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