“Painless Fracture Hides Rare Bony Malignancy”

Le résumé fourni par la source

HISTORY: 48 year old male with history of unprovoked DVT presents to the ED with left knee pain for 3 months. Symptoms began at rest, and described as sharp constant pain localized to the knee. Three weeks prior, he was evaluated by his primary care doctor and was clinically diagnosed with a knee sprain with conservative management. Two weeks ago, he felt an atraumatic “pop” in his lower extremity. Since that time he has since been unable to weight bear. No constitutional or B-type symptoms. PHYSICAL EXAM: Thin, well appearing male, seated in a wheelchair. Seated exam was performed secondary to the patient’s pain. He was unable to bear weight on his left lower extremity and it was held in passive internal rotation. His left hip had no tenderness over the greater tuberosity and he had limited range of motion. His left knee was without erythema, effusion or warmth and there was no tenderness over the medial or lateral joint lines. Range of motion of his knee was limited. No specialized tests were able to be performed given patients positioning and discomfort. His left ankle was nontender with no gross deformities. His dorsalis pedis pulse was 2+ and flexion/extension of the toes were intact. DIFFERENTIAL DIAGNOSIS: 1)Hip dislocation/fracture, pelvic fracture / fragility fracture 2)Internal derangement of the knee 3)Femoral DVT 4)Pathological fracture TEST AND RESULTS: X-ray of Left Knee AP and Lateral Displaced and angulated fracture of distal left femoral diaphysis. MRI Left Lower Extremity (T1) Abnormal soft tissue invades the mid to distal femoral shaft extending into anterior compartment of quadriceps and a portion of the short head of biceps femoris. NM Bone Scan Focal, mild to moderate increased tracer uptake noted in the left femur from the mid shaft to distal region. Operative Biopsy Malignant fibrous histiocytoma / undifferentiated pleomorphic sarcoma WORKING DIAGNOSIS: Occult femur fracture secondary to rare primary bone neoplasm TREATMENT AND OUTCOMES: 1)Patient transferred to outside facility for orthopaedic oncology service and operative plate fixation 2)Radiotherapy - post-operative of primary lesion site 3)Transfer to inpatient rehab facility with post-operative protocol 4)Remaining work-up and management follow-up pending - including oncologic imaging and therapy, surgical outcomes, rehabilitation course.

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