214 Clinical Communication

Clinical Outcomes and Complications after Open

Reduction and Internal Fixation Utilizing
Conventional Plates in 65 Distal Radial and Ulnar
Fractures of Miniature- and Toy-Breed Dogs
Takeshi Aikawa1 Yuta Miyazaki1 Taichi Shimatsu1 Kyoko Iizuka1 Masaaki Nishimura1

1 Department of Surgery, Aikawa Veterinary Medical Center, Address for correspondence Takeshi Aikawa, BVSc, PhD, Diplomate
Tokyo, Japan JCVS, Department of Surgery, Aikawa Veterinary Medical Center,
4-3-1 Nishi-ochiai Shinjuku-ku, Tokyo 161-0031, Japan
Vet Comp Orthop Traumatol 2018;31:214–217. (e-mail: taikawa@wb3.so-net.ne.jp).

Abstract Objective This article aims to evaluate clinical outcomes and complications of distal

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radial and ulnar fractures in miniature- and toy-breed dogs treated with conventional
bone plate fixation.
Methods Medical records (2001–2010) of miniature- and toy-breed dogs with distal
radial and ulnar fractures repaired with open reduction and internal fixation utilizing
conventional plates were reviewed. The inclusion criteria were body weight of <7 kg,
fracture located in the distal antebrachium (distal-to-total radial length ratio < 0.4)
and follow-up radiographs available.
Keywords Results All 65 fractures healed without developing non-union, and had a successful
► distal radial and ulnar return to normal function (median follow-up: 73 months; range: 2–149 months). Minor
fracture complication in seven fractures and major complication in four fractures were
► conventional plate identified.
fixation Clinical Significance Open reduction and conventional plate fixation of distal radial
► miniature- and toy- and ulnar fractures in miniature- and toy-breed dogs are effective means of fixation that
breed result in normal functional outcome without developing non-union.

Introduction Distal radial and ulnar fractures in miniature- and toy-

Distal radial and ulnar fractures are common in miniature- and
toy-breed dogs.1,2 Several techniques of distal radial and ulnar
fracture fixation in miniature- and toy-breed dogs with casts,
intramedullary pinning, or external skeletal fixation have been
reported.2–4 Open reduction and bone plating are the treat-
ment of choice for radial and ulnar fractures.5–8 It has been
reported that distal radial and ulnar fractures in miniature-
and toy-breed dogs have a high risk of delayed union or non-
union because of poor intraosseous vascularity and limited
periosseous soft-tissue coverage compared with larger dogs.9
Due to the reported high complication rate in distal radial and
ulnar fractures in miniature- and toy-breed dogs, various
modified treatment methods have been presented recently.1,2
breed dogs may be more challenging to stabilize because
these fractures have often limited space available for screw
and plate placement in the short distal bone fragment.8
Although the high complication rate and non-union of distal
radial and ulnar fractures in miniature- and toy-breed dogs
were historically reported,3,4 recent studies have shown that
conventional plate fixation of these fractures are not asso-
ciated with such a high complication rate when fractures are
treated with an appropriately sized bone plate.6,10,11
The purposes of this study are to report the effectiveness
and clinical outcomes of distal radial and ulnar fractures in
miniature- and toy-breed dogs treated by one surgeon with
open reduction and internal fixation utilizing conventional
plates and to document the related complications.

