Embed Size (px)
Citation preview
For Review O
nly
Bilateral Maxilofacial Fracture in an Equine
Journal: Equine Veterinary Education
Manuscript ID: Draft
Wiley - Manuscript type: Case Report
Date Submitted by the Author: n/a
Complete List of Authors: Rondelli, André Luis; UFMT, CLIMEV Ávilla, Heidi Belle; UFMT, CLIMEV da Silva, Leilane; UFMT, CLIMEV Souza, Roberto; UFMT, CLIMEV Veronezi, Regina; UFMT, CLIMEV
Discipline: Diagnostic imaging: general, Surgery general
Body System/Disorder: Musculoskeletal: bone < Musculoskeletal
Abstract:
Mandible and maxillar fractures are most often caused by direct trauma, but occasionally, pathologic fractures may occur due to tumor lesions. The surgical approach is determined by the type and the location of the mandible fracture. A 3-year-old Arabic horse male was examined for a significant facial injury. On physical examination, asymmetric muzzle, and maxillar fracture were noted. Radiographic of the maxilla was consistent with bilateral transverse multiple fractures on the incisors and maxillary bones. Two surgical methods were used: cerclage wires and fixation with a U-bar which the latter was made using intramedullary pins molded into U shape in the entire length of the dental arcade. The therapy surgical presented a satisfactory outcome.
Equine Veterinary Education
For Review O
nly
1
Bilateral Maxilofacial Fracture in an Equine 1
A.L.H. Rondelli1, H.B.S. Ávila¹, L.A.Silva², R.L. Souza³, R.C. Veronezi1 2
3
1 Setor de Clínica de Grandes Animais e de Equinos. Universidade Federal de Mato Grosso (UFMT). Av. 4
Fernando Corrêa da Costa, 2367, Bairro Boa Esperança, Cuiabá, Mato Grosso CEP 78060-900, Brasil. 5
2 Laboratório de Patologia Veterinária. Universidade Federal de Mato Grosso (UFMT). Av. Fernando 6
Corrêa da Costa, 2367, Bairro Boa Esperança, Cuiabá, Mato Grosso CEP 78060-900, Brasil. 7
3 Setor de Cirurgia e Anestesiologia Veterinária. Universidade Federal de Mato Grosso (UFMT). Av. 8
Fernando Corrêa da Costa, 2367, Bairro Boa Esperança, Cuiabá, Mato Grosso CEP 78060-900, Brasil. 9
10
*Correspondence author email: [email protected] 11
Tel.: +55 65 36158662 12
Page 1 of 11 Equine Veterinary Education
For Review O
nly
2
Case Report 13
Summary 14
Mandible and maxillar fractures are most often caused by direct trauma, but occasionally, pathologic 15
fractures may occur due to tumor lesions. The surgical approach is determined by the type and the location of 16
the mandible fracture. A 3-year-old Arabic horse male was examined for a significant facial injury. On 17
physical examination, asymmetric muzzle, and maxillar fracture were noted. Radiographic of the maxilla 18
was consistent with bilateral transverse multiple fractures on the incisors and maxillary bones. Two surgical 19
methods were used: cerclage wires and fixation with a U-bar which the latter was made using intramedullary 20
pins molded into U shape in the entire length of the dental arcade. The therapy surgical presented a 21
satisfactory outcome. 22
23
Keywords: equine, osteosynthesis, bone, trauma, radiograph. 24
25
Introduction 26
Fractures of the mandible and maxilla are common in equine and usually are traumatic in origin 27
(DeBowes et al. 1981). Most facial injuries in equine results from falls, coices, collisions and trauma which 28
the mandibles bone are the most affected site. Moreover, iatrogenic fractures may also occur during dental 29
extraction or in some pathological conditions such as osteosarcoma and osteomyelitis (Turner 1984). Clinical 30
signs associated with mandibular fracture are excess salivation, facial swelling, difficulty in masticate, 31
hemorrhage, halitosis, instability of teeth or bones and tongue protrusion (Auer 2006; Freitas 2010). 32
In equine, numerous techniques of mandibular fracture repair have previously been described 33
(Belsito et al. 2001) with variable success including cerclage wires, wire and pin fixation, fixation with a U-34
