Vol. 22, No.
11 November 2000 V
CE Refereed Peer Review
FOCAL POINT
★Choosing appropriate orthopedic
implants and surgical techniques
is critical to the successful
management of supracondylar
femoral (SCF) fractures in adult
animals.
KEY FACTS
■ SCF fractures may be more
challenging surgically in adult
dogs than in immature animals
in which the fracture tends to
be through the growth plate.
■ After the fracture is thoroughly
assessed, implants and surgical
techniques should be tailored to
individual fracture configurations.
■ Traditional repair methods such
as intramedullary pinning and
standard bone plating may not
provide ideal stability for SCF
fractures.
■ Alternative devices should be
considered to stabilize SCF
fractures in adult animals.
Supracondylar Femoral
Fractures in Adult
Animals
University of Tennessee
David A. Lidbetter, BVSc, MVS, CertSAS, MACVSc, MRCVS
University College Dublin
Mark R. Glyde, BVSc, MVS, MACVSc, MRCVS
ABSTRACT: Supracondylar femoral (SCF) fractures in adult animals present significantly
greater challenges to veterinary orthopedists than do fractures in immature animals in which
the bone breaks are usually type I or II Salter-Harris physeal fractures. In adult animals, SCF
fractures are often unstable because of their distal position and propensity to be comminuted.
Because of the composition of the distal femur, minimal bone stock is usually available for im-
plant placement. As a result, traditional implants such as intramedullary pins and dynamic
compression plates may not be adequate to stabilize fracture forces. A range of available im-
plants offers additional approaches to the management of this relatively uncommon fracture.
F
emoral fractures are commonly repaired in small animals. Midshaft dia-
physeal fractures are the most common femoral fractures, followed by frac-
tures of the distal epiphyseum. Supracondylar femoral (SCF) fractures oc-
cur infrequently in adult animals.1 The major texts and veterinary scientific
literature cover the management of growth plate injuries in immature animals
and midshaft femoral fractures in adults in some detail; however, far less infor-
mation is available on the management of the often more challenging distal frac-
tures.2–8 In humans, SCF fractures are a common fracture in which two distinct
patient populations exist: Younger people sustain these fractures as a result of
high-velocity trauma, and elderly people with osteoporosis often sustain them
after minimal trauma.9–20 Various orthopedic implants and techniques, including
intramedullary (IM) pinning, blade plating, buttress condylar plating, dynamic
compression plating, interlocking nailing, Zickel supracondylar nailing, and
double plating, are employed in humans to repair the fractures.9–20
Management of distal femoral fractures in young animals is typically straight-
forward because of the simple nature of the fracture and the innate potential of
young animals to heal rapidly. The fractures normally occur through the weak
zone of hypertrophy in the physis; the surface of the fracture often interdigitates
in a W shape, giving the repair some inherent stability.21
Small Animal/Exotics
In adult dogs, SCF fractures
can present substantial challenges
because of the unique composi-
tion of the distal femur and the
fact that the fractures are often
more comminuted and unstable
(Figure 1). These fractures are
difficult to manage because of
the presence of large moments
and forces acting on them with
short segments of bone distally.
SCF fractures are located near an
area of high motion due to the
presence of the knee joint and
have a small distal target for im-
plant placement that is eccentri-
cally placed to the bone column.
In adult animals in which bio-
buttress formation is slow, maxi-
mum stability (which is difficult
to achieve because of the small
eccentric distal target) must be Figure 1—Lateral radiograph of a comminuted su- and neurologic examinations are
obtained from the implant used pracondylar femoral fracture.
to repair the fracture. Recently,
veterinary orthopedists have seen
an influx of new repair devices that can be used to
manage these more difficult fractures (Table I).
ANATOMY
The shaft of the distal femur is composed of hard
cortical bone, typical of the diaphysis of long bones.
The femur begins to flare in its central midshaft region
and is widest in the supracondylar/epicondylar area.
The condylar bone is spongy, being primarily cancel-
lous with a thinner cortical rim. Cranially, the condylar
region of the femur is bordered by the medial and later-
al condylar ridges and trochlear sulcus, which are cov-
ered by hyaline cartilage.22 Distally, the condyles curve
caudally with the intercondylar notch, separating the
medial and lateral condyles. The intercondylar notch is
the origin of the cranial and caudal cruciate ligaments.
The stifle joint is a hinge joint with limited ability to widespread recognition and are not used universally.23,24
rotate and is primarily stabilized by the cruciate liga-
ments. Primary mediolateral stability is from the collat-
eral ligaments. The lateral collateral ligament attaches
the caudal distal femoral condylar region to the head of
the fibula, and the medial collateral ligament attaches
the medial epicondyle to the proximal medial tibia.22
More cranially on the lateral side of the stifle, the long
digital extensor tendon attaches onto the distal femoral
condyle.
The relevance of the local anatomy is that SCF frac-
tures result in minimal bone stock in which to place
DISTAL FEMUR ■ IMPLANT PLACEMENT ■ CRUCIATE LIGAMENTS
Compendium November 2000
implants to stabilize the fracture.
The bone tends to have poorer
holding potential because of its
material properties; however, it
does have a greater surface area
for fracture healing to occur. Im-
plant placement must also avoid
key structures (e.g., articular car-
tilage, collateral and cruciate lig-
aments).
CLINICAL FINDINGS
AND DIAGNOSIS
Animals with SCF fractures
commonly present in an unsta-
ble condition and may have suf-
fered concurrent injuries. They
are usually non–weight-bearing
in the affected leg and will have
considerable femoral swelling.
Thorough physical, orthopedic,
necessary. Assessment of the cru-
ciate and collateral ligaments is
especially important. Instability
from the fracture and local swelling can make assess-
ment difficult. The cruciate ligaments in these animals
should be assessed directly by inspection via arthroto-
my during fracture repair. Initial diagnostics should in-
clude a complete blood count, chemistry panel, urinal-
ysis, and chest and abdominal radiography. Continuous
electrocardiography for 24 to 48 hours is advised.
FRACTURE CONFIGURATION
AND NOMENCLATURE
Fracture classification systems, which are based on
the patterns of large numbers of fractures, have been
created for humans. These systems aid in rationalizing
the use of a particular treatment, evaluating outcome,
and prognosticating. Although such systems have been
devised in veterinary orthopedics, they have not gained
For reasons of simplicity, SCF fractures can be classified
as supracondylar, condylar, and supracondylar/inter-
condylar. Commonly used descriptive terms include
simple, multiple, comminuted, and open or closed.
SURGICAL APPROACH
Occasionally, SCF fractures that are incomplete or min-
imally displaced may be treated closed without any surgi-
cal approach. With the introduction of image intensifiers
in veterinary surgery, closed reduction may be increasingly
used with implants placed percutaneously. Most often,
Compendium November 2000 Small Animal/Exotics

