Clinicopathological seminar

• Pain in left groin–duration 2 years– activity related on initiation–morning stiffness lately–no rest or at night pain– last 2 months get worse – analgesics

• No treatment in childhood

Clinical case 5/12 – female 54 y

• On examination–palpation tenderness in groin area–palpation tenderness over the greater

trochanter– restricted ROM• flexion 0-100 °• internal rotation 0• external rotation 0-10 °• abduction 0-20 °• adduction 0-20 °

Clinical case 5/12 – female 54 y

• laboratory examination

– ESR 12/20, Hb 136 g/l, Ery 3 400 000/μl, Hct 0,38, Leu 8600/μl–Na 141 mmol/l, K 4,4 mmol/l, Cl 120

mmol/l, bili 9,9 mmol/l, AST 0,20 μkat/l, ALT 0,22 μkat/l, urea 5,4 mmol/l, creatinin 85 μmol/l, CRP 7,4 mg/l–urine analysis negative

Clinical case 5/12 – female 54 y

• laboratory examination

– ESR 12/20, Hb 136 g/l, Ery 3 400 000/μl, Hct 0,38, Leu 8600/μl–Na 141 mmol/l, K 4,4 mmol/l, Cl 120

mmol/l, bili 9,9 mmol/l, AST 0,20 μkat/l, ALT 0,22 μkat/l, urea 5,4 mmol/l, creatinin 85 μmol/l, CRP 7,4 mg/l–urine analysis negative

Clinical case 5/12 – female 54 y

• X-ray pelvis and hip joints–flattening of the femoral head Rt– acetabular subchondral sclerosis bilat.–narrowing of joint space bilaterally–marginal osteophytes acetabulum

bilaterally– cysts in head and acetabulum Rt–findings worse in Rt

Clinical case 5/12 – female 54 y

• What is this disease?

• What will be the conservative therapy?

• What pharmacotherapy is appropriate?

• What surgical treatment is possibly coming?

Clinical case 5/12 – female 54 y

• What is this disease?– coxarthrosis grade III.• What will be the conservative therapy?

• What pharmacotherapy is appropriate?

• What surgical treatment is possibly coming?

Clinical case 5/12 – female 54 y

• What is this disease?

• What will be the conservative therapy?– regime measures– pharmacotherapy– physiotherapy

• What pharmacotherapy is appropriate?

• What surgical treatment is possibly coming?

Clinical case 5/12 – female 54 y

• What is this disease?

• What will be the conservative therapy?

• What pharmacotherapy is appropriate?– anti-inflammatory drugs– analgesics– chondroprotectives

• What surgical treatment is possibly coming?

Clinical case 5/12 – female 54 y

• What is this disease?• What will be the conservative therapy?

• What pharmacotherapy is appropriate?

• What surgical treatment is possibly coming?– osteotomies– hip replacement

Clinical case 5/12 – female 54 y

• degenerative disorders of joints–pathophysiology–morphological changes

Clinical case 5/12 – female 54 y

• three days subfebrile • swelling, redness and pain in the lower

leg• today can no longer stand on Rt leg• 10 years ago treated for infected fracture

of Rt leg

Clinical case 8/12 – male 45 y

• body temperature– 38,9 °C (102°F)

• on lower extremity Rt–swelling and redness–palpable tenderness–no failure of blood supply and

innervation of peripheral limb

Clinical case 8/12 – male 45 y

• laboratory examination–ESR 68/90, Hb 146, Ery 3 600 000/μl,

Hct 0,42, Leu 12600/μl–Na 143 mmol/l, K 4,2 mmol/l, Cl 117

mmol/l, bilirubin 12,9 mmol/l, AST 0,30 μkat/l, ALT 0,42 μkat/l, urea 6,4 mmol/l, creatinin 75 μmol/l, CRP 268 mg/l–urine analysis negative

Clinical case 8/12 – male 45 y

• laboratory examination–ESR 68/90, Hb 146, Ery 3 600 000/μl,

Hct 0,42, Leu 12600/μl–Na 143 mmol/l, K 4,2 mmol/l, Cl 117

mmol/l, bilirubin 12,9 mmol/l, AST 0,30 μkat/l, ALT 0,42 μkat/l, urea 6,4 mmol/l, creatinin 75 μmol/l, CRP 268 mg/l–urine analysis negative

Clinical case 8/12 – male 45 y

• X-ray of Rt leg–deformed bone–bony sequestra cannot be excluded–appropriate use of CT

Clinical case 8/12 – male 45 y

• angiography–aa. tibialis anterior et posterior visible

to the periphery

Clinical case 8/12 – male 45 y

• What is this disease?

