pathological fracture

Download Pathological Fracture

Post on 08-Mar-2015

75 views

Category:

Documents

2 download

Embed Size (px)

TRANSCRIPT

PRESENTED BY: INTERNS 5TH BATCH DR. ADITI MISHRA DR. APARNA MISHRA DR. SASHMI MANANDHAR

PATHOLOGICAL FRACTURE(SHAFT OF FEMUR)DEPARTMENT OF ORTHOPAEDICS DH-KUTH

AUGUST 19, 2010

1

A CASE PRESENTED AS

AUGUST 19, 2010

2

Particulars and Complains: Name: Age/ Sex: Add: Duration of stay: 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 painAUGUST 19, 2010

Mr. Man Bahadur Lama 64 yrs/ M Dapcha 100 days

3

Associated History: No LOC Fever for 2 mMorning and evening

Cough for 2 mProductive Mucoid Yellowish Blood mixed

Medical Rx at DapchaAUGUST 19, 2010

4

On Examination: Vitals:BP: 100/70 mm Hg PR: 82/ min SpO2: 92% GCS: 15/15

GC: fair Chest/CVS: NormalAUGUST 19, 2010

5

Local examination: Attitude:Flexion: + External rotation: + Shortening: +

ROM: Painful DNVS: IntactAUGUST 19, 2010

6

DIAGNOSIS # OF SHAFT OF LEFT FEMUR, LOW VELOCITY INJURY

AUGUST 19, 2010

7

Investigations-Blood picture: Hb: 8.5 gm TC: 5600 ESR: 64 Sugar: 95 Na+: 133

N: 76 BT: 2 Urea: 29 K+: 3

L: 24 CT: 10 Creatinine:0.9

AUGUST 19, 2010

8

Others:

Mantoux: 15 mm after 72 hrs FNAC: No evidence of malignancy Sputum cytology: No evidence of malignancy XRay: USGLung: 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

AUGUST 19, 2010

9

XRAY FINDINGS # proximal 3rd of

femur, transverse, displaced superiorly Post Op:IMIL

AUGUST 19, 2010

10

Surgery done: OR +IMIL Sent for Biopsy

AUGUST 19, 2010

11

Biopsy result: Metastatic sq cell Ca

AUGUST 19, 2010

12

BACKGROUND

AUGUST 19, 2010

13

Introduction Mechanical failure

Pathological #:

Of an abnormal bone Due to trivial injury or even spontaneously

AUGUST 19, 2010

14

Causes: Generalized bone diseases:OI Osteoporosis Myeloma Fibrous dysplasia Paget s dz Metabolic cond

Local benign conditions:Chronic infec Chondoma Solitary bone cyst Fibrous cortical defect ABC

Pri. Malignant tumors:Chondrosarcoma Osteosarcoma Ewing s tumor

Metastasis:Breast Colon Lung Prostate Kidney Thyroid

AUGUST 19, 2010

15

Pathological #: Metastatic lesions more common in axial

than appendicular skeleton In femur:Commoner in subtrochanteric region Commonly from the breast

AUGUST 19, 2010

16

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

AUGUST 19, 2010

17

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 sizeAUGUST 19, 2010

18

COMPLICATIONS: Non Union Pain Fractures

AUGUST 19, 2010

19

And the journals say

AUGUST 19, 2010

20

ATYPICAL # OF THE FEMORAL DIAPHYSIS IN POST MENOPAUSAL WOMEN TAKING ALANDRONATE 2008 The New England Journal of MedicinePotential link between Alandronate use and low energy # of the femur

AUGUST 19, 2010

21

PATHOLOGICAL BONE FRACTURE IN NONHODGKIN'S LYMPHOMA Journal of Clinical Oncology, Vol 25, No 21 (July 20), 2007: pp. 3175-317675-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 bonesAUGUST 19, 2010

22

HYPERBILIRUBINEMIA MAY ACTIVATE HISTIOCYTIC OSTEOLYSIS 2007 Journal of Orthopaedics6-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.

AUGUST 19, 2010

23

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 supportAUGUST 19, 2010

24

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-BDiffuse 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.AUGUST 19, 2010

25

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

AUGUST 19, 2010

26

FRACTURE RISK FOLLOWING B/L ORCHIDECTOMY 2003 Melton et al, The Journal of UrologyBone loss reported in patients with prostate cancer with androgen deprivation therapy Significant increase in osteoporotic fracture following B/L orchidectomy

AUGUST 19, 2010

27

PROGNOSTIC EFFECT OF PATHOLOGIC # IN LOCALIZED OSTEOSARCOMA 2009 Kim et all Journal of Surgical OncologyNegative prognostic effect of pathological # likely to be due to confounding by tumor size and location Presence of a pathological fracture has no prognostic significance

AUGUST 19, 2010

28

THANK YOU

AUGUST 19, 2010

29