TABLE I
Devices Used to Repair Supracondylar Fractures in Adult Animals
Repair Devices Indications Relative Contraindications Important Points

Intramedullary pins Use as adjunct fixation Most SCF fractures Poor rotational stability

Crossed K-wires Cats; small dogs; transverse, Comminuted, cortical defect Simple technique; requires
short oblique fractures fractures limited equipment

Rush pins Cats; small dogs; transverse, Comminuted, cortical defect More difficult technique;
short oblique fractures fractures requires specialized equipment

Lag screws Small chondrodystrophoid Nonchondrodystrophoid Avoid screw placement into

breeds of dogs; very distal breeds of dogs; comminuted intercondyloid fossa; careful
transverse fractures fractures case selection

DCP Many SCF fractures, Chondrodystrophoid breeds Avoid trochlear ridge and
particularly more proximal of dogs; very distal fractures intraarticular screw placement;
fractures use care with capsule closure

Reconstruction Cats; small- and medium-sized Large dogs; comminuted or Requires load sharing with
plate dogs; chondrodystrophoid cortical deficit fractures bone; contour to distal caudal
breeds of dogs femoral bow

Plate/rod Most breeds and sizes of dogs Some cats and small dogs; Place bicortical screws in
and cats; comminuted and very narrow medullary canals metaphysis; place monocortical
cortical defect fractures screws in diaphysis

Modified type I All breeds and sizes of dogs and SCF fractures with an Use positive-profile pins; avoid
ESF cats; comminuted, open SCF articular component quadriceps
fractures

Customized hook Most breeds and sizes of dogs; Use extra care with cats and Modification of existing DCP
plate most fracture configurations small dogs required

Interlocking nails Most breeds and sizes of dogs Chondrodystrophoid breeds Requires specialized equipment
and cats; more proximal SCF of dogs; some cats with very and training
fractures distal fractures

Tibial head Large-breed dogs; most fracture Animals weighing <25 kg Right-sided plates are used for
compression plate configurations left-sided fractures

Hybrid circular Most SCF fractures; most SCF fractures with an Technically difficult; requires
ESF breeds and sizes of dogs and articular component specialized training and
cats; very distal fractures equipment

DCP = dynamic compression plate; ESF = external skeletal fixator; K = Kirschner; SCF = supracondylar femoral.

however, either a full-open approach, mini-approach, or
open-but-do-not-touch approach is employed.25,26 Typical-
ly, because of the instability of these fractures and their dis-
tal location, an approach to the shaft of the femur is com-
bined with a lateral approach to the stifle as described by
Piermattei and Greeley.27
An alternative technique, which provides excellent
exposure with only a minor increase in morbidity, com-
bines the approach to the lateral femur with a tibial
crest osteotomy and proximal reflection of the straight
patella ligament and quadriceps group.10,27 The firmly
attached periosteum and joint capsule should be elevat-
ed from the distal lateral condylar region when a bone
plate repair of the femur is applied.

