by Gillian Hick
I drove home after the first session on a high of depth gauges and drill bits, screw diameters and sizes. The Saturday morning continued with lectures which led to an afternoon of ‘cadaver practicals’ – putting the lectures into practice on real, although sadly, deceased, canine bodies. By Saturday afternoon, I was delighted to find myself happily drilling a pin into a femur and wiring it in place with a series of orthopaedic wires.
The twenty delegates were a very mixed group, some totally green, like myself, but also including people who could probably have given the course themselves, but all with an interest in orthopaedics. The whole atmosphere was one of total enthusiasm, with the more experienced vets delighted to show ‘the youngsters’, like myself, their own little tips and techniques. The lunchtimes and tea-breaks ended up being just as informative as the practical sessions and lectures. By the first Sunday afternoon, I came away with one job offer – should I ever want to take it – and a few phone numbers of like-minded vets with whom I still keep in touch.
As usual, Seamus wasn’t overly enthusiastic with my new-found skills. He laughed when I displayed the new ‘toys’ that I had ordered while on the course – the basic tools to carry out some orthopaedic repairs. While I waited for a suitable case, it was noticeable that the queues in the evening clinics lengthened considerably as each patient was treated to a thorough orthopaedic examination, regardless of their presenting problem.
With the second part of the course not due until the following spring, my enthusiasm had waned somewhat by Christmas, when I still hadn’t had a chance to put any of my new skills to use. It seemed that the cats and dogs of Wicklow had developed an innate street sense that they had previously lacked. The lectures themselves were gradually becoming a bit of a blur.
However, one morning in January, a time of year when mixed practice is usually relatively quiet, Arthur rang to tell me that he had admitted a dog he thought might need to have his leg pinned. I was ecstatic, hoping against all hope that the fracture would be a type that had been covered in the first course. Skipping lunch, I rushed back to the practice to find a handsome German Shepherd sitting expectantly in the kennels. His radiographs were on the viewing box and as I stared at the clear images on the screen, I tried to convince myself that this was the perfect case. The fractured bone in question was a femur, the long bone running from the hip to the knee. The fracture itself was oblique, spiraling from the top end to half way down the shaft. I tried to ignore a few jagged fragments and the sheer size of the bone and the weight of the dog himself.
A very first session of the now distant orthopaedic course had been spent discussing fracture scoring. This involved a thorough assessment of each particular fracture and how it might have happened, the nature of not only the patient in question, but also the owner. Carefully, I assessed the dog himself, his giant weight and athletic potential, the type of fracture, the fragments, and reluctantly acknowledged that a pin and wire repair wasn’t going to be the best option. The sheer size and activity of the dog and the obvious velocity of the impact that had created the fracture all pushed me towards a bone plate, although, sadly, I realised that bone plating would not be covered until the following course! Having carefully weighed up all the options, I picked up the phone to ring the owner. Mrs Devlin sounded very hesitant as I outlined my plans. Ideally, I explained, Boris would be sent to the veterinary college for a bone plate, but when I gave a rough estimate of cost, the sharp intake of breath suggested that this was not going to happen. I continued to outline the option of a pin and wire, trying to emphasise that the repair would not be as stable as the first option and therefore, would be less likely to succeed. I gave what I thought was a fair quote, significantly cheaper than the first option, but Mrs Devlin didn’t sound a whole lot more enthusiastic. The only other option, I informed her, would be to have the dog put to sleep; amputating a hind leg in a large, active German Shepherd would be a disaster.
‘I’ll have a chat with Jimmy and get back to you,’ she told me quickly. ‘Although,’ she continued, ‘he does have a brother who is good with the auld hounds. We might give him a ring and see if he could do anything. His father had a dog once with a broken leg that healed up right well without any of them fancy things you’re talking about.’
I looked in despair from my shiny new tool box to the unfortunate Boris and wondered why I had bothered. ‘They just don’t get it, do they?’ I complained to Boris. He whimpered slightly as he shifted his weight onto his good limb and then lay down, head dejectedly between his broad paws.
