Vol. 19, No.
2 February 1997
Continuing Education Article
FOCAL POINT
★The causes of the high
prevalence of antebrachial
fractures and associated
complications in toy breed dogs
are unclear, but the treatment of
choice is rigid stabilization with a
bone plate in combination with
cancellous bone autograft.
KEY FACTS
■ Fractures of the antebrachium
can occur in toy breeds after
apparently minimal trauma.
■ Treatment of distal antebrachial
fractures in toy breeds with
bone plate fixation has a low
complication rate compared
with other methods.
■ Delayed union or nonunion
is particularly prevalent in toy
breeds and may eventually
necessitate amputation.
■ Bone is weakest in shear,
followed by tension and
compression; when a bending
load is applied, the convex
(tension) side will fail first,
followed by the concave
(compression) side.
Distal Antebrachial
Fractures in
Toy-Breed Dogs
University of California
Peter Muir BVSc, MVetClinStud, PhD, MACVSc, MRCVS
F ractures of the antebrachium account for approximately 17% of canine
fractures.1 Motor vehicle trauma is a prevalent cause. In toy breeds, how-
ever, fractures of the antebrachium can occur after apparently minimal
trauma, such as jumping or falling, and usually affect the distal region of the
diaphysis.2
Treatment of distal antebrachial fracture in toy breeds with bone plate fixa-
tion has a low complication rate,3 whereas a high complication rate can be ex-
pected with other treatment methods, such as external coaptation or in-
tramedullary pinning.3,4 More recently, external skeletal fixation has been used
to successfully treat this type of fracture.5 Routine use of cancellous bone auto-
graft for fracture treatment is also considered important.2
The prevalence of delayed union or nonunion in canine fractures is 3.4%.6
This complication occurs most commonly after fracture of the distal ante-
brachium and is particularly prevalent in toy breeds.6–8 Development of de-
layed union or nonunion after surgery is a potentially serious complication, be-
cause limb amputation may eventually be necessary.9 Although the prevalence
of antebrachial fracture and complications after treatment in toy breeds has
been recognized for many years,7,10 the causative biological mechanisms are
poorly understood.
Various hypotheses regarding the prevalence of delayed bone healing after
distal antebrachial fracture in toy breeds have been suggested, including frac-
ture instability,9 increased and persistent formation of cartilage within the frac-
ture site,11 and decreased osteogenesis compared with larger dogs.4,8,11 Differ-
ences in vascular density at the metaphyseal–diaphyseal junction have also been
implicated,12 but blood supply at the fracture site has not been measured di-
rectly.
The hypothesis examined in this study of distal antebrachial fractures in toy
breeds is that a small region of the distal part of the diaphysis fails mechanically
after trauma. Fracture patterns, which have been identified radiographically,
are evaluated in detail, with the long-term goal of better defining reasons why
the antebrachium in toy breeds appears to be so vulnerable to fracture. Further-
Small Animal The Compendium February 1997

more, the results of ment displacement,

treatment of distal and regional loca-
antebrachial frac- tion of the main
tures have been com- fracture line were
pared to determine recorded. Using the
whether a particu- mediolateral radio-
lar treatment method graphic view, the
was associated with im- distance between
proved outcome. the distal end of the
radius and the main
MATERIALS fracture line was
AND METHODS measured, and the
The medical rec- result expressed as a
ords of all dogs percentage of the
with antebrachial total length of the
fracture presented radius from distal
to the University of (0%) to proximal
California, Davis (100%). Fractures
Veterinary Medical were categorized as
Teaching Hospital delayed union if the
(UC Davis VMTH) degree of fracture
from April 1987 to healing was consid-
March 1996 were ered abnormally re-
reviewed retrospec- duced for the time
tively using the UC elapsed between in-
Davis VMTH com- jury and presenta-
puterized data base tion or treatment.
for patient records. Fractures with loss
Of 127 dogs pre- of bone adjacent to
sented, 40 weighed the fracture and a
less than 5 kg. Of minimal healing re-
these 40 dogs, med- sponse were catego-
ical records of 26 rized as atrophic non-
were complete and union.
were examined for
this study. Treatment and
Figure 1A Figure 1B Follow-up
Clinical Findings Figure 1—Craniocaudal radiographic views of the right antebrachium. The treatment
Signalment and (A) This transverse fracture of the distal radius and ulna, at 23% of the radial methods and use of
body weight were length, occurred in a 2-month-old female miniature pinscher after it jumped cancellous bone au-
recorded. Fracture from its owner’s arms. Transverse fractures typically result from bending over- tograft were deter-
information in- load. (B) This oblique fracture of the distal radius and ulna, at 24% of the ra- mined. Outcome
cluded time from dial length, occurred when a 5-month-old miniature pinscher jumped off a was determined for
coffee table. Oblique fractures typically result from compressive overload.
fracture to presen- dogs reexamined at
tation, fracture du- UC Davis VMTH,
ration, unilateral including healing of
versus bilateral fracture, and open versus closed frac- the fracture and development of complications.
ture. Prior treatment(s) and outcome were also record-
ed. RESULTS
Clinical Findings
Radiography Breeds included toy poodles (n = 11), Pomeranians
Mediolateral and craniocaudal radiographic views of (n = 5), Chihuahuas (n = 3), papillons (n = 2), minia-
the antebrachium were examined. Fracture type, frag- ture pinschers (n = 2), Italian greyhound (n = 1), toy fox

