External Coaptation in Birds: Bandages and Splints

Key Points

  • Orthopedic injuries are rarely a matter of life or death. Stabilize the patient first, providing analgesia and supportive care.
  • Bandages and splints are generally indicated for short-term stabilization only. Surgical fixation often provides the best long-term prognosis.
  • The figure-of-eight wrap is the main technique for support of the wing. A bellyband is incorporated for humeral or pectoral girdle fractures.
  • Lateral splints are a great option for stabilization of the tibiotarsus or tarsometatarsus. Tape splints may work best for small patients.
  • House birds with splints or bandages in a smooth-sided enclosure with low or no perches.

Introduction

Traumatic orthopedic injuries are relatively common in the avian patient. Although bird bones are strong when intact, they tend to shatter on impact as the cortices are thin and brittle (Ponder 2016, Redig 2008, Orosz 2002). A lack of abundant soft tissue coverage often leads to open fractures (Fig 1).

 

bald eagle suffering from a fracture involving the right wing

Figure 1. Juvenile bald eagle (Haliaeetus leucocephalus) suffering from a fracture involving the right wing. Photo credit: US Fish and Wildlife Service via Flickr Creative Commons

 

The goals of fracture management include: establishing early and rigid stability of the bone fragments while maintaining normal alignment, promoting load sharing, and limiting use during the healing process (Redig 2008, Martin & Ritchie 1994). Preservation of soft tissues is of utmost importance for maintaining bone integrity (Ponder 2016, Redig 2008, Orosz 2002). Be sure to immobilize the joints proximal and distal to the fracture site to ensure healing. Radiographic evaluation of orthopedic injuries should include two orthogonal views.

Orthopedic injuries are rarely life-threatening emergencies, therefore the patient should always be stabilized first. Provide analgesia (Table 1) and supportive care such as fluids and tube feeding as needed. Antibiotics are also indicated in the treatment of open fractures. Popular empirical choices include trimethoprim-sulfa and clindamycin. Clindamycin may be indicated in cases of osteomyelitis (Ponder 2016, Redig 2008, Orosz 2002).

Note: To prevent and reduce the propagation of bacterial resistance to antibiotics, health care professionals should prescribe and deliver antibiotics only when necessary. Antibiotics considered critically important for human medicine, such as fluoroquionolones, should be avoided as much as possible.–Graham Zoller, 2017

 

Cage rest

Cage rest alone is suitable for the treatment of very small birds, such as finches and canaries, and/or injuries that are not amenable to bandaging or surgery like pelvic fractures. Cage rest involves more than merely confining the bird to a cage (Ponder 2016):

  • Place the bird in a smooth-sided enclosure such as an aquarium, cardboard box, or acrylic pet cage to prevent climbing.
  • Provide low or no perches.
  • Offer bite-size food items for patients with leg injuries, especially early in the healing process.
  • If the bird is agitated, decrease light levels to reduce activity, although adequate light must be provided at least twice daily for feeding.

Other home care instructions are standard. The owner should watch the toes for changes in color or size. The bandage should be kept clean and dry.

 

General principles

Splints or bandages are generally applied for only short-term stabilization of orthopedic injuries as they provide increased comfort to the patient but minimal stabilization of the fracture (Martin & Ritchie 1994). Although very small patients or birds with pathologic fractures may do well with external coaptation, external or internal fixation techniques are associated with better long-term prognosis for bone alignment and return to function, particularly in larger birds (Orosz 2002). External coaptation is acceptable as a primary stabilization technique only when a limited post-fracture range of motion is satisfactory, the patient is too small to facilitate surgical repair, the fracture is minimally displaced, or anesthesia and surgery would jeopardize the patient’s life (Martin & Ritchie 1994).

    • Place splints or bandages under general anesthesia.
    • Position limbs in a functional position so that joints are arranged at natural angles. Use the normal limb as your guide.
    • Pluck feathers before applying a bandage or splint to the pelvic limb.
    • Incorporate tape stirrups to minimize slippage.
    • Cut bandage material to an appropriate width to prevent bunching. A lumpy wrap will be uncomfortable, and bunching may also promote the creation of constriction bands.
    • Splints and bandages in large birds should contain all three layers: cast padding, gauze, and a protective layer. Wraps in smaller patients must be lighter and frequently contain only one or two layers.