It seemed that ‘the brother’ was losing his touch somewhat as no mention was made of him when Mrs Devlin’s other half arrived at the surgery later that day.
With only a passing glance at Boris, he wrung his hands, and leaning his massive weight against the consulting table said that they had decided the best option would be to put the dog to sleep. Although I wasn’t altogether surprised, I couldn’t believe that Boris wasn’t even going to be given a chance. What, I thought to myself, was the point in going to courses and investing heavily in specialised surgical equipment when people didn’t want the treatment for their animals?
‘Well, I told you that, didn’t I?’ said Seamus as I relayed my tale of woe to him the next morning. ‘You were the one running off to do your course.’
A regular part of veterinary practice involves euthanasia of animals: some much-loved pets at the end of a long road, others following serious illness or injury but, sadly, too many for the simple reason that they are unwanted. Boris fell in between two categories, but it sickened me to think of such a magnificent animal not being given a chance.
Not long after Mr Devlin had left the surgery, I dialled the house number. Mrs Devlin sounded surprised to hear from me.
‘Oh, it’s yourself, is it?’ she said. ‘Ah the poor old dog, isn’t it a terrible pity? But there was nothing to be done for the brute,’ she added as though in defiance of my lengthy lecture earlier that day.
‘Well, the thing is, Mrs Devlin, I was wondering, as you want to have Boris put to sleep, would you mind if we were to take over his ownership? I will do the surgery myself at my own expense and re-home him afterwards if his leg heals.’
As I spoke to her, I tried to ignore not only Seamus’s reaction at what was probably quite an unprofessional suggestion and also Donal’s when he realised that we would be inheriting yet another dog for the recovery period and one that was going to involve a lot of time and aftercare.
Mrs Devlin didn’t take too much persuading. I realised just how genuine she was in her declared affection for the dog when she magnanimously offered to take him back when he had made a full recovery, if all went well. ‘But only,’ she reiterated, ‘if he doesn’t have a limp or anything like that.’ She seemed unfazed when I told her she would have to legally sign the dog over to me.
Donal was delighted for me that at last I had succeeded in obtaining a real orthopaedic case, but not as enthusiastic when he realised that Boris would be coming to stay with us for a while after the surgery. Although, ideally, I would like to have kept Boris until he was fully recovered and ready for rehoming, the imminent arrival of Molly’s sibling meant that I would have to organise for one of the local welfare groups to take over his care a few weeks after the surgery.
For the next few days, while I ordered the correct size pins and wire, Boris stayed at the surgery where daily treatment helped to reduce the tissue swelling in preparation for his surgery.
The night before the surgery I slept amongst an array of surgical atlases, course notes and any other relevant articles I could get my hands on. The surgical kit was duly sterilised and the battery for the drill fully charged.
On the fateful morning, Boris lazily wagged his tail as I slowly injected the intravenous anaesthetic. He was, by now, quite fond of me.
Arthur had readily agreed to assist at the surgery. He was happy to observe the procedure without the responsibility of actually doing it, and I was glad to have
a bit of ‘professional hand-holding’, even though he had never done any orthopaedic work himself. With Boris sleeping peacefully, I suspended the entire hind leg from a hook in the ceiling and carefully clipped the leg until it resembled an over-sized, if somewhat bruised, chicken drumstick. I wrapped the paw in a sterile drape before draping the surgical site. Once Boris was prepared, I scrubbed and gowned, finally putting on the sterile gloves before taking a last look at the surgical atlas, reminding me somewhat of a recipe book, propped up on the shelf behind.
