Introduction

The techniques for chelonian shell repair in this paper have been developed for wild tortoises and turtles that have traumatic injuries. These injuries are usually caused by run-ins with cars and sometimes pet dogs. Developing the prognosis and then a successful treatment plan will assist the clinician in guiding the course of action to be taken. There are five basic categories of prognosis: excellent prognosis; good prognosis, fair prognosis, guarded/poor prognosis, and grave prognosis. With time, an experienced practitioner may be able treat more complicated cases with great chance of a favorable outcome.

Tortoise Wound Care

In many cases dirt, bone fragments and other foreign bodies may be in the wound and irrigation may drive them deeper into the coelom. By holding the wound ventrally the foreign bodies should be flushed out. During the first irrigation a 2% solution of Chlorhexidine solution (Nolvasan Fort Dodge, Fort Dodge, IA 50501) is flushed into the wound followed by sterile saline, in a 1:2 ratio. Depending on the severity of the wound and clinical signs of infection, this may have to be repeated daily and switched to every other day and then weekly if needed.

Once the wound is irrigated, a wet-to-dry bandage should be applied. Sterile 4x4 gauze pads soaked with sterile saline should be applied to the wound with a layer of dry gauze pads over the top. This can then be secured to the shell with tape. The author has found that elastikon (Johnson and Johnson) tape holds to the shell well and allows the wound to breath. This bandage will have to be changed daily. In some cases of severe infection, silver impregnated gauze (Acticoat, Smith and Nephew, Largo, FL 33773) may be used to reduce pathogen load at the wound. Wet to dry bandages should be placed over all wounds for the first week or two as this will reduce contamination and assist with healing. If only closed fractures are present, after two weeks (or less) of wet to dry bandages, topical Silver Sulfadiazine (SSD) (Watson Laboratories Inc, Corona, CA 92880) can be applied to the cracks to assist with pathogen reduction and granulation bed formation. In addition the wounds can be bandaged to keep additional contamination from occurring.

Open wounds or missing areas of shell will have to be monitored for many months. After the first two weeks the bandage should be changed twice a week. At this point non-adherent dressing can be applied followed by gauze and then tape. The author uses SSD ointment on the wound to help prevent contamination. When changing the bandage the wound should be irrigated with saline and or dilute chlorhexidine if needed. After one month a thick "leather like" granulation bed may form, it may be a brown or grey color but should have no odor. Keep this area clean and treat appropriately. By 6–8 weeks the wound should be left alone to heal, however the wound should be kept clean with occasional irrigation with saline. Once this thick granulation bed has formed and the surface is dry the wound does not need banding on a daily basis and can be monitored weekly.

Aquatic Turtle Wound Care

Aquatic turtle husbandry makes wound care more challenging. Depending on the area and severity of damage these animals can be held out of the water for 10–14 days. They must however be given oral or intra-coelomic fluids in addition to short baths to wet down. Aquatic turtles with simple, closed fractures can be kept dry docked for 7–10 days and then wounds can be cleaned and SSD ointment applied. To keep water out of the wound, Ilex ointment (Medcon Biolab Inc, Grafton, MA 01519) can be applied. This is available in most pharmacies and is a topical skin cream for infants. Ilex, when applied over a wound and placed in water becomes impervious to the water. It can be applied directly on granulation tissue and has no ill effects. To assist with keeping ilex in large wounds a piece of Tegaderm (3M Health, St. Paul, MO 55144) can be placed over the Ilex and then glued to the shell with tissue glue. This bandage should be changed at minimum every week. Once the thick "leather like" granulation bed is in place the bandage can be removed and the wound exposed to water. This may change the look of the granulation, however, biweekly flush with chlorhexidine and mild debridement will keep down any pathogens.

