JULY CASE!!! (Full Version)

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Dr.Wagner -> JULY CASE!!! (July 10, 2008 1:00:10 AM)

A 49-year-old man with a past medical history of cervical spine fracture, diabetes mellitus, and hearing loss presents with increasing pain at the site of a previous complicated right femoral fracture, after a minor fall onto the affected area earlier in the day. No other trauma is noted, and the fall itself is thought to have been mechanical, with no antecedent symptoms (such as lightheadedness). He has no significant history of alcohol use or illicit substance use. The patient had sustained a displaced transverse fracture of the right proximal femur 6 months ago as a result of a car accident. The fracture had been treated with operative reduction and internal fixation; the hardware was removed prematurely 2 months after the accident, at an outside facility for unknown reasons (although it was thought to be because of increased pain). Despite an aggressive physical therapy regimen, the patient remained bedridden, with continued pain in the injured extremity.

Review the initial xray...what is abnormal??


Shill -> RE: JULY CASE!!! (July 10, 2008 1:51:29 PM)

Well Doc,
The film has no reference to which side is which, BUT, I would say he has screw holes in his right trochanteric region from the hardeware removal, at a bare minimum.  He has a suspicious ovoid lesion in the inferomedial right femoral head, and perhaps even a fracture at the juncion of the superior and lateral acetabulum with the femoral head (whoops, thats the acetabulum superimposed. sorry).  He also has a metal rectangle stuck in his sacrum up to L5 from some sort of archaic attempt at a hemifusion, OR it is a belt from a strap holding him down. (the latter of course).   I assume what appears to be a shortened femoral neck on what might be the left is actually just a rotated view of sorts.  More views would help.
Seems to me that the hardware removal was a bad idea.

Long Tracts -> RE: JULY CASE!!! (July 10, 2008 3:23:57 PM)

This particular film appears to be diffusely osteosclerotic.  How did he fracture his C-spine?  You mentioned hearing loss, did he have a cranial nerve exam?

I'll wait for others to chime in.....

KAK -> RE: JULY CASE!!! (July 10, 2008 11:52:59 PM)

Mottled look inferior aspect of the femoral head- avascular necrosis?

bonez -> RE: JULY CASE!!! (July 11, 2008 1:54:01 AM)

Do you have an alk phosphtase test number and serum calcium? Besides hearig loss how about kidney stones, loose teeth ? My first thoughts are Paget's disease based on the Hx then myleoproliferative disorders next.

T_Thom -> RE: JULY CASE!!! (July 11, 2008 8:07:55 AM)

Mottled bone due to osteopetrosis.

jma -> RE: JULY CASE!!! (July 12, 2008 3:33:12 AM)

I too see the ovoid feature at the head of the femur and I do hope those rectangular rings are from a belt because nothing was mentioned about lumbar spine pathology

Dr.Wagner -> RE: JULY CASE!!! (July 12, 2008 5:22:58 PM)

alkaline phosphatase level is 131
All other labs are WNL

The oblong metal pieces you see are from straps...sorry.


The cardiac and pulmonary examinations are within normal limits. The examination of the right leg reveals a healed scar over the lateral thigh, with diffuse tenderness to palpation of the proximal femur. There is mild limitation in hip flexion to 100 degrees and severe limitation in knee flexion to 30 degrees, with muscle stiffness and atrophy noted as well. The lower leg and foot of the affected extremity are well-perfused, with bounding distal pulses. There are no overlying, chronic skin changes except for a well-healed scar over the site of the previous operative repair. The neurologic examination, including motor strength and deep tendon reflexes, are normal in the affected leg.

PT_Darren -> RE: JULY CASE!!! (July 13, 2008 12:40:42 AM)

I'm going to guess paget's. If he's got great peripheral circulation I'm thinking the diabetes isn't contributing to the lack of bone healing. Paget's also covers the hearing loss. 

Shill -> RE: JULY CASE!!! (July 14, 2008 1:28:57 PM)

I'd say he still hurts and is bedridden because it is still an unstable fracture.

bonez -> RE: JULY CASE!!! (July 14, 2008 7:11:56 PM)

The lab values suggest that the Paget's call is on track. The new film suggests that there has been failed/nonunion of the proximal fracture. this is likely due to the fact that the site was through the transitional tissue undergoing the Pagetoid change. There did not seem to be anything in the blood values to suggest that an operative infection is present but we would have to watch for this too.
The first film also shows the two hemipelvic structures to be of different shape. this could be positional from the patient's position working with the fracture but also traumatic from the original injury.

Hpsg -> RE: JULY CASE!!! (July 14, 2008 9:49:17 PM)


The first film also shows the two hemipelvic structures to be of different shape. this could be positional from the patient's position working with the fracture but also traumatic from the original injury.

It could be adaptational too, secondary to pain maybe.

Dr.Wagner -> RE: JULY CASE!!! (July 19, 2008 8:31:51 AM)

Osteopetrosis (marble bone disease) is a rare hereditary disorder of diminished osteoclast function characterized by deficient bone resorption.[5] In this patient, the plain radiograph of the right femur shows a marked, diffuse increase in the density of the osseous structures, and evidence of refracture is noted through the proximal middiaphyseal/subtrochanteric region (see Figure 1). A similar pattern, with increased bone density (which gives the bones a very bright appearance), is noted on the radiograph of the pelvis.

As a consequence of deficient bone resorption resulting from diminished osteoclast functioning, bone modeling and remodeling are impaired in osteopetrosis. Defective bone turnover results in skeletal fragility, despite the fact that there is an increase in bone mass. The condition is a heterogeneous disorder encompassing different molecular lesions (over 14, some with human homologs, have been identified in the murine model) and a wide range of clinical features in its phenotypic manifestation in affected individuals.Bone marrow tends to be replaced by defective osseous tissue, which leads to bone marrow failure with resultant pancytopenia. Patients may have anemia, a tendency to bruise easily, and bleeding resulting from thrombocytopenia; recurrent infections may occur because of inherent defects in the immune system.

This case is not an original Wagner case, credit goes to Medscape.

SJBird55 -> RE: JULY CASE!!! (July 19, 2008 12:05:41 PM)

HeHe... Yeah, I knew that Wags... the case showed up in my reader. 

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