It was only as I started to prepare for my incision that I really noticed the amount of swelling and discolouration in the area over the shaft of the femur. My surgical atlas displayed, in simple line diagrams, the site of the incision which would expose the two main muscle bodies. The next page indicated the shaft of the femur which would lie directly underneath, once I had separated the muscle mass. Tentatively, I prodded the area, hesitating for a few moments, trying to decide where exactly to make the incision in the distorted limb. Finally, taking a few deep breaths, I sliced an incision over a ten-centimetre-long section of the leg. Dark, red, watery fluid oozed out along the full length. Arthur diligently swabbed the site with sterile gauze so that I would have a clear view of what lay beneath.
I glanced back at the picture in my atlas, feeling slightly disconcerted that it wasn’t looking terribly similar. Cautiously, I started to separate the edges of the skin and pick at bits of traumatised connective tissue or fasciae. I suddenly noticed I was feeling rather hot, although it was cold in the operating room in mid-winter and my knees had taken on a rather jelly-like consistency that had nothing to do with my state of advanced pregnancy.
After some time, during which I cautiously stabbed at the oedematous fasciae, I noticed Arthur glancing at his watch.
‘So, what’s next?’ he eventually asked.
‘Well, I just have to find the divide between the two muscles, but,’ I added, glancing again at the simple line drawing, ‘the cadavers we operated on in the course didn’t have a half a pound of mince meat in there.’
I couldn’t understand why he laughed as, by now, a cold gush of fear was starting to seep through me.
Eventually, I could swab no more and had to try to discern the muscle divide. A few times I picked up the tissue forceps and Metzenbaum scissors and half-heartedly incised in what I thought was the right area. The glistening strip of fasciae that should have acted as my guideline had long since disappeared, lost in a mass of traumatised tissue.
Eventually, the tips of the scissors divided the two muscles, although I suspected not exactly at the right place. At an agonising pace, I swabbed and fiddled and eventually opened the divide to match the length of my initial incision, although the distal end did run off at an angle over the last few centimetres or so. Finally, I put the instruments back in the tray and ran my finger deep into the incision until I was able to feel the bony shaft of the femur. With more force than I thought would have been necessary, I was eventually able to break down the tissue attached to the shaft, enough to feel my way to the roughened fracture end. Using a combination of gloved fingers, scissors tips and a periosteal elevator, I was, with difficulty, able to expose the point of the fracture at the proximal end, although it obstinately remained deep within the massive limb.
Arthur was, by now, looking like he regretted ever offering to help as I ignored any attempts at conversation, so intent was I on trying to figure out how I was ever going to complete the surgery.
In the time between completing the first surgical course and meeting Boris, I had read and reread the lecture notes. I had imprinted on my brain the importance of not traumatising the tissue and trying not to strip the muscle from the bone, as the muscle provided the blood supply that was essential for the repair of the fracture. That morning, I had vowed to leave every bit of muscle attached but, by now, my standards had dropped; I was now merely trying to expose the bone any way possible.
Having finally exposed the proximal end as best I could, I drew a few deep breaths and carefully tried to unravel my back and hunched shoulders before turning my attention to the other end of the fracture. All the time I had worked on freeing the jagged proximal end, I had been aware of the shaft of the femur running alongside. Now I ran my finger along its length, gradually breaking down the soft tissue attachments, and realised, with dismay, that the two ends of the bone overlapped by what seemed to be at least three centimetres.
I glanced up at the X-ray viewer to see the first radiograph which indicated an overlap of maybe half a centimetre. In the days in between, the strong musculature of the huge dog had contracted to an extent that the two ends looked like they would never meet again.
After my initial setback in trying to locate the femur, I had finally achieved it and quietly reassured myself that the hardest party was over. Now, with a sense of dread, it dawned on me that my work was only beginning.
Arthur, too, seemed to have noticed my dilemma and had stopped the smalltalk. ‘How are you going to get the two ends together?’ he asked quietly, annoying me with his assumption that I would know.
The surgery in the course had involved dead dogs, with artificial fractures that were in place and ready to repair. Little mention had been made of how to reduce the fracture or to realign the two ends of the bone. The surgical atlas neatly skipped from locating the fracture to sewing up the muscle layers afterwards.
