Fundamentals of Orthopedic Surgery and Fracture Management

Chapter 32


Fundamentals of Orthopedic Surgery and Fracture Management



General Principles and Techniques




Definitions


Unique terms used in orthopedic surgery include descriptions of examination and reduction maneuvers, classification of fractures and fracture healing, types of grafting material, and surgical outcomes. A partial list of definitions is provided in Box 32-1. Other terms are described in the text of this chapter.



image Box 32-1   Orthopedic Terms




Allograft—bone transplanted from one animal to another of the same species


Apophyseal osteotomies—procedures performed to enhance surgical exposure of a joint


Autograft—bone transplanted from one site to another in the same animal


Avulsion fracture—occurs when the insertion point of a tendon or ligament is fractured and distracted from the rest of the bone


Bridging plates—span a comminuted fracture


Cerclage wire—orthopedic wire placed around the circumference of the bone and compressing an oblique fracture


Closed reduction—fractured bone alignment performed without a surgical exposure


Compression plates—plates that act to compress the fracture


Corrective osteotomies—elective procedures in which the diaphysis or metaphysis of the bone is cut, realigned, and stabilized until union occurs


Cranial drawer—the abnormal movement elicited during a physical examination that is caused by the tibia sliding cranially in relationship to the femur in the absence of the cranial cruciate ligament


Crepitation—the “grating feel” or sound associated with manipulating a fractured bone or an arthritic joint


Delayed unions—fractures that heal more slowly than anticipated


Direct bone union—bone formed without evidence of callus


Endochondral bone formation—bone formed on a cartilaginous precursor


External coaptation—fracture fixation using casts or splints


External fixation—fracture fixation in which pins penetrate the bone and skin and are connected externally


Greenstick fracture—an incomplete fracture in which a portion of the cortex is intact


Hemicerclage wire or interfragmentary wire—denotes wire that is placed through predrilled holes in the bone


Indirect reduction—the process of restoring fragment and limb alignment by distracting the major bone segments


Internal fixation—fracture fixation using internal implants to secure the bone


Intramedullary pins—implants that are positioned in the medullary canal of long bones


Intramembranous bone formation—direct differentiation of mesenchymal stem cells into osteoblasts so bone forms without a cartilaginous precursor


Luxation—complete dislocation of a joint


Malunions—healed fractures in which anatomic bone alignment was not achieved or maintained during healing


Neutralization plates—support a reconstructed fracture


Nonunion—a fracture that has an arrested repair process that requires surgical intervention to create an environment conducive to bone healing


Normograde placement—the pin is started at one end of the bone, driven to the fracture area, and then seated at the other end of the bone


Open fracture—one in which the fracture is exposed to the external atmosphere


Open reduction—fracture repair performed after a surgical approach to the bone


Ortolani maneuver—the manipulation used to subluxate a dysplastic hip


Ostectomies—removal of a segment of bone


Osteomyelitis—an inflammatory condition of bone and the medullary canal


Osteotomies—procedures in which the bone is cut into two segments


Procurvatum—cranial bowing of a bone


Recurvatum—caudal bowing of a bone


Reduction—process of reconstructing or realigning a fractured bone


Retrograde placement—the pin is inserted at the fracture area, driven proximally to exit the bone, the fracture is reduced, and the pin is driven distally to seat at the end of the bone


Staged disassembly—process of modifying a fixation frame at approximately 6 weeks after surgery to increase the loading on the healing fracture


Subluxation—partial dislocation of a joint


Valgus deformity—angulation of the distal portion of the limb laterally


Varus deformity—angulation of the distal portion of the limb medially



Problem Identification


Orthopedic surgery includes procedures used to (1) stabilize fractured bones; (2) explore, débride, and stabilize injured joints; (3) replace damaged joints; (4) stabilize spinal column injuries; (5) decompress the spinal cord; (6) resect musculoskeletal tumors; and (7) repair tendon and ligament injuries. Patients with orthopedic problems represent a significant percentage of the general practice population. The most common complaints are associated with joint disease, and trauma is frequently noted. Before the most appropriate method for treating a problem can be selected, the orthopedic problem must be identified and assessed. Developing surgical skills and familiarity with specialized instrumentation is necessary for performing most orthopedic procedures. Veterinarians should be aware of their limitations and refer complicated cases when necessary. Knowledge of potential complications and pitfalls helps surgeons take the appropriate preventive steps.


