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Similar to P03 ped pathologic fxs
P03 ped pathologic fxs
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- 2. Pathologic Fracture = Fracturethrough Abnormal Bone
- 3. Osteopetrosis - failedfixation of femoral neck fracture. No osteoclasts - No remodeling.
- 4. With every fracture Askthe question - Is this fracture through NORMAL bone?
- 5. •Orthopaedic surgeon maybe the first to have opportunity to make the diagnosis. (malignancy, metabolic disease, etc.) Often Need to Do More than Treat the Fracture
- 6. •Minor Or NoTrauma •Any Antecedent Pain? •Night pain? •Recent Illness? •Weight loss? •Fevers? History
- 7. History • Ask aboutgrowth and development • Dietary habits • kidney disease • thyroid disease • Family history
- 8. •AskAsk about priormalignancies, even in the child •Families will not always volunteer this information History
- 9. •Look for softtissue mass vs. fracture hematoma •Other systems- skin, lymphatics, solid organs •Height - weight percentiles Physical Exam
- 10. 11 yo -OGS
- 11. •CBC with differential •ESR •Calcium,Phosphorus, Alkaline phosphatase •Bun/Cr Lab Tests
- 12. •Osteopenia •Physeal width (rickets) •Softtissue calcifications •Presence of mass •Any periosteal reaction Radiographs Be Suspicious
- 13. •Where is lesionlocated? •What is lesion doing to bone? •What is bone doing to lesion? •Are there clues to type of lesion? Enneking’s 4 Questions
- 14. •Size •Margination •Cortex •Soft tissue mass Benignvs. Malignant Mankin’s Criteria
- 15. •Benign Bone Lesion •MalignantBone Lesion •Infection •Metabolic Bone Disease •Skeletal Dysplasia •Neuropathic •Osteopenia- Disuse •Overuse Make Diagnosis/Categorize
- 16. •Metaphyseal •Proximal humerus, femur •3-14years old •Males > females Unicameral Bone Cyst UBC
- 17. •Fallen leaf sign(or fragment) •Active= adjacent to physis •tx= immobilize •fx heals; cyst persist in 85% UBC Pathologic Fracture
- 18. •Steroid injections •Bone marrowinjections •Bone graft substitutes •Open currettage/graft •disrupt hydraulics- puncture, screw, wires, rods UBC Persistent
- 19. •18 ga spinalneedle •C-arm •Serous fluid, straw colored •2nd needle- vent •Depomedrol 160 mg •may need multiple injections UBC Injection
- 20. LJ, 8 yowith arm pain when throwing, injected once with methylprednisolone (multiple sites), healing at 3 months
- 21. UBC - RiskFactors for Recurrence • Age < 10 • male • “active” lesions • large size • multiloculated • cyst index (Kaelin)
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- 23. •Expansile •Often wider thanphysis •Eccentric •Aggressive at margins Aneurysmal Bone Cyst ABC
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- 27. 5 yo femalewith 1 year of hip pain and 4 prior steroid injections, progressive coxa vara
- 28. •Currettage and bonegraft •+/- internal fixation •high recurrence ABC
- 29. Currettage, biopsy consistentwith aneurysmal bone cyst
- 30. 1 month aftercurrettage, bone grafting, valgus/internal fixation, spica immobilization
- 31. Nonossifying Fibroma (NOF) • Letfracture heal • most NOF’s persist • assume if fractures once with minimal trauma, high risk to fracture again unless bone changes with healing • currettage/bone graft
- 32. 10 yo male- running during soccer. NOF fracture - at 4 weeks underwent allograft DBM / cancellous bone graft. Healed at 9 mos.
- 33. NOF - ProphylacticBone Graft? • Controversial • Arata and Peterson, JBJS 1981 - >50% diameter, >33 mm length • Easley and Kneisl, JPO 1996 - prophylactic surgery not necessary in many
- 34. Fibrous Dysplasia • Weightbearingbones - ORIF or structural graft • Enneking - cortical struts alone for femoral neck • cancellous bone graft will remodel into fibrous dysplasia, therefore cortical grafts recommended
- 35. 14 yo female- fell walking across front yard 3 months of left hip pain - Motrin referred for “path fx through Ewing’s sarcoma” Dx -polyostotic fibrous dysplasia
- 36.
