7/21/2019 Goody Et Al 2012 a Novel Approach to Tibiotarsal Fracture Management in the Hawaiian Nene

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W I L D L I F E R E H A B I L I T AT I O N A N D M E D I C I N E

J. Wildlife Rehab. 32(1): 7–10. © 2012 Inter-national Wildlife Rehabilitation Council.

ABSTRACT:An endangered Hawaiian nene(Branta sandvicensis) with a traumatic,compound, transverse fracture of the lefttibiotarsus was admitted for treatment tothe Three Ring Ranch, Kailua-Kona Hawai’i,United States. An intramedullary pin wassurgically inserted longitudinally throughthe tibiotarsal bone from hock to knee.External support was provided by a modi-ed Schroeder–Thomas splint (hereafterSchroeder–Thomas–Goody); this allowedwildlife rehabilitators to immediatelyaccess the foot for physical therapy andthe patient to assume a natural recumbent

position. In the past, rehabilitation of birdswith similar injuries has been arduous dueto the prolonged and intensive physicaltherapy required to correct contracturesthat develop from immobilization of thehock and foot. The modications of thesplint enabled physical therapy to begin 72hr post-operation. Full recovery and releaseof the nene followed 5 wk later, as opposedto the standard rehabilitative period of 4 to10 mo for this type of injury.

KEY WORDS: Contractures, fracture repair,Hawaiian goose, intramedullary pin, nene,physical therapy, Schroeder–Thomas splint,

tibiotarsal fracture .CORRESPONDING AUTHORAnn Goody, Ph.D., CuratorThree Ring Ranch75-809 Keaolani DrKona, Hawai’i 96740, USA808–331-8778

Email: animals@threeringranch.org

A Novel Approach to Tibiotarsal Fracture Management in theHawaiian NeneAnn Goody, Jacob Head, Athena Gianopoulos, Sharon Liu, and Brianna McCoy

IntroductionManagement of fractures in birds has traditionally been challenging due to the high calciumcontent of bird bones and the resulting brittleness (Bennettet al. 1992). Surgical repairs of frac-tured pelvic limbs commonly involve internal xation with pins in combination with externalsupport with splints (Harrison and Harrison 1986; Rebecca Duerr, International Bird Rescue,Faireld, California USA, pers. comm.). External xation devices used for psittacines and rap-tors have not been well tolerated by waterfowl and seabirds, who frequently remove the devicesthemselves, causing extensive damage. Effective as external support during fracture repair, thetraditional Schroeder–Tomas (S ) splint immobilizes digits of the bird in a contracted state.In captive psittacines and raptors that typically perch at rest, the degree of restoration of digitfunction after splint removal, while less than optimal, has been adequate. While the completerestoration of function in the digits is not essential for companion birds, such a recovery isnecessary if wild birds are to thrive after release. Achieving this using a traditional S splintrequires a period of immobilization and intensive physical therapy for the digits. As a result,this form of fracture management is not optimal for birds intended to be returned to the wild,especially in birds that depend on a at-footed gait, such as waterfowl. raditional S

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A N N G O O D Y

Figure 1. Nene upon intake with a traumatic, compound, transverse frac ture of theleft tibiotarsus.

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8 Journal of Wildlife Rehabilitation

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, traditionalS 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 exor to function normally.

Te 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.Tis can result in fractures and, in the past, has required lengthy wildlife rehabilitation times. At Tree Ring Ranch ( RR), 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–Tomas–Goody (S G) modiedsplint, rehabilitation time was dramatically reduced due to thelightweight structure and the resulting accessibility of the footfor physical therapy within just days of surgery. Te nene, bandnumber 446 by the Hawai’iDepartment of Land and Nat-ural Resources (HDLNR), was the rst case using themodied splint. Tis nene wasreleased after only 5 wk.

Natural history of theHawaiian nene goose(Branta sandvicensis)

Believed to be a descendant of

both the lesser Canada goose(Branta canadensis parvipes )and the lesser snow goose(Chen caerulescens caerules-cens ), 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. Tese geese are grazers that spend mostof their time browsing in grasses, feeding predominantly on plantmaterial, and do not actively seek insects or other invertebrates.