Most animals present with obvious lameness and pain, but identifying the cause of the lameness may be difficult. Accurate historical information, thorough general examination, orthopedic examination, and diagnostic imaging are essential for accurate diagnosis. Once the diagnosis is made, the decision-making process includes selecting the appropriate therapy, which may not always be surgery. Identifying a fracture as the cause of non–weight-bearing lameness is usually straightforward. The challenging problem is to assess the patient, classify the fracture, and develop plans for fixation that will allow predictable and consistent results.



Differential Diagnosis


A differential diagnosis is developed based on results of history, signalment, and physical examination. Other tests or procedures may be necessary to define the disease once the aforementioned findings have narrowed the diagnostic possibilities. Many orthopedic diseases are predictable within certain age groups and breeds (Table 32-1). Information on the animal’s general condition includes anorexia, depression or fever, limb affected, multiple limb involvement, degree of pain or lameness, duration, intensity of onset, historical trauma, effect of exercise, time of day of greatest clinical signs, effect of rest, and changes in lameness associated with weather. Such information provides initial clues to form a differential list of potential causes. Additional questioning, physical examination, and imaging will usually provide data to make a definitive diagnosis.




Orthopedic Examination



Physical Examination


The animal’s general health should be assessed as part of the physical examination. Baseline examination includes obtaining the animal’s temperature, pulse, and respiration. The animal’s overall appearance should be noted (e.g., obesity) and thoracic auscultation and abdominal palpation performed. A general health evaluation is important before anesthetizing any animal that has orthopedic disease. Traumatized animals brought in for fracture evaluation should have thoracic radiographs and serial electrocardiograms (ECGs) performed. Evaluation of the abdominal cavity is done initially with palpation and evaluation of serum chemistry tests. Abdominocentesis (see p. 380) and radiographic or ultrasonographic evaluation of the urinary tract (see p. 757) should be performed if clinical signs suggest injury. Traumatized animals with long bone fractures frequently have concurrent soft tissue injuries (e.g., pneumothorax, traumatic myocarditis, diaphragmatic hernia, and ruptured bladder or urethra). It is crucial to diagnose and treat these injuries before the animal is anesthetized for fracture repair.



Orthopedic Examination


An orthopedic examination begins by observing the animal for signs of lameness while obtaining the history. This is necessary even if the owner has attributed the lameness to a particular limb because the correct limb may not have been identified. The animal should be observed in the examination room for obvious lameness and for more subtle signs, such as reducing the weight placed on the affected limb when standing or sitting. Other observations may include unilateral or bilateral muscle atrophy and abnormal muscle development. Dogs with bilateral hip dysplasia or chronic cruciate ligament rupture may appear underdeveloped or weak in the rear quarters and heavily muscled in the forequarters.


If the lameness has not been localized during the initial observation, the animal should be observed while walking and trotting. It may be necessary to take dogs outside to improve footing. To protect a sore limb, animals quickly shift their weight from the affected limb, making it appear that they are landing heavily on the opposite, or “good,” limb. Animals with forelimb lameness will lift their heads after the lame limb strikes the ground in an attempt to remove weight from the affected limb. A short stride occurs when the animal has a decreased range of motion in a diseased joint (e.g., hip dysplasia). External swinging, or paddling, of the affected limb(s) occurs when the animal tries to advance a limb that cannot be adequately flexed. This is often observed in dogs with severe degenerative joint disease of the elbows. Animals with bilateral lameness may not limp, but they often show more subtle signs, such as shifting their weight from limb to limb while standing, shortened stride, shaking, and bilateral muscle atrophy.