REPAIR DEVICES ■ LATERAL APPROACH ■ QUADRICEPS

Small Animal/Exotics Compendium November 2000

not fit, K-wiring can be a simple, effi-

Figure 2—Craniocaudal postoperative Figure 3—Craniocaudal radiograph of a chase and strength, and the pins are of-
radiograph of a supracondylar femoral supracondylar fracture repaired with ten driven into the proximal condylar
fracture repaired with crossed Kirschner stacked intramedullary pins. Note the region, immediately adjacent to the
wires. poor purchase of distal metaphyseal
cancellous bone predisposing to insta-
bility.
TREATMENT
The goals of fracture repair are as follows: rigid ana-
tomic reduction and fixation, when possible; anatomic
reduction of the joint surface and rigid fixation (articu-
lar fractures); reduction and stabilization or buttressing
of the metaphyseal region (comminuted fractures);
restoration of normal axial alignment and length; and
early controlled motion.
Intramedullary Pinning, Kirschner
Wiring, or Rush Pinning
Crossed Kirschner wiring (K-wiring), which is the
mainstay of distal femoral fracture repair in immature
animals, has limited applications in SCF fractures in
mature dogs, although its use may be indicated in
small- or toy-breed dogs or cats. The availability of
bone stock in these animals may be so small that it pre-
cludes the use of other implants. Contact between the
fracture fragments must be achievable. A lateral ap-
proach can be made to the distal femur, and the caudal-
ly displaced fracture can be reduced and maintained
with reduction forceps. Care should be taken to avoid
crushing the bone in young adult animals. Fine, plain
K-wires should be placed in cross-fashion either from
the medial and lateral sides or both from the lateral side
(Figure 2).2-8,28–32 The pins may be placed distal to prox-
imal or proximal to distal, depending on personal pref-
erence. In small adult animals with transverse distal
SCF fractures in which larger, stronger implants may
cient means of successful fracture re-
pair.
In general, IM pinning is not recom-
mended as a reliable means of fracture
stabilization of SCF fractures in adult
animals. In one study,33 159 primarily
immature cats and dogs reported good
results using IM pins normograded
from the stifle. Single IM pinning ap-
pears to work best in young cats with
distal femoral fractures because of their
relatively straight femurs and small size.
However, IM pinning alone is often
less than satisfactory for treating SCF
fractures in adults. The technique re-
sults in poor distal bone-holding pur-
fracture line instead of more distally in
deeper condylar bone. Single IM pins
overcome rotational forces poorly, of-
ten resulting in inadequate stability.34
Pins that are stacked probably do not gain greater pur-
chase distally and do not achieve greater cortical contact.
Stacked pins are technically more difficult to place and
often do not improve stability (Figure 3). Instead of being
used as a sole implant, IM pinning can be incorporated as
a valuable adjunct to external fixation or bone plating be-
cause it overcomes bending forces.
Rush pinning can be an excellent means of stabilizing
these fractures in cats and small- to medium-sized dogs,
particularly when the fracture line is transverse or short
oblique. Rush pinning allows for three points of fixa-
tion, providing greater tension and stability. Rush pins
are introduced from either side of the distal fragment at
an acute angle after the pins have been prestressed.34
The points are beveled so as not to engage the cortex.
Awls to start the guide holes and driver extractor tools
are required for placement. Where comminution or
cortical deficits exist, the pins may not provide suffi-
cient stability and fracture collapse can occur. Rush
pinning requires specialized equipment and training.
IM cross-pinning has also been described.35
Lag Screw
Some SCF fractures may be extremely distal because
of the marked bow of the femur in chondrodys-
trophoid breeds. Occasionally, there may be room on
the distal fragment for only one implant (e.g., one bone
plate screw hole, one fixator pin) to be placed. Instead
of using crossed K-wires in some of these fractures, lag

BONE STOCK ■ FRACTURE STABILIZATION ■ BONE PLATING

Compendium November 2000
Figure 4A Figure 4B
Figure 4—(A) Lateral radiograph of an extremely distal supracondylar fracture in a
chondrodystrophoid dog. (B) Lateral postoperative radiograph showing repair using
two 2.7-mm cortical lag screws.
screws may be positioned in parallel fashion from the
cranioproximal femur to the caudodistal condylar re-
gion of the femur (Figure 4). This technique is useful
only in chondrodystrophoid breeds when other im-
plants do not fit. Because the strength of this type of re-
pair is limited, it should only be used in certain cases.
Dynamic Compression Plate
In midshaft femoral fractures, conventional and lim-
ited-contact dynamic compression plating is often cho-
sen because of the ease of approach, minimal contour-
ing needed to apply the plate, and rigid stability of the
plate. In proximal SCF fractures, dynamic compression
plating is also used for all sizes and breeds of adult ani-
mals. With more distal SCF fractures, insufficient distal
bone stock typically limits screw placement. Two screws
in each fracture fragment are the minimum require-
ment for stability. Ideally, at least three screws should
be placed, but it is often impossible to place even two
screws.36 Because dynamic compression plates (DCPs)
can only be bent in two planes, they cannot be con-
toured caudally with the natural bow of the femur.
Apart from reducing the number of potential screw
holes, plates often overrun the distal femur protruding
past it, impinging on the lateral edge of the trochlear
groove and patella fibrocartilage (Figure 5). DCPs may
also interfere with closure of the joint capsule and sur-
gical wound and perhaps, most importantly, may dis-
turb the dynamics of the patella and quadriceps mecha-
nism. The patella may be luxated laterally or displaced
dorsally as a result of the position of the plate.
CORTICAL LAG SCREWS ■ SCREW PLACEMENT ■ PATELLA
Small Animal/Exotics
Figure 5—Lateral postoperative radio-
graph of a supracondylar fracture re-
paired with a 3.5-mm dynamic com-
pression plate. Inadequate stability is
achieved because only four cortices are
engaged and the plate overruns the dis-
tal femur.
Reconstruction Plate
Reconstruction plates are ideally suited to fractures of
the distal femur because of their unique ability to be con-
toured in three planes. The plates are available in 2.7, 3.5,
and 4.5 mm and have notches manufactured into them
between screw holes to allow them to be bent. Recon-
struction plates are not extensively cold worked and are
left in the annealed or soft state, thus giving them the
property of ductility.36 In humans, these plates were initial-
ly designed for maxillofacial fractures but also have been
used extensively in pelvic fracture repair. These anatomic
areas in humans are usually under minimal strain; there-
fore, the plate has some protection.10 These plates are not
designed to withstand the forces of weight bearing and
should not be used to buttress fractures with bone deficits
and marked instability.36 These plates can easily undergo
cycling and bend, or they can fatigue and break.
Reconstruction plates can be bent caudally and flared
outward to contour to the distal femur and have been
used for SCF fractures in small animals (Figure 6). This
can increase bone purchase by increasing the number of
screws engaging the bone and preventing plates from
extending distally, interfering with the stifle.
Reconstruction plates ideally are used in smaller
adult animals in which there can be reconstruction of
the bone column and sharing of the load through the
bone and plate when the animal bears weight on the
limb. These plates are particularly useful in chon-
Small Animal/Exotics
Figure 6—Lateral radiograph of supra- Figure 7A
condylar fracture repair using a 2.7-mm Figure 7—Craniocaudal radiographs of a highly comminuted midshaft supracondylar
reconstruction plate. femoral fracture (A) and repair using a plate rod technique (B).
drodystrophoid breeds in which marked caudal bowing
of the condylar region precludes using standard bone
plates in more distal fractures.36 When only one or two
screws are placed in the distal fragment, crossed K-
wires should be used for additional stability.
Plate–Rod Combination
The plate–rod technique attempts to synergize the
actions of IM pins and bone plates.8,25,26,37–39 This tech-
nique is especially useful in highly comminuted frac-
tures or when a significant cortical deficit that cannot
be anatomically reconstructed is present (Figure 7). An
open approach to the femur and stifle should be made,
and an IM pin can be placed either retrograde or nor-
mograde in order to reduce the fracture and aid align-
ment. The trochlear sulcus and greater trochanter can
be used as landmarks to avoid rotation of the stifle or
anteversion of the femoral neck and head. The limb
should be checked for varus deformation before a plate
is applied to the lateral femur. The plate neutralizes ro-
tational, bending, and axial forces while the pin, which
is placed centrally in the bone, protects the plate and
guards against bending.25,26,37–39
Although this technique involves a significant num-
ber of implants, no attempt should be made during re-
pair to anatomically reconstruct multiple small fracture
fragments. This biological approach to the repair tries
to minimally disrupt the already fragile blood supply to
the fracture.25,26,38 A bone graft should also be placed. A
minimum of three monocortical screws and one bicor-
tical screw should be used on either side of the frac-
COMMINUTED FRACTURES ■ OPEN APPROACH ■ PIN DIAMETER
Compendium November 2000
Figure 7B
ture.8 Guidelines for pin size and screw number have
been published; a pin diameter of no greater than 50%
of the medullary canal at its narrowest point is recom-
mended. Because screw placement in the diaphysis is
often extremely difficult, it may only be possible to
place screws in the metaphyseal regions.
Modified Type I External Fixator
The modified type I external skeletal fixator (ESF),
which can be used in all cats and dogs, can be applied
to most SCF fractures, including those that are trans-
verse, comminuted, or very distal. No implants are
placed at the fracture site and either a complete open
approach, a limited approach, or closed reduction and
frame application can be used. This type of implant has
the potential for less soft tissue and associated vascular
damage. Initially, in veterinary practice, the use of ESFs
was primarily reserved for the distal limb with less use
in proximal limbs owing to the larger mass of soft tissue
and impingement of the body wall medially. The use of
fixators in the femur and humerus in cats and dogs has
increased because of the introduction of modified and
more complicated strategies and frames.
Simple type I ESFs can be used in SCF fractures;
however, gaining adequate purchase in the distal frag-
ment is not always feasible. Placing one or two centrally
threaded positive-profile full pins in the distal condylar
region from lateral to medial allows the use of a bent,
additional connecting bar to be passed from the medial
side of the distal femur to the lateral proximal femur
(Figure 8).40,41 This increases the stiffness of the frame
Small Animal/Exotics Compendium November 2000