bar, external fixation with Kirschner apparatus, lag screw fixation, methacrylate fixation and orthopedic bone 35
plating (Schneider 1990; Tremaine 1998). 36
A previous survey of equine clinical cases in United Kingdom (UK) revealed that the recorded 37
fractured cases were around 3.3%. The incidences of the fractures were also differed according to the 38
Page 2 of 11Equine Veterinary Education
For Review O
nly
3
affected region which 7% were caused by kick (Owen et al., 2012). In Brazil reports of surgery procedures 39
on equine maxillary fractures are sparse (Alves et al. 2008; Nóbrega et al. 2013). 40
The purpose of the present case is describes the osteosynthesis methods combination conducted on 3 41
years old male Arabe equine presented with bilateral premaxilla fracture. 42
Case history 43
A 3-year-old Arabe equine was presented to the Large Animal Hospital at the Federal University of 44
Mato Grosso with a history of bilateral premaxilla fracture. According to the owner the horse was kept under 45
semi stabled environment with other horses and the trauma was resulting from a muzzle kick taken by 46
another horse. 47
The horse was referred to the veterinary hospital one day after the facial injury. Upon evaluation by 48
the referring veterinarian, the equine had asymmetric muzzle, pain on palpation and the upper incisors were 49
displaced forward of the lower incisors which was loose handling (Fig 1). Radiographs were taken to 50
confirm the maxilla lesion and loss of some incisors teeth. 51
Clinical findings 52
Upon presentation, all vital parameters, a complete blood count and biochemistry were within 53
normal limits. No medication has been administered prior to the first examination. Standard radiographic 54
projections of the maxilla were obtained including the laterolateral and dorsoventral views. There were a 55
bilateral transverse multiple fractures on the incisors and maxillary bones as far rostral as caudal of the root 56
of the incisor teeth. Additional moderate harm of the alignment of the 3rd incisor and left canine teeth as well 57
as absence of the right upper canine tooth was also seen. 58
Treatment 59
In preparation for mandibular surgery was administered detomidina hydrochloride (Detomidin 1%)¹ 60
(0.05 mg/kg bwt i.v.) as a premedication to obtain adequate sedation. General anaesthesia was induced with 61
ketamine (ketamina Agener 10%)² (2mg/kg bwt i.v.) and maintained with guaiacol glyceryl ether (GGE 62
10%), ketamine (Ketamina Agener 10%)² (2 mg/ml bwt i.v.) and xylazine (Calmiun 2%)² (1 mg/ml bwt i.v.), 63
combination given intermittently (1-2ml/kg/h) according to the horse reaction for constancy and duration of 64
the anesthesia. In addition, infraorbital foramen block were performed with lidocaine 2% (Lidovet)³ (7ml). 65
The oral cavity and fracture site were thoroughly cleaned with sterile saline and povidone-iodine and then 66
the loose bone fragments were removed. Open wounds were also debrided and whased. 67
Page 3 of 11 Equine Veterinary Education
For Review O
nly
4
The equine was positioned in lateral recumbency under general anesthesia. The fracture stabilization 68
was achieved with a 1mm cerclage wiring between the first incisive teeth and right interdental space through 69
4mm holes made in the jaw bone with drill bit. Thereafter, the wiring was done over the left interdental space 70
passed in “X” manner. The intraoral lacerated soft tissue lesions and hard palate were sutured with nylon 71
(n.2). 72
The post-operative care included flunixin meglumine (Flunixina)4 (1.1mg/Kg bwt i.v.), administered 73
for 5 days and ceftiofur sodium (TopCef)5 (4mg/kg, bwt i.m.) while the bone exposure were noted. A 74
bandage in the maxillar region was replaced once or twice a daily. The mouth was flushed with tap water 75
after each meal to prevent food material accumulation around the wires. Also, chlorhexidine 0.12% 76
