Pathologic Femur Fracture

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HISTORY: 55-year-old F with a PMHx of breast cancer treated by bilateral mastectomy 1.5 years ago presented with a 2-week history of right hip and leg pain. The pain initially started while doing yard work and worsened after pulling her foot out from being stuck in mud. She was previously seen in two prior urgent care visits and given an IM steroid dose and a course of steroids with no relief. XR of the R hip was negative except for evidence of old pelvis fractures from a MVC 20 years prior. She then presented to the sports medicine clinic for further management. She felt that her R leg would buckle without the use of a cane while ambulating and noted pain was worse when lying on her side, walking, and driving. PHYSICAL EXAMINATION: The lumbar exam did not reveal any abnormalities. The right hip demonstrated normal ROM. Palpation over the greater trochanter demonstrated mild tenderness. Axial loading of the hip did not reproduce pain. FADIR reproduced lateral side proximal thigh pain and FABER produced pain along the adductor muscles. Gait analysis with cane demonstrated a significant antalgic gate with the appearance of the right leg giving out. She identified sharp, severe pain to the proximal, anterior third of the femur, just distal to the level of the greater trochanter which was reproducible on palpation. DIFFERENTIAL DIAGNOSIS: 1. Greater trochanteric pain syndrome2. Lumbar radiculopathy3. Femur fracture TEST AND RESULTS: Right femur radiographs obtained on day of visit demonstrated subtle cortical osteolytic cysts on the posterior lateral cortex of the proximal shaft of the right femur, faint periosteal reaction in the cortex of this region, and a subtle mixed lytic/sclerotic intramedullary lucency along the proximal femoral shaft. Findings were concerning for femoral shaft osseous metastatic disease with suspected non-displaced pathologic fracture. FINAL WORKING DIAGNOSIS: Pathological fracture of the right femur with probable metastatic osseous lesions. TREATMENT AND OUTCOMES: 1. Immediate admission to the hospital with orthopedic consult. 2. CT chest abdomen pelvis w/ contrast were obtained upon admission demonstrating extensive appearing metastatic disease of the lungs, mediastinum, sternum, chest wall, liver, lumbar spine, and pelvis. 3. Patient underwent a R hip cephallomedullary nail fixation with biopsy

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