Figure 9—Customized hook plate from

a regular dynamic compression plate.
Figure 8A Figure 8B
Figure 8—(A) Supracondylar femoral (SCF) fracture treated with a modified type I
external skeletal fixator (ESF) with only a lateral connecting bar. (B) SCF fracture
treated with a modified type I ESF with both lateral and medial connecting bars.

and minimizes fracture instability and pin loosening. It
is advisable to use another one or two half-pins in the
distal fragment, if possible, and four half-pins proxi-
mally. Positive-profile pins are used because of their
added cortical bone contact, increased pin pull-out
strength, and lower incidence of pin–bone interface
problems.42–44 This frame is well tolerated by cats and
dogs and results in minimal to no body wall contact
with the frame.45
Alternatively, an acrylic frame can be used in the
humerus to connect the lateral type I pins across the
distal femur to the medial side, then continuing proxi-
mally over the thigh to the lateral proximal aspect.46
The bending strength of the frame is improved by plac-
ing an IM pin in the shaft of the femur and then con-
necting it to the main lateral frame in a “tied-in” con-
figuration.47 In SCF fractures, fixators are often placed
via an open approach because of the difficulty in reduc-
ing the fractures closed. If an open approach is made to
a comminuted SCF fracture, it is usually an open-but-
do-not-touch approach in which the proximal and dis-
tal bone columns are reduced, the hip and stifle joints
are aligned, and no attempt is made to anatomically re-
construct the bone column.25,26
The presence of pins in the distal femur can cause ir-
ritation to the joint capsule, retinaculum, and soft tis-
sue. The stifle, being a high motion area, can add to
the irritation. The quadriceps muscle should be avoid-
ed, and soft tissue entrapment can be minimized by us-
ing retraction or drill guides. Morbidity associated with
the pins can include pin tract discharge and infection,
pin loosening, and decreased stifle range of motion and
leg usage.42–44 Although significant complications are
uncommon, veterinarians and owners should monitor
and clean the skin surrounding the pins, encourage
controlled physical therapy, and monitor radiographs
for evidence of pin loosening.
Customized Hook Plate
A customized hook plate has been developed recently
for use in metaphyseal fractures when minimal bone
stock is a complicating consideration.48 The technique
involves bending a standard DCP and fashioning sharp,
pointed hooks with a hacksaw blade (Figure 9). This
modified implant can be useful in SCF fractures with
small distal targets and can have some advantages over
conventional plates. The same number of screw holes
can be used as in a DCP, with the addition of the fash-
ioned hooks. Two parallel holes set the width of the
plate apart should be drilled into a distal portion of the
femoral fragment before gently hammering the hooks
into the bone (Figure 10). Drill diameter should be
slightly larger than that of the hooks. The fracture
should be reduced and a screw hole in the proximal
fracture fragment filled, securing reduction. The re-
mainder of the screw holes in the distal and proximal
fragments should be drilled and filled.
In humans, a dynamic compression screw may be
used to compress SCF/intercondylar femoral fractures,
or an AO (Arbeitsgemeinschaft fur Osteosynthesefra-
gen) blade plate can be used to provide increased sur-
face area contact of the plate in distal bone.10,11,13,17