SIGNALMENT ■ RADIAL LENGTH ■ FRACTURE CLASSIFICATION ■ BREEDS

The Compendium February 1997 Small Animal

Figure 2A Figure 2B Figure 2C

Figure 2—Mediolateral radiographic views of the right antebrachium of an 18-month-old castrated male Yorkshire terrier
cross. (A) At presentation (8 weeks after fracture). Delayed union of the distal radius and ulna, at 26% of the radial length,
developed after failure of the intramedullary pin and external coaptation technique. (B) Immediately after surgical revision.
The fracture has been debrided and stabilized with a 2.0-mm dynamic compression plate. (C) Sixteen weeks after plating.
The delayed union fracture has healed.

terrier (n = 1), and Yorkshire terrier (n = 1). Nine of the
26 dogs were younger than 1 year of age at the time the
fracture was sustained. Sixteen dogs ranged in age from
1 to 4 years, and the age of one dog was unknown. Of
14 females, 6 were spayed; of 12 males, 6 were castrated.
Body weight ranged from 1 to 4 kg (mean, 2.3 kg).
Seventeen dogs were presented with acute fractures
(<7 days from injury) without receiving definitive or-
thopedic treatment. Nine dogs had sustained fractures
1 to 3 months before presentation and had received
prior treatment with intramedullary pinning, external
coaptation, intramedullary pinning combined with ex-
ternal coaptation, or bone plating. The treatment his-
tory in one dog was unknown. Fracture etiologies in-
cluded jumping or falling, often from a minimal
height (n = 16), being stepped on (n = 3), motor vehi-
cle trauma (n = 1), being attacked by another dog (n =
1), and being caught in a door (n = 1). In four dogs

