Extern jassdakorn suaypring 29 ธค60

3.  A : can speak , no stidor
c-spine - not tender/ movable
 B : clear equal both lung , CCT negative
 C : BP 114/71 mmHg , PR 96 bpm
no active bleeding , PCT negative
 D : E4V5M6 , pupil 3 mm RTLBE
 E : no external wound , no deformity

4.  A : no allergy
 M : no current medication
 P : U/D : HT
 L : 1 day ago
 E : Next page -->

5.  U/D : HT (Lifestyle modify – No medication)
 2 weeks PTA ผู้ป่วยเริ่มมีอาการปวดสะโพก-ต้นขาซ้าย
ไม่ร้าวไปที่ไหน มีอาการขณะกาลังเดิน นั่งพักแล้วดีขึ้น ทานยาแก้ปวด
อาการดีขึ้น ไม่เคยเป็นมาก่อนหน้านี้ ไม่เคยประสบอุบัติเหตุมาก่อน
ไม่มีไข้ไม่มีเบื่ออาหาร-น้าหนักลด ไม่สูบบุหรี่/ดื่มเหล้า/ใช้สมุนไพร
 1 day PTA ผู้ป่วยลื่นล้ม สะโพก-ขาซ้ายกระแทกพื้น ไม่มีศีรษะ
กระแทกพื้น ปวดสะโพก-ต้นขาซ้ายมาก ขยับไม่ได้ไม่มีบวมแดง/
บาดแผลภายนอก

6.  GA : aThai woman , alert,
 HEENT: not pale, anicteric sclera
 LN : no lymphadenopathy
 Heart & Lung:WNL
 Abdomen: soft, not tender
 Extremities:Anvil & Rolling positive
Lt. hip - Marked tender , Limited ROM due to
pain , no wound / deformities
Lt. knee - Not tender , Full ROM

9.  Both hip AP / Lt. lateral
: Osteolytic lesion at neck & head of Lt. femur
– ill defined border / no sclerotic rim /
no periosteal reaction / no soft tissue shadow

10.  Closed fracture of Right neck of femur
 Pathologic fracture
 U/D: HT

11.  Bone fracture which occurs without
adequate trauma and is caused by a
preexistent pathological bone lesion
(Distored archetecture /bone density)

12.  Primary bone tumor (benign/ malignancy)
 Bone metastatic tumor :
- Breast / Lung /Thyroid / Kidney / Prostate
 Spine / Pelvis / Rib / Skull / Proximal femur
/ Proximal humerus

13.  Fractures more common in benign tumors
(vs malignant tumors)
 most asymptomatic prior to fracture
 antecedent nocturnal/rest symptoms rare
 most common in children (humerus/femur)
: unicameral bone cyst, NOF, fibrous dysplasia,
eosinophilic granuloma

14.  Fractures observed more often in
males than females
 May be active or latent
 Almost always solitary
 First two decades
 Humerus and femur most common
sites
“fallen fragment”sign
Fractures through benign tumors

15.  Most common benign tumor
 Femur, distal tibia, humerus
 Multiple in 8% of patients
(associated with
neurofibromatosis)
 Increased risk of pathologic
fracture in lesions >50%
bone diameter & >22mm
length

16.  Solitary vs. multifocal
(solitary most common)
 Femur and humerus
 First and second decades
 May be associated with
café au lait spots and
endocrinopathy
(Albright’s syndrome)

17.  Relatively rare (often unsuspected)
 May occur prior to or during treatment
 May occur later in patients with radiation
osteonecrosis (Ewing’s, lymphoma)
 Osteosarcoma, Ewing’s, malignant fibrous
histiocytoma, fibrosarcoma

18. Correctable diseases Uncorrectable diseases
Renal osteodystrophy
Hyperparathyroidism
Osteomalacia
Disuse osteoporosis
Osteogenesis imperfecta
Polyostotic fibrous dysplasia
Postmenopausal osteoporosis
Paget's disease
Osteopetrosis
Others : Osteomyelitis , Old fracture , Radiation , Steroid

19.  Adenoma
 Mental status changes
 Abdominal pain
 Nephrolithiasis
 Polyostotic disease
- mixed radiolucent/radiodense
 May be secondary to
renal failure
Multiple brown tumors

20.  Radiographic appearance
 Thickened cortices
 Purposeful trabeculae
 Mixed sclerosis/lysis
 Bowing deformities
 Joint arthrosis
 Fracture
 delayed healing
 malignant transformation
Fracture through
Pagetic bone

22.  Lab (rule out systemic conditions)
- ESR , CBC , serum Ca / PO4 / ALP
 Skeletal Survey (rule out pending fracture in
axial skeleton, femurs, and humerus)
 Bone scan
 Bone marrow aspiration / biopsy
- Malignancy : the biopsy should be done
before fixation of the bone is undertaken.

27.  Score < 7 (4%) - no need for prophylaxis
(conservative treatment)
 Score 8 (15%) - border line
 Score >9 (33%) - prophylactic fixation

29.  Like all fractures, reduction & immobilization
 But a biopsy needs to be done first to define the
cause of the fracture.
 Benign bony lesion, heal without surgery
Healing time is slower but can be expected to occur.

30.  Nails versus plates versus arthroplasty
 plates, screws and cement for torsional loads
 interlocked nails stabilize entire bone
 Cement augmentation
 Radiation/chemotherapy/bisphosphonates
 Aggressive rehabilitation

31.  Ratio survival time : surgical recovery time
 Ability to ambulate
 Ability to use extremity
 Capacity to return to full function
 Pain not controlled by analgesics
 Location of disease – high risk area