received Copyright © 2018 Schattauer DOI https://doi.org/

February 9, 2017 10.1055/s-0038-1639485.
accepted after revision ISSN 0932-0814.
January 30, 2018
 Clinical Outcomes and Complications after Open Reduction and Internal Fixation
Materials and Methods
Inclusion Criteria
Medical records of miniature- and toy-breed dogs admitted
to the Aikawa Veterinary Medical Center between 2001 and
2010 with fractures of distal radius and ulna treated by open
reduction and internal fixation utilizing conventional plates
by one surgeon (T.A.) were reviewed. Criteria for inclusion in
this study were body weight of 7.0 kg or less, fracture located
in the distal antebrachium (distal-to-total radial length ratio
<0.4) and follow-up radiographs available.
Medical Records Review and Fracture Descriptions
Data pertaining to breed, body weight, age, sex, affected limb,
fracture configuration, width of the radius at the fracture
site, location of the fracture (ratio of the distal fragment
length/overall radial length), used surgical implants (plate,
screw), postoperative fracture reduction, use of postopera-
tive bandage or splint, outcome and complications were
recorded.
Stabilization Description
Surgical treatment was performed with the dog positioned
in lateral recumbency with the affected limb uppermost,
using a craniolateral approach.12 Anatomical reduction was
achieved followed by cranial plate application. Closure of the
surgical wound was routine. Postoperative radiographs were
taken immediately to evaluate fracture reduction and
implant position. Postoperative fracture reduction was eval-
uated for translational malalignment: mediolateral or cra-
niocaudal displacement of the distal bone fragment relative
to the proximal fragment, determined as the ratio of the
maximal displacement to the width of the bone at the level of
the fracture site. Percentages were grouped as <5% (perfect
to near anatomical reduction), <10%, <25% and >25%.1 A
modified Robert–Jones bandage was applied to all patients
24 hours postoperatively.
Outcome Evaluation
All dogs were evaluated radiographically and clinically 3 to
4 weeks after surgery, and monthly radiographs were
obtained for 3 to 4 months to evaluate progress of fracture
healing. Bone union was defined as the point when bridging
callus was present or when the fracture line was no longer
visible. If possible, annual follow-up radiographs were
obtained.
Complications were considered minor if they were man-
aged without any surgery and major if they required
surgery. For dogs that were not re-examined with annual
follow-up radiographs, last long-term follow-up was con-
ducted by telephone interview with the owner or the
referring veterinarian. Owners or referring veterinarians
were asked to describe the dog’s limb function. Limb
function was classified as four grades: normal, occasional
lameness, severe weight-bearing lameness or non–weight-
bearing lameness. Additional questionnaires were used:
Does the dog have any other problems? Does the dog
need further surgery?
Aikawa et al. 215
Results
Animals
Sixty-five fractures in 62 dogs met the inclusion criteria.
Breeds represented were Toy Poodle (n ¼ 20), Italian Grey-
hound (n ¼ 14), Papillon (n ¼ 7), Pomeranian (n ¼ 7), Chi-
huahua (n ¼ 6), Yorkshire Terrier (n ¼ 2), Miniature
Schnauzer (n ¼ 2), Miniature Pinscher (n ¼ 1) and cross-
breed (n ¼ 3). The median body weight and age were 3.0 kg
(range: 1.0–6.2 kg) and 11 months (range: 3–96 months),
respectively. Twenty-nine dogs were males (6 were
castrated), and 33 dogs were females (5 were spayed;
see ►Supplementary Table S1, available in online version
only).
Fracture Description
All 65 fractures were simple and closed, and 30/65 fractures
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were transverse and 35/65 were short oblique fractures.
There were 39 left fractures and 26 right fractures. Bilateral
fractures occurred in 3 of 62 dogs. The mean width of the
radius at the fracture site was 5.9 mm (  1.2 mm; range:
4.0–9.0 mm). Mean length of the distal fragments was
18.6 mm, with a mean distal-to-total radial length ratio of
0.21 (0.07–0.39; see ►Supplementary Table S2, available in
online version only).
Stabilization Method
All fractures were treated with a 2.7-, 2.0- or 1.5-mm bone
plates on the basis of the patient size, bone size, fracture
configuration and surgeon preference. All screws were self-
tapping. Plates used were as follows: 2.7-mm dynamic
compression plate (DCP; DePuy Synthes Vet, West Chester,
Pennsylvania, United States; n ¼ 4), 2.7/2.0-mm veterinary
cuttable plate (VCP; Cut-To-Length Plate: DePuy Synthes Vet;
n ¼ 6), 2.0-mm DCP (n ¼ 11), 2.0/1.5-mm VCP (n ¼ 3), 2.0-
mm straight plate (n ¼ 25; Straight Plate: DePuy Synthes
Vet), 1.5-mm straight plate (n ¼ 6) and 2.0/1.5-mm T-plate
(2.0-mm/1.5 mm T-Plate: DePuy Synthes Vet; n ¼ 10). Com-
pression of the bone fragments was achieved in most frac-
tures treated with a DCP or T-plate. On postoperative
radiographs, 61 had perfect-to-near anatomical reduction
(<5%), 4 had <10% of translational malalignment. A modified
Robert–Jones bandage with the splint rod attached was
applied to 44 fractures. This bandage was typically used in
patients with only two screws placed in the distal fragment,
bilateral fractures or the owners were unable to restrict the
activity. The median duration of bandage application was
21.5 days (range: 0–74 days; see ►Supplementary Table S2,
available in online version only).
Outcome Evaluation and Complications
Radiographic evidence of bone union was confirmed in all 65
fractures with radiographic follow-up. None of the fractures
developed non-union.
Minor complications were observed in seven fractures
(10.8%). Minor complications included skin dehiscence
(n ¼ 2) and pressure sores associated with postoperative
modified Robert–Jones bandage with the splint rod (n ¼ 4).
Veterinary and Comparative Orthopaedics and Traumatology Vol. 31 No. 3/2018
216 Clinical Outcomes and Complications after Open Reduction and Internal Fixation
Screw loosening was radiographically detected in one dog
12 months postoperatively. This dog had no treatment
because the dog showed no lameness and the owner declined
further surgical procedure.
Major complications were observed in four fractures
(6.2%). All four fractures required plate removal. These