After the lame limb has been identified, the animal should be returned to the examination room. Limb palpation and a screening neurologic examination should be performed simultaneously. Optimally the first examination should be done without sedation to determine the animal’s response to pain; however, this may not be possible in aggressive animals. The examiner should develop a consistent evaluation pattern. One technique is to start at the front of the animal and work toward the rear. Also, starting at the toes of each limb and progressing proximally is useful. It is preferable to begin examining a sound limb to identify the individual’s normal response to manipulation and pressure. The initial examination should be done with the animal standing to assess muscular symmetry, joint enlargement, and proprioceptive responses. As each bone, joint, and soft tissue area is palpated, any asymmetry (between limbs), response to pain, swelling, abnormalities in range of motion, instability, and crepitation should be noted. Asymmetry should be assessed before and during individual limb palpation and may indicate tumor, abscess, atrophy, joint swelling, or greenstick fracture. Long bones should be palpated to determine if there is swelling (e.g., fracture or tumor), a response to pain while firm pressure is applied (e.g., panosteitis, fracture, or tumor), instability, or crepitation (e.g., fracture). Joints should be isolated and moved through a complete range of motion to detect crepitation, pain, or abnormalities in range of motion. Additional tests of shoulder, hip, and stifle instability should be performed if abnormalities are detected in these joints (see p. 1039 [shoulder], p. 1041 [hip], and p. 1040 [stifle]). Muscles and tendons should be palpated to determine if they are normal and intact. After the initial orthopedic examination to localize pain, the animal may be sedated to facilitate closer examination and to obtain radiographs (Tables 32-2 and 32-3).





Forelimb


A complete orthopedic examination of the forelimb includes the following manipulations.




Carpus

Gently palpate the dorsal surface of the carpus to determine if fluctuant swelling is associated with joint effusion. This may be a subtle finding in the carpus and is more easily noted when the animal is standing because loading the joint forces the fluid peripherally. Compare the affected limb with the opposite carpus.


Bilateral swelling may occur with some diseases, such as rheumatoid arthritis. Extend and flex the carpus. Maximum extension of the carpus should be about 180 to 190 degrees; maximum flexion should be 35 to 45 degrees. Hyperextension is best noted when the dog is standing and indicates carpal subluxation from disruption of the palmar ligaments. A decreased range of motion may indicate degenerative joint disease.


Note any crepitation. Extend and stress the carpus in the mediolateral plane to determine if there is joint instability.




Elbow

Palpate the elbow for fluctuant swelling in the space between the lateral condyle and olecranon and over the medial coronoid process. Fluctuant swelling indicates joint effusion, which results from several elbow diseases. Joint effusion may be more easily detected when the animal is standing. Firm, generalized swelling of the elbow often indicates degenerative joint disease. Flex and extend the elbow (Figs. 32-1 and 32-2).




Normal extension and flexion are about 165 degrees and 40 to 50 degrees, respectively. The carpus should almost touch the shoulder when the elbow is flexed. Decreased range of motion caused by incomplete flexion of the elbow usually suggests degenerative joint disease, which occurs secondary to a fragmented coronoid process, an ununited anconeal process, or osteochondritis dissecans. While the elbow is in extension, check the integrity of the collateral ligaments by applying medial and lateral force to the radius and ulna.




Shoulder

Swelling from joint effusion is difficult to detect in the shoulder because of the overlying muscles. Move the shoulder through a range of motion, including hyperextension and hyperflexion, while stabilizing the scapula (Fig. 32-3). Dogs with osteochondritis dissecans of the humeral head often show a pain response when the shoulder is hyperextended.



Palpate the biceps tendon and apply pressure; a painful response may indicate a biceps tendinopathy.


With the animal in lateral recumbency, hold the acromial process stationary and mobilize the humeral head in both a cranial caudal direction and mediolateral direction to detect luxation or subluxation. Many shoulder joints pop or click without significance, but any translation of the humeral head in relationship to the acromion process is abnormal. Grasp the acromial process, and place medial pressure on it to stabilize the scapula. Hold the distal limb and with the elbow and shoulder in extension abduct it to its physiologic limit. The angle of the distal limb in relation to the scapula is called the abduction angle. Abduction angles greater than 50 degrees obtained with the dog sedated or anesthetized may indicate medial shoulder instability.




Rear Limb


Complete orthopedic examination of the rear limb involves various manipulations.




Hock

Palpate the tarsal joints for fluctuant swelling indicative of joint effusion.


This may be a subtle finding in the hock and is more easily noted when the animal is standing because loading the joint forces the fluid peripherally. Firm swelling suggests degenerative joint disease. Extend and flex the hock. Normal flexion should be about 40 to 45 degrees. Decreased flexion indicates degenerative joint disease, which may be secondary to osteochondritis dissecans. Pain on manipulation of the joint (especially coupled with soft tissue swelling) may indicate a fracture. Simultaneously, extend and adduct or abduct the hock and metatarsal bones to demonstrate instability of the collateral ligaments. With the stifle in extension and the hock stressed into flexion, palpate the Achilles tendon (Fig. 32-4). Rupture of the entire tendon complex allows hock flexion while the stifle is extended. Rupture of the gastrocnemius tendon and common tendon of the biceps femoris, gracilis, and semitendinosus muscles, with preservation of the superficial digital flexor, allows partial flexion of the hock while the stifle is extended and causes simultaneous flexion of the digits.






