Case HistoryCase History

CC: Left leg pain.CC: Left leg pain.

HPI: 15 yo female reports feeling a “snap” in her left leg while HPI: 15 yo female reports feeling a “snap” in her left leg while running sprints at volleyball practice. She felt immediate pain with running sprints at volleyball practice. She felt immediate pain with inability to bear weight. Patient presented to ER for evaluation. She inability to bear weight. Patient presented to ER for evaluation. She denies any trauma to her leg or similar incidents in the past. Denies denies any trauma to her leg or similar incidents in the past. Denies loss of consciousness, chills, fever, SOB, chest pain, N/V.loss of consciousness, chills, fever, SOB, chest pain, N/V.

PMH: Asthma, Occasional temporal/frontal HAPMH: Asthma, Occasional temporal/frontal HA

No significant PSurHx, Social Hx. NKDA. No significant PSurHx, Social Hx. NKDA.

Medications: Ortho Tri-CyclenMedications: Ortho Tri-Cyclen

H&P ContinuedH&P Continued

Vitals: T: 36.5 BP: 105/59 P: 71 R: 20 O2: 100%Vitals: T: 36.5 BP: 105/59 P: 71 R: 20 O2: 100%

PE: Patient NAD, AAOX3. Pt. able to move all aspects of LLE but PE: Patient NAD, AAOX3. Pt. able to move all aspects of LLE but not w/o extreme pain. 2+ dorsalis pedis and posterior tibial pulses. not w/o extreme pain. 2+ dorsalis pedis and posterior tibial pulses. Sensation intact.Sensation intact.

Plain films of LLE taken. 2 views ordered: Pelvis, single view w/ left Plain films of LLE taken. 2 views ordered: Pelvis, single view w/ left hip; Left femur, single view.hip; Left femur, single view.

In ER, pt. LLE put in 20 lbs traction after insertion of traction pin on In ER, pt. LLE put in 20 lbs traction after insertion of traction pin on proximal left tibia.proximal left tibia.

FindingsFindings

Impression of plain films:Impression of plain films:

Cystic expanding lesions w/in left femoral neck and proximal shaft of left femur, Cystic expanding lesions w/in left femoral neck and proximal shaft of left femur, most likely consistent with fibrous dysplasia.most likely consistent with fibrous dysplasia.

Pathologic fracture of proximal left femur.Pathologic fracture of proximal left femur.

DDX of cystic expanding lesions in bone:DDX of cystic expanding lesions in bone:

Fibrous dysplasiaFibrous dysplasia Enchondroma Enchondroma

• Small bones, typical calcifications in rings or arc patternSmall bones, typical calcifications in rings or arc pattern Unicameral bone cystUnicameral bone cyst

• Fluid filled cystFluid filled cyst Aneurismal bone cystAneurismal bone cyst

• Commonly in spine, assoc. w/ trauma, “soap bubble” appearanceCommonly in spine, assoc. w/ trauma, “soap bubble” appearance Giant cell tumorGiant cell tumor

• 33rdrd decade, closed epiphyseal plates, central lucency, peripheral density decade, closed epiphyseal plates, central lucency, peripheral density Low Grade OsteosarcomaLow Grade Osteosarcoma

• ““Cloudlike” appearance, involves soft tissue, cortical discontinuityCloudlike” appearance, involves soft tissue, cortical discontinuity

Fibrous DysplasiaFibrous Dysplasia

Skeletal development anomaly in which medullary bone is replaced by Skeletal development anomaly in which medullary bone is replaced by fibrous tissue. Presents with bone pain, limp, limb-length discrepancy, or fibrous tissue. Presents with bone pain, limp, limb-length discrepancy, or pathologic fracture.pathologic fracture.

Ages 3-15 yo; M=F; 5-7% of benign bone tumors.Ages 3-15 yo; M=F; 5-7% of benign bone tumors.

Monostotic (70%) vs. Polystotic (30%)Monostotic (70%) vs. Polystotic (30%) Polystotic associated with McCune Albright Syndrome, Cushing syndrome, Polystotic associated with McCune Albright Syndrome, Cushing syndrome,

hyperthyroidism, and hyperparathyroidism.hyperthyroidism, and hyperparathyroidism.

Treatment options: Bisphosphonates; Surgery; ObservationTreatment options: Bisphosphonates; Surgery; Observation

Plain radiograph is first line study:Plain radiograph is first line study: Relatively homogenous cyst with characteristic ground-glass or “smokey” Relatively homogenous cyst with characteristic ground-glass or “smokey”

appearance.appearance. Absent periosteal reaction.Absent periosteal reaction. May have then sclerotic rim around cyst with cortical thinning.May have then sclerotic rim around cyst with cortical thinning. ““Shepherd’s crook” deformity of proximal femurShepherd’s crook” deformity of proximal femur

Hospital CourseHospital Course

Patient was taken to OR for intramedullary nail of her left femur with Patient was taken to OR for intramedullary nail of her left femur with 26x11.5 titanium Recon nail. 26x11.5 titanium Recon nail.

During procedure, pathologic specimens of bone cyst were obtained During procedure, pathologic specimens of bone cyst were obtained and sent to pathology.and sent to pathology.

POD #1: patient w/ decreased swelling and increased LLE motion.POD #1: patient w/ decreased swelling and increased LLE motion.

POD #2: patient ambulating w/ crutches per PT evaluation. Patient POD #2: patient ambulating w/ crutches per PT evaluation. Patient discharged home with pain medications.discharged home with pain medications.

ReferencesReferences

Favus MJ, Vokes T. Favus MJ, Vokes T. Harrison’s Principles of Internal Medicine, 16Harrison’s Principles of Internal Medicine, 16thth Ed Ed. . Section 2. 2005.Section 2. 2005.

DiCaprio MR, Enneking WF. “Fibrous Dysplasia: Pathophysiology, DiCaprio MR, Enneking WF. “Fibrous Dysplasia: Pathophysiology, Evaluation, and Treatment.” Evaluation, and Treatment.” The Journal of Bone and Joint SurgeryThe Journal of Bone and Joint Surgery. 2005; . 2005; 87: 1848-1864. 87: 1848-1864.

Presentation by: Amee PatelPresentation by: Amee Patel 44thth Year Visiting Student Year Visiting Student Georgetown UniversityGeorgetown University