POSITIVE-PROFILE PINS ■ METAPHYSEAL FRACTURES ■ MODIFIED IMPLANT

Compendium November 2000
Figure 10—Customized hook plate placed using predrilled
holes and a mallet.
These implants are generally too large to use in most
animals; however, the customized hook plate follows
similar principles to that of the blade plate. The tight
security of the hooks is less important than is their con-
tact in the bone.10 Screws can be placed through the
hooked area, thus the number of screws in the distal
fragment is not reduced yet the points of contact are
increased.48 The drawback of this technique is that be-
cause an aiming jig is not available for screw placement,
moderate force may be needed to hammer the hooks
into the bone holes. This does not, however, detract
significantly from the technique. Similar to the DCP,
the modified hook plate may cause difficulty in closing
the joint capsule and can affect the patella if the plate is
positioned too close to the trochlea ridges.
The technique is adaptable and has been used suc-
cessfully in medium to large dogs. Care may be needed
in small dogs and cats to ensure adequate width is pres-
ent for the hooks to be placed distally.
Interlocking Nails
Adapted from human medicine, the Dueland inter-
locking nail system is designed for veterinary patients.49
The nails are solid, surgical stainless steel with screw
holes at either end. An open approach to the femur is
usually made and limited muscle reflection is necessary.
Screws should be inserted through the bone to engage
the nail, thereby preventing rotation of the fracture and
axial collapse (Figure 11).49–51 Interlocking nails (ILNs)
offer the advantage of positioning the implant centrally
in the bone, thereby providing excellent bending
strength. Three nail models are available with lengths
from 140 to 230 mm. Nail diameters range from 4.7 to
BLADE PLATE ■ AXIAL COLLAPSE ■ MEDULLARY CANAL
Small Animal/Exotics
Figure 11—Surgical application of an interlocking nail.
8 mm and accept 2.0-, 2.7-, 3.5-, and 4.5-mm screws.49
The largest nail that fits the medullary canal should be
chosen. The nail should be long enough to place the
screw holes 2 cm from the fracture site, and nails of
similar length and contralateral limb radiographs
should be used to ensure that the pin is seated in distal
metaphyseal cancellous bone.49–51 The distal fragment
in SCF fractures may need to be overreduced. The nails
are usually placed in normograde fashion; however, an
opening in the proximal cortex may be made using a
separate pin in a retrograde fashion.
Because the nails have been customized for animals,
problems with aiming and executing the technique
have been ameliorated. Nails are now made with more
distal screw hole placement so that they can be applied
to SCF fractures. An obstacle with this technique is the
inability to lodge the pin distal enough to gain screw
purchase below the fracture line; occasionally, a single
screw hole below the fracture line is necessary. This
should not significantly alter stability at the repair
site.51
The ILN is an adaptable system requiring specialized
equipment, which can be used for most sizes and
breeds of adult animals. It can be used in transverse and
comminuted fracture patterns. Complications with the
technique include problems with screw aiming and
placement, breakage of the nail at the screw hole, and
sciatic nerve damage if the nail protrudes from the in-
tertrochanteric fossa.49
Tibial Head Compression Plate
The tibial head compression plate is primarily for use
in dogs weighing more than 25 kg. The design of the
Small Animal/Exotics
plate allows for more screws to be
placed in the distal fragment below the
SCF fracture line. The plate, which
has been precontoured to fit the proxi-
mal lateral tibia in humans, was de-
signed for complex fractures of the tib-
ial plateau.10,52 The plate has the same
thickness as the 3.5-mm broad DCP,
although it is 2 mm wider. The plate is
available with five, seven, or nine DCP
shaft holes, which accept 4.5-mm cor-
tical screws, and is available in 118- to
240-mm lengths. One end of the plate
is flared to a maximum width of 26
mm and curves in a convex fashion
about 13˚ (Figure 12).53 The flared
head thickness gradually reduces cen-
trally to 1.57 mm and has three round
holes in a triangular pattern.53 The
round holes are separated from regular
DCP holes by an oval hole that can act Figure 12— Lateral tibial head plates.
as a positioner when the first screw is
placed. The round head holes accept 4.5-mm cortical,
6.5-mm cancellous, and cannulated screws.
When the plate is placed in the opposite fashion to
its use on the tibia (i.e., a right-sided tibial plate is placed
on the left femur upside down), it mimics the caudal
bow of the femur and its distal flaring.53 The advantage
in SCF fractures in larger dogs is that more screws can
be placed in the distal fragment when there is minimal
bone stock because of the unique shape of the plates,
neck, and head (Figure 13).
Hybrid Circular External Skeletal Fixator
Over the past 10 years, there has been increased at-
tention in veterinary medicine to the use of circular
ESFs for fracture repair, bone lengthening, and gradual
correction of angular limb deformities.54–56 Most reports
concentrate on the use of full rings for tibial and ra-
dius/ulna fractures.55 In the humerus and femur, full