Fracture Fixation

Over the years chelonian shell fracture fixation has changed and been modified. There are many different techniques, and indeed they all have merit and may be used in part or in combination. The technique used by the author has been developed by many people and may be used with great success. Using removable hardware such as screws, plates, rods and wire may be combined with techniques that employ epoxy and other methods. (Table 2)

Epoxy

The use of epoxy has been popular for many years. Indeed with elective plastronotomy closure and non-displaced fractures, epoxy resin with fiberglass cloth is the preferred method of closure.⁴ However, with trauma and infected wounds, the use of epoxy may not be warranted. Traumatic and contaminated wounds repaired with epoxy resin could seal in contamination resulting in infection and septicemia. Thus a more open system of wires and screws that still allow for wound management are preferred. The author has used epoxy in conjunction with plates to stabilize a plastron fractures with success. Other disadvantages of epoxy include: it should not come in contact with soft tissue or live bone, as it may impede healing. This is a semi-permanent technique that may stay adhered to the shell for months or even years; the long term effects on wild tortoises is not known. The use of epoxy may be fine for an adult turtle but for a growing turtle the effects are not known. In any case epoxy resin is one of the many tools that can be used in shell fixations and may be used under the correct circumstances.

Fixation Application

For fractures that need stabilization the use of external fixation has provided excellent results. This technique is not complicated and can be attempted by any veterinarian. It only takes a few basic tools and minimal fixation such as screws, wire, bone plates and external fixator rods. As these fixation devices are external, they can be purchased from a number of home improvement centers or be comprised of recycled equipment from other cases. Even though in many cases the fractures are considered contaminated the author suggests having the screws, plates, wire and rods autoclaved to reduce contamination.

Once the animal is anesthetized it should be place on a heat pad while the fixation is performed. In many cases, an assistant may be needed to help position and hold the chelonian while the fixator is being placed. The shell and soft tissue around the fixation area should be surgically prepared. Once prepared and dried off the fixation may take place. Depending on the severity of the fracture, some imagination must be used to piece the shell back together. If there are missing pieces, the surgeon must try to piece the shell together, leaving the open space where the missing piece is, (like a jigsaw puzzle). If the missing pieces total more than 30% of the shell, or if the shell cannot be stabilized without the missing pieces prognosis is grave. Missing shell fragments are common and occur in about 30% of the cases seen by the author. These fragments vary in size from a ¼ to 2–3 inches (1–8 cm).

The first step in fixation is to place screws for the fixation wire to be attached. First select a drill bit that is slightly smaller than the screw. The author commonly uses #6¼ inch, Philips head screws. This will allow for easy placement of the screw and provide a secure hold. When drilling, if possible, stay back at least 0.5 cm from the edge of the fracture to provide proper purchase for the screw. When drilling, be careful not to place too much pressure on the drill as you may sink the bit in several cm into the coelom and damage the internal organs. The author suggests placing a piece of tape around the drill bit at 0.30 cm (¼ inch) of depth, this will allow for a guide to drilling depth. If the shell is penetrated, it is not a problem as long as trauma to internal organs has not taken place. If drilling is prolonged, heat from the drilling may produce necrosis of the tissue. To avoid this, drip sterile saline on the drill bit when engaged. Once a few screws have been placed it is time to apply the wire. As an alternate to wire fixation some wildlife rehabilitators utilize zip ties, attached to plastic grommets glued to the shell to stabilize fractures.² A newly described technique using clothing hooks glued to the shell to replace screws as hold points for the wire has also been described.¹ Both of these techniques may be an option and will save time under anesthesia.

