Imagine this clinical scenario...
You are presented with a four year old male Cocker Spaniel that has been involved in a road traffic accident. Upon X-ray you find that he has mid diaphyseal fractures of all four of his left metacarpal bones with moderate displacement and marked instability. Your first instinct is to recommend surgery, but the client is concerned about the financial implications. They are willing to go ahead with surgery if it’s the best option for the dog, but want to explore non-surgical options. You decide to consult the evidence to ascertain whether conservative management with external coaptation or surgical intervention offers the best outcomes for dogs with metacarpal/metatarsal fractures.
The evidence
Five papers were identified that relate to this topic, all of them retrospective case studies. Bellenger et al. (1981) studied the cases of 23 racing greyhounds with metacarpal and metatarsal fractures treated between 1974 and 1980. 10 other cases of various breeds were excluded from the study. 14 dogs underwent an internal fixation operation, 8 were treated conservatively, and 1 was euthanised. Outcomes studied included; fracture location and configuration, radiographic follow up, ability to return to racing, and racing performance.
Kapatkin et al. (2017) reviewed the cases of 25 dogs treated between 1986 and 1996 who had fractures in the metacarpals or metatarsals in one leg. 9 of the dogs were treated with a variety of surgical interventions, while 16 were treated conservatively. Clinical outcome scoring was determined through a combination of telephone questionnaires with owners and follow-up examinations.
Kornmayer et al. (2014) studied the cases of 100 dogs of mixed breed and age that had presented with metabone fractures, had undergone treatment, and had a radiographic follow up. 67 are the conservative management group, 25 were treated with surgical intervention alone, and 8 are the combination group.
Manley (1981) studied the cases of 31 dogs with distal extremity fractures treated between 1978 and 1980. 12 cases were also reviewed but were excluded for not meeting the inclusion criteria. 20 were treated with conservative management by external immobilisation, and 11 were treated surgically. Outcomes studied included; long-term outcomes, and evidence of residual lameness.
Muir & Norris (1997) studied cases of 37 dogs with metabone fractures over a 9-year period. 11 dogs were treated surgically, 24 were treated conservatively with external coaptation, and 2 were treated conservatively with exercise restriction only. Outcomes studied included pre- and post-treatment radiographs, and treatment outcomes.
Limitations of the evidence
The overall strength of evidence is weak. All five papers are retrospective studies, with no use of randomisation of treatment groups, blinding, or the use of control groups. All of the papers also use outdated case data; three papers were published in the 20th century (Bellenger et al., 1981; Manley, 1981; Muir & Norris, 1997), while the remaining two featured cases from the 20th century (Kapatkin et al., 2000; Kornmayer et al., 2014). Some of the cases featured date back over 50 years, during which time there have been advances in surgical treatments. This limits the applicability of the findings to present-day practice.
The papers all had relatively small case numbers except for Kornmayer et al. (2014), the only paper with over 50 cases. Kornmayer et al. (2014) was also the only paper to provide convincing follow-up data, which is a notable limitation of the other four papers. Surgical techniques also varied across the papers which limits their comparability.
Bellenger et al. (1981) studied cases of track injuries suffered by racing dogs, which limits the applicability of their findings to the general canine population. Kapatkin et al. (2017) had the following further limitations; inaccuracies due to a reliance on owners to make final assessments, and follow-ups performed too early to give an accurate final outcome.
Kornmayer et al. (2014) had the following further limitations; variable re-evaluation periods make it difficult to draw conclusions, and potential for clinician bias due to subjective lameness assessment. Manley (1981) had the following further limitations; outcome assessment methods were poor and created potential for bias, and patient age and weight data was absent.
Muir & Norris (1997) had the following further limitations; no set time frames for observation or determination of non-union, and no clinical assessment of ongoing lameness.
Summary of findings
The evidence suggests that outcomes for surgical intervention and external coaptation in dogs with fractured metatarsals or metacarpals are similar. However, this must be considered in the context of the limitations above. Bellenger et al. (1981) provided follow-up data for 16/33 cases; 14 surgical cases, all of which were classed as being ‘healed’, and 2 conservatively managed cases whose outcomes were recorded as ‘callus’.
Kapatkin et al. (2017) noted no statistical difference in outcome between surgery and conservative treatment. Owners/clinicians noted ‘perfect’ results in 9/16 conservatively managed cases and 7/9 surgically managed cases. Kornmayer et al. (2014) found both methods of treatment effective but highlighted no significant difference in outcome between them. A poor functional outcome occurred in 2/67 conservatively managed cases, 1/25 surgically managed cases, and 0 cases using both treatments.
Manley (1981) reported poor outcomes with both methods, with persistent lameness present in 8/11 surgically treated cases and 8/20 of conservatively treated cases. Muir & Norris (1997) reported that 13/24 dogs experienced progressive healing, while 10 were lost to follow-up. Mixed results were reported in the 11 surgically managed cases, which used a variety of techniques. 1/1 cases treated with intra-articular cross pinning failed, 2/2 cases treated with IM pinning saw progressive healing but with an element of non-union, 6/6 of cases treated with bone plates saw progressive healing but only 3/6 had improved fracture alignment, and 2/2 cases treated with bone screws had persistent lameness but went on to progressive healing.
Conclusion
The limitations of the papers we studied mean that clinicians should consider other variables when weighing up treatment options for dogs with metatarsal and metacarpal fractures, such as clinical expertise, financial feasibility, and patient temperament. The fact that surgical techniques were less advanced when much of the data in these papers were collected diminishes their applicability to modern veterinary practitioners. Additionally, it should be noted that external coaptation still carries a financial cost which can increase if complications occur. As the client in the clinical scenario above had financial concerns, this would be a factor to consider when making decisions on treatment options.
The full Knowledge Summary can be found in RCVS Knowledge’s open access journal Veterinary Evidence.
Disclaimer
The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise; patient’s circumstances and owner’s values; country, location or clinic where you work; the individual case in front of you; and the availability of therapies and resources.
Small Animal Orthopaedic Surgery
ISVPS General Practitioner Certificate (GPCert)
Postgraduate Certificate (PgC)
June 2026
Online | Swindon or Sheffield
