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

A CASE PRESENTED AS

AUGUST 19, 2010

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 pain
AUGUST 19, 2010

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

Associated History:
 No LOC  Fever for 2 m
Morning and evening

 Cough for 2 m
Productive Mucoid Yellowish Blood mixed

 Medical Rx at Dapcha
AUGUST 19, 2010

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

 GC: fair  Chest/CVS: Normal

AUGUST 19, 2010

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

 ROM: Painful  DNVS: Intact

AUGUST 19, 2010

DIAGNOSIS # OF SHAFT OF LEFT FEMUR, LOW VELOCITY INJURY

AUGUST 19, 2010

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

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

AUGUST 19, 2010

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
 Mechanical failure

Pathological #:

 Of an abnormal bone  Due to trivial injury or even spontaneously

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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

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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

AUGUST 19, 2010

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PATHOLOGICAL BONE FRACTURE IN NONHODGKIN'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
AUGUST 19, 2010

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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.

AUGUST 19, 2010

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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
AUGUST 19, 2010

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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

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