Instability and infection seem to be the main problems preventing efficient 
healing. There is extensive infection of the bone (osteomyelitis) around the 
fracture site, which has delayed healing via lysis. Aggressive local and 
systemic antibiotic therapy is necessary, probably a second or third generation 
cephalosporin, based on sensitivity and FDA approval in ruminants.  Local 
perfusion of antibiotic can be done at the time of surgery. The systemic 
antibiotic will be given IV until the animal goes home, and it can than be given 
IM by the owner.  The animal will be given antibiotics for a minimum 6 weeks.  
After six weeks a second culture can be taken a few days after discontinuing the 
therapy to determine the status of the infection.

Cancellous bone grafting may be considered if financially feasible to the owner.  
Removal of avascular material from the fracture ends and medullary canal is 
necessary in cases of slightly hypertrophic or oligotrophic viable delayed 
union.  A limited reduction through the open fracture may allow better alignment 
and access to the fracture site for bone grafting and foreign body removal. 
Closed reduction is a feasible alternative if cost is a concern or if the 
fracture is truly comminuted.

Surgical treatment of the osteomyelitis will be performed at the same time as 
the surgical treatment of the fracture, if a limited reduction is chosen as 
opposed to closed reduction.  Dead avascular bone will be removed and the 
remaining bone will be debrided of dead tissue until bleeding. This will ensure 
that only the healthiest bone remains.  Local perfusion of the area with 
antibiotics can be done at this time.

Fracture instability is the main problem with this delayed union fracture, thus 
fixation devices are the main thrust of treatment. The best way to provide 
sufficient stability is with transfixation pins incorporated into a fiberglass 
cast.  Pins will provide more stability to the fracture ends than simply 
recasting the limb, and also require minimal postoperative care Ð an important 
consideration in the case of food animal species.  Stall confinement with lots 
of bedding is still mandatory. 

Internal fixation is not a likely choice since intramedullary pins are seldomly 
used in large animals (long bone configuration is not compatible).  Cerclage 
wires are not strong enough to withstand the forces of a large animal's weight, 
and the irregular bone remodeling over the past months would make plate 
placement rather difficult.  The external fixators with acrylic sidebars might 
not be feasible here because of the close proximity of the fracture to the 
metacarpal-phalangeal joint.

Analgesics can be given to the animal after surgery to alleviate post-operative 
pain.

Since this patient is in generally good health with normal laboratory values and 
nursing we can give an improved prognosis. Viable delayed union means that 
osteogenic potential is still present, also improving prognosis.  Holes left 
after the pins are removed will be weak points in adult large animals, which may 
lengthen the time necessary until return to normal function.