Te 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 rst humans pushed the birds to the rockiest, harshestenvironments in which they were forced to travel great distancesto forage and maintain their metabolic intake. Tis 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. Adult

nene fell easy prey to humans, while their egg and young popula-tions were 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 NotesIntake Te trauma to nene 446 occurred on 27 January 2011 as a resultof a golf ball strike. Te bird was delivered by the HDLNR fortreatment 5 days later. A left leg fracture was suspected due tosignicant displacement and consequential shortening of thelimb. Initial physical exam and radiographs revealed a transverse

tibiotarsal fracture of the left leg.Te foot had good circulationbut was folded, rotated, anddeveloping contractures. hebird was thin but not emaciated. All other ndings 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 signicant transversemidshaft tibiotarsal fracture.Te bird was kept still in a smallICU crate until surgery. Swell-

ing immobilized the injured limb sufficiently until surgery the nextmorning. Te bird was medicated for pain with an intramuscular(i.m.) injection of buprenorphine 0.006 mg. Te patient was a3-yr-old, otherwise healthy ambulatory bird and was, therefore,a good anesthetic candidate for internal xation. (Hawaiian neneare all banded by the HDLNR prior to rst ight, so we knew

not 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 splinting Te 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

Figure 2. Pre-operative radiograph of tibiotarsal fracture.

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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. Te intramedullary pin was 3/32 in (0.24 cm) in diam-eter and was placed 4.33 in (11 cm) into the tibiotarsus, continuing3.92 in (9.90 cm) proximal to the fracture. Te distal end of thepin was bent to prevent displacement. Te patient was inducedusing isourane (isouorane USP; Baxter, Deereld, 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 intramedul-lary pin would allowadequate bending ofdistal joints and providefor stability of the frac-ture ends. he incision was closed with mono-lament absorbable suture.

he bird was medicatedfor pain with an injectionof buprenorphine 0.006mg i.m. at the time of sur-gery and again 12 hr post-operatively. Additional painmedication was providedonce daily for 3 days.

he S G modified

splint was applied whilethe patient was under anes-thesia to provide externalsupport to the leg and foot.Surgery lasted for 2 hr, sig-nicantly longer than theanticipated time of half anhour for similar procedures. Te extended surgery time was dueto severe edema, fracture displacement, and contracture compli-cations exacerbated by the prolonged period between the time ofinjury and the time of admittance for treatment (veried to be 5days based on eyewitness report of initial injury).

Te S G splint provided two novel features that played acrucial role in accelerating the rehabilitation of the patient. First,the traditional S splint was modied from having a fully enclosedring at the pelvic end to having a semicircle that supported thelateral lower abdomen (Figs. 3, 4). Tis modication 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, theS G splint also accommodated the nene’s natural tendency to reststernally recumbent; a traditional S splint would have interfered

with a nene’s ability to rest naturally and the injured limb wouldbe forced into a tripod angle when resting in a recumbent position.Te 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). Tis modication enabled access to the foot, allowingphysical therapy to begin at 72 hr without removal of the splint. After application of the modied splint, a supportive boot was

secured to the foot for10 days to limit con-tractures and maintainposition of function.Te sole and heel of theboot was constructedfrom a tongue depres-sor padded with ban-dage tape. Half of thetongue depressor waspressed at against theplantar surface of thefoot so that the foot was in the full positionof function; the secondhalf created the heel ofthe boot. Te L-shapedboot was secured tothe foot with bandagetape, leaving access tothe distal half of the

foot. Tis boot prevented contractures by exing the hock andextending the digits, thereby minimizing the duration of physicaltherapy required.

Post-operative care Nene 446 was housed in a 3 × 6 × 6 ft (0.9 × 1.8 × 1.8 m) indoorcage that limited excessive mobility. o 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 exion and extension. Te boot providedpressure to the sole of the foot, which prevented hyperextensionof the hock and balling of the foot. Physical therapy occurred

initially as sets of ve repetitions, ve times daily and graduallyincreased to 20 repetitions, ve times daily for the rst 10 days.Physical therapy after the boot was removed continued similarly, with the hock being included in the passive range-of-motion andexion and extension exercises.

Te intramedullary pin and the S G modied splint wereremoved under anesthesia on 1 March 2011. A radiograph taken toassess the fracture site showed a well-formed callus (Fig. 6). Physi-cal assessment of the surrounding soft tissue showed no edema.

o decrease the likelihood of re-injury, housing the patient

Figure 4. Post-operative radiographof STG modied splint and intra-medullary pin

Figure 3. The ST-modied (Schroeder–Thomas–Goody; STG) splint frame.

Figure 5. Illustration of modiedsplint with relationship to legand body of nene.