  • Companion parrots, particularly medium or large species, also require a chew layer (i.e. porous tape), which slows down the speed with which the bandage is destroyed.
  • Distraction tabs can also help to protect the bandage (Fig 2).
  • Although a parrot may normally chew at its wrap some, excessive picking can indicate the bandage is uncomfortable or that pain that has not been adequately addressed.
  • In rare instances or in very large species, it may be necessary to apply bitter apple spray and/or collars to protect the bandage.
Distraction or chew tabs of porous tape can be applied to minimize chewing on the protective layer of bandages in psittacine birds

Figure 2. Distraction or chew tabs of porous tape (arrow) can be applied to minimize chewing on the protective layer of bandages in psittacine birds. Click image to enlarge.

Thoracic limb injuries

Injuries of the thoracic limb (Fig 3) may present as a wing droop or an inability to fly (Ponder 2016).

 

Pectoral girdle skeleton: 6 = Sternum 3 = Clavicle 4 = Coracoid 19 = Scapula 21 = Humerus 23 = Radius 22 = Ulna 27 = Alular digit (alula) 24 = Metacarpal bones 25, 26 = Major and minor digit (manus)

Figure 3. Pectoral girdle skeleton: 6 = Sternum 3 = Clavicle 4 = Coracoid 19 = Scapula 21 = Humerus 23 = Radius 22 = Ulna 27 = Alular digit (alula) 24 = Metacarpal bones 25, 26 = Major and minor digit (manus); Photo credit: Svtiste via Wikimedia Common. Click image to enlarge.

 

The figure-of-eight bandage or wing wrap is the basic method of wing external coaptation. Keep in mind that application of this bandage can lead to compression, contraction, and dysfunction of the wing web or patagium if wrapped too tightly or not removed every 2-3 days for physical therapy of the patagium (Ponder 2016, Redig 2008).

 

  • Pectoral girdle fractures or shoulder luxations often do best with strict cage rest, and fractures of the pectoral girdle do best without bandaging (Scheelings 2014).
  • Powerful flight muscles cause most humeral fractures to distract significantly. Surgical repair is necessary in most cases, although a proximal humeral fracture may do well with a wing wrap alone. A figure-of-eight bandage and belly band can be placed short-term to support humeral fractures and some pectoral girdle fractures. The belly band serves to immobilize the wing against the body wall (Fig 4) (Orosz 2002).
    wing wrap diagram Redig

    Figure 4. Figure-of-eight or wing wrap placement. Posted with permission by Dr. Patrick Redig from Medical Management of Birds of Prey, 3rd ed. Click image to enlarge.

    A.Gather the primary, secondary, and tertiary feathers together for inclusion in the bandage.
    B.The free end of a roll of bandage material is grasped under the leading edge of the primaries and held in place. The gauze is then brought through the axillary space to the dorsum of the wing and wrapped. Direct the bandage material from inside to outside over the top of the wing—this will roll the wing inward and prevent an outward twist of the wing.
    C.As the bandage material is brought around the next time, instead of coming through the axillary space, the material is brought around the front of the wing, under the leading edge, and then up through the axilla. It then continues over the top, underneath, and up in front of the wing.
    D.Alternate wraps in front and behind the wing until sufficient bulk has been achieved. Note that an effort is made to hold the primary feathers in a partially extended manner so as not to overflex the wrist joint or tighten the primary feathers into an abnormal position (the leading edge of the primary feathers should lie parallel to the secondary feathers) (Redig 2008).
    E-F.Cover the gauze layer with elastic bandage material (e.g., Vetrap, 3M)
    *To immobilize the shoulder joint, pass a belly band once or twice around the body. Start placement of the tape at mid-keel with the tape direction moving away from the fractured wing. The final tape placement should cross the affected wing at the midpoint between the shoulder and the elbow and be centered at mid-keel level. Make sure one or two fingers can easily pass underneath the band, as constriction over the keel can make it difficult for the bird to breathe (Redig 2008).