It was only later that I realised with shock that it took almost an hour as I pulled and rotated and tried against all odds to get the two ends of the bone together. Arthur, similarly scrubbed up, followed my directions as he manipulated the end of the leg. With neither of us having any experience of what we were doing, it was agonisingly slow, as millimetre by millimetre we gradually made progress.
In all the time, I drew consolation from the fact that Boris’s anaesthetic was the only part of the case that could be described as textbook. I was reassured by his regular, even breathing as he slept, oblivious to our struggles.
The clock ticked as lunchtime came and went and Arthur’s shift at the local factory approached. My mind was numb with the sheer monotony of attempting to get the ends to meet and it wandered to thoughts of replacing prolapses in cows, which, until now, I had found arduous. Nothing could compare to the numbing of my fingers and the strain over neck and back, or the cramped thumbs that finally led to the two ends of the fracture eventually being hauled, not into a perfect fit, but to some sort of alignment. Arthur was by now anxiously watching the clock and despite my exhaustion, I was aware not only of the fact that I was soon going to lose my assistant, but also of the length of time that Boris had been anaesthetised.
At least the next part of the surgery I had done before on the course, but it took every last ounce of energy to drill the nine-millimetre stainless steel pin from the fractured end up the shaft of the fracture, until it protruded out at the top of the leg. I cut a small incision to allow the pin to pass out through the skin and continued drilling it up until the other end was just protruding at the fracture site. Both the sheer size and the amount of swelling of the leg made it impossible for me to assess if my pin placement had avoided the sciatic nerve that ran behind the femur, but by now that seemed the least of my worries. With my gleaming new bone clamp holding the two ends of the fracture in rough alignment, I then drilled the pin back down the length of the leg into the second half of the bone. Using an identical pin, I was able to measure how far up the shaft the pin had travelled until it seemed to be in the right place.
Despite the pain deep in my back and shoulders and the fact that I was drenched in sweat, I felt a sneaking sense of triumph through my exhaustion. Cautiously, I moved the part of the pin that was protruding from the top of the leg and noticed how the entire leg now moved as one unit when I angled the pin. The leg was now, relatively, back in one piece.
‘So. That’s it, then,’ announced Arthur, sounding glad that the ordeal was almost over.
‘Well, now I just have
to put the cerclage wire around the oblique edges.’
He couldn’t hide his dismay and shifted awkwardly for a few more minutes until, looking pointedly at his watch, told me that he had to go to his shift in the factory.
‘I didn’t think it would take this long or I would have asked Seamus to swap with me,’ he ended apologetically.
‘Neither did I,’ I replied wearily, wondering as I did if the pin would hold without the three cerclage wires. Reluctantly, I dismissed the thought, knowing that in such a big dog, the repair wasn’t going to be ideal even with the wires.
As I cut the first length of wire, Arthur flushed the surgical site with several sixty-millilitre syringes of heated saline. The muscle around the site was beginning to take on a blueish tinge that worried me.
Then, with Arthur gone, a renewed flush of weariness washed over me, dissipating my momentary triumph. By now, I wasn’t surprised to find that it wasn’t as easy as I had thought it would be to angle the wire placer under the fractured shaft of the bone before threading the stainless steel wire through. The weakness that seemed to have taken me over made it difficult to pull the thick wire through the curved instrument. With the wire finally in place, I took up the wire twisters and, remembering the detail in the notes, I twisted the two ends of the wire around each other, leaving loop after loop, until the loops were down to the level of the bone. I cut the wire, leaving three loops to ensure the knot wouldn’t open. The next wire was slightly easier to place and, as I tightened it, I began to feel that my ordeal might finally be coming to an end. As I readied myself to cut the wire, I gave one last twist to ensure it was tight enough, and watched in dismay as the wire snapped. I didn’t even have the energy to berate myself as I wearily threaded through yet another loop until the second and third wires were finally placed.