Patella

Extend and flex the stifle while holding one hand over the cranial aspect of the joint to detect crepitation. Next examine the stability of the patella in relationship to the femur. Extend the stifle, internally rotate the foot, and apply digital pressure in an attempt to displace the patella medially (medial patellar luxation). Detect lateral patellar luxation by slightly flexing the stifle, externally rotating the foot, and applying digital pressure to attempt to displace the patella laterally (Fig. 32-5). The patella normally moves slightly medially and laterally but is considered to be luxating when it leaves the trochlear groove.




Collateral ligaments

Hold the stifle in full extension and simultaneously attempt to open the stifle on the medial and lateral aspects to assess the integrity of the collateral ligaments. Test the medial collateral ligament by using one hand to brace the femur while the other hand abducts the tibia. Normally the medial collateral ligament will not allow joint laxity. Test the lateral collateral ligament by bracing the femur with one hand and using the other hand to adduct the tibia (Fig. 32-6). An intact lateral collateral ligament will prevent joint laxity. If the stifle is allowed to flex while the tibia is adducted, it may feel as though there is lateral laxity of the joint. This is a result of anatomic location of the lateral collateral ligament and internal rotation of the tibia and is normal.




Cruciate ligaments

Test the integrity of the cruciate ligaments by trying to elicit a cranial or caudal drawer motion or by performing a tibial compression test to elicit cranial tibial thrust. Drawer movement is caused by the tibia sliding cranially or caudally in relationship to the femur. This motion is not possible when the cruciate ligaments are intact in adult animals. Immature animals may have slight drawer motion, but it stops abruptly as the ligament tightens. To elicit direct drawer motion, place the index finger and thumb of one hand over the patella and lateral fabellar regions, respectively. Place the index finger of the opposite hand on the tibial tuberosity, and with the thumb positioned caudal to the fibular head, slightly flex the stifle. Stabilize the femur, and gently move the tibia cranial and distal to the femur. Do not allow tibial rotation. Tense muscles may prevent drawer motion. If tibial rotation occurs, gently flex and extend the stifle to relax the animal, and repeat the procedure. Test drawer motion with the femur flexed and extended (Fig. 32-7). Usually the greatest movement is felt with the stifle in flexion. If the patella is luxated, replace it in the trochlear groove before attempting the drawer motion.



Perform the tibial compression test to detect cranial tibial thrust. Detect forward motion of the tibia by placing the index finger along the patella and the tibial tuberosity. With the leg in a standing position, flex the hock to tense the gastrocnemius muscle (Fig. 32-8). This compresses the femur and tibia together, causing the tibia to move forward in a cranial cruciate-deficient stifle. The presence and amount of drawer motion depend on the animal’s age, size, state of relaxation, and the duration and type of cruciate pathology. There is minimal drawer motion in normal dogs and cats, although very young puppies may have a “lax” stifle. Sedation or general anesthesia increases the likelihood of a positive drawer sign in dogs with cranial cruciate rupture. Minimal drawer motion may be noted with chronic cruciate pathology (especially in large dogs) because periarticular fibrosis restricts stifle motion. Minimal or partial drawer motion may also occur with incomplete tears or stretching of the cranial cruciate ligament. Drawer motion is also evident with a torn caudal cruciate ligament. To identify caudal drawer motion, start with the stifle in a neutral position. Most caudal ligament ruptures are not discovered until exploration because they are mistaken for cranial ligament injuries.







Hip luxation

To detect luxation of the hip, use the position of the greater trochanter in relationship to the tuber ischium as a landmark. In the standing animal, compare the distance from the greater trochanter with the tuber ischium bilaterally. A unilateral increase in the distance indicates hip luxation. Animals with acute hip luxations are not weight bearing and may have swelling over the greater trochanter. Externally rotate the femur while placing the thumb in the space between the greater trochanter; the thumb should become displaced (Fig. 32-9, A and B). With hip luxation, the trochanter rolls over the thumb (Fig. 32-9, C and D).