     

  • Antebrachial fractures typically require surgery to minimize the risk of synostosis or bridging callus between the radius and ulna. Synostosis limits wing flexibility and prevents return to normal function. Exceptions to this rule of thumb include (Orosz 2002):
    1. Non-displaced radial or ulnar fractures in a small patient: The intact bone serves as an internal splint and the fracture may heal with a wing wrap.
    2. Carpal and metacarpal fractures: These lesions are extremely challenging to manage and difficult to repair surgically (Redig 2008). Options for repair of metacarpal fractures include the figure-of-eight wrap, the curved edge sandwich splint, and external skeletal fixation. The wing wrap and sandwich splint are generally use on minimally displaced metacarpal fractures. Heat-pliable plastic or padded aluminum splint material is bent into an “L” or “U” shape along the length of the metacarpus, extending the length of the carpus to the distal phalanx and folding over the leading edge of the bone. If an L-shape is used, the long side goes on the ventral aspect of the metacarpus and the 90° degree bend goes at the cranioventral aspect, leaving the short end to point dorsally. If the splint is “U”-shaped, fit the wing into the splint so that there is support ventrally, dorsally, and cranially. Both shapes are wrapped into place. Monitor for soft tissue swelling and adjust the fit as needed (Ponder 2016, Redig 2008, Orosz 2002).

Regular removal of the wing wrap and passive range of motion exercises are critical to maintain joint and propatagial flexibility. Physical therapy should initially be performed under general anesthesia. A good rule of thumb is to perform passive range of motion exercises for 5 minute sessions twice weekly for the first 1-2 weeks. Stretching and holding exercises are alternated with range of motion movements to the extent the limb will allow. Care should be taken not to overextend the limb during these exercises (Fig 5) (Redig 2008, Orosz 2002).

 

Passive range of motion exercises in a red-tailed hawk

Figure 5. Passive range of motion exercises in a red-tailed hawk (Buteo jamaicensis). Never overextend the limb during these exercises. Photo credit: Dr. Christal Pollock

Pelvic limb injuries

Injuries of the pelvic limb (Fig 6) can present as lameness, unequal weight bearing, localized swelling and pain, and/or an uneven grip (Ponder 2016).

 

Avian pelvic limb

Figure 6. Avian pelvic limb. Image by Dr. Christal Pollock.

Strict cage rest may be sufficient in a small bird with a pelvic fracture or coxofemoral luxation after closed reduction. Femoral fractures typically override with external coaptation. Therefore surgery is indicated for return to normal function, although cage rest may be acceptable in small birds. Modified spica splints or modified tape splints, which extend up to the rump, have also been described.

Tibiotarsal fractures are very common in the avian patient. Options for support include:

    • The lateral splint is a soft padded wrap reinforced by an aluminum rod, syringe case, tongue depressor, or lightweight, moldable plastic. Moldable plastic is stiff at room temperature, but malleable in hot water. Available products include Veterinary Thermoplastic (IMEX Veterinary, Inc.), Orthoplast (Johnson & Johnson), and Vetlite, formerly known as Hexcelite (Jorgenson).
    • The modified Schroeder-Thomas splint (Fig 7) is created using appropriately sized wire (i.e. 14 to 18-gauge) bent, shaped, and padded to the fit the limb. Thomas splints are usually made for medium to large birds.
      ST Splint Redig

      Figure 7. Modified Thomas-Schroeder splints are usually generally made for medium to large birds exceeding 300 grams. Posted with permission by Dr. Patrick Redig from Medical Management of Birds of Prey, 3rd ed. Click image to enlarge.