ring constructs cannot be used because of the presence
of the body wall.
Hybrid circular fixators combine one or two full
rings attached to the distal femoral fragment and are
linked to a lateral connecting bar where half-pins simi-
lar to a type I external fixator are used.57 The full rings
allow two or more small-diameter wires or pins to be
placed percutaneously; these can be tensioned by a de-
vice that increases the bending stiffness of the wires.
Circular fixators provide similar torsional bending and
shear resistance as do type I external fixators.57 There is
less axial stiffness and increased continual micromotion
at the fracture site when the animal is walking, which is
TIBIAL PLATE ■ FULL RINGS ■ HALF-PINS ■ CORTICES
Compendium November 2000
conducive to bone healing.57
Hybrid circular fixators, which can
be used in all breeds and sizes of dogs
and cats, have an advantage over con-
ventional external fixators in SCF frac-
tures. Because the pins are so small,
more can be placed in a finite area;
thus more cortices can be engaged in
the case of very distal fractures.54,55
Overall stability of the frame can be
increased by using the smallest-diam-
eter ring, allowing for 1 to 2 cm be-
tween the ring and skin for swelling;
placing two parallel rings, if possible;
increasing the number of wires per
ring; placing wires as close to 90° to
each other as possible; using tear-drop
shaped wires; and using positive pro-
file half-pins in the proximal frag-
ment.54–59
Hanging of the limb operatively
helps aid reduction and preplanning;
partially constructing the frame preoperatively can help
reduce surgical time. As with the ESF, the hybrid circu-
lar fixator can be placed after closed reduction or after a
limited approach. The hybrid circular fixator is an
adaptable technique that requires specialized equip-
ment and training.
SURGICAL PITFALLS
When fracture fragments cannot be reduced anatom-
ically, the femoral neck must be maintained at the cor-
rect angle with respect to the stifle or a change in the
angle of anteversion/retroversion at the coxofemoral
joint will occur. This may lead to progressive degenera-
tive joint disease, dysplasia, or predisposition to cox-
ofemoral luxation.
Appreciation of the normal anatomy of the lateral
surface of the femoral shaft is essential. From slightly
proximal to the midshaft, the bone begins to flare and
widen. If this contour is not accounted for in the plate,
the limb will be plated with a varus deviation and result
in an incongruity in joint alignment, which may also
result in lameness or degenerative joint disease. Radiog-
raphy of the contralateral leg can aid in avoiding this
mistake when contouring the plate.
Distal femoral fractures usually require an approach
to the lateral stifle if internal implants are to be placed.
As a result, the lateral retinacular tissue of the patella
and soft tissue support is divided. If the implant ex-
tends to the distal lateral limit of the femur or past the
femur, the potential exists that the patella will not be
stabilized correctly at closure, resulting in laxity. This
Small Animal/Exotics
Figure 13A Figure 13B
Figure 13—Lateral postoperative (A) and craniocaudal (B) radiographs in an adult German shepherd of a supracondylar femoral
fracture repaired with a lateral tibial head plate. (C) The lateral tibial head plate in situ.
can lead to luxation or abnormal wear. In addition, it
can be difficult to adequately close the joint capsule be-
cause of the presence of the implant. The common per-
oneal nerve, which lies caudal to the lateral fabella on
the medial surface of the biceps, must be visualized be-
fore fracture repair to prevent iatrogenic damage.
POSTOPERATIVE REHABILITATION
Supracondylar femoral fractures predispose the ani-
mal to soft tissue complications. Quadriceps contrac-
ture and tie-downs, which are seen more frequently in
immature animals with fractures, can also occur in ma-
ture animals.60 Often, the quadriceps may be damaged
by the trauma involved in creating the SCF fracture.
After open surgical repair, the muscle is prone to un-
dergo fibrosis and to scar to the underlying periosteum.
Signs of quadriceps contracture begin subtly and in-
clude decreased limb usage, muscle atrophy, pain, stiff-
ness, and a reduced range of stifle motion. This condi-
tion can rapidly progress to rigid hyperextension of the
affected leg with reduced flexion of both the stifle and
the hock. The quadriceps becomes firm and severely at-
rophied.
After quadriceps contracture has begun, the process
can be difficult to reverse; therefore, prevention is often
better than cure.61 A physical therapy program must be
instituted soon after surgery. Rigid surgical stabilization
and adequate analgesia are required.
Following surgery, the limb should be iced, the cir-
cumference measured, and range of motion assessed
with a goniometer.62 If available, force plate analysis can
be used to document weight-bearing status. This base-
GONIOMETER ■ FORCE PLATE ANALYSIS ■ HYDROTHERAPY
Compendium November 2000
Figure 13C
line data can be used throughout the recovery period to
quantify progress. Early use of the limb is of paramount
importance; therefore, range-of-motion exercises
should be performed daily. The limb should be iced be-
fore each session and massaged before beginning vigor-
