CASE REPORTA WOMAN 55 YEARS OLD WITH PATHOLOGICAL

PROXIMAL FEMORAL FRACTURE DEXTRA

D E L L A P U T R I A R I YA N IL E C T U R E R :D R. A R S A N T O T R I W I D O D O S P. O T , F I C S , K- S P I N E , M H K E S

IDENTITY

• Mrs. TatiName• 55 years oldAge • FemaleSex • Housewife Occupation • MoeslemReligion • MarriedMarital status• October, 15th 2013 (from 5th floor

block C)Admitted • October, 16th 2013Date of

examination

ANAMNESA

Main Complaint Additional Complaint

Can not move the right leg since 10 days ago. -

Patient came to the hospital with complaints can’t move the right foot since 10 days ago.

Admitted patients that can’t move the right foot since August because patients perceive sound in hip fracture while taking ablution,

after which the patient felt pain in her hip, but still able to walk.

HISTORY OF PRESENT ILLNESS

After that, the patient is still able to move and do not mind the pain at her hip.

In september when admitted hospital patients who felt more and more ill.

and when the patient is not able to walk on two legs, the patient requires a stick.

and then 10 days before entering the hospital the patient complained of can’t move her right leg and was not able to walk with a cane, a wheelchair only.

Headache, Fever, flu, nausea,

vomiting(-)

appetite down,

abdominal pain (-)

bladder smooth, (-)

first menstruation 13 yo, menopause 49 yo

No history of problems

during pregnancy

history of the growth and

development good

Never did the surgical

removal of the thyroid.

HISTORY OF PAST ILLNES

Patient never had a problem like

this before

had a history of left breast ca and mastectomy was performed on 2nd

years ago.

Diabetes mellitus, Hypertension (-)

Thyroid disease (-) Fractures open (-)

HISTORY OF PAST TREATMENT

6 times chemotherapy

30 times Radiation

But, as long as the complaint is not control

and drug consumption is

up.

Every 2 months control

HISTORY OF FAMILY ILLNES

Never have the same

illnes in her family

Diabetes, Hypertension (-)

Asthma and Heart disease

(-)

HABITS OF HISTORY

Imbalanced diet

Smoking (-)

GENERAL CONDITION

•Moderately ill

General condition

• Compos Mentis

Consciousness

VITAL SIGN

Vital Sign

s

Blood Pressure

110/70 mmHg

Respiration Rate24X/

minute

Pulse Rate88x/minute, weak pulse

Temperature

36,8 °C

PHYSICAL EXAMINATION

Head• Normocephali

Eyes• Anemic conjunctiva -/-, • Icteric sclera -/-

Mouth• Lip: cyanosis(-) dryness (-)• Pharynx: hyperemic (-), symmetrical, uvula at midline• Thypoid tounge -

Neck• Lymph gland & Thyroid gland is not palpable

THORAX EXAMINATION Lung

• Movement of brething left and right symmetric, retraction intercostal space(-/-), lession(-)

• visible marks of mastectomy on the left breast

Inspeksi

• vocal fremitus left and right symmetric, no compresive pain(-/-)

Palpasion

• sonor in both side of lungPercusion

Auskultation sound of breathing right and left

vesikuler, ronchi (-/-), wheezing(-/-)

Heart

Examination

Inspection: Ictus cordis is available

Palpation: Ictus cordis is palpable at 5th ICS LMCS

Percussion :•Right heart border: ICS III-V LSD•Left heart border: ICS V 1cm medial LMCS•Upper heart border: ICS III LPSS

Auscultation: Regular I - II heart sound no murmur and gallop

ABDOMINAL EXAMINATION

Inspection:

• Brown skin• Skin

abnormality (-)

Palpation:

• Sociable• Defense

muscular (-), mass (-)

• No enlargement of liver and spleen

Percussion:

• No pain present on abdominal percussion

• Sounds dull• Shifting

dullness (-)• CVA (-)

Auscultation:

• Bowel sound (+)

• Arterial bruit (-)

• Venous hum (-)

EXTREMITY Upper extremity

Conclusion: There is no problem in upper extrimity

  Right Left

Muscle Eutrophy Eutrophy

Tonnus Normotony Normothony

Mass No abnormality No abnormality

Joints No abnormality No abnormality

Movement Active Active

Edem No Edema No edema

LOCAL STATE ( RIGHT HIP )  Right

Look       

- Deformity: No angulation External rotation No shortening

- Oedem (-)- Hyperemic (-)- Bruises (-)- Mass (-) 

Feel - No crepitation- No palpable mass- tenderrness (+)- CRT < 2s- sensoric normal

Move - ROM Limitted do to pain

LABORATORY EXAMINATIONOn October 15th, 2013

RESULT Normal RangeHemoglobin 13,8 (12 – 17) g%Leucocytes 11.200 (5.000 – 10.000)/μLThrombocytes 288.000 (150.000 –

450.000)/μLHt 39 (37 – 43) %

On October 17th, 2013

RESULT Normal RangeHemoglobin 12.1 (12 – 17) g%Leucocytes 12.000 (5.000 – 10.000)/μLThrombocytes 232.000 (150.000 –

450.000)/μLHt 35 (34 – 43) %Differential Count 0/0/0/82/12/6 0-1/1-3/2-6/50-70/20-

40/2-8Erythrocytes 4.030.000 4.5-5.5 jutaRandom blood sugar level

137 <140

LED 33 <10Alkaline phosphatase 49 42-98LDH 350 <480

on October 18th 2013LDH : 418

CHEST X-RAY

• CTR < 50%• There are no consolidation or infiltrate at the apex of both

lungs.• Hiperlusent at a both lungs• Tears drop of the hearts• Decrease of diafragma Conclusion : Emfisematous

HIP AP

OS FEMUR AP

• Lytic lesions form on the right hip, • Ill defined, • There is no sign of periosteal reaction, • And the reaction zone wide.

