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case discussion 3
- 2. Q7/a 7yr old boy with FDA • What is the most likely Dx? • Extension type supracondylar fracture • Garland III
- 3. • Why children most prone to this type of injury • Hyper active prone to injury • Growth spurt of distal epiphysis as compared to supracondylar area
- 4. • What additional radiography, if any do you wish to order? • Johns view,contralateral elbow • Oblique view/internal or external • to see the commination
- 5. What aspect of this child exam are concerning • Distal neurovascular • Perfusion • Pin and median nerve • Tense swelling • Puckering
- 6. How do you manage this pt?
- 8. Q8/pelvis x ray of 12yr young • What is the most likely dx • SCFE/SUFE • Epiphysis with in the hip but • Posterior mostly • Anterior • Lateral/valgus relative to neck
- 9. • Classification • Time • Acute • Chronic • Acute on chronic • Functional • stable • unstable
- 10. • Displacement/southwick angle or femoral epiphysis shaft angle and compare the difference from contralateral side of hip • Mild <30 deg • Mod 30 -60 deg • Sever>60 deg • If both side involved measure from normal • AP..145DEG • Frog leg lat 10 deg
- 11. What aspect of this pt history put him at risk for this injury • Male • Adolescent • Obesity • Hyper active • Left hip • Family hx • Endocrinopathy • Metabolic disease
- 15. investigation • X ray • AP and lateral • u/s • CT • MRI • Technetium-99 Bone Scan
- 16. • What is the next step in the management of this patient • Start with pain management • Immobilization or avoid wt bearing • Use crunch and ttable even for x ray • Avoid cross leg lateral x ray in unstable slip…induce pain • AP and frog leg lat x ray • Look for slip as well as open physis • Admit bed rest • Definitive treatment
- 17. • Goal • Stabilization of slip and prevent further slippage • Closer o physis • Reduction of displacement
- 18. In Situ Pinning • Single scre …stable • Doubble screw or unstable for rotation • Avoid subchondral placement • 6.5- to 7.3-mm stainless steel or titanium cannulated screw • Closed or open reduction pinning or screw • Open epiphysisdosis • Deformity surgery ---osteotomy
- 19. prognosis • Complications • Osteonecrosis of femoral head (4-6%) • may occur as the result of • initial trauma • increased risk with high grade slips (~45-50%) • operative complication (4-6%) • hardware placement in posteriosuperior femoral neck has the greatest risk of disrupting the vascular supply • Contralateral hip SCFE • most common complication after unilateral surgical fixation (20-80%) • risk factors for contralateral slip include • male, obesity, young age of initial slip, endocrine disorders
- 20. • Chondrolysis (0-2%) associated with • unrecognized implant penetration of the articular surface (0-2%) • spica cast immobilization • decreased prevalence with modern fluoroscopy • Residual proximal femoral deformity & limb length discrepancy • increased α-angle associated with symptomatic impingement caused by failure of proximal femur to remodel • Treatment • intertrochanteric osteotomy (Imhauser) • produces flexion, internal rotation and valgus • subtrochanteric osteotomy (Southwick's • cuneiform osteotomy (controversial due to high rate of osteonecrosis and arthritis)
- 21. • sip progression • occurs in 1-2% of cases following single screw fixation • Infection (0-2%) • Chronic pain (5-10%) • Degenerative arthritis • Pin associated proximal femur fracture • Labral tearing and degeneration • seen with high anterior and medial 2nd screw in-situ fixation
- 22. Q9 • An otherwise healthy 65- year-old man reports thigh pain of insidious onset. He states that the pain is increased with weight bearing and also occurs at night. He denies any history of cancer. Radiographs are shown below. A bone scan shows an isolated lesion. CT scans of the chest and abdominal are negative for any other lesions.
- 23. Describe the x ray findings? • Multiple lytic lesion with sclerotic bone and cortical distraction no gross periosteal reaction
- 24. Similar x ray
- 25. What is the most likely diagnosis? Chondrosarcoma Infection boride Secondary metastasis Fibrous dysplasia Multiple myeloma
- 26. Describe the stepwise management approach of this patient? • CT and MRI • Biopsy ,FNAC is not representative • RX • Wide excision +chemotherapy
- 27. Treatment -chondrosarcoma • Operative • intra-lesional curettage • Indications • Grade 1 lesions • treatment of grade 1 lesions located in the pelvis or axial skeleton is controversial • many authors recommend wide excision of all chondrosarcomas (even grade 1) if located in the pelvis
- 28. • wide surgical excision • Indications • grade 2 or 3 lesions • some say grade 1 lesions in pelvis • historically, there is no significant role for radiation or chemotherapy in typical intramedullary chondrosarcoma • wide surgical excision combined with multi-agent chemotherapy • Indications • mesenchymal chondrosarcoma • the role of chemotherapy in de-differentiated chondrosarcoma is very controversial
- 30. • THANK YOU!
Editor's Notes
- In most patients the cause of SCFE is unknown, but mechanical, endocrine, and genetic factors are thought to play a role
- Definitive treatment alternatives for the management of SCFE include in situ internal fixation or pinning; bone graft epiphysiodesis; primary osteotomy through the apex or base of the femoral neck or intertrochanteric area, with or without fixation of the epiphysis to the femoral neck; and application of a spica cast. The choice of treatment depends on the type of slip and its severity, and individual preferences and prejudices.
- Postoperative Management. We allow protected partial weight bearing with crutches as soon as the patient is comfortable, usually within 24 hours of surgery; patients with unstable slips may be slower to walk. The patient uses crutches for 6 weeks, during which time the pain should resolve completely. Athletic activities are allowed after 3 months. The patient is monitored for the development of complications or contralateral slip by clinical examination and radiography every 3 to 6 months until skeletal maturity.
- Presentation Symptoms o pain is the most common symptom o may present with slowly growing mass or symptoms of bowel/bladder obstruction due to mass effect in the pelvis o 50% of de-differentiated chondrosarcomas present with a pathologic fracture
- Imaging Radiographs o lytic or blastic lesion with reactive thickening of the cortex low-grade chondrosarcomas show similar appearance to enchondromas with additional cortical thickening/expansion and endosteal erosion high-grade chondrosarcomas show cortical destruction and a soft tissue mass o intra-lesional "popcorn" mineralization may be seen described as rings, arcs, and stipples of mineralization o de-differentiated chondrosarcomas radiographically show a lower grade chondroid lesion with superimposed highly destructive area consistent with the high grade transformed dedifferentiated chondrosarcoma MRI or CT o helpful to determine cortical destruction, marrow involvement, and the soft tissue involvement Bone scan o is usually very hot in all grades of chondrosarcoma