What Is Your Diagnosis?

Author(s):
Source: Journal of Avian Medicine and Surgery, 31(1):75-78.
Published By: Association of Avian Veterinarians
DOI: http://dx.doi.org/10.1647/2016-175
URL: http://www.bioone.org/doi/full/10.1647/2016-175

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 Journal of Avian Medicine and Surgery 31(1):75–78, 2017
Ó 2017 by the Association of Avian Veterinarians

What Is Your Diagnosis?

History
A free-living adult barred owl (Strix varia) was
presented to the Wildlife Clinic at Cummings School
of Veterinary Medicine at Tufts University after
being observed ‘‘down’’ and unable to fly by a
member of the public. No other history was available.
On presentation, the owl was depressed and in
sternal recumbency and was determined to be
approximately 5% dehydrated with good capillary
refill time assessed on the cutaneous ulnar vein.
Physical examination showed the owl to be in good
Figure 1. Lateral radiographic image of the left distal
body condition, weighing 670 g. Mild swelling of
wing of a free-living barred owl that was presented after
the left carpus was noted, although no crepitus or being found down and unable to fly.
joint laxity was palpable. Ophthalmic examination
revealed no abnormal findings in the right eye. The
Over the next 7 days, the owl’s mentation
left eye had mild aqueous flare, a small chorioret- improved. When the owl began standing, a mild
inal tear, and minimal vitreal hemorrhage, consis- ataxia was noted, which resolved during the first week
tent with presumed blunt trauma. The packed cell after admission. The bird was handled and examined
volume, total solids, and blood glucose were within daily and force-fed whole mice, because it was not
normal limits for this species. self-feeding. Meloxicam (0.2 mg/kg PO q24h) (Meta-
Initial supportive therapy for presumed head cam, Boehringer Ingelheim, St Joseph, MO, USA)
trauma included subcutaneous fluids (lactated was administered as an anti-inflammatory and
Ringer’s solution, 45 mL/kg; Baxter Healthcare analgesic treatment. The left carpus remained mildly
Corporation, Deerfield, IL, USA; q12-24h), bu- swollen, although no wing droop was noted.
prenorphine (0.25 mg/kg SC q12h) (Buprenor- Eight days after admission, the bird’s neurologic
phine Hydrochloride, Pharmaforce Inc, Columbus, signs had resolved, and the bird was deemed stable
OH, USA), and placement in a nonheated critical for isoflurane (Abbott Laboratories, North Chica-
care unit (maintained at ambient room tempera- go, IL, USA) anesthesia to obtain whole-body
ture) with supplementary oxygen provision. One ventrodorsal and lateral radiographs (Fig 1).
drop of 0.03% flurbiprofen (Pacific Pharma, Irvine, Additionally, radiographs of the left and right
CA, USA) was administered to the left eye q12h. carpi were obtained.

Please evaluate Figure 1, the history, and the results of the physical examination and diagnostic tests.
What lesion can be identified on the radiograph? What is the prognosis for a wild bird with this problem?

75
76 JOURNAL OF AVIAN MEDICINE AND SURGERY

Figure 4. Ventrodorsal radiographic image of the left

carpometacarpus of the owl described in Figure 1, 49
days after admission. Bony bridging and remodeling of
the fracture fragment, not observed in Figure 2, is
evident.
Figure 2. This magnified image of Figure 1 shows the
significant periarticular swelling (filled white arrowhead)
and the radiolucency, consistent with a nondisplaced
oblique fracture of the extensor process of the
carpometacarpus (filled black arrowhead).