complications included exposure of the plate (n ¼ 2), repe-
titive skin ulceration (n ¼ 1) and osteopenia (n ¼ 1). All dogs
that had plate exposure or skin ulceration were Italian
Greyhound and plates used were 2.7/2.0-mm VCP (n ¼ 2)
and 2.0-mm T-plate (n ¼ 1). The median time to plate
removal was 17 months postoperatively (range: 4–44
months). None of these cases had plate or screw breakage.
In the four dogs that required plate removal, a 10-month-old
Italian Greyhound was re-presented because of re-fracture
58 days after plate removal, and the re-fracture was treated
with external skeletal fixation. The functional outcome was
normal at the last follow-up, 68 months after the original
surgery. The dog with osteopenia detected at the 2-month
radiographic follow-up was 7-month-old Toy Poodle weigh-
ing 2.3 kg, and plate used was 2.0-mm straight plate. Of the
six screws placed in this case, four screws were first removed
for destabilization 61 days after the original surgery, and
Fig. 1 Craniocaudal and mediolateral radiographs of the right antebrachium of a 7-month-old Toy Poodle (dog 21). (A) Transverse fracture of the
distal radius and ulna. (B) Postoperative stabilization with a 2.0-mm straight plate. (C) Radiographic follow-up at 2 months postoperatively,
osteopenia was detected. (D) One-month follow-up radiographs post destabilization. (E) Follow-up radiographs at 2 months after plate removal.
Veterinary and Comparative Orthopaedics and Traumatology Vol. 31 No. 3/2018
Aikawa et al.
then the remaining two screws and plate were removed
73 days after the destabilization (►Fig. 1). The dog did not
have re-fracture, and had a normal functional outcome at the
last follow-up, 93 months after the original surgery.
All dogs in this study had a successful fracture union and
return to normal function at the last follow-up with either
follow-up radiographs or telephone interview (median:
73 months; range: 2–149 months).
Discussion
This study demonstrated that all distal radial and ulnar
fractures in miniature- and toy-breed dogs treated with
open reduction and conventional plate fixation resulted in
a successful fracture union and return to normal function at
the last follow-up.
In the present study, most frequent complications were the
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skin problems. One explanation for the occurrence of this
condition could be that there are limited soft tissue volumes in
miniature- and toy-breeds or sighthounds,13 suggesting these
breeds are susceptible to developing skin complications asso-
ciated with the plate or modified Robert–Jones bandages, and
extreme care should be taken.13 The controversial decision
 Clinical Outcomes and Complications after Open Reduction and Internal Fixation
whether to apply postoperative modified Robert–Jones ban-
dage with sprint rod attached for precaution was made based
on the evaluation of the surgical repair and the implant
strength. One would expect that postoperative bandage pro-
vides initial stability to the repair, allowing the surgeon to
select smaller plates, which may alleviate osteopenia due to
the vascular compromise or latent stress protection and the
need for subsequent implant removal.11 In retrospect, the
application of the postoperative modified Robert–Jones ban-
dages in some cases might have been unnecessary.
Excessively rigid plate fixation has historically been con-
sidered to associate with the stress protection and subse-
quent osteopenia, which may in part be responsible for re-
fracture risk.14,15 Stress protection–induced osteopenia has
been reported as a frequent (7.1–20%) finding after plate
fixation of distal radial and ulnar fractures in miniature- and
toy-breed dogs.5–7 The low incidence (1.5%; 1/65) of osteo-
penia in the present study may in part be because of selection
of appropriate plate size with proper technique. Stress
protection–induced osteopenia can be detected following
long-term plate application15; therefore, inconsistent long-
term annual radiographic follow-up evaluations in the pre-
sent study may have underestimated the true incidence. On
the other hand, a recent study suggested that vascular
compromise to the bone cortex is responsible for the devel-
opment and progression of osteopenia.16 Stress protection
may not be an important factor affecting bone adaptation
after plate fixation of the distal radial and ulnar fractures in
miniature- and toy-breed dogs, and routine plate removal is
not necessary when fractures are treated with an appro-
priate manner using a plate of appropriate size.5,6 Plate
removal is indicated only if there is a specific need.
In the dog with osteopenia, the 2-mm screws occupied
40% of the 5 mm width of radius bone, as the maximum size
allowed for the bone17 may have reduced the bone strength
or have impaired the vascular supply resulting in osteope-
nia.9,16 The removal of the plate and screw resulted in
gradual increase of radial bone density in this dog. The
clinical significance of osteopenia needs to be further inves-
tigated, but it is beyond the scope of this study.
Major limitations are inherent to the retrospective design
of our study. Inconsistent and sporadic radiographic follow-
up evaluations did not allow us to precisely determine the
earliest time to union. A further limitation is our lack of
consistent and objective measurement of functional out-
comes. Evaluation of long-term outcome was performed
mainly by the owners using a telephone interview. Therefore,
detailed limb functions were frequently not included in the
medical record.
From the results of this study, we conclude that open
reduction and internal fixation using conventional plate of
distal radial and ulnar fractures in miniature- and toy-breed
dogs is an effective means of fixation that results in normal
functional outcome without developing non-union.
Conflict of Interest
None.
Aikawa et al. 217
Author Contribution
Takeshi Aikawa contributed to the conception of study,
study design, and data analysis and interpretation. The
author also drafted and revised and approved the submitted
manuscript. Taichi Shimatsu, Kyoko Iizuka, and Masaaki
Nishimura contributed to acquisition of data. Yuta Miyazaki
contributed to acquisition of data, and data analysis and
interpretation and drafted and revised the submitted
manuscript.
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