(Periogard)6 associated with Dakin solution was administrated in the gingival wounds and fracture. The 77
animal was maintained on semisolid diet composed by feed and Tifton hay crushed and moistened. 78
Additionally, vitamins (Hemolitan 20ml, PO; Glicopan 10ml, PO)7 were administrated orally daily for next 79
60 days. Approximately 11 days after, the equine required a second surgery with U-bar fixation due to 80
complications of the original injury characterized by loss of soft tissue around the fracture and detachment of 81
some bone fragments causing instability of the lesion. The bilateral maxillar fracture stabilization was done 82
through the use of two 4mm intramedullary pin which were molded into U shape in the entire length of the 83
dental arcade bilaterally. The brace pin was fixed to the incisor teeth and bone of the premaxilla by 1 mm 84
steel cerclage wires (Fig 2a). The cerclage wire (steel wire) placed on the right jaw in the first surgery was 85
maintained. Thereafter the wires were placed an intraoral splint was made by molding methyl methacrylate 86
resin around the interdental wires and hard palate (Fig 2b). Post operatively, was administered flunixin 87
meglumine (Flunixina®)4 (1.1mg/Kg bwt i.v.) for 5 days. Ceftiofur sodium (TopCef)5 (4mg/kg bwt i.v.) and 88
chlorhexidine 0.12% (Periogard)6 was applied locally administrated during all treatment. 89
After second surgery, radiographs were taken to evaluate bone calcification, healing or bone 90
sequestrum formation. At 60 days, the methyl methacrylate resin, intramedullary pin and cerclage wire were 91
removed and the maxilla repair was apparently stable. Hydrogen peroxide and chlorhexidine 0.12% 92
(Periogard)6 was applied locally and the dressings were done daily. Bone exposures were observed on the 93
surface of the hard palate and were debrided with a gauze order to stimulate granulation tissue and 94
epithelium overlying the hard palate. Two months after the second surgery, the radiological examination has 95
shown complete consolidation of the incisors and maxillary bones. Additionally, partial restoration of 96
Page 4 of 11Equine Veterinary Education
For Review O
nly
5
paranasal sinus, persisting on the left a small hiperluscente area was also seen. After 143 days of treatment, 97
the fracture was stabilized, the hard palate was healed and the horse was discharged. 98
Outcome 99
The owner was contacted at 12 weeks post-surgery. The equine was reported to have returned to the 100
previous level of activity, which included return out in the pasture. 101
Discussion 102
Reports of bilateral transverse maxillar fracture are rare to seen in clinical practice (Beard 2010). The 103
history of previous trauma in the equine maxillofacial region led to the development of lesion which is in 104
agreement with other equine cases reported in the literature (Gopinathan et al. 2013). For each type of 105
fracture there are many available options and techniques can be easily combined or modified as necessary to 106
achieve the goals of alignment and stability (Beard 2010). In this case, the bilateral maxillar fracture was 107
highly unstable and was accompanied by a variable amount of comminution and loss of the right canine 108
tooth compromising the use of some methods of fracture repair. 109
In the first surgery, the anatomic reduction was achieved and the cerclage wire repair was completely 110
stable. However, maxillar fractures are often high-energy fractures with comminution and disruption of the 111
skin or oral mucosa and consequently they are prone to sequestration (Haralambus et al. 2010). On 11th 112
postoperative day, it was observed fracture instability as a result of damage of soft tissue and sequestrum 113
formation from avascular bone fragments. Studies have record up to 68% complications in unstable bilateral 114
