Casts and bandages are frequently used to treat orthopaedic conditions, especially in situations where clients have financial constraints that rule out surgical treatment.
Necrotic foot: a complication after inappropriate monitoring of a Robert Jones bandage (zoom).
However, these techniques have an extremely high probability of complications, including:
malunion, delayed or non-union
fracture disease – which refers to joint stiffness, muscle atrophy and disuse osteopenia associated with prolonged casting
And, most commonly:
soft tissue injury – ranging in severity from mild dermatitis or pressure sores to sepsis and avascular necrosis of tissues
Check and check again
Although avoidance of using coaptation techniques is recommended, very stringent case selection may help to reduce the risk of complications occurring.
If you do end up having to attempt external coaptation, the most important thing to do is to schedule very regular checks and re-application of the cast or bandage.
Get clients to monitor for:
any unusual smells coming from the bandage
changes in the way the patient walks, e.g. increase in lameness
discolouration of the bandage
any signs of pain or irritation
Always err on the side of caution and schedule the checks more frequently than you think you should, otherwise you could end up with a situation as seen in the image above.
It was a couple of weeks before I set off for Bristol and an uncertain, but exciting life on the vet course that my mother – who’s been a member of the medical field for many years – began pointing out various dogs and cats to me as we passed them, stating that, once I began studying medicine, I would never look at these animals in quite the same way.
They would be patients, not just pets, she reminded me. In the same way she herself subconsciously clocked subtle signs and symptoms in the people she interacted with day to day, not even meaning to look for things a person without the same training or knowledge would ever think to look for.
At the time, I was dubious. To my mind, a cavalier King Charles spaniel would always be, to me, an adorable cavalier King Charles spaniel. Two years on, I can, perhaps begrudgingly, admit to her she was right.
A blessing and a curse
I think one of the greatest strengths of any medical profession – their extensive and almost unfathomable reserve of knowledge – is also their greatest curse.
There’s a reason they say doctors and nurses make the worst patients – it’s most likely because when you‘re drilled over your 5-year to 6-year course – whatever your poison – to consume gargantuan amounts of knowledge about anatomy, physiology, microbiology and how it all goes wrong, when it comes to your down time, you can’t just switch that off.
There’s no way to know all you need to know between 9am and 5pm, and then just un-know it until you need it again the following morning. Knowing everything that can and could go wrong is perhaps one of the plethora of reasons why medical staff – human and veterinary – suffer from stress the way they do.
Can’t help but think about…
To put this into context for you, I am a lover of fluffy breeds and, aside from empathising with them a little over the hotter months, I didn’t ever think too much about them in the way of anything remotely pathological.
Now, though, I can’t help but catch a glimpse of what is undoubtedly a very well-cared for animal without thinking about the dermatitis, the ear mites, the conjunctivitis…
I don’t want to be thinking about that, I can assure you. I’d much rather be thinking about the adorable dog I’ve just witnessed – but take it from me, it’s a really hard thing not to do; much like being told not to think about elephants and then finding yourself only thinking about elephants.
Wealth of knowledge
Don’t get me wrong; I love having this ever-growing pool of information at my fingertips. But is the knowledge of every disease or parasite I could ever contract slightly stressful? Yes. Is the act of learning all of these also somewhat stressful? Also yes.
But learning all this is half the reason any of us decided to become vets, doctors, nurses and so on in the first place. There’s a lot of good that can be done with it. For starters, I was completely unaware of the medical issues surrounding brachycephalic breeds until my first year on the vet course. If vets don’t know the worst that could happen, how can they advise owners on how to prevent or manage it?
One of the greatest responsibilities of medical practitioners is to educate; to pass the knowledge on. It will be a part of your life in a much wider capacity than just your career, so it’s not something to be scared of, but taken advantage of.
When your course is a minimum of five years long, and your days are filled with lab work, lectures and study, it can be easy to lose sight of the big picture – the real core driver behind why you wanted to be a vet in the first place.
Forgive me if I’m wrong, but I’m sure no 18-year-old, fresh from 14 years of full-time education, has ever signed up for their degree purely for a love of spending the fleeting British summertime in an exam hall and 9am-5pm every day staring at a white board.
For most of us, investing the money and dedicated years of our lives that university demands are all part and parcel of building the foundations for our futures.
What’s it all for?
For vets especially, many options are available: whether you’re driven towards specialised surgery, welfare, research or first-opinion practice, it all starts with the same degree, the same path, the same investment.
However, while the journey may be unavoidable, the repetitive humdrum of student life (and life in general for that matter) can make it difficult to keep your eyes on the end goal.
How bad do you want it?
It’s not a matter of commitment. Trust me; if you even manage to get an interview for a veterinary course, you’re as committed as they come. There’s no way you’ll find a teenager voluntarily scooping poop – from a staggering variety of sources – on their weekends without a real solid mindset as to where they want to be.
When I was applying to vet schools, the standard requirements for work experience ranged from four to 12 weeks. I just about managed the latter, but I had friends around me doubling that – don’t ask me how.
