pathological fracture
TRANSCRIPT
AUGUST 19, 2010 1
PATHOLOGICAL FRACTURE(SHAFT OF FEMUR)DEPARTMENT OF ORTHOPAEDICS
DH-KUTH
PRESENTED BY:INTERNS – 5TH BATCH
DR. ADITI MISHRADR. APARNA MISHRADR. SASHMI MANANDHAR
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A CASE PRESENTED AS…
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Particulars and Complains: Name: Mr. Man Bahadur
Lama Age/ Sex: 64 yrs/ M Add: Dapcha Duration of stay: 100 days c/o:
Injury to the left thigh due to tripping, 3 hrs prior to presen
Inability to bear weight on the injured limb
Swelling and pain
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Associated History:
No LOC Fever for 2 m
Morning and evening Cough for 2 m
Productive Mucoid Yellowish Blood mixed
Medical Rx at Dapcha
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On Examination:
Vitals: BP: 100/70 mm Hg PR: 82/ min SpO2: 92% GCS: 15/15
GC: fair Chest/CVS: Normal
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Local examination:
Attitude: Flexion: + External rotation: + Shortening: +
ROM: Painful
DNVS: Intact
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DIAGNOSIS# OF SHAFT OF LEFT FEMUR, LOW
VELOCITY INJURY
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Investigations-Blood picture: Hb: 8.5 gm TC: 5600 N: 76 L: 24 ESR: 64 BT: 2 CT: 10 Sugar: 95 Urea: 29
Creatinine:0.9 Na+: 133 K+: 3
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Others: Mantoux: 15 mm after 72 hrs
FNAC: No evidence of malignancy
Sputum cytology: No evidence of malignancy
XRay:
USG Lung:
Large hypoechoic mass lesion with multiple hypoechoic foci in upper lobe of rt. side
Minimal pleural effusion Kidney:
Large exophytic cortical cyst arrising from inf pole of lt side Liver:
Focal cystic lesion with reticular internal echos in lt lobe
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XRAY FINDINGS
# proximal 3rd of femur, transverse, displaced superiorly
Post Op: IMIL
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Surgery done:
OR +IMIL Sent for Biopsy
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Biopsy result:
Metastatic sq cell Ca
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BACKGROUND…
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Introduction – Pathological #: Mechanical failure Of an abnormal bone Due to trivial injury or even
spontaneously
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Causes:
Generalized bone diseases: OI Osteoporosis Metabolic cond Myeloma Fibrous dysplasia Paget’s dz
Local benign conditions: Chronic infec Solitary bone cyst ABC ChondomaFibrous cortical defect
Pri. Malignant tumors: Chondrosarcoma Osteosarcoma Ewing’s tumor
Metastasis: Breast Lung Kidney Thyroid Colon Prostate
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Pathological #:
Metastatic lesions more common in axial than appendicular skeleton
In femur: Commoner in subtrochanteric region Commonly from the breast
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Management - Investigations: XRAY:
Affected bone Lungs Urogenital tract
Blood: Full blood count ESR Protein electrophoresis
Urine: RBC Bence Jones protein
Bone scan: Local Whole body
Biopsy: Along with open reduction As definitive procedure
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Management - Treatment
Principles: Reduce Hold - # fixation of long bone shaft
Internal fixation - IMIL Cement packing – Acrylic
Local irradiation Exercise
Pain Manangement RX of cause Prophylactic fixation:
>1/2 diameter of bone >3cm on any view Painful irrespective of size
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COMPLICATIONS:
Non Union Pain Fractures
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And the journals say…
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ATYPICAL # OF THE FEMORAL DIAPHYSIS IN POST MENOPAUSAL WOMEN TAKING ALANDRONATE
2008 The New England Journal of Medicine
Potential link between Alandronate use and low energy # of the femur
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PATHOLOGICAL BONE FRACTURE IN NON-HODGKIN'S LYMPHOMA
Journal of Clinical Oncology, Vol 25, No 21 (July 20), 2007: pp. 3175-3176 75-year-old woman diagnosed with stage
IVB primary diffuse large B-cell gastric lymphoma with lymphoma infiltration of the bone marrow
Pathological fracture in bone lymphoma uncommon
Pathological fracture secondary to lymphoma involvement of the femur uncommon even in patients with lymphoma
involvement of the long bones
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HYPERBILIRUBINEMIA MAY ACTIVATE HISTIOCYTIC OSTEOLYSIS
2007 Journal of Orthopaedics 6-year-old boy with Alagille syndrome Pathological fracture of the femur with local bone
atrophy, malunion and insufficient callus formation Macroscopically, the femur stained dark green Histology of the resected bone at the site of the
malunion Presence of histiocytes and osteoclast-like
multinucleate giant cells containing bilirubin particles in the cytoplasm
Multinucleate giant cells found to have caused bone resorption
Bilirubin might activate macrophages to form osteoclast-like multinucleate giant cells, resulting in bone resorption and osteoporosis.
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CRITICAL EVALUATION OF MANAGEMENT OF FRACTURE SHAFT FEMUR
The Internet Journal of Orthopedic Surgery. 2002 Volume 1 Number 2 Consecutive femoral shaft fractures of the
femur treated with the Brooker-Wills locking nail system
System differing from conventional interlocking nails in providing the distal locking by a pair of blades or fins
Very effective in opposing the angulatory and rotatory stresses
Lacking in providing adequate axial support
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TREATMENT OF PATHOLOGICAL FRACTURE OF THE FEMUR DUE TO DIFFUSE
HAEMANGIOMA IN THE LOWER LIMB 2005 Journal of Bone and Joint Surgery -
British Volume, Vol 87-B Diffuse haemangioma of the lower limb
complicated by pathological fracture of the femoral shaft
One treated by a bone graft and immobilisation in a cast
Other by external fixation and injection of bone marrow
A review of the literature identified difficulty in control of bleeding and obtaining bony union.
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DIFFICULTY IN DIAGNOSING THE PATHOLOGICAL NATURE OF AN
ACUTE FRACTURE OF THE CLAVICLE
2009 Malik et all, Journal of Orthopaedic Surgery and Research
Medial clavicular # uncommon with low energy trauma
The most common site of pathological # in clavicle: Medial part of clavicle
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FRACTURE RISK FOLLOWING B/L ORCHIDECTOMY
2003 Melton et al, The Journal of Urology
Bone loss reported in patients with prostate cancer with androgen deprivation therapy
Significant increase in osteoporotic fracture following B/L orchidectomy
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PROGNOSTIC EFFECT OF PATHOLOGIC # IN LOCALIZED OSTEOSARCOMA
2009 Kim et all Journal of Surgical Oncology
Negative prognostic effect of pathological # likely to be due to confounding by tumor size and location
Presence of a pathological fracture has no prognostic significance
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THANK YOU