Hip laxity

With the animal in lateral recumbency, perform the Ortolani maneuver to detect hip laxity associated with hip dysplasia. Place one hand over the dorsal pelvis. Grasp the stifle with the other hand, and orient the femur parallel with the table surface. Simultaneously adduct and push the stifle toward the pelvis. Maintain the pressure and abduct the stifle. As the femoral head returns to the acetabulum, use the hand stabilizing the pelvis to detect a click (Fig. 32-10). The Ortolani maneuver can also be performed with the animal in dorsal recumbency, with the stifles held parallel to each other and perpendicular to the table. Apply downward pressure on the stifle to subluxate the hip. Maintain pressure and abduct the stifle. With both procedures, a click is noted as the femoral head returns to the acetabulum in a subluxated hip (Fig. 32-11). The angle of subluxation is the point at which the hip subluxates, and the angle of reduction is the point at which the femoral head returns to the acetabulum. Evaluation of hip laxity is best done with the dog sedated or anesthetized.






Rule Out Neurologic Disease


Because neurologic disorders may mimic orthopedic diseases or may occur concurrently, every orthopedic examination should include several neurologic examination maneuvers performed to screen for neurologic disease. If evidence of neurologic disease is discovered, a complete neurologic examination is indicated (see Chapter 38). Evaluate conscious proprioception in all four limbs by gently supporting the animal and individually turning each paw until the dorsal surface of the paw contacts the ground. Normal animals return the paw to the correct position almost immediately. Loss of conscious proprioception usually indicates neurologic disease; however, animals with fractured limbs may be reluctant to move the limb and therefore may appear to have conscious proprioception deficits. Flex and extend the neck and bend it laterally in both directions. Apply direct pressure on the lateral processes of the sixth cervical vertebra. Animals may exhibit a forelimb lameness associated with cervical nerve root pain (root signature sign), and it is important to rule out cervical disease or nerve root tumors. Apply direct pressure on the thoracolumbar spine while supporting the abdomen. A painful response, exhibited by vocalization, flinching, or tightening the abdominal musculature may indicate thoracolumbar spinal disease. Apply direct pressure on the ventral lumbar musculature to isolate lumbosacral pain (Fig. 32-12).



It is important to differentiate lumbosacral and hip pain because many older dogs with radiographic signs of hip dysplasia have concurrent lumbosacral pain, which may cause lameness and reluctance to rise and move. Pressure on the dorsal lumbosacral area also pressures the hip, making it difficult to differentiate the source of the pain. Likewise, hip extension also pulls on the iliopsoas muscles, again making it difficult to pinpoint the source of the pain. Apply pressure to digits of the affected limb to elicit a response to superficial and deep pain. Peripheral nerve damage may result concurrently with fractures of the middle to distal humerus (radial nerve) or sacrum (sciatic nerve). No response may indicate peripheral nerve damage.



Additional Diagnostic Techniques


A differential diagnosis is developed based on results of history, signalment, and physical examination. Definitive diagnoses may require additional diagnostic tools including imaging, hematology, serum biochemistry, cytology, or electrodiagnostics. Radiography is generally the initial imaging modality employed to arrive at a definitive diagnosis; however computed tomography, magnetic resonance imaging, ultrasonography, and scintigraphy may be indicated for diagnosis and/or improved visualization of some problems (Table 32-4). Joint taps are useful for differentiating degenerative and inflammatory disease (see p. 1217). Fine needle aspirates or biopsies are essential for diagnosing neoplastic disease (see p. 1398).



image TABLE 32-4


Imaging Modalities for Orthopedic Problems


image


1, Imaging modality used for primary evaluation; 2, imaging modality used for additional evaluation.




Perioperative Patient Management



Preoperative Management


Perioperative management of surgical patients is discussed in detail in Chapter 4. Orthopedic patients may be brought in for elective surgery (e.g., cranial cruciate ligament injury, hip dysplasia, and osteochondritis dissecans), or nonelective surgery (e.g., bone fractures and joint luxations). When animals are brought in for elective surgery, there is ample time to perform an appropriate preoperative diagnostic evaluation. Younger patients (less than 5 to 7 years old) should have selected screening laboratory tests, including packed-cell volume (PCV), and serum total solids. Urinalysis, fecal analysis, and heartworm tests may be indicated, depending on the history and the animal’s geographic location. The need for further laboratory evaluation should be based on signalment, physical examination, and results of initial screening tests.


