2. PATIENT IDENTIFICATION
➤ Case ผู้ป่วยเด็กชายไทย อายุ 14 ปี
➤ No known Underlying Disease
Chief complaint: เข่าซ้ายผิดรูป 5 hr PTA
3. PRIMARY SURVEY
➤ A : patent airway, no cervical tenderness
➤ B : normal and equal breath sound both lungs,
CCT : negative
➤ C : BP = 120/70 mmHg , PR = 80 bpm, PCT :
negative
➤ D : E4V5M6 , pupil 3mm RTLBE
➤ E : no active external bleeding, left knee deformity,
popliteal pulse 2+, dorsalis pedis pulse 2+, no
paresthesia
4. SECONDARY SURVEY
A : No Hx food or drug allergy
M : No current medication
P : No known underlying
disease
L : Last meal 12.00
E : 5 hr PTA ขณะที่กาลังเตะฟุตบอล
ผู้ป่วยสะดุดล้มลงกระแทกพื้น ไม่ได้กระแทกรุนแรง
ผู้ป่วยได้ยินเสียงกระดูกซ้ายหัก ปวดขาซ้ายมาก มี
ขาซ้ายบวมและผิดรูป เดินลงน้าหนักไม่ได้ ไม่ชา
ไม่อ่อนแรง
5. MANAGEMENT AT COMH
➤ On Splint
➤ NPO
➤ NSS 1,000 ml IV rate 80 ml/hr
➤ Pethidine 10 mg IV stat
➤ Refer
6. AT MNRH
➤ Primary Survey : same as COMH
➤ Secondary Survey : same as COMH
7. HEAD TO TOE PHYSICAL EXAMINATION
➤ V/S : BP = 120/70mmHg, PR = 80 bpm, Temp = 37c,
RR 20/min
➤ GA : A Thai male, good consciousness, well cooperate
➤ HEENT : not pale conjunctiva, anicteric sclera
➤ Heart : normal S1, S2 , no murmur
➤ Lungs : normal breath sounds, equal both lungs
➤ Abdomen : soft, not tender, normoactive bowel sounds
➤ Neurological : E4V5M6, pupil 3 mm RTLBE
8. HEAD TO TOE PHYSICAL EXAMINATION
➤ Extremities : Left lower extremity
➤ severe tender, swollen, deformity, limit ROM due to
pain
➤ No numbness, no bruit or expanding
hematoma/hemarthrosis
➤ Can dorsiflexion
➤ Capillary refill <2 sec
➤ DPA 2+, PTA 2+, symmetrical
22. TOPICS
➤ Diagnosis of the pathological fracture and staging of
patient
➤ Management of pathological fractures
➤ Management of impending fractures
23. PATHOLOGIC FRACTURE
➤ “A fracture through diseased or abnormal bone”
➤ Resulting from a force insufficient to produce a
fracture in normal bone
➤ Occur through bone at its weakest point or where
the tumor mass occupies the most space
24. BONE STRUCTURE
➤ Diaphysis
➤ Epiphysis
➤ End of a long bone
➤ Metaphysis
➤ Between epiphysis and diaphysis
➤ Growth plate
➤ Medullary canal
➤ Contains bone marrow
➤ Periosteum
➤ Fibrous covering of diaphysis
➤ Cartilage
➤ Connective tissue that provides a smooth articulation surface for other
bones
26. SUSPECTED PATHOLOGIC FRACTURE
History:
• Trivial trauma
• Pain (or limp) before the fracture
• Known history of cancer
• Symptoms suggestive of cancer (weight loss,
heamoptysis, heamatemesis, bleeding PR, urinary ..)
• History of previous irradiation
27. SUSPECTED PATHOLOGIC FRACTURE
Xray:
• Abnormal bone quality
• Underlying lytic, blastic or mixed lesion
• Other lesions in the same or adjacent bone
• Abnormal fracture pattern
31. OPERATIVE MANAGEMENT IN PATHOLOGIC FRACTURE
➤ The underlying lesion may continue to erode bone
and no healing will occur so mechanics will depend
totally on the implant.
➤ Surgery should be followed by radiotherapy to halt
the disease process.
➤ There may be other weak areas in the bone present
at the time of fracture or may appear later on.
➤ Surgery is to do Internal fixation.
32. PROPHYLACTIC MANAGEMENT
❖ Recommended if the weakened bone state is detected
before the fracture occurs.
• Impending fracture:
The goals of surgical treatment in a patient with an
impending pathologic fracture are to alleviate pain, reduce
narcotic use, restore skeletal stability, and regain
functional independence.
33. The Mirels system classifies the risk of pathologic fracture based on
scoring four variables on a scale of 1-3: location of lesion, radiographic
appearance, size, and pain. An overall score is calculated, and a
recommendation for or against prophylactic fixation is made.
a Size is determined as a fraction of the diameter of the bone.
b Functional pain is defined as severe pain or pain aggravated by limb
function.
321
IntertrochantericLower extremityUpper extremityLocation
LyticMixedBlasticRadiographic
appearance
>2/31/3 - 2/3< 1/3Sizea
FunctionalbModerateMildPain
34. Recommendation%Fracture Risk
Prophylactic fixation is
recommended
33-100≥9
Clinical judgment should be used15=8
Observation and radiation therapy
can be used
<4≤7
Commonly, a lesion is considered to be at risk for fracture if it is painful,
larger than 2.5 cm, and involves more than 50% of the cortex
Advantages of prophylactic management :
· Decreased morbidity
· Decreased hospital stay
· Easier rehabilitation
· More immediate pain relief
· Faster surgery and less
35. OPERATIVE TREATMENT
• Goals of surgical intervention are:
➤ Prevention of disuse osteopenia.
➤ Mechanical support for weakened or fractured bone to permit the
patient to perform daily activities.
➤ Pain relief.
➤ Decreased length and cost of hospitalization.
• Internal fixation, with or without cement augmentation, is
the standard of care for most pathologic fractures,
particularly long bones. Internal fixation will eventually fail if
the bone does not unite.
37. DEFINITION
➤ Osteosarcoma is an aggressive malignant
neoplasm arising from primitive transformed
cells of mesenchymal origin (and thus a
sarcoma) that exhibit osteoblastic
differentiation and produce malignant osteoid.
➤ most common of primary bone cancer in age
12-25yrs.
➤ originates more frequently in the metaphyseal
region of tubular long bones, with 42%
occurring in the femur
38. 38
RISK FACTORS:
➤ Radiation exposure
➤ Patients who survive after taking therapy for
another Cancer.
➤ Retinoblastoma(malignant tumor arising from
retina of eye).
45. X– RAY
➤ Codman triangle is a term used to describe the
triangular area of new subperiosteal bone that is
created when a lesion, often a tumour, raises the
periosteum away from the bone.
➤ sun-burst" appearance on X-ray examination due
to the tumor spicules of calcified bone radiating in
right angles
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