PATIENT AGE ■ TREATMENT HISTORY ■ FRACTURE ETIOLOGY

Small Animal
the etiology was unknown. In 6 of 26 dogs, fractures
were bilateral. There were no grade II or grade III
open fractures.
Radiography
Of the 17 dogs presented with acute fractures, 14
had 16 transverse or short oblique fractures. All frac-
tures involved the distal antebrachium (Figure 1), oc-
curring between 15% and 37% of the radial length
(mean ± SD, 25% ± 6%). An intraarticular fracture
of the distal radius and a contralateral distal ante-
brachial fracture (22%) were sustained by one dog
following motor vehicle trauma. A comminuted mid-
diaphyseal antebrachial fracture (58%) was sustained
by one dog after being stepped on. Bilateral commin-
uted mid-diaphyseal antebrachial fractures (54% and
70%) were sustained by one dog after being attacked
by another dog. This dog also sustained a humeral
fracture.
Nine dogs presented with 11 chronic fractures, in-
cluding 3 atrophic nonunion fractures, 3 delayed union
fractures, and 5 healing malunions. Atrophic
nonunions were associated with prior intramedullary
pinning (n = 1), external coaptation (n = 1), and in-
tramedullary pinning combined with external coapta-
tion (n = 1). Delayed unions were associated with prior
intramedullary pinning (n = 2) or intramedullary pin-
ning combined with external coaptation (n = 1). Mal-
unions were characterized by lateral deviation of the
paw distal to the fracture and were associated with ex-
ternal coaptation (n = 3), bone plating (n = 1), and un-
known treatment (n = 1). Remodeling of the fractures
prevented precise determination of the original fracture
pattern. Eight of 11 fractures affected the distal ante-
brachium (mean ± SD, 27% ± 13% of radial length;
range, 16% to 55%).
Treatment and Follow-up
Bone plate fixation was used to stabilize 15 acute an-
tebrachial fractures, and cancellous bone autograft was
used to treat 4 of these fractures. Nine fractures healed
without complication, and 5 fractures were lost to fol-
low-up. Instability of the bone plate construct resulted
in eventual fracture malunion in one dog, with lateral
deviation of the paw distal to the fracture. External
coaptation was used to treat four acute fractures in four
dogs that were younger than 5 months of age. Three of
these fractures healed, and one fracture was lost to fol-
low-up. One dog with bilateral acute fractures was dis-
charged to the referring veterinarian for treatment with
external coaptation.
Bone plate fixation was used to stabilize four
chronic fractures, of which cancellous bone autograft
FRACTURE TYPE ■ FRACTURE STABILIZATION ■ BENDING LOAD ■ HUMAN FRACTURES
The Compendium February 1997
was used in three. Three of these fractures healed
without complication (Figure 2). Instability of the
bone-plate construct in one dog resulted in delayed
malunion, with lateral deviation of the paw distal to
the fracture, despite use of cancellous bone graft. Ap-
plication of a type II external skeletal fixator, using
small Kirschner wires and methylmethacrylate con-
necting bars, combined with cancellous bone auto-
grafting was used to treat three chronic fractures.
Two fractures healed (Figure 3). One fracture was lost
to follow-up at 2 months, at which time fracture
union had not occurred. Three stable malunion frac-
tures received no further treatment, and one fracture
was lost to follow-up. Overall, bone–plate removal
was performed for 8 of 19 fractures. Refracture of the
antebrachium occurred in one dog after plate re-
moval. This fracture healed after treatment by the re-
ferring veterinarian.
DISCUSSION
Fracture of the distal antebrachium after apparently
minimal trauma remains a prevalent clinical problem
in toy breeds. Despite being recognized for many
years as a clinical phenomenon, the etiology is still
not completely understood. In this case series, the sig-
nalment of affected dogs was similar to that reported
in other studies. 3,10,13 In dogs presented with acute
fractures in which precise determination of fracture
pattern was possible, the injury sustained by those
with a history of minimal trauma was characteristical-
ly a transverse to oblique fracture of the distal region
of the antebrachium. This fracture pattern is similar
to Colles’ fracture,14 which occurs commonly in hu-
mans. In general, dogs with comminuted fractures lo-
cated more proximally in the antebrachium appeared
to sustain their fractures as a result of more severe in-
jury.
Bone is weakest in shear, followed by tension and
compression.15,16 When a bending load is applied to
bone, the convex side is loaded in tension and the con-
cave side is loaded in compression. The convex (ten-
sion) side will fail initially, generating a crack. As the
crack propagates, the neutral axis of the bone will be
shifted toward the compressive side, thereby allowing
propagation of the crack across the bone to create a
transverse fracture.16 If a compressive load is applied to
bone, an oblique fracture is typically produced, with
bone failure occurring because of shear stresses within
the bone. Such fractures typically occur in the meta-
physeal regions of bones because cancellous bone is sig-
nificantly weaker in compression than cortical bone.16
Comminuted fractures with a butterfly fragment are
typically a result of a combined bending and compres-
The Compendium February 1997 Small Animal

Figure 3—The right antebrachium

of a 3-year-old female toy poodle.
(A) Transverse fracture of the distal
radius and ulna, at 18% of the radi-
al length, was sustained after jump-
ing. (B) Mediolateral radiographic
view. Before presentation, the frac-
ture was stabilized using an in-
tramedullary pin and external coap-
tation technique, with penetration
of the antebrachiocarpal joint by
the pin. (C) Mediolateral radio-
graphic view on presentation 12
weeks after injury. Atrophic non-
union has developed with severe os-
teopenia of the antebrachium and
carpus as a consequence of the ini-
tial treatment. (D) Craniocaudal ra-
diographic view 4 weeks after revi-
sion surgery. Cancellous bone
autograft has been placed around
the fracture, and the fracture has
been stabilized with a type II exter-
nal skeletal fixator using Kirschner
wires and acrylic connecting bars.
Pins were placed in the proximal
ulna and metacarpus as well as
Figure 3A Figure 3B Figure 3C
the antebrachium. Osteopenia im-
proved, and fracture dynamization
was performed by removal of the
proximal and distal pins. (E) Craniocaudal radiographic
view of the right antebrachium 10 weeks after revision.
The external fixator was removed because osteopenia fur-
ther improved, and healing of the fracture has progressed.