To attach the wire, precut a few pieces of wire 6 inches (15 cm) long (20 gauge stainless steel wire). Wrap around one screw head, between the screws cross over the wire (like a figure eight) and wrap one end around the second screw head and then wrap the two ends around each other. The knot should be between the two screw heads, which allows for the knot to be folded against the shell when completed. At this point do not tighten the wire with pliers, only hand tight for 2–3 twists. If a fractured shell fragment is attached to the underlying tissue, but not attached to the rest of the shell, place screws and wires on all sides and then proceed to hand tighten. Tighten alternate sides to make even contact with the surrounding shell. Some small gaps may not close fully but will heal over time. With more severe cases the entire shell may not become stable until the last few wires have been tightened. Once tightened some of the wires may have become loose and should be removed and retightened. When tightening the wire you may place 5–8 twists on the wire, much more and the wire may snap. This takes a little experience. Additionally you do not want to tighten the wires too tightly as this may place too much pressure on the tissue margins causing pressure necrosis. Once tight, use side cutters to remove the twisted knot to the level of 4–5 twists and use the pliers to bend the twist down to be parallel with the wire and the shell. In some cases this is difficult to flatten the knot against the shell and you can place a bead of commercial epoxy putty to protect the sharp wire tip. Occasionally depression fractures appear, where a fragment of shell in pushed into the coelomic cavity and may or may not be attached to the surrounding bone. These may be difficult to treat as the surgeon cannot get under the fragment to raise it. However it may be possible by placing a number of screws in the fragment to anchor lifting wires. To bridge the depression a bone plate or external fixator rod can be used. Then wire is placed around the screws and then around the bone plate or rod. Once the wire is tightened this will have the effect of lifting up on the fragment and it may be possible to close or reduce the gap of the depression. In any case if a depression is still present this may stabilize the wound and allow for healing. The shell may not be perfect but the author has seen many wild tortoises and turtles with these types of wounds that have healed successfully.

Fractures of the plastron are best stabilized with bone plates. In many cases the plastron is flat; bone plates make it easy to bridge the fracture. This will allow for minimal drag and the leading edge of the plate may be ground down or place epoxy over it to stop it from catching on substrate. Once removed the bone plate may be re-sterilized and used for another case.

Healing Time

The fixation device should be monitored every few days. Occasionally over time some of the wires may need some additional tightening. If screws become loose they should be removed and replaced if necessary. Healing time should be similar to bone in other species 4–8 weeks. This will depend on severity of the fracture and how stable the fixation. Simple closed fractures may have complete bone healing in 4 weeks while more severe cases may be 8 weeks or longer. In more complicated fractures the author suggests a staged removal of the screws and wires over 2–3 weeks. Radiographs may be helpful but often do not show callus formation. A better guide to a healed fracture is the stability of the fracture on palpation.

Fixation Removal

The area of the shell should be prepared similar to a surgical preparation. This procedure may be a little uncomfortable but does not require general anesthesia however, analgesia such as meloxicam should be used. Screws may be removed with a screwdriver and then the holes flushed with saline and packed with SSD ointment. This step should be completed twice a week for two weeks to ensure no infection enters the coelom. If the animal has more than a few screws, a second 3-week course of antibiotic is indicated. Once screws and wires are removed the time frame to release is a week to a month depending on the number of screw holes.

Conclusion

Medical and surgical intervention of chelonian shell fractures can be prolonged but very rewarding. These reptiles often have life spans greater than 50 years. By rehabilitating an adult chelonian you are assisting with conservation as well as helping individual animals whom are often overlooked.

Acknowledgments

The author would like to thank the Veterinary Services Department, of Disney's Animal Kingdom, including the veterinary technicians, hospital keepers and wildlife interns who look after the day to day needs of these chelonian patients. A special thanks goes to Leanne Blinco and Beth Schille for assistance with this compiling this paper.

Table 1. Selected drug dosages for chelonians.

Table 2. List of equipment needed for external fixation.

 Drill, battery operated

 Drill bits, autoclaved or cold sterile prepared

 #6 -¼ inch Flat head Phillips screws (local hardware)

 18–22 gauge stainless wire

 Wire cutters

 Wire twisters

 Pliers

 Assortment of rods and plates

 Epoxy putty

 Bandage material

 SSD ointment

 Ilex ointment

 Sterile saline

 Chlorhexidine solution

 Alcohol

References

1.  Bogard C, Innis C. A simple and inexpensive method of shell repair in Chelonia. J Herp Med Surg. 2008;18(1):12–13.

2.  Forrester H, Satta J. Easy shell repair. 2005. http://asianturtlenetwork.org/

3.  Mader DR. Euthanasia. In: Mader DR, ed. Reptile Medicine and Surgery. 2nd ed. Saunders Elsevier Publishing, St. Louis, MO 2007:564–568.

4.  Mader DR, Bennet RA, Funk RS, et al. Surgery. In: Mader DR, ed. Reptile Medicine and Surgery 2nd ed. Saunders Elsevier Publishing, St. Louis, MO 2007:581–630.