This document discusses orthopaedic trauma, specifically pathological fractures and sprains. It provides details on the etiology, signs and symptoms, investigations, and management of pathological fractures. Common causes include osteoporosis, tumors, and infections. Diagnosis involves history, physical exam, imaging like x-rays, and sometimes biopsy. Treatment depends on factors like location and stability but may include bracing, surgery like nailing or prosthetics, and adjuvant therapies. Sprains and strains are also discussed, distinguishing between injuries to ligaments and muscles/tendons. Treatment follows RICE principles with rehabilitation.
5. Fragility Fractures:
-Low energy pathological fractures occuring in an
osteoparotic bone.
-Most common cause of pathological fractutes is
OSTEOPOROSIS.
-Common sites of Fragility Fractures are:-
-Vertebral #,
-Proximal Femur #
-Distal Radius #.
6. • Common Metastatic Cancers-
– Breast -Lung
– Prostate -Thyroid
– kidney
• Common sites of metastasis:-
– Spine
– Pelvis
– Ribs
– Skull
– proximal femur
– Proximal humerus.
7. Approach for Diagnosis of
Pathological #
HISTORY:-
• Degree of trauma (Trivial Trauma).
• Presence of prodromal pain at site of #.
• Previously diagnosed or treated for cancer,
• H/O Radiation Rx.
• Weight loss, Fever, Night sweats, Fatigue.
8. Factors Suggesting Pathlogical #
• Spontaneous fracture without Trauma,
• Fractures after minor trauma,
• Pain at the site before the fracture,
• Multiple recent fractures,
• Unusual # patterns,
• Patient older than 45 years.
• History of Malignancy.
9. Examination
• Symptoms and Signs of Fracture.
• Palpation of mass.
• Neurovascular examination.
• Evaluation of possible primary sites
(Breast, Prostate, Lung, Thyroid)
• Lymphadenopathy.
11. • Search for Occult Primary:-
-DEXA Scan for Osteoporosis,
-Plasma protein electrophoresis,
-Breast examination, Mammography, CA-125.
-Per-rectal examination, PSA.
-Thyroid examination, Thyroid profile.
12. • N-telopeptide and C-telopeptide are markers of
bone collagen breakdown measured in serum
and urine.
– Confirm increased destruction caused by bone
metastasis.
– Measure the overall extent of bone involvement.
– Assess the response of the bone to
bisphosphonate treatment.
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16. • Osteoporosis-
– Thinning of cortices
– Loss of normal trabecular pattern
• Permeative or moth eaten pattern of cortical
destruction is highly suggestive of malignancy.
• Hyperparathyroidism
– Looser lines-compression side radiolucent lines
– Calcification of small vessels
– Phalangeal periosteal reaction.
17. Performing biopsy for Lytic Lesions
• Solitary bone lesion in a patient with or
without history of malignancy, biopsy
should be done.
• Biopsy should be obtained from a site near but
unaffected by fracture.
• Site should be as small as possible,
longitudnally in line with the extremity.
• Cultures for all biopsy to rule out infections
that may mimic tumors on x rays.
18. Impending Pathological #
• Known skeletal mets usually treated by
Radiation/Chemotherapy +/- prophylactic
fixation.
• Radiological assesment of lesion and patient
symptoms necessary to calculate the risk.
• Mirels developed a scoring system based on
pain, location, size of the lesion, radiographic
appearance.
19.
20. • Lesions with score of less than 7 can be irradiated
safely, >8 require prophylactic fixation.
• Patients treated prophylactically have:
– Shorter hospitalization
– More immediate pain relief
– Faster and less complicated surgery
– Less blood loss
– Quicker return to premorbid function
– Improved survival
– Fewer hardware complications.
21. • Fracture risk is greatest during patient
positioning, prepration and draping.
• Decision making includes:
– Life expectancy of the patient
– Patient comorbidities
– Extent of the disease
– Tumor histology
– Anticipated future oncologic treatments
– Degree of pain
22. Management considerations
• Treatment of local bone lesion.
• Surgical stabilisation +/- resection: large lytic
lesion at risk of fractures/pathologic fractures.
• Radiation: Adjuvant local treatment for entire
operative field.
• Functional bracing.
• Bisphosphonates: inhibit osteoclast mediated
bone resorption.
23. Bracing
• Indicated in-
– Limited life expectancies
– Severe comorbidities
– Small lesions
– Radiosensitive tumors
• Humerus shaft, forearm, tibia.
• Weight bearing should be limited.
24. • Perioperative antibiotics
• DVT prophylaxis
• Nutritional Support
• Post Operative Pulmonary exercises
• Early mobilisation.