sive failure load.16 Jumping or falling was the most

common cause of distal antebrachial fracture in the
dogs in this report, and such an event would be likely
to create the compressive or bending failure loads that
would be necessary to create the fracture patterns ob-
served.
Why toy breeds appear to have decreased ante-
brachial failure load compared with larger dogs remains
obscure. Larger dogs typically sustain hyperextension
injury to the carpus after jumping or falling.17 Recent
ex vivo studies in dogs18 and humans19 have shown that
geometric variables, such as cross-sectional cortical area
and area moment of inertia, are at least as important as
bone mineral density20 in determining bone failure load
and risk of fracture. In this study, many of the ante-
brachial fractures that resulted from apparently mini-
mal trauma occurred in a small region of the distal dia-
physis, centered at the 25th percentile of radial length.
The region from 30% to 40% of radial length appears
Figure 3D Figure 3E to be mechanically weakest in humans, based on de-

FRACTURES IN LARGER DOGS ■ GEOMETRIC VARIABLES

Small Animal
tailed evaluation of bone geometry.21 Fractures after
minimal trauma are most common in the elderly, and
age-related alterations in bone mineral density and
bone geometry have been demonstrated in the distal ra-
dius.22 Bone mineral density declines with increasing
age, and compensatory adaptive remodeling results in
altered bone geometry that contributes to the preserva-
tion of bone strength.22
Distal antebrachial fractures in toy breeds typically
occur in young growing or adolescent dogs.10 Whether
age-related changes in antebrachial bone mineral densi-
ty or bone geometry result in increased antebrachial
failure load in toy breeds in later life has not been in-
vestigated. Further comparative study of the material
and structural properties of the antebrachium of toy
breeds versus larger dogs is needed to confirm whether
this region of the antebrachium, which is so prone to
fracture in toy breeds after apparently minimal trauma,
is abnormally weak. Because the relative height of
falling may tend to be greater for toy-breed dogs than
for larger dogs, bone failure load may be exceeded more
easily after jumping or falling.
Successful fracture healing usually occurred after
rigid stabilization of the antebrachium using a bone
plating technique. The presence of chronic atrophic
nonunion, delayed union, or malunion fracture at pre-
sentation was typically associated with prior treatment
with intramedullary pinning and external coaptation.
On the basis of this and other studies,3,13 rigid stabiliza-
tion with a bone plate, combined with use of cancel-
lous bone autograft, is the treatment of choice for all
acute antebrachial fractures in toy breeds, although
union of the fracture will usually occur after bone plate
fixation alone. Intramedullary pin fixation and external
coaptation of antebrachial fractures in toy breeds are
contraindicated because these stabilization methods are
associated with an unacceptably high complication
rate,3,8,13 although delayed union or nonunion after ex-
ternal coaptation in young dogs is uncommon.10 The
antebrachiocarpal joint is often damaged by in-
tramedullary pin fixation of distal antebrachial frac-
tures. Development of a complication such as atrophic
nonunion is potentially serious and may ultimately ne-
cessitate limb amputation.9 Development of severe at-
rophic nonunion usually necessitates treatment with ex-
ternal skeletal fixation,5 because of loss of mineralized
bone stock.
Bone mass and bone architecture are controlled by
adaptive bone modeling and remodeling.23 Mechanisms
controlling modeling and remodeling of bone include
functional load bearing, stimuli associated with bone
growth in adolescence, and the influence of calcium-
regulating hormones.23 Bone remodeling is also influ-
RELATIVE HEIGHT ■ BONE PLATING ■ LIMB AMPUTATION
The Compendium February 1997
enced by fatigue damage to bone.24 The apparently low
failure load of the toy breed antebrachium, the higher
risk of complicated fracture healing after inadequate
stabilization, and the rapid decline in bone mineral
density associated with external coaptation and func-
tional disuse2–4,8,10,11 could hypothetically be influenced
by any of the above-mentioned mechanisms controlling
modeling and remodeling. Such hypotheses still require
investigation.
About the Author
When this article was submitted, Dr. Muir was affiliated with
the Department of Surgical and Radiological Sciences,
School of Veterinary Medicine, University of California,
Davis, California. He is currently affiliated with the Depart-
ment of Small Animal Medicine and Surgery, The Royal
Veterinary College, University of London, London, UK. He
is a Diplomate of the American College of Veterinary Sur-
geons and the European College of Veterinary Surgeons.
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