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Closed reduction and application of a coaptation splint followed by Sarmiento brace after 7-10 days
3%
75/2642
Immediate intramedullary nailing with reamings sent to pathology
91/2642
Open reduction and internal fixation with open biopsy followed by bone scan and CT chest/abdomen/pelvis
18%
480/2642
Closed reduction and application of a coaptation splint followed by bone scan and CT chest/abdomen/pelvis
75%
1969/2642
Closed reduction and application of a coaptation splint followed by initiation of IV antibiotics
0%
11/2642
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The patient's clinical presentation is most consistent with a pathologic fracture through a likely metastatic lesion in her right humerus. It is important to recognize pathologic fractures and perform a thorough evaluation and staging prior to any surgical intervention. Appropriate staging of this lesion involves radiographs, CT of the chest, abdomen, and pelvis, bone scan, pre-operative labs, and once complete, an open biopsy for a tissue diagnosis. If