1/7. Metastatic disease of the femur. Surgical management.Treatment of actual or impending pathologic fractures of the femur provides the senior author with some of the most rewarding surgical interventions of his practice. The patients' survival outlook is not changed, but their quality of life is enhanced significantly. Most health care providers usually provide the metastatic cancer patient only temporary symptomatic relief, at best, and often at the expense of continued pain, suffering, or sickness, such as is seen with chemotherapy-associated morbidity. Patients with metastatic bone disease are usually incredibly grateful for the restoration of function and diminution of their pain that results from the proper operation on metastatic bone disease. These patients typically are among the most appreciative patients and often express their gratitude when seen in follow-up in the clinic or office. Despite their metastatic disease state, their usual enthusiasm is uplifting to the surgeon and to the staff. To help a patient be pain-free and functional in the waning days of his or her life affords the patient, the physician, and the physician's staff with an emotionally rewarding experience and one that is well worth the time and effort required to care for these patients. By following the techniques outlined in this article, most patients with metastatic disease of the femur can be appropriately managed with excellent results.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/7. sternum insufficiency fracture presenting as acute chest pain: a case report and review of the literature.The spine, pelvic bones and long bones of the lower extremities are common sites for insufficiency fractures. Cases of sternum insufficiency fractures have been rarely reported in an elderly patient. Insufficiency fracture tends to occur in bones with decreased mechanical strength. It tends to occur in elderly patients, especially in postmenopausal women, with underlying diseases. We describe a case of sternum insufficiency fracture in a patient with rheumatoid arthritis and systemic lupus erythematosus on long-term corticosteroid therapy diagnosed in an emergency setting. sternum insufficiency fracture is a rare cause of chest pain. This case serves to remind the emergency physician to remain vigilant for other noncardiac and nontraumatic causes of chest pain. If diagnosed accurately, these patients can be discharged and treated as outpatients.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
3/7. Renal hypophosphatemic osteomalacia unmasked by hyperthyroidism.A case of renal hypophosphatemic osteomalacia (RHO) that was unmasked by hyperthyroidism is presented. The patient presented at age 64 with pathologic leg fractures. There was no family history of osteomalacia or rickets. Initial evaluation revealed hyperthyroidism, which was treated with radioactive iodine. Despite control of thyroid function, the patient had recurrent pathologic fractures. Further evaluation revealed histologically proven osteomalacia and the biochemical findings of RHO: elevated serum alkaline phosphatase, decreased serum phosphate and tubular resorption of phosphate, and normal serum calcium, parathyroid hormone, and vitamin d levels. Other causes of osteomalacia were excluded. Treatment with phosphate and calcitriol reversed the osteomalacia. This case demonstrates that hyperthyroidism, and possibly other illnesses that affect vitamin d or bone metabolism, may unmask metabolic bone disease and that physicians should be alert for the subtle clinical and biochemical indicators of unrecognized metabolic bone disease in adults.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
4/7. Surgical stabilization of pathological neoplastic fractures.The most important factor to consider in deciding between treatment options in the management of metastatic bone disease is the level of the patient's dysfunction and pain. Severe dysfunction or pain demands a treatment that predictably leads to a quick resumption of the painless activities of daily living. A treatment that predictably will restore function in months may seem reasonable in patients with a normal remaining life span, but is untenable if those months represent a high percentage of remaining life span, as they do in metastatic disease afflicted patients. The treating physician needs also to understand the basis for the patient's dysfunction. A destroyed joint will not return to painless function even if the metastasis responsible is totally eliminated. A bone that has lost its structural integrity, even though not grossly fractured, will not support weight bearing for months even if the metastasis is eliminated. Control of the metastatic tumor does not always equate with return to function. Treatment options in the management of metastatic bone disease are not mutually exclusive. In many patients treatment options are combined. Surgical stabilization may best return the patient's function while he is being treated postoperatively with radiotherapy or chemotherapy for good neoplasm control. Neoplasm control should not be such an overriding concern that function is not addressed. Function can almost always be returned to the patient, but neoplasm "cure" is rarely achieved in this group of patients. It is a reasonable goal to avoid allowing bone metastasis to progress to pathological fracture. Routine periodic examinations and bone scans should commonly alert the treating physician to the presence of metastatic bone disease well before fracture occurs. Pathological fracture narrows the range of treatment options, mitigates against full functional restoration, demands a rehabilitation hiatus, and acutely frightens the patient who does not have time to participate fully in treatment decisions. An impending pathological fracture can be treated with surgery, radiotherapy, chemotherapy, or hormonal manipulation. The options are basically operative or nonoperative. Lesions that predictably will fracture short term, involve joints, or will cause catastrophic consequences if fracture occurs should be strongly considered for surgical stabilization. Other factors to consider are the location of the metastasis, the primary tumor, and the expected response to nonoperative therapy. The patient becomes a surgical candidate for the above reasons and not because of any estimated life span.(ABSTRACT TRUNCATED AT 400 WORDS)- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/7. osteopetrosis in trauma.A 19-year-old male with a bone disease that predisposes to pathological fractures was involved in an automobile accident. Although the physician must always look for multiple injuries in any trauma patient, this case illustrates that in the patient with bone disease, the probability of multiple fractures is extremely high. The differential diagnosis of dense-bone disease is discussed as are considerations relevant to caring for the trauma patient with bone disease.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
6/7. Reversal of the histology of bone after parathyroidectomy in patients with hyperparathyroidism.hyperparathyroidism is commonly seen in patients with end-stage renal disease and less commonly in the primary form. The skeletal manifestations of hyperparathyroidism are the same in both forms and are well described in the literature. We treated a patient from each category. Multiple bony lesions and pathologic fractures were observed. The clinical presentations and radiologic and histologic findings confirmed the diagnosis of hyperparathyroidism and osteitis fibrosa cystica in both patients. Subtotal excisions of the parathyroid glands were done in both patients. Appropriate treatment of the bony lesions and pathologic fractures resulted in healing. Histologic evaluation of the bony lesions indicated an osteoblastic or healing response. The reversal of the histologic pattern in just 5 days and 16 days after parathyroidectomy was noted. In treating such patients, physicians should consider parathyroidectomy as an aid in the overall management of patients.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
7/7. Orthopedic manifestation in a child with hyperimmunoglobulin E syndrome.We report a 12-year-old girl with hyperimmunoglobulin E (HIE) syndrome who presented with genu vulgus of left knee, joint deformities involving both hands, and frequent fractures. She had had chronic eczema and recurrent skin and soft tissue infections since infancy, and was found to have a pneumatocele during admission. Immunologic abnormalities included extremely elevated serum IgE levels (18989 IU/ml) and cutaneous anergy to candida, purified protein derivative, and tetanus toxoid. The results of polymorphonuclear leukocyte function tests including the nitroblue tetrazolium test and chemotaxis were normal. A high index of suspicion for HIE syndrome should be given in patients with recurrent skin infections and orthopedic complaints. The physician should anticipate orthopedic problems in caring for patients with HIE syndrome, and optimal antibiotics prophylaxis should be used.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |