MSGM Case Presentation September 2024

Prepared by Dr Teoh Keang Tat

Supervised by Professor Dr Terence Ong

Location of study: University Malaya Medical Centre

Title: Pathological Fracture, an Invisible Menace in Orthogeriatric Care

Presenting Complaint

Madam K is a 74-year-old woman who developed pain in her right thigh suddenly when she tried to get off her motorbike. There was no history of trauma, and the pain has persisted since then. Over the coming weeks, the pain worsened and she became more dependent. She lost her ability to ride her motorbike, her activities of daily living became affected (e.g housework and cooking) and she was using walking frame to ambulate due to pain.

Eventually, her daughter who was concerned about her acute disability and worsening pain insisted her to be assessed in hospital. The day prior to her hospital presentation, the pain in her right thigh was constant, even while she was sitting down and was only partially relieved by over-the counter analgesia. There is no history of fever, constitutional symptoms, significant loss of weight/-appetite, or typical symptoms suggestive of malignancy.

Premorbid Baseline History

Madam K is a full-time housewife who lives in a single-story terrace house with her husband. she was independent in her mobility and basic and instrumental activities of daily living (ADL) prior to the onset of her pain.

Comorbid Medical and Surgical History

1. 1. Type 2 diabetes mellitus (HbA1c Level : 7.1%)

2. 2. Hypertension

3. Dyslipidaemia

3. 4. Degenerative lumbar spine disc disease with radiculopathy managed conservatively

4. 5. Peripheral vascular disease

6. Bilateral total knee replacement 10 years ago

Chronic diseases followed up at Klinik Kesihatan

Medication list

 PO Metformin 1g BD

 PO Perindopril 4mg OD

 PO Simvastatin 20mg ON

 s/c Mixtard 32unit BD

Investigation Findings

Blood results:

Plain Radiograph:

Radiograph of Right Femur: lytic lesion over neck of femur (blue arrow) and presence of sub trochanteric fracture

Diagnosis :

Closed pathological subtrochanteric fracture of the right femur

Clinical Question:

1. What is the further investigation required in this situation?

2. Should prompt time to surgical fixation (i.e within 48 hours as per best practice

guideline for hip fragility fractures) be applicable in this situation?

3. What factors need to be considered to ensure safe surgical fixation?

4. Which specialist teams need to be involved in the management of this patient?

Management

Further blood investigations

Hepatitis B and C screening non-reactive

Peripheral Blood Film:

Red Blood Cell: normocytic normochromic with occasional polychromatic cells noted, no rouleaux formation

White Blood Cell: adequate and unremarkable

Platelet: slight reduced, few platelets clumping seen

Serum protein Electrophoresis: Beta globulins increased, but no paraprotein band detected.

Further radiological investigation

Positron Emission Tomography (PET) scan

Summary of findings:

A comminuted fracture of the right subtrochanteric femur is noted, with coarse calcification and a surrounding soft tissue mass exhibiting heterogeneous hypermetabolic activity (SUVmax 4.4/8.6x8.9x10.6 cm). There is increased bulkiness in the adjacent thigh muscles.

Additionally, an isometabolic lobulated cystic mass is present in the pancreatic head, containing coarse calcification (SUVmax 2.0/3.6x3.0x2.1 cm). The remainder of the pancreas is atrophied, but there is no dilation of the pancreatic duct. The liver parenchyma appears normal with no focal lesions. The portal vein is patent, and there is no biliary duct dilation.

No significant lymphadenopathy was observed in the mediastinal, axillary, abdominal, or pelvic regions. There was no suspicious bone activity detected, and no other notable findings suggest a primary malignancy in any other organs.

Management progress:

The geriatric team was involved early in managing the patient, focusing on optimizing blood pressure and glucose levels through medication reconciliation for the upcoming surgery. They also coordinated with allied health professionals, including physiotherapist, occupational therapist, and dietitian, to support muscle health and preserve her function while the patient was immobile.

Initially, there was a communication gap between the family and the orthopaedic team,causing frustration due to the delay in surgery. The geriatric team promptly facilitated family meetings with the orthopaedic and orthopaedic oncology team to determine the optimal timing for the surgery and clarifying the need to confirm the fracture's pathology beforehand. Unfortunately, the patient developed delirium while awaiting surgery due to inadequate pain management and constipation. The geriatric team quickly identified and addressed the precipitants of delirium.

Madam K then underwent a core needle biopsy of the right femoral lesion and a Positron Emission Tomography (PET) scan to assess the nature of the pathological fracture. After confirming the presence of malignancy, the Orthopaedic Oncology team planned a resection of the right proximal femur and the replacement of the proximal femur with an endoprosthesis.

Operation procedure:

Intraoperative findings showed a closed pathological fracture of the subtrochanteric right femur, attributed to metastasis, with high vascularity. The implants used were implant cast right femoral head and proximal femur endoprosthesis.

A core biopsy of the femur and the resected femoral bone were sent for histopathological examination. Both results indicated metastatic adenocarcinoma, with a possible primary source in the upper gastrointestinal tract or the pancreatic-hepatobiliary system.

Further follow-up progress

Unfortunately due to extended immobility and physical deconditioning post operation, the patient was discharged home with wheelchair ambulation and a moderate to severe dependence on assistance for daily activities. A multidisciplinary team meeting was held later to address the diagnosis dilemma and future management. Initial PET scan revealed a subtrochanteric right femur fracture with high metabolic activity and a pancreatic lesion with similar activity. An endoscopic ultrasound suggested the pancreatic lesion was a branch duct intraductal papillary mucinous neoplasm (BD-IPMN), but no biopsy was performed as there were no malignancy features.

A CT scan of the liver showed an irregular hypodense lesion, which raised concern for atypical hepatocellular carcinoma. A CT-guided liver biopsy was conducted, and the result indicated non-alcoholic fatty liver disease with cirrhosis. Following this, the patient was advised to consider another liver biopsy and local radiotherapy for the right femur. However, the patient declined further invasive tests and therapy due to the uncertainty and repetition of procedures but agreed to serial CT scans for monitoring of malignancy progression.

Summary of Management (Timeline)

Clinical Question:

1. What is the best modality of scan for this patient in term of availability and

detection? (CT scan vs PET CT scan)

2. What is the role of geriatric team in term of Ortho-oncology management?

3. what pathways exist for hospital that do not have specialist orthopaedic

oncology teams?