      D-E.Appropriately sized wire is bent, shaped, and padded to fit the limb. Note the outward bend in the struts just below the circular portion of the splint. This is needed to properly align the splint with the bird leg. A proper splint should have bends just below the circular portion and at the level of the hock.
      F.Apply a light wrap and attach the bandage to the splint using porous tape.
      G.Cover the entire structure with a protective layer such as Vetrap (3M).
    • A tape splint or Altman splint is created by applying pieces of masking tape or porous tape to either side of the leg of small bird less than 150 grams (Fig 8 – Fig 10). Some clinicians apply tissue glue (Vetbond®, 3M) to make the tape stiff. Tape splints must be removed under general anesthesia (Ponder 2016, Redig 2008).
      tape splint Cyndi Brown

      Figure 8. Create a tape splint by applying pieces of masking tape or porous tape to either side of the leg of birds less than 150 grams. Position the limb with the joints flexed in a normal perching position. Photo credit: Dr. Cyndi Brown. Click image to enlarge.

      tape splint hemostat Cyndi Brown

      Figure 9. Use hemostats to crimp the tape as close to the leg as possible. Finally trim the tape to reduce the weight of the splint. Photo credit: Dr. Cyndi Brown. Click image to enlarge.

      Tape splint

      Figure 10. Tape splint. Photograph provided by Dr. Isabelle Langlois.

 

Options for support of the tarsometatarsus include the lateral splint, Schroeder-Thomas splint, and a tape splint, which includes ankle stirrups (Harcourt-Brown 2002). In birds weighing less than 150 grams with closed and otherwise uncomplicated fractures, a tape splint combined with taping the hock in flexion allows the tarsometatarsus to be splinted by the tibiotarsus (Redig 2008).

Cage rest may be the best choice for closed toe fractures. A snowshoe splint or ball bandage are other options (Fig 11), although some authors report adhesion formation and poor return to function with splinting therefore monitor toes closely for loss of viability and necrosis (Harcourt-Brown 2002).

 

ball bandage Ariana Finkelstein

Figure 11. A ball bandage is one option for management of a closed toe fracture. Photo credit: Dr. Ariana Finkelstein. Click image to enlarge.

 

 

Pododermatitis

Pododermatitis or “bumblefoot” is an infection of the plantar surface of the foot (Fig 12). Pododermatitis can develop in any bird with a leg injury on the “good” or weight-bearing foot, however it is particularly likely in heavy-bodied birds such as raptors and waterfowl. Monitor patients with leg injuries carefully for redness and wearing of the papillae on the bottoms of the feet. Factors that increase the risk of pododermatitis include obesity, malnutrition, and inappropriate perch material.

Pododermatitis

Figure 12. Pododermatitis or “bumblefoot” can develop in any bird with a leg injury on the “good” or weight-bearing foot. Lesions are especially common in heavy-bodied birds such as raptors and waterfowl. Photo credit: Dr. Ed Ramsay

Measures to reduce the risk of pododermatitis in the avian patient include:

  • Gradually reduce body weight.
  • Correct dietary deficiencies and supplement vitamin A as needed.
  • Wrap perches with self-adhesive bandage material (e.g. Vetrap, 3M) or artificial turf. Avoid dowel perches, and provide natural tree branches as variations in diameter will vary pressure points on the feet.
Table 1. Commonly used analgesics in the avian patient (Hawkins 2013)    
DrugDosageRouteFreqComments
Bupivicaine

(Marcaine, AstraZeneca)
2 mg/kgSC, topical Based on research in ducks
Buprenorphine HCl

(Buprenex, Reckitt & Colman)
0.05-1.0 mg/kgIMq8-12h 
Butorphanol tartrate

(Torbugesic, Fort Dodge)
0.5-0.6 mg/kgSC, IMq4-6h 
Carprofen

(Rimadyl®, Pfizer)
2-10 mg/kgPO, SC, IMq8-12h 
 1-2 mg/kgIM, IVq12-24h 
Ketoprofen

(Ketofen, Fort Dodge)
1-10 mg/kgPO, IMq12h 
Lidocaine

(Xylocaine, Abraxis)
1-3 mg/kgTopical Dilute 1:10
Meloxicam

(Metacam, Boehringer Ingelheim)
1 mg/kgPO, IMq24hRaptors
1 mg/kgPO, IMq12hPsittacine birds
PO: per os IM: intramuscular SC: subcutaneous q: every

References