Patients older than 5 to 7 years with orthopedic disease must be assessed more carefully than younger patients. Just as the physiologic properties of the musculoskeletal system decline with age, other organ systems also deteriorate. Thorough physical examination remains the foundation of preoperative evaluation and should be supplemented with a complete blood count, chemistry profile, and urinalysis. Special diagnostic tests (e.g., coagulation profile) may be indicated, depending on the history, signalment, and physical findings.


Trauma patients should have a thorough and complete physical evaluation. Serial examinations are important because serious or potentially lethal problems may not become evident for several hours or days after the injury. Although organ dysfunction may be evident (or suspected) on initial physical examination, repeated examinations may be necessary to define the severity of injury. Animals that have received an external blow severe enough to disrupt musculoskeletal integrity (e.g., fracture and luxation) often have concurrent external or internal organ system injury. Cardiovascular, pulmonary, urinary, and neurologic systems are most frequently injured. If abnormalities are found, a differential diagnosis and diagnostic plan for each problem should be developed and additional diagnostic tests completed. For example, cardiac arrhythmias and femoral pulse abnormalities may be found in patients with traumatic myocarditis, necessitating thoracic radiographs and an ECG to assess treatment options and anesthetic risk. Auscultation may detect pulmonary injury (e.g., lung contusion and pneumothorax), but physical changes may be subtle and missed on physical examination. Because one third or more of fracture patients have some degree of pulmonary injury, preoperative evaluation should include thoracic radiographs. A minimum database should include a complete blood count, serum biochemistry profile, and urinalysis. Additional laboratory tests (e.g., coagulation profile, electrolytes [if not part of the biochemical profile], and acid-base balance) may be required to assess differential diagnoses developed on physical examination. Abnormal values should be assessed in light of physical findings, and the need for additional or serial tests should be determined. Serial tests are useful to validate abnormal findings and monitor patient progress. Delaying surgical intervention until abnormal organ function returns to normal is optimal; however, it is often not feasible. Some abnormalities may necessitate that surgical repair of the orthopedic disease be delayed (e.g., uroabdomen), whereas others may alter the prognosis such that repairing the orthopedic condition is not justified (e.g., vertebral fracture with loss of deep pain sensation).



Pain Management and Anesthesia


Orthopedic patients benefit from perioperative analgesics (Table 32-5). The projected level of postoperative discomfort and the duration of discomfort should be assessed to determine the choice of preoperative analgesic. Most orthopedic surgeries are considered moderately to severely painful. Although there is much debate concerning preemptive analgesia, especially in the human medical literature, there are several principles that must be followed in order for preemptive analgesia to be successful. First, the depth of analgesia must be sufficient to block pain receptors during surgery. Second, nociceptive receptors from the entire field must be blocked. And last, analgesia must be continued in the postoperative period (see Chapter 12).



Anesthetic protocols should be chosen based on signalment, physical examination findings, and laboratory analysis. Patients treated for elective orthopedic problems (e.g., cruciate reconstruction) and who have no preoperative findings suggestive of major organ dysfunction can be managed using a variety of anesthetic techniques (see Table 32-5). Patients with cardiovascular compromise or trauma should be anesthetized with care (Table 32-6). When appropriate, balanced anesthetic protocols that include analgesic agents supplemented with epidural analgesia are recommended to decrease intraoperative pain response and reduce the amount of anesthetic needed (Tables 32-7 and 32-8). Epidural anesthesia (with lidocaine, bupivacaine, or ropivacaine) in combination with general anesthesia provides profound relaxation by temporarily paralyzing rear limb muscles, easing fracture reduction of the pelvis, femur, and tibia (see Chapter 12). The duration of action depends on the drug used, ranging from 1 to 6 hours. Fentanyl, morphine or buprenorphine can be added to the epidural injection, providing postoperative pain relief for up to 24 hours. Additionally, opioids may be used alone in the epidural space when relaxation of muscles is not warranted but postoperative analgesia is desired. A brachial plexus block using local anesthetics will provide additional analgesia and muscle relaxation in patients undergoing surgery of the forelimb.


Sep 11, 2016 | Posted by in SMALL ANIMAL | Comments Off on Fundamentals of Orthopedic Surgery and Fracture Management
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