CASE REPORT

A WOMAN 55 YEARS OLD WITH PATHOLOGICAL

PROXIMAL FEMORAL FRACTURE DEXTRA
DELLA PUTRI ARI YANI
LECTURER :
DR. ARSANTO TRI WI DODO
SP. OT, FI CS, K- SPI NE, MHKES

IDENTITY
Mrs. Tati
Name
55 years old
Age
Female
Sex
Housewife
Occupation
Moeslem
Religion
Married
Marital status
October, 15
th
2013 (from 5th floor block C)
Admitted
October, 16
th
2013
Date of examination
ANAMNESA
Main Complaint Additional Complaint
Can not move the right
leg since 10 days ago.
-
Patient came to the hospital with complaints
cant move the right foot since 10 days ago.
Admitted patients that cant 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 cant
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.
HISTORY OF FAMILY ILLNES
Never have the
same illnes in
her family
Diabetes
,
Hyperten
sion (-)
Asthma
and
Heart
disease
(-)
HABITS OF HISTORY
Imbalanced
diet
Smoking
(-)
Alkohol (-)
GENERAL CONDITION
Moderately ill
General
condition
Compos
Mentis
Consciousness
VITAL SIGN
Vital
Signs
Blood Pressure
110/70 mmHg
Respiration
Rate
24X/minute
Pulse Rate
88x/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 lung
Percusion
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 EXAMINATION
On October 15
th
, 2013
RESULT Normal Range
Hemoglobin 13,8 (12 17) g%
Leucocytes 11.200 (5.000 10.000)/L
Thrombocytes 288.000 (150.000 450.000)/L
Ht 39 (37 43) %
On October 17
th
, 2013
RESULT Normal Range
Hemoglobin 12.1 (12 17) g%
Leucocytes 12.000 (5.000 10.000)/L
Thrombocytes 232.000 (150.000 450.000)/L
Ht 35 (34 43) %
Differential Count 0/0/0/82/12/6 0-1/1-3/2-6/50-70/20-40/2-8
Erythrocytes 4.030.000 4.5-5.5 juta
Random blood sugar level 137 <140
LED 33 <10
Alkaline phosphatase 49 42-98
LDH 350 <480
on October 18th 2013
LDH : 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 DIAGNOSIS
1. From anamnesis
Identity : 50 years old
Mechanism of fracture
History of past ilness: ca mammae and post mastectomy 2nd
years ago

2. From physical examination
From 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 operative
Proximal femur
intamedullary nailing.



Ringer Laktat
Cefotaxim
Tramadol
Ondancentron
Normal diet
PROGNOSIS
Ad
Vitam:
dubia ad
malam
ANATOMY FEMUR
VASCULARISATION
DEFINITION
Fracture (from Latin fractra) 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.
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 BONE
The 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 FEATURES
Pain.
Pathologic fractures

PATHOLOGIC FRACTURES
The 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 TESTS
A complete blood count (CBC)
Elevated erythrocyte sedimentation rates (ESR)
C-reactive protein (CRP)
Tumor marker
Lactate 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 lyticblastic 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.