ous physical therapy. Exercises can include sit-stand,
short leash walks, treadmill walking, or walking up in-
clines. Supervised hydrotherapy in a bath or underwa-
ter treadmill can begin after suture removal. At dis-
charge, owners must be thoroughly educated regarding
care and procedures, and regular follow-up visits should
be encouraged.
To avoid soft tissue disease, active physical therapy
must be continued until fracture healing is completed.
Further therapy after this time will help reverse muscle
atrophy and improve long-term limb function.
REFERENCES
1. Braden TD, Eicker SW, Abdinoor D, Prieur WD: Charac-
teristics of 1000 femur fractures in the dog and cat. Vet
Comp Orthop Trauma 3:130–134, 1990.
2. Anderson J: The stifle, in Houlton JEF (ed): Manual of
Small Animal Arthrology. Cheltenham, United Kingdom,
BSAVA, 1994, pp 267–300.
3. Brinker WO, Piermattei DL, Flo GL: Handbook of Small
Animal Orthopedics and Fracture Treatment, ed 2. Philadel-
phia, WB Saunders Co, 1997, pp 129–134.
4. Gilmore DR: Internal fixation of femoral fractures, in Bo-
jrab MJ, Ellison GW, Slocum B (eds): Current Techniques in
Small Animal Surgery, ed 4. Baltimore, Williams & Wilkins,
1998, pp 1040–1050.
5. Olmstead ML: Fractures of the bones of the hindlimb, in
Olmstead ML (ed): Small Animal Orthopedics. St. Louis,
Mosby, 1995, p 234–238.
6. Milton JL: Fractures of the femur, in Slatter D (ed): Text-
Compendium November 2000
book of Small Animal Surgery, ed 2. Philadelphia, WB Saun-
ders Co, 1993, pp 1805–1817.
7. McLaughlin R: Intra-articular stifle fractures and arthrode-
sis. Vet Clin North Am Small Anim Pract 22:877–895, 1992.
8. Hulse DA, Johnson AL: Management of specific fractures,
in Fossum TW (ed): Small Animal Surgery. St. Louis, Mos-
by, 1997, pp 767–882.
9. Karpman RR, Del Mar NB: Supracondylar femoral fractures
in the frail elderly. Clin Orthop 316:21–24, 1995.
10. Schatzker J, Tile M: The Rationale of Operative Fracture
Care, ed 2. Berlin, Springer-Verlag, 1996, pp 387–413.
11. Siliski JM, Mahring M, Hofer HP: Supracondylar-inter-
condylar fractures of the femur. J Bone Joint Surg 71A:95–
104, 1989.
12. Leung KS, Shen WY, So WS, et al: Interlocking in-
tramedullary nailing for supracondylar and intercondylar
fractures of the distal part of the femur. J Bone Joint Surg
73A:332–340, 1991.
13. Merchan ECR, Maestu PR, Blanco RP: Blade plating of
closed displaced supracondylar fractures of the distal femur
with the AO system. J Trauma 32:174–178, 1992.
14. Giles JB, DeLee JC, Heckman JD, Keever JE: Supracondy-
lar-intercondylar fractures of the femur treated with a supra-
condylar plate and lag screw. J Bone Joint Surg 64A:864–
870, 1982.
15. Zickel R, Fietti VG, Lawsing JF, Cochrane GVB: A new in-
tramedullary fixation device for the distal third of the femur.
Clin Orthop 125:185–191, 1977.
16. Marks DS, Isbister ES, Porter KM: Zickel supracondylar
nailing for supracondylar femoral fractures in elderly or in-
firm patients. J Bone Joint Surg 76B:596–601, 1994.
17. Mize RD, Bucholz RW, Grogan DP: Surgical treatment of
displaced, comminuted fractures of the distal end of the fe-
mur. J Bone Joint Surg 64A:871–879, 1982.
18. Pritchett JW: Supracondylar fractures of the femur. Clin Or-
thop 184:173–177, 1984.
19. Shahcheraghi GH, Doroodchi HR: Supracondylar fracture
of the femur: Closed or open reduction? J Trauma 34:499–
502, 1993.
20. Sanders R, Swiontkowski M, Rosen H, Helfet D: Double
plating of comminuted, unstable fractures of the distal part
of the femur. J Bone Joint Surg 73A:341–346, 1991.
21. Braden TD: Histophysiology of the growth plate and
growth plate injuries, in Bojrab MJ, Smeak D (eds): Disease
Mechanisms in Small Animal Surgery, ed 2. Philadelphia, Lea
& Febiger, 1993, pp 1027–1041.
22. Evans HE: Miller’s Anatomy of the Dog, ed 3. Philadelphia,
WB Saunders Co, 1993, pp 204–252.
23. Prieur WD, Braden TD, Rechenberg B: A suggested fracture
classification of adult small animal fractures. Vet Comp Or-
thop Trauma 3:111–116, 1990.
24. Unger M, Montavon PM, Heim UFA: Classification of frac-
tures of long bones in the dog and cat: Introduction and clin-
ical application. Vet Comp Orthop Trauma 3:41–50, 1990.
25. Aron DN, Palmer RH, Johnson AL: Biologic strategies and
a balanced concept for repair of highly comminuted long
bone fractures. Compend Contin Educ Pract Vet
17(1):35–49, 1995.
26. Palmer RH: Biological osteosynthesis. Vet Clin North Am
Small Anim Pract 29:1171–1185, 1999.
27. Piermattei DL, Greeley RG: An Atlas of Surgical Approaches
to the Bones of the Dog and Cat, ed 3. Philadelphia, WB
Saunders Co, 1996, pp 270–277.
28. Dietrich F, Chalman JA, Butler HC: The use of paired pins
Small Animal/Exotics
in the fixation of distal femur fractures in the dog and cat.
JAAHA 22:173–178, 1986.
29. Tarvin G, Froehlich PS: Surgical management of supra-
condylar femur fractures. Calif Vet 2:17–22, 1981.
30. Milton JL, Horne RD, Goldstein GM: Cross pinning: A sim-
ple technique for treatment of certain metaphyseal and phy-
seal fractures of the long bones. JAAHA 16:891–905, 1980.
31. Shires PK, Hulse DA: Internal fixation of physeal fractures
using the distal femur as an example. Compend Cont Educ
Pract Vet 2(11):854–861, 1980.
32. Alcantara PJ, Stead AC: Fractures of the distal femur in the
dog and cat. J Small Anim Pract 16:649–659, 1975.