I L L U S T R A T I ON

: A N N

G O OD Y

MODIFIED

SPLINT

FRAME

TIBIOTARSUS

FRACTURE

IM PIN

BOOT TO

SUPPORT FOOT

IN FUNCTIONAL

POSITION

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10 Journal of Wildlife Rehabilitation

in a controlled environment during rehabilitation was necessary.Once awake post-pin removal, the nene was placed in a 35 × 8 ×12 ft (10.6 × 2.4 × 3.6 m) outdoor aviary on grass. At this point, nophysical therapy was required as the bird was ambulating graduallyback and forth through the entire length of the enclosure to graze.

Functionality of the foot increased from 60 to 90 percent in 9 daysand was determined by the bird’s ability to move back and forthacross the pen without subsequent limp. Nene 446 was releasedon 12 March 2011, only 12 days after the pin was removed, with100% function of the foot; standard release criteria at RR is thata bird exceeds 85% restoration of foot function.Summary

raditional S splints have been useful in captive raptors andpsittacines. Previous attempts to redesign them for weight-bearingbirds such as the wild nene resulted in heavy, cumbersome splintsthat soiled easily and created panic in the patient. At RR, wehave found through trial and error that, by providing access tothe foot for immediate physical therapy post-operatively, we canassure mobility for the foot while keeping the hock immobile.In addition to minimizing foot contractures and the duration ofrehabilitation, the modied splint also enabled the bird to rest inits natural, sternally recumbent position which further reducedstress. Because the S G modied splint worked well for nene 446,its application would likely be an ideal alternative to the use oftraditional S splints for wildlife rehabilitators across the boardin not only geese but in raptors and psittacines.Literature Cited16 U.S.C. §1531 et seq (ESA). 1973. Endangered Species Act

(ESA) of 1973. United States Government Printing Office.Bennett, A. R., and A. B. Kuzma. 1992. Fracture management

in birds. Journal of Zoo and Wildlife Medicine 23(1): 5–38.Harrison, G. J., and L. R. Harrison. 1986. Clinical avian medicine

and surgery, including aviculture. W. B. Saunders, Philadel-phia, Pennsylvania, USA. 717 pp.

U.S. Fish and Wildlife Service. 2010. [On-line.] HawaiianGoose—Pacic Islands Fish and Wildlife Office. [Updated25 March 2010; cited 23 August 2011]. Available from: http:// www.fws.gov/pacicislands/fauna/HIgoose.html

About the Authors Ann Goody, RN,Ph.D ., is curatorof the ASA- andGFAS-AccreditedTree Ring RanchExotic AnimalSanctuary (www.threeringranch.org)in Kailua Kona,Hawai’i. She cares for the 150 or so residents of the Sanctu-ary along with her husband, Norm Goody, M.D. Prior to hercurator position she was an emergency room nurse and theadministrator of a home health care agency.

Dr. Jacob Head was born and raised in Hawaii. At anearly age he was instilled with a sense ofstewardship for the land and the animals onit. Raised on a farm in South Kona, he wasan active participant in 4H. His family still

owns and operates an organic coffee farmthat they tend with the help of a ock of white Chinese Geese. Dr. Head spent 18years of his adult life in Colorado. After heobtained his DVM in 1998, he completed

an internship in small animal medicine and surgery in NewMexico. Dr. Head works at the Keauhou Veterinary Hospital,the only AAHA-accredited practice on the Big Island, and is amember of the AVMA, CVMA, HVMA, and the VeterinaryOrthopedic Society. Dr. Head, his wife, and three children work and reside with him in Kailua-Kona, Hawaii.

Athena Gianopoulos has a BS from Berkeley and plans on

pursuing a degree in veterinary science.Sharon Liu graduated from U.C. Berkeley in 2010 with a BA

in Integrative Biology and hasbeen working at Pet Emergency

reatment & Specialty ReferralCenter since. She cooks for Loth-lorien Berkeley Student Coop-erative, a vegetarian house of 60,and will be attending veterinaryschool in 2012. She enjoys volunteering at Te Marine MammalCenter, serenading, bird-watching, and crocheting critter beanies.

Brianna McCoy, BS, BA graduated from the Universityof California Berkeley with degrees inConservation and Resource Studies andIntegrative Biology. She currently worksfor the Wildlife Branch of the CaliforniaDepartment of Fish and Game andplans to attend veterinary school to study wildlife medicine.

Figure 6. Post-operative radiograph after removal of STG modi-ed splint and intramedullary pin.

P H OT O

©N

OR M G

O OD Y .

Ann Goody

Brianna McCoy

Dr. Jacob Head

Sharon Lin

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C o p y r i g h t o f J o u r n a l o f W i l d l i f e R e h a b i l i t a t i o n i s t h e p r o pR e h a b i l i t a t i o n C o u n c i l a n d i t s c o n t e n t m a y n o t b e c o p i e d o p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .