A Novel Approach to Tibiotarsal Fracture Management in the ...

splints are meant to keep an animal upright and enable weightbearing on the lower edge of the splint, which works well forcanine, feline, raptors, and psittacines. Furthermore, traditionalST splints limit the ability of waterfowl to rest sternally recumbentand they create pressure on the femoral nerve, damaging nervefunction and rendering the affected foot unable to naturally flexor to function normally.The endangered Hawaiian nene (Branta sandvicensis) goose isan example of such a weight-bearing bird. Due to human impact,this species has been pushed to occupy hazardous landscapes suchas golf courses, where they are occasionally struck by golf balls.This can result in fractures and, in the past, has required lengthywildlife rehabilitation times. At Three Ring Ranch (TRR), anexotic animal sanctuary and native wildlife rehabilitation centerbased in Kona, Hawai’i, the average admission period for thisinjury was 4–6 mo but has taken as long as 10 mo. With theutilization of the Schroeder–Thomas–Goody (STG) modifiedsplint, rehabilitation time was dramatically reduced due to thelightweight structure and the resulting accessibility of the footfor physical therapy within just days of surgery. The nene, bandnumber 446 by the Hawai’iDepartment of Land and NaturalResources (HDLNR),was the first case using themodified splint. This nene wasreleased after only 5 wk.Natural history of theHawaiian nene goose(Branta sandvicensis)Believed to be a descendant ofboth the lesser Canada goose(Branta canadensis parvipes)and the lesser snow goose(Chen caerulescens caerulescens),the nene, state bird ofHawai’i, is an endangeredspecies endemic to the state. Unlike its migratory cousins, nenesnever leave the islands and have the smallest range of any goose.With terrestrial habits, the nene possess stouter legs, shorter wings,and partial loss of webbing. These geese are grazers that spend mostof their time browsing in grasses, feeding predominantly on plantmaterial, and do not actively seek insects or other invertebrates.The birds undergo a complete molt of their feathers over a periodof 6–8 wk which coincide with the rearing of their young. Likemany island species, the nene evolved in an environment absent ofpredators and became the only surviving goose in Hawai’i. Arrivalof the first humans pushed the birds to the rockiest, harshestenvironments in which they were forced to travel great distancesto forage and maintain their metabolic intake. This resulted in thesturdy and comparatively robust goose we know today. Dramaticdecline in their numbers is attributed to their lack of fear responsetoward humans and to introduced mammalian predators. Adult8 Journal of Wildlife RehabilitationFigure 2. Pre-operative radiograph of tibiotarsal fracture.nene fell easy prey to humans, while their egg and young populationswere decimated by predation. Habitat destruction limitedthe nene’s ability to feed and breed, subsequently limiting theirpopulation’s ability to recover. Between the 1890s and 1940s, thenene population plunged from 25,000 to 30 individuals. Breedingprograms began in the mid-1950s, and the goose was listed asendangered under the Endangered Species Act on 28 December1973 (16 U.S.C. §1531 et. seq.). Repopulation programs are inplace and have had the most success on the mongoose-free islands.Approximately 1,950 nene exist in the wild today with 416 onMaui, 165 on Molokai, 850–900 on Kauai, and 457 on the islandof Hawai’i (U.S. Fish and Wildlife Service 2010).Clinical NotesIntakeThe trauma to nene 446 occurred on 27 January 2011 as a resultof a golf ball strike. The bird was delivered by the HDLNR fortreatment 5 days later. A left leg fracture was suspected due tosignificant displacement and consequential shortening of thelimb. Initial physical exam and radiographs revealed a transversetibiotarsal fracture of the left leg.The foot had good circulationbut was folded, rotated, anddeveloping contractures. Thebird was thin but not emaciated.All other findings were normal.When the bird was preppedfor surgery and anesthetized, ahealing skin break was noted,changing the diagnosis to anopen comminuted fracture.Upon intake (Fig. 1), nene446’s initial radiograph (Fig. 2)showed a significant transversemidshaft tibiotarsal fracture.The bird was kept still in a smallICU crate until surgery. Swellingimmobilized the injured limb sufficiently until surgery the nextmorning. The bird was medicated for pain with an intramuscular(i.m.) injection of buprenorphine 0.006 mg. The patient was a3-yr-old, otherwise healthy ambulatory bird and was, therefore,a good anesthetic candidate for internal fixation. (Hawaiian neneare all banded by the HDLNR prior to first flight, so we knewnot only the hatch year but the geographical location at whichthe bird was hatched.) We had the availability of an exceptionallytrained orthopedic surgeon, Jacob Head, D.V.M., who donatedhis time and services to operate on nene 446 on 3 February 2011.Surgery and splintingThe midshaft tibiotarsal fracture was reduced with an openapproach to the lateral surface of the fracture site. Closed reductionalone was not enough to adequately reduce the fracture ends due toa large soft-tissue callus already present at the time of surgery. Once

the fracture was reduced, an intramedullary pin was introducedfrom the distal lateral condyle of the tibiotarsal bone and pushedproximally through the fracture site and ending in the proximalsegment. The intramedullary pin was 3/32 in (0.24 cm) in diameterand was placed 4.33 in (11 cm) into the tibiotarsus, continuing3.92 in (9.90 cm) proximal to the fracture. The distal end of thepin was bent to prevent displacement. The patient was inducedusing isoflurane (isofluorane USP; Baxter, Deerfield, Illinois, USA)delivered through a mask at a rate of 2–3 L/min at an initial 3.5percent and a maintenance rate of 2.5–3.0 percent. A brief increaseto 3.5 was requiredduring alignment ofthe fracture ends.We determinedthat the intramedullarypin would allowadequate bending ofdistal joints and providefor stability of the fractureends. The incisionwas closed with monofilamentabsorbable suture.The bird was medicatedfor pain with an injectionof buprenorphine 0.006mg i.m. at the time of surgeryand again 12 hr postoperatively.Additional painmedication was providedonce daily for 3 days.The STG modifiedsplint was applied whilethe patient was under anesthesiato provide externalsupport to the leg and foot.Surgery lasted for 2 hr, significantlylonger than theanticipated time of half anFigure 3. The ST-modified (Schroeder–Thomas–Goody; STG) splint frame.modifiedsplintframetibiotarsusfractureIM pinboot tosupport footin functionalpositionFigure 5. Illustration of modifiedsplint with relationship to legand body of nene.hour for similar procedures. The extended surgery time was dueto severe edema, fracture displacement, and contracture complicationsexacerbated by the prolonged period between the time ofinjury and the time of admittance for treatment (verified to be 5days based on eyewitness report of initial injury).The STG splint provided two novel features that played acrucial role in accelerating the rehabilitation of the patient. First,the traditional ST splint was modified from having a fully enclosedring at the pelvic end to having a semicircle that supported thelateral lower abdomen (Figs. 3, 4). This modification allowed forfull pivoting of the hip while providing rotational stability of thefracture, and it also permitted immediate weight-bearing by thebird. With the reduction of splint material at the pelvic end, theSTG splint also accommodated the nene’s natural tendency to reststernally recumbent; a traditional ST splint would have interferedIllustration: Ann Goodywith a nene’s ability to rest naturally and the injured limb wouldbe forced into a tripod angle when resting in a recumbent position.The splint was well tolerated and the patient was, overall, morecomfortable during recovery when compared to prior similar cases.Second, although the base of the bird’s foot was enclosed bythe splint frame and the hock of the bird secured to the splint bybandage tape, the foot itself remained exposed (see illustrationin Fig. 5). This modification enabled access to the foot, allowingphysical therapy to begin at 72 hr without removal of the splint.After application of the modified splint, a supportive boot wassecured to the foot for10 days to limit contracturesand maintainposition of function.The sole and heel of theboot was constructedfrom a tongue depressorpadded with bandagetape. Half of thetongue depressor waspressed flat against theplantar surface of thefoot so that the footwas in the full positionof function; the secondhalf created the heel ofthe boot. The L-shapedboot was secured toFigure 4. Post-operative radiographof STG modified splint and intramedullarypinthe foot with bandagetape, leaving access tothe distal half of thefoot. This boot prevented contractures by flexing the hock andextending the digits, thereby minimizing the duration of physicaltherapy required.Post-operative careNene 446 was housed in a 3 × 6 × 6 ft (0.9 × 1.8 × 1.8 m) indoorcage that limited excessive mobility. To further minimize stressand activity, a screen provided a visual barrier. Physical therapybegan 72 hr after surgery and consisted of passive range-of-motionof the toes, including flexion and extension. The boot providedpressure to the sole of the foot, which prevented hyperextensionof the hock and balling of the foot. Physical therapy occurredinitially as sets of five repetitions, five times daily and graduallyincreased to 20 repetitions, five times daily for the first 10 days.Physical therapy after the boot was removed continued similarly,with the hock being included in the passive range-of-motion andflexion and extension exercises.The intramedullary pin and the STG modified splint wereremoved under anesthesia on 1 March 2011. A radiograph taken toassess the fracture site showed a well-formed callus (Fig. 6). Physicalassessment of the surrounding soft tissue showed no edema.To decrease the likelihood of re-injury, housing the patient