33. Stigen O: Supracondylar femoral fractures in 159 dogs and
cats treated using a normograde intramedullary pinning
technique. J Small Anim Pract 40:519–523, 1999.
34. DeYoung DJ, Probst CW: Methods of internal fracture fixa-
tion, in Slatter D (ed): Textbook of Small Animal Surgery, ed
2. Philadelphia, WB Saunders Co, 1993, pp 1805–1817.
35. Whitney WO, Schraeder SC: Dynamic intramedullary
crosspinning technique for repair of distal femoral fractures
in dogs and cats: 71 cases (1981–1985). JAVMA 191:1133–
1138, 1987.
36. Lewis DD, van Ee RT, Oakes MG, Elkins AD: Use of re-
construction plates for stabilization of fractures and os-
teotomies involving the supracondylar region of the femur.
JAAHA 29:171–178, 1993.
37. Hulse D, Hyman W, Nori M, Slater M: Reduction in plate
strain by addition of an intramedullary pin. Vet Surg 26:
451–459, 1997.
38. Hulse DA, Aron DN: Advances in small animal orthopedics.
Compend Contin Educ Pract Vet 16(7):831–832, 1994.
39. Johnson AL, Smith CW, Schaeffer DJ: Fragment recon-
struction and bone plate fixation versus bridging plate fixa-
tion for treating highly comminuted femoral fractures in
dogs: 35 cases (1987–1997). JAVMA 213:1157–1161, 1998.
40. Klause SE, Schwarz PD, Egger EL, Piermattei DL: A modi-
fication of the unilateral type I external skeletal fixator con-
figuration for primary or secondary support of supracondylar
humeral and femoral fractures. Vet Comp Orthop Trauma
3:130–134, 1990.
41. Whitehair JG, Vasseur PB: Fractures of the femur. Vet Clin
North Am Small Anim Pract 22:149–159, 1992.
42. Clary EM, Roe SC: Enhancing external skeletal fixation pin
performance: Consideration of the pin-bone interface. Vet
Comp Orthop Trauma 8:1–8, 1995.
43. Anderson MA, Palmer RH, Aron DN: Improving pin selec-
tion and insertion technique for external skeletal fixation.
Compend Contin Educ Pract Vet 19(4):485–494, 1997.
44. Aron DN, Dewey CW: Application and postoperative man-
agement of external skeletal fixators. Vet Clin North Am
Small Anim Pract 22:69–97, 1992.
45. Langley-Hobbs SJ, Carmichael S, McCartney W: Use of ex-
ternal skeletal fixators in the repair of femoral fractures in
cats. J Small Anim Pract 37:95–101, 1996.
46. Guerin SR, Lewis DD, Lanz OI, Stalling JT: Comminuted
supracondylar humeral fractures repaired with a modified
type I external fixator construct. J Small Anim Pract
39:525–532, 1998.
47. Aron DN, Foutz TL, Keller WG, Brown J: Experimental
and clinical experience with an IM pin external skeletal fixa-
tor tie-in configuration. Vet Comp Orthop Trauma 4:86–94,
1991.
48. Robins GM, Eaton-Wells R, Johnson KA: Customized hook
plates for metaphyseal fractures, non-unions and osteotomies
Small Animal/Exotics
in the dog and cat. Vet Comp Orthop Trauma 6:56–61,
1993.
49. McLaughlin R: Internal fixation: Intramedullary pins, cer-
clage wires and interlocking nails. Vet Clin North Am Small
Anim Pract 29:1097–1116, 1999.
50. Dueland RT, Johnson KA: Interlocking nail fixation of dia-
physeal fractures in the dog. A multi-center study of
1991–1992 cases. Vet Surg 22:377–381, 1993.
51. Dueland RT, Berglund L, Vanderby R, Chao EYS: Structural
properties of interlocking nails, canine femora, and femur-in-
terlocking nail constructs. Vet Surg 25:386–396, 1996.
52. Helfett DL, Koval KJ: The management of fractures of the
tibial plateau. Int J Orthop Trauma 3:148–160, 1991.
53. Dueland RT, VanEnkevort: Lateral tibial head buttress plate:
Use in a pathological femoral fracture secondary to a bone
cyst in a dog. Vet Comp Orthop Trauma 8:196–199, 1995.
54. Stallings JT, Lewis DD, Welch RD, et al: An introduction
to distraction osteogenesis and the principles of the ilizarov
method. Vet Comp Orthop Trauma 11:59–67, 1998.
55. Lewis DD, Radasch RM, Beale BS, et al: Initial clinical ex-
perience with the IMEX circular external skeletal fixation
system. Part I: Use in fractures and arthrodeses. Vet Comp
Orthop Trauma 12:108–117, 1999.
56. Lewis DD, Radasch RM, Beale BS, et al: Initial experience
with the IMEX circular external skeletal fixation system: Use
in bone lengthening and correction of angular and rotational
deformities. Vet Comp Orthop Trauma 12:118–127, 1999.
Compendium November 2000
57. Marcellin-Little DJ: Fracture treatment with circular exter-
nal fixation. Vet Clin North Am Small Anim Pract 29:1153–
1170, 1999.
58. Lesser AS: Ilizarov technique, in Bojrab MJ, Ellison GW,
Slocum B (eds): Current Techniques in Small Animal Surgery,
ed 4. Baltimore, Williams & Wilkins, 1998, pp 950–963.
59. Lewis DD, Bronson DG, Samchukov ML, et al: Biome-
chanics of circular external skeletal fixation. Vet Surg
27:454–464, 1998.
60. Bardet JF, Hohn RB: Quadriceps contracture in dogs. JAV-
MA 183:680–685, 1983.
61. Hodges CC, Palmer RH: Postoperative physical therapy, in
Harari J (ed): Surgical Complications and Wound Healing in
the Small Animal Practice. Philadelphia, WB Saunders Co,
1993, pp 389–405.
62. Taylor RA, Lester M, Gannon JR: Physical therapy in ca-
nine sporting breeds, in Bloomberg MS, Dee JF, Taylor RA
(eds): Canine Sports Medicine and Surgery. Philadelphia, WB
Saunders Co, 1998, pp 265–274.
About the Authors
Dr. Lidbetter is affiliated with the Department of Small Ani-
mal Clinical Sciences, University of Tennessee, Knoxville.
Dr. Glyde is affiliated with the Department of Veterinary
Surgery, University College Dublin.