WORKING DIAGNOSIS

Pathological fracture of right hip et causa suspect Metastatic bone disease, Dd: Ca mammae

BASE OF DIAGNOSIS1. From anamnesis Identity : 50 years old Mechanism of fracture History of past ilness: ca mammae and post

mastectomy 2nd years ago

2. From physical examinationFrom local status Deformity of right hip

3. From x ray finding Lytic lesions form on the right hip, Ill defined, There is no sign of periosteal reaction, And the reaction zone wide.

MANAGEMENT

Operative Non operativeProximal femur intamedullary nailing.  

 

Ringer Laktat Cefotaxim Tramadol Ondancentron Normal diet

PROGNOSIS

Ad Vitam: dubia

ad malam

Ad Fungsionam: dubia ad Malam

Ad

Sanationam:

ad Malam

CASE REVIEW

ANATOMY FEMUR

VASCULARISATION

DEFINITION σ Fracture (from Latin fractūra) a breakin the continuity

of a bone, a broken bone. A fracture is present when there is loss of continuity in the substance of a bone.

σ A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process. Causes of weakened bone include tumors, infection, and certain inherited bone disorders. There are dozens of diseases and conditions that can lead to a pathologic fracture

EPIDEMIOLOGY Between 220,000 and 250,000 proximal femoral fractures occur in the

United States each year; 90% of these fractures occur in patients older than 50 years.

The incidence of proximal femoral fractures among females is 2 to 3 times higher than the incidence of such fractures among males

Proximal femoral fractures in elderly patients are often pathologic, usually resulting from minimal-to-moderate physical trauma to areas of bone significantly affected by osteoporosis and can be caused by any type of bone tumor, but the overwhelming majority of pathologic fractures in the elderly are secondary to metastatic carcinomas.

Bone is the most common site for metastasis in cancer and is of particular clinical importance in breast and prostate cancers because of the prevalence of these diseases.

METASTATIC TUMORS OF BONEThe most common primary malignancies that metastasize to bone are breast, lung, kidney, prostate, and thyroid carcinomas, which account for approximately 700,000 new primary cases in the U.S. annually. Metastatic bone disease can have very detrimental effects on quality of life. The prognosis for patients with metastases to bone largely depends on the aggressiveness of the primary tumor, with lung cancer patients having the shortest length of survival. Unlike primary bone tumors, the early diagnosis and treatment of secondary tumors will not result in a cure. However, much of the significant morbidity related to bone metastases and pathologic fracture can be lessened with early intervention. The evaluation and management of patients with metastatic bone disease is best done with a multidisciplinary approach including medical oncologist, radiologist, pathologist, orthopedic surgeon, physical therapist, and social worker.

LOCATION

Skeletal metastases are often multifocal; however, breast, renal and thyroid carcinomas are notorious for producing solitary lesions. By far the most common location for osseous metastases is the axial skeleton, followed by the proximal femur and proximal humerus.

PRESENTATION• varied presentations• extremely painful and disabling to asymptomatic

CLINICAL FEATURESPain.Pathologic fractures

PATHOLOGIC FRACTURESThe destruction of bone by metastatic disease reduces its load-bearing capabilities and results initially in microfractures, which cause pain. Subsequently, fractures occur (most commonly in ribs and vertebrae). It is the fracture of a long bone or the epidural extension of tumor into the spine that causes the most disability. As the development of a longbone fracture has such detrimental effects on quality of life in patients with advanced cancer, efforts have been made to predict sites of fracture and to preempt the occurrence of a fracture by prophylactic surgery. Fractures are common through lytic lesions in weight-bearing bones. Damage to both cortical and trabecular bone is structurally important. Several radiological features have been identified that may predict imminent fracture;fracture is likely if lesions are large, are predominantly lytic, and erode the cortex. A scoring system has been proposed by Mirels based on the site, nature, size, and symptoms from a metastatic deposit.

DIAGNOSTIC LABORATORY TESTSA complete blood count (CBC) Elevated erythrocyte sedimentation rates (ESR) C-reactive protein (CRP)Tumor markerLactate dehydrogenase (LDH)

IMAGING

High quality, plain anteroposterior and lateral radiographs that show the involved bone, including one joint proximally and distally, are the standard for initial assessment of metastatic bone disease. One should look for lytic, blastic, or mixed lesions

Metastases from lung, renal, and thyroid tumors tend to be entirely lytic. Breast metastases may be lytic or may show a mixed lytic–blastic appearance. The majority of prostate bone metastases are blastic though lytic lesions do occur.

Computed tomography (CT) is the study of choice when looking for bone detail and cortical destruction, but is not as sensitive at assessing marrow replacement. MRI on the other hand is very sensitive to early marrow replacement and can locate metastases prior to their appearance on radiographs and CT, but is not as helpful for bony anatomy.

MANAGEMENT

The goals of surgery for impending or pathologic fracture in the setting of metastatic disease are to provide pain relief and a functionally stable and durable construct that will allow the patient to ambulate shortly after surgery and will persist for the life of the patient.

Adequate pain control is necessary for participation in physical therapy. DVT prophylaxis is very important in cancer patients that are immobilized. Bisphosphonates, radiation therapy, and chemotherapy should be used as indicated, keeping in mind that radiation and chemotherapy decrease wound healing and may be delayed.

THANK YO

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