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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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