Getting sidetracked
University life can be repetitive, not to mention full on… in a particularly heavy week, I managed to have a dream about revising ectoparasites, so let me tell you, sometimes there really is no escaping it.
Through all this it’s understandable you might lose track of the driver that got you here in the first place, let alone what you want to do when you leave. When you‘re struggling to keep your head above water to deal with the task in front of you, how on earth are you supposed to look so far ahead?
Personally, I didn’t realise I’d reached this point until very recently.
The epiphany
My university had organised “practice consult sessions” with some of its vet surgery’s genuine clients. Each client came to us with his or her dogs and had been told by our teaching staff to be as difficult as possible in an attempt to get us out of our shells.
In groups, we had to practise gathering a patient history – not easy, as it turns out, when the client’s been instructed not to play ball – and describe a simple neutering, addressing both pros and cons.
Not only did this supply a very realistic “hands-on” scenario, it forced us to use the collective knowledge provided to us in countless lectures and seminars and regurgitate it in a manner that was both professional and understandable. For example, a lot of the clinical terms we’re encouraged to memorise aren’t commonly used by the general public, so you must find easier ways of explaining things without oversimplifying anything important like surgical risks.
Remind yourself
I can’t describe how motivated I felt when I came home after that practical – I was buzzing.
I had stood behind real vets in real consultations for so long, watching how they interacted with clients and patients and itching, from such a young age, to do what they did. I wish I could carry that feeling with me every day, but, of course, after a while you find yourself treading water again.
I think the important thing is to give yourself moments every now and then to stop and reflect on how far you’ve already come, as well as where you want to go. The course, the workload, life in general – none of it’s easy. But if you want it enough, it’s so, so worth it.
Tape cytology from dog with Malassezia dermatitis (Dif-Quik stain) – note the “peanut-shaped guys”. Image: Wikimedia Commons
Ever had one of those cases, which seem to typically occur around this time of year, that you think must be the start of an allergic dermatitis?
These present with pruritus, erythema and sometimes a yellowish/grey, greasy feel to the skin and hair coat.
The dog is already on a regular POM-V broad-spectrum antiparasiticide.
Initial thoughts
Pyoderma immediately springs to mind – it’s 6.55pm on a Friday, you skip the cytology and start on an appropriate antibiotic; maybe even a short course of prednisolone.
A week later and the dog has not really improved, so it’s a great time for some cytology. There is a good chance we have got a Malassezia dermatitis, and hey presto – the peanut-shaped guys are visible on microscopy. A couple of Malaseb shampoos later and we are rocking.
Then the fun really starts as we try to determine the underlying cause…
Itchy Charlie by Dan Boldy [CC-BY-SA-3.0], via deviantART.Given my interest in dermatology a lot of itchy canine and feline individuals are passed in my direction.
They often have a history of recurrent microbial skin infections either in the form of Staphylococcal pyoderma or Malassezia dermatitis, which is treated as and when it occurs.
I’m often surprised to find these individuals are not receiving routine parasite control, even when many of them have been prescribed it (sadly it is not effective while still in the packet), particularly as we do have both lungworm (Angiostrongylus vasorum) and Sarcoptes about in our practice locality.
My tip would be start to look for the underlying cause when these patients keep coming back – starting with Sarcoptes (and I personally prefer the blood test because I rarely find mites on scrapings).
I now try to avoid running food trials in mid-summer. Certainly on first presentation, with no previous history of allergic dermatitis, I tend to treat accordingly and wait to see what happens later in the year as vegetation dies back.
Food allergic dermatitis does not have a seasonal basis, so if the signs resolve or exacerbate over the course of the year, food allergy is not the primary cause (although some cases can confuse us as they have both an element of food allergy and atopic dermatitis).
I have also seen cases started on food trials in the summer months that appear to get better as the year progresses, only for the owner to become reluctant to challenge as the dog is “better” – whereas, in reality, the improvement is the result of reduced exposure to an environmental allergen.
So I usually wait and see if the signs persist to suggest a non-seasonal allergic dermatitis, and THEN do a food trial.
“Canine Atopy” with dermatitis around the eye, caused by rubbing. Via Wikipedia Commons.
My colleagues and I use immunotherapy on a fair number of dogs to treat atopic dermatitis. Research tells us it can be a valuable tool in some dogs, but at the same time up to a third of dogs respond poorly.
We are lucky in our practice as anecdotally we find the majority of dogs do well, and we only get 10% to 15% that do not respond. This may be because:
We are really hot on parasite control in our practice – we have a large urban fox population and see cases of angiostrongylosis – so we advise Advocate on a regular, monthly basis. So it is unusual for us to see atopic dogs that flare due to concurrent parasite infestation.
We strongly advise owners to do and/or preserve with food trials – and some, okay, just one or two, do respond and relapse on challenge.
We also try to make sure we keep the perpetuating factors, for example, pyoderma and Malassezia dermatitis, to a minimum with medicated wipes and shampoos.
The older the dog when it starts immunotherapy the less likely it is to respond and we advise our owners accordingly.
Good luck with those frustrating allergy cases – hopefully there are some tips here to help. And cats also do well on immunotherapy.