- 37. Fibrous Dysplasia • Considerother sites • Bone scan, MRI • For extensive involvement (McCune- Albright) consider intramedullary fixation/splinting
- 38. 11 yo male– fem neck path fx, nondisplaced. Fibular allograft (neck) and titanium elastic nails (subtroch and shaft)
- 39. 13 yrs old– 2 years postop. FD in rt femur and tibia. No pain in hip, in karate. Fibular graft gone - ? Treat Painful tibia. ? nail ?pamidronate
- 40. 5 yo -Albright’s polyostotic fibrous dysplasia
- 41. Prophylactic Treatment of FibrousLesions (NOF /FD) • Any mechanical pain? • Location and size - relative issues • supracondylar femur, proximal femur more worrisome • pharmacologic approach (pamidronate) for painful fibrous dysplasia – role?
- 42. •Abnormal type Icollagen •Severe type - multiple fractures prior to skeletal maturity •Lower extremity > upper extremity •Femur, tibia, humerus Osteogenesis Imperfecta (OI)
- 43. •Early onset (fxsprior to walking)- more fractures (2x) •Closed tx- limit immobilization time •IM fixation often needed OI
- 44. 3 yo OI- multiple fxs Lt femur
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- 47. •Minimize disuse osteoporosis •EarlyIM fixation •Alendronate, pamidronate, other bisphosphonates / osteoclast inhibitors OI- New Methods
- 48. Ollier’s Disease Enchondromatosis • Linearmasses of cartilage in metaphyseal and diaphyseal regions of long bones • asymmetric, often unilateral • usually sporadic occurrence • pathologic fx may occur
- 49. 7 yo male- femur fracture jumping on bed Enchondromatosis femur/tibia/ pelvis Rt LE
- 50. •Infection always indifferential •Pathologic fracture uncommon •Delayed diagnosis •Femur, tibia •Involucrum may be supportive Osteomyelitis
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- 52. 10 yo femaleALL - chemotherapy/steroids fx after fall from chair. Tx = immobilization
- 53. •Myelomeningocele, paraplegics, sensory neuropathies •Oftenmistaken for infection, DVT, tumor Neuropathic Fractures
- 54. 3 yo MMC- swollen leg Consult = DVT vs infection? Take an xray - healing fx may look like malignancy
- 55. 11 yo male- Duchenne Muscular Dystrophy Hip pain for 2 months. Disuse fracture/nonunion
- 56. •usually through normalbone subjected to abnormal stresses •May be mistaken for more serious pathology (esp. longitudinal stress fxs) •History of recent increased activity •femur, tibia, fibula Stress Fractures
- 57. 12 yr oldmale, activity related pain, training for baseball, running 6 miles per day, referred for Ewing’s sarcoma. Longitudinal femoral stress fracture
- 58. Stress Fractures • Canoccur through pathologic bone • Congenital abnormalities, metabolic disorders (osteoporosis, osteomalacia)
- 59. Congenital Tibial Dysplasia Presentedat age 10 after fracture from minor trauma Had “bowed leg”her entire life No other msk abnormalities
- 60. •Referral to musculoskeletal oncologist •Requirescomplete staging •Biopsy needed - follow proper “rules” for biopsy • Avoid fracture callus, notify pathologist of fx - biopsy soft tissue mass Malignant Appearing Pathologic Fracture
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- 62. Malignant Pathologic Fractures •May need immediate amputation • OGS - some fx may heal during neoadjuvant chemotherapy • Ewing’s - closed immobilization, chemotherapy
- 63. Path fx lesser trochanter StageIIB MRI - soft tissue mass posterior
- 64. Ewings sarcoma -allograft-prosthesis composite
- 65. Pediatric Pathologic Fxs •Be suspicious - scrutinize every fracture film • Usually benign process • Make the diagnosis to guide treatment • Appropriate referral / workup for suspected malignancy • prophylactic treatment for benign lesions on an individual basis
- 66. •Unicameral Bone Cysts(UBC) •Nonossifying Fibromas •Aneurysmal Bone Cyst (ABC) Benign Bone Lesions
- 67.
- 68. Malignant Bone Lesions •Osteogenic Sarcoma • Ewing’s Sarcoma • Leukemia/Lymphoma
- 69. •Fibrous Dysplasia •Osteogenesis Imperfecta •Ollier’sDisease •Osteopetrosis Skeletal Dysplasias Return to Pediatrics Index