maxillary and mandibular fractures in horse (Henninger et al. 1999). Our result is in agreement with the 115
outcome of 2 retrospective studies (Henninger et al. 1999; Reif et al. 2000) where sequestration was reported 116
to be a common complication after mandibular fractures in horses and cattle. Application of U-bar repair 117
should be considered when intraoral wiring alone does not provide sufficient stability of an equine maxillar 118
fracture (Belsito et al. 2001). In the current case, the intraoral splint generally made from aluminum rods or 119
malleable brass was replaced by two intramedullary pins which together were molded around the contours of 120
the maxilla in U-shaped suggesting that this fixation method is practical and it might be possible to make this 121
adaptation with a little instrumentation and low costs. 122
As reported previously (Henninger et al. 1999), average hospitalisation time was 11 days for houses 123
repaired via U-bars. Meanwhile, the median hospitalisation time was 132 days after de second surgery in the 124
current study. A possible explanation might be the excessive presence of multiple small fragments of 125
Page 5 of 11 Equine Veterinary Education
For Review O
nly
6
avascular bone causing the formation of large areas of tissue necrosis making healing difficult. Moreover, a 126
direct kick can transfer a force of more than 10,000 Newtons of impact to any location of the equine head 127
and affected a large surface area (Leach et al. 1983; Exadaktylas et al. 2002) making the time for healing and 128
tissue repair jaw fractures in horses are associated with the type of injury and the type of fracture. 129
In the case of equine maxillar fractures, the primary objectives are to restore the patient`s ability to 130
eat normally in the immediate postoperative period and to achieve a strong and lasting fracture repair 131
(Belsito et al. 2001). Although it has been reported that techniques using cerclage wires, intramedullary pins 132
and U-bar need to force feeding via nasograstric tube or indwelling oesophagostomy tube (Lischer et al. 133
1997), the horse in the current study was not required forced feeding and was able to eat within 24h of 134
surgery. Nevertheless, the choice of paste food was an attempt to minimize the movement of areas 135
undergoing osteosynthesis according to Lopes et al. (2001). 136
Radiographs are the main imaging modality used in veterinary medicine to characterize the bone 137
fractures. In the present case, although a diagnosis could be made clinically, a through radiographic 138
evaluation was important to determinate the extent of the injury and a presence of bony fragments, which 139
may sequestrate. 140
In conclusion, the present study confirms that surgical therapy is effective in providing a favorable 141
prognosis in the bilateral maxillar fracture. Future studies evaluating maxillar and mandible fractures, with 142
sufficient numbers of horses to perform inferential statistics are warranted. 143
Authors’ declaration of interests 144
No conflicts of interest have been declared. 145
146
Manufactures addresses 147
¹Syntec. Cotia, São Paulo, Brasil. 148
²União Química Farmacêutica Nacional SA. São Paulo, São Paulo, Brasil. 149
³Bravet. Rio de Janeiro, Rio de Janeiro, Brasil. 150
4 UCB Saúde Animal. Jaboticabal, São Paulo, Brasil. 151
5 Eurofarma. São Paulo, São Paulo, Brasil. 152
6 Colgate-Palmolive Ind. e Com. Ltda São Paulo, São Paulo, Brasil. 153
7 Vetnil Ind. e Com. de Produtos Veterinários Ltda. São Paulo, São Paulo, Brasil. 154
Page 6 of 11Equine Veterinary Education
For Review O
nly
7
References 155
Alves, G.E.S., Pagliosa, G.M., Oliveira, H.P., Gheller, V.A., Faleiros, R.R. (2008) Fraturas odontomaxilares 156
e mandibulares em equídeos tratados por diferentes técnicas de osteossíntese. Arq. Bras. Med. Vet. Zootec. 157
60, 1382-1387. 158
Auer, J.A. (2006) Craniomaxillofacial Disorders. In: Equine Surgery, 3rd edn, Ed: Auer, J.A., Stick, J.A., 159