• What pharmacotherapy is appropriate?

• What surgical treatment is possibly coming?

Clinical case 5/12 – male 45 y

• What is this disease?– osteomyelitis

• What pharmacotherapy is appropriate?

• What surgical treatment is possibly coming?

Clinical case 5/12 – male 45 y

• What is this disease?

• What pharmacotherapy is appropriate?– analgesics, antipyretics– antibiotics (what?)

• What surgical treatment is possibly coming?

Clinical case 5/12 – male 45 y

• What is this disease?

• What pharmacotherapy is appropriate?

• What surgical treatment is possibly coming?– surgical revision of bone cavity– removal of necrotic and infected tissue–defect coverage with well-perfused tissues

Clinical case 5/12 – male 45 y

• osteomyelitis– acute and chronic–non specific and granulomatous infections

Clinical case 8/12 – male 45 y

• thigh pain–duration 3 months–get worse–in morning on initiation, permanently

now–initially alleviated by aspirine

Clinical case (11/12) – female 46 y

• lower extremity Lt–no palpation thigh pain–no swelling and palpable mass–ROM hip and knee without restriction–during hip abduction feel tension in the

abductors muscles–no failure of blood supply and

innervation of peripheral limb

Clinical case (11/12) – female 46 y

• X-ray of proximal femur–thickening of medial cortex–appropriate use of CT

Clinical case (11/12) – female 46 y

• CT of proximal femur–well-formed bone tissue –nidus not seen, but probably it is the

osteoid osteoma

Clinical case (11/12) – female 46 y

• What is this disease?

• What next treatment is possibly coming (conservative, surgical)?

• What is the prognosis of patient?

Clinical case (11/12) – female 46 y

• What is this disease?–osteoid osteoma–benign tumour

• What next treatment is possibly coming (conservative, surgical)?

• What is the prognosis of patient?

Clinical case (11/12) – female 46 y

• What is this disease?

• What next treatment is possibly coming (conservative, surgical)?– always surgical– growing of tumour, progression of the

symptoms

• What is the prognosis of patient?

Clinical case (11/12) – female 46 y

• What is this disease?

• What next treatment is possibly coming (conservative, surgical)?

• What is the prognosis of patient?–prognosis is very good after surgical

removal of the nidus

Clinical case (11/12) – female 46 y

•bone tumours–primary–metastases

Clinical case (11/12) – female 46 y

• fall–she had a dizziness–circumstances does´nt remember– then can no longer stand on Rt

leg

• pain in Rt groin area

Clinical case 6/12 – female 80 y

• head–haematoma on her forehead

• lower extremity Rt–shortening 2 cm–pain in Rt groin area–signif. painfull restriction of ROM–no failure of blood supply and innervation

of peripheral limb

Clinical case 6/12 – female 80 y

• X-ray pelvis and hip joints

–interruption of the femoral neck Rt

–distal fragment displaced proximally

Clinical case 6/12 – female 80 y

• What is this disease?

• Is necessary rule out coincidence disease or stroke? What?

• Next management (exam, Tx)?

• The patient is at risk for life? If so, what?

Clinical case 6/12 – female 80 y

• What is this disease?–fracture of the femoral neck

• Is necessary rule out coincidence disease or stroke? What?

• Next management (exam, Tx)?

• The patient is at risk for life? If so, what?

Clinical case 6/12 – female 80 y

• What is this disease?

• Is necessary rule out coincidence disease or stroke? What?– stroke– subdural haematoma

• Next management (exam, Tx)?

• The patient is at risk for life? If so, what?

Clinical case 6/12 – female 80 y

• What is this disease?

• Is necessary rule out coincidence disease or stroke? What?

• Next management (exam, Tx)?–standard preOP exam + neurological exam–surgery (hemiarthroplasty)

• The patient is at risk for life? If so, what?

Clinical case 6/12 – female 80 y

• What is this disease?• Is necessary rule out coincidence

disease or stroke? What?• Next management (exam, Tx)?

• The patient is at risk for life? If so, what?–risk of bleeding complications (CNS) –risk of immobilization

Clinical case 6/12 – female 80 y

•osteoporosis–pathophysiology–morphological changes

Clinical case 6/12 – female 80 y