Figure 3. Ventrodorsal radiographic image of the left

carpometacarpus of the owl described in Figure 1, 23
days after admission. Note that the previous
periarticular swelling noted in Figure 2 is much
reduced and that the extensor process fracture
fragment appears well aligned with a well-defined
fibrous callus felt on palpation.
 WHAT IS YOUR DIAGNOSIS?
Diagnosis
The lateral radiographic image (Figs 1 and 2)
revealed a soft tissue swelling around the left
carpus and the radiolucency noted, consistent with
a nondisplaced oblique fracture of the extensor
process of the carpometacarpus. No other abnor-
malities were detected.
Discussion
In light of the radiographic findings and the
owl’s improved mentation and increased activity
level, a figure-of-eight bandage was placed on the
bird’s left wing to immobilize the carpus and
elbow. The owl was anaesthetized with isoflurane
(5% isoflurane administered in 1L oxygen via face-
mask) every 5–7 days to change the bandage,
palpate and manipulate the affected carpus, and
repeat radiographs, as well as to do physiotherapy
on the affected wing to prevent periarticular
fibrosis. The owl was maintained on pain medica-
tion (meloxicam, 0.2 mg/kg PO q24h).
Repeated palpation of the left carpus and
radiography revealed a well-aligned and fibrosing
fracture site. The bandage was removed 16 days
after it was first placed (23 days after admission)
(Fig 3). Because clinical stability of a fracture has
been shown to occur before radiographic evidence
that the bone is healed,1,2 the figure-of-eight
bandage was removed at this point.
We considered it important that the owl not be
allowed unrestricted flight before bony healing of
the fracture site had occurred, to reduce the risk of
a possible avulsion fracture from strain on the
fracture fragment from the pars longus tendon.
After bandage removal, the owl was initially
maintained in outside enclosures that did not
allow excessive exercise. Although little callus
formation is usually visible radiographically in
avian patients when the fracture is well aligned,3
further palpation and intermittent radiographic
evaluations showed increased bony bridging and
reduced visibility of the fracture line (Fig 4). The
owl was allowed to start flight exercise 25 days
after bandage removal (32 days after admission)
and was progressively allowed to increase its flight
distance. Daily pain medication was discontinued,
and the owl was caught every 7 days to obtain a
body weight, evaluate pectoral muscle mass, and
fully palpate the left wing; at all stages of the bird’s
rehabilitation, the left wing showed a full range of
motion in all left wing joints.
During the final stage of flight reconditioning,
active flight was encouraged within a 30.5-m-long
by 12-m-wide (100-foot-long by 40-foot-wide)
77
flight cage. When the owl’s flight and conditioning
were considered normal at around 14 weeks after
admission, the owl was released.
The extensor process arises from the cranial
proximal aspect of the carpometacarpus4 and is
extremely important for flight; it is the primary site
for attachment of the tensor propatagialis muscle
on the carpus, via the pars longus tendon.5 The
extensor process also receives insertions from the
extensor metacarpal radialis tendon and the
extensor longus alulae tendon.4 All of the tendons
listed above cause extension of the carpus when the
associated muscle bodies are contracted. The
extensor process is also attached to the alula via
the extensor brevis alulae muscle,1 which causes
extension of the alula, abducting it from the
carpometacarpus bone. Similarly, the cranial
collateral ligament of the metacarpophalangeal-
alular joint has its insertion on the extensor
process.1
The propatagium is a double fold of skin (both
dorsally and ventrally) that has numerous liga-
ments throughout its surface and a complex of
muscles,5 referred to here as the tensor propata-
gialis muscle (although it may consist of up to 3
different muscles).5 The tensor propatagialis mus-
cle complex has its origin over the dorsal proximal
humerus,5 and its primary function is to maintain
the cranial edge of the wing, between shoulder and
carpus, as a tight band, creating an aerofoil effect
during flight. The alula is a small bone, sometimes
referred to as the first digit, which is located on the
cranial aspect of the wing, just distal to the carpus.
It has some periosteal feather insertions and has a
large degree of mobility (flexion, extension, abduc-
tion, and adduction), which helps prevent the bird
from ‘‘stalling’’ at slow flying speeds,6 such as
during landing. In essence, the propatagium serves
the same function as the wing on an airplane.6
Without a stable extensor process, and thus a fully
functional propatagium and alula, a bird will not
be able to fly.
Fracture repair in birds depends on the bone
involved, the location and type of fracture, and the
chronicity of the injury.7 Furthermore, the success
and rate of fracture repair depends on several
factors, such as the displacement of the bone
fragments involved, the amount of damage to the
blood supply, whether an infectious agent is
present, and the amount of motion at the fracture
site.8
Secondary bone healing in birds initially involves
proliferation of fibroblasts surrounding the frac-
ture site forming a ‘‘soft’’ fibrous callus, whereas
osteogenic cells migrate from the periosteum and
78 JOURNAL OF AVIAN MEDICINE AND SURGERY
endosteum and proliferate at the fracture site.8
Endosteal callus formation7 provides rapid stabili-
zation in bones that are properly aligned,8 whereas
periosteal proliferation is much reduced compared
with mammalian species7 and is minimal if the
bones are rigidly immobilized.8 Calcium is then
deposited in the callus, and this soft callus then
becomes bone through the process of endochon-
dral ossification.8 The remodeling stage of bone
healing involves a period of accelerated deposition
and resorption, with changes in the shape of the
bone until the function and strength of the bone is
fully restored.8 Because of the amount of cell
proliferation and the high rate of metabolism at the
fracture site, an adequate blood supply to the
fracture site is imperative to allow healing.9–11
The amount of time needed for an avian fracture
to heal has been shown to be inversely correlated
to the amount of immobilization obtained at the
fracture site.9 Suggested methods of achieving
carpometacarpal fracture repair range from the
use of a standard figure-of-eight bandage, or the
incorporation of a reinforced splint into a figure-
of-eight bandage, to the use of type 1 external
skeletal fixators.5,12 Most metacarpal fractures are
high-energy fractures5,12 caused by blunt trauma.
This fact, coupled with the sparse soft tissue
coverage in this area, has led to concern that
metacarpal fractures may have a poorer prognosis
for healing than other long bone fractures.5,12
However, observations at Tufts Wildlife Clinic
indicate that metacarpal fractures have a good
prognosis for healing when managed with external
coaptation (M. Murray, unpublished data, 2010).
Because of the nondisplaced, nondiaphyseal
nature of the fracture in this owl, it was determined
that external coaptation with a simple figure-of-
eight bandage would allow maintenance of the
alignment, stabilization, and immobilization
deemed necessary for optimal fracture healing.11
Possible complications associated with the use
of figure-of-eight bandages are loss of range of
motion in the elbow and carpus, caused by
periarticular fibrosis, propatagial contracture, or
both as a result of long-term immobilization of
the wing.5 Consequently, in this owl, not remov-
ing the bandage before the fracture was deter-
mined to be stable as well as removing the
bandage as soon as possible were equally impor-
tant to minimize the risk of long-term joint
problems in the left wing.
This case demonstrates that conservative man-
agement of an extensor process fracture can lead to
complete bony healing with a full return to flight
and function in a free-living bird of prey.
This case was submitted by Ian Ashpole, BSc
(Hons), BVSc, MRCVS, and Maureen Murray,
DVM, Dipl ABVP (Avian), Wildlife Clinic, Cum-
mings School of Veterinary Medicine, Tufts
University, 200 Westboro Road, North Grafton,
MA 01536, USA.
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