25. Operative treatment
• Intramedullary device or modular prosthesis provides better
stability.
• Bone cement-
– Increases the strength of fixation
– Should not be used to replace segment of bone
• Goal should be to stabilize as much of the bone as possible.
• Perioperative antibiotics
• DVT prophylaxis
• Nutritional Support
• Post Operative Pulmonary exercises
• Early mobilisation.
28. Proximal Femur
• Painful lytic lesions should be stabilised-
– High risk of fracture
– Ease of surgery
• Stabilize as much of proximal femur to avoid
future implant failure- since lytic process is
continous.
29. Femur Neck #
• Cemented prosthesis procedure of choice.
• Curette all tumour tissue before putting the
implant.
• Use a long stem component for adjacent lesions-
cement to be injected in a fairly liquid state after
canal prepration.
30. Intertrochanteric Region #
• High failure rate of DHS.
• Intramedullary device (PFN) or
prosthetic replacement.
• A cephalomedullary device has an added
function of protecting the femoral neck.
• Cemented calcar replacing prosthesis used for
more extensive lesions.
31.
32. Subtrochanteric Region #
• locked intramedullary nail +/- bone cement.
• Failed internal fixation/ extensive
destruction:Modular proximal femur device.
• Increased risk of dislocation and abductor
weakness with megaprosthesis.
• Bipolar head is used to provide additional
stability if acetabulum is not involved.
• Largest diameter nail used for diaphysis.
33. Distal Femur #
• Difficult to treat due to poor bone stock and
communition.
• Lateral locking plate with cement or modular
distal femur prosthesis.
• For extensive destruction modular prosthesis is
the optimum choice as it allows resection en-bloc.
• Retrograde nail.
• Diaphysis # - Intramedullary nail.
34. A 58-year-old man with a pathologic fracture
of the distal femur due to lung cancer
36. Spine
#
• Any Malignancy patient with back pain- Consider
metastasis.
• Any patient treated for osteoporotic compression
fracture should undergo a biopsy when not
responding to treatment or when there is excessive
destruction of bone.
• CT guided biopsy.
37. • X ray- Loss of pedicle on the AP view.
• MRI
– Complete replacement of the vertebral segment
– Multiple vertebral body lesions
– Pedicle involvement
– Intact intervertebral disk
• Bone marrow biopsy.
39. Indications of surgery
• Progression of disease after radiation Rx.
• Neurologic compromise caused by bony
impingement,
• Radioresistant tumor within the spinal canal,
• Impending fracture,
• Spinal instability caused by a pathologic #,
• Progressive deformity.
41. What are Sprains & Strains..?
• Sprains and strains are two types of
musculoskeletal disorders.
• MSD’s are injuries or disorders of the: muscles,
nerves, tendons, joints, cartilage, and supporting
structures of the upper and lower limbs, neck and
lower back that are caused, precipitated, or
exacerbated by sudden exertion or prolonged
exposure to physical factors. (e.g. force,
repetition, vibration or awkward posture)
- CDC/NIOSH
42. • A sprain is a stretch or tear
of a ligament (band of fibrous
tissue that connects two or
more bones at a joint);
stretched too far from normal
position.
• One or more ligaments
may be injured at the
same time.
• Most common:
- sprained ankle.
43. 6
• A strain is an injury to a muscle or tendon (thick,
tough fibrous cord of tissue that connects a muscle
to a bone).
• Can be as simple as overstretching a muscle or
tendon, or it can be a partial or
complete tear.
• Most common: strained back.
44. Symptom & Signs
• SYMPTOMS:-
-Pain,
-Swelling,
-Bruising,
-not being able to move
the joint.
-SIGNS:-
-Swelling,
-Ecchymosis,
-Tenderness,
-Stress Test.
47. Treatment
• FIRST STAGE – To reduce swelling and pain.
RICE therapy (Rest, Ice,
Compress, Elevate) for
the first 24 to 48 hours.
1. Rest the injured area
(reduce regular
activities as needed)
2. Ice the injured area, 20
minutes at a time, four
to eight times a day.
48. 3. Compress the injured area, using bandages, casts,
boots, elastic wraps or splints to help reduce swelling.
4. Elevate the injured area, above the level of the
heart, to help decrease swelling while you are lying
or sitting down.
49. • Anti-inflammatory drug to help decrease
pain and inflammation.
• Grade 1 sprain little or no immobilization.
• Grade 2 Sprain 4 to 6wks immobilization
followed by gradual mobilization.
• Grade 3 sprain, need surgery to repair torn
ligament.
50. • SECOND STAGE – Rehabilitation
Physical therapy/exercise program: designed to
help reduce swelling, prevent stiffness and
restore normal, pain-free range of motion.
