragments do not need pins through them, as they 
will form part of the callus.  The first and last pins in each of the two larger fragments 
will be placed as far as possible from each other but not any closer than 1 cm from the 
fracture line.  We will use screw threaded pins so that the angle is not as important.  The 
pins will be cut on either side as close to the limb as possible and the last part should be 
bent to hold the acrylic.  Anesthetic scavenge tubing will be used as a mold for the acrylic 
side bars. 

Considering that both legs are involved, it complicates the healing process by not 
allowing full function on either hind limb until adequate healing has occurred.  Since 
early activity is associated with faster healing and less muscle atrophy and better motion 
in the joint, internal fixation for the femur and external fixation of the tibia provides the 
best prognosis for fast recovery and return to function.   The prognosis for this dog is 
relatively good because he is relatively young (but not still growing) and healing will be 
optimal.  We would also like to mention that prognosis is extremely affected by the blood 
supply to the existing bone fragments.   If the blood supply to any fragment is completely 
destroyed and the fragment cannot be resorbed by the body, a sequestrum may form.  
This avascular piece of dead bone will predispose the animal to conditions such as 
osteomyelitis.   

Immediate radiographic evaluation would be important to assess the quality of reduction 
for any of the discussed procedures.   

As for post-operative care, it depends on the type of treatment the clients select.  
Recovery will be much longer if they choose to only splint the fractures.  The internal 
and external fixations require cage rest for at least a week.  Then limited activity (leash 
walks) for 5 weeks or until radiographic evidence of healing is present.   The external 
fixation of the tibia will require additional care.  The pin tracts need to be cleaned daily 
with water and then drying can be done with a towel or hair dryer.  Chewing of the pins 
and/or side bars need to be prevented.  Complete removal can be done when bony 
bridging is visible on the radiographic check up.  After removal, exercise should be 
restricted for a week or two.  The bone plate can be removed 3 to 6 months after the 
fracture has healed, because it can cause local tissue reaction, irritation and erosion of the 
plate.