Saunders: Missouri, pp. 1341-1361. 160
Beard, W. (2010) Fracture repair techniques for the equine mandible and maxilla. Equine Vet. Educ. 21, 352-161
357. 162
Belsito, K.A., Fischer, A.T. (2001) External skeletal fixation in the management of equine mandibular 163
fractures: 16 cases (1988-1998). Equine vet. J. 33, 176-183. 164
DeBowes, R.M., Cannon, J.H., Grant, B.D., Nickels, F.A. and Wagner, P.C. (1981) Lag screw fixation of 165
rostral mandibular fractures in the horse. Vet. Surg. 10, 153-158. 166
Exadaktylos, A.K., Eggli, S., Inden, P. Zimmermann, H. (2002) Hoof kick injuries in uncounted equestrians. 167
Improving accident analysis and prevention by introducing an accident and emergency based relational 168
database. Emerg Med J. 19, 573-5. 169
Freitas, F.C., Agostinho, J.M.A., Moraes, A.B.T., Brasil, F.B.J. (2010) Osteossíntese associada à homeopatia 170
na consolidação óssea de fratura mandibular em equino. Nucleus Animalium. 2, 117-122. 171
Gopinathan, A., Singh, K., Saxena, A.C., Mohsina, A., Boh, D., Mahan P., T. (2013) Successful Surgical 172
Repair of Rostral mandible and Maxilla Fracture with Cross Pinning and Cerclage Wire in a Horse. Vet. 173
Scan.7, 68-72. 174
Haralambus, R.M.A., Werren, C., Brehm, W., Tessier, C. (2010) Use of a pinless external fixator for 175
unilateral mandibular fractures repair in nine equids. Vet Surg. 39, 761-764. 176
Page 7 of 11 Equine Veterinary Education
For Review O
nly
8
Henninger, R.W., Beard, W.L., Schneider, R.K., Bramlage, L.R., Burkhardt, H.A. (1999) Fractures of the 177
rostral portion of the mandible and maxilla in horses: 89 cases (1979-1997). J Am Vet Med Assoc. 214, 1648-178
1652. 179
Leach, D.H., Dagg A.I. (1983) A review of research on equine locomotion and biomechanics. Equine Vet J. 180
15, 93-102. 181
Lischer, C.J., Fluri, E., Kaser-Hotz, B. et al. (1997) Pinless external fixation of mandible fractures in cattle. 182
Vet Surg. 26,14-19. 183
Lopes, M.A.F., Pompermayer, L.G., Felipe, A.H.B., Araujo, I.C. (2001) Nutrição de equinos via 184
esofagostomia. Cienc. Rural. 31, 135-139. 185
Nóbrega, F.S., Ferreira, M.P., Alievi, M.M., Beck, C.A.C., Gonzalez, P.C., Dal-Bó, I.S., Stédile, R. (2013) 186
Osteossíntese de mandíbula e maxila em equinos adultos: relato de quatro casos. Arq. Bras. Med. Vet. 187
Zootec. 65, 1706-1712. 188
Owen, K.R., Singer, E.R., Clegg, P.D., Ireland, J.L., Pinchbeck, G.L. (2012) Identification of risk factors for 189
traumatic injury in the general horse population of north-west England, Midlands and north Wales. Equine 190
Vet J. 44, 143-148. 191
Reif, U., Lischer, C.J., Steiner, A. (2000) Long-term results of bovine mandibular fractures involving the 192
molar teeth. Vet Surg. 29, 335-340. 193
Schneider, R.K. (1990) Mandibular fractures. In: Current Practice of equine Surgery, 1st edn., Eds: N.A. 194
White and Moore, J.B. Lippincott Co., Philadelphia. 589-595. 195
Tremaine, W.H. (1998) Management of equine mandibular injuries. Equine Vet. Educ. 10, 146-154. 196
Tuner, A.S. (1984) Conditions of the mandible and maxilla. In: The Practice of Large Animal Surgery, 2nd 197
edn, Ed: P.B. Jennings, W.B. Saunders Co., Philadelphia. Pp. 893-897. 198
199
200
Page 8 of 11Equine Veterinary Education
For Review O
nly
9
Figures 201
Fig.1. Equine, male. Maxilla. Multiple rostral maxilla fractures and canine tooth falling out. 202
Fig.2. A. Maxilla recovered with methyl methacrylate resin. B. U-bar fixation technique thought the use of 203
intramedullary pin. 204
Page 9 of 11 Equine Veterinary Education
For Review O
nly
Equine, male. Maxilla. Multiple rostral maxilla fractures and canine tooth falling out. 148x197mm (300 x 300 DPI)
Page 10 of 11Equine Veterinary Education
For Review O
nly
Maxilla recovered with methyl methacrylate resin. B. U-bar fixation technique thought the use of intramedullary pin.
252x101mm (300 x 300 DPI)
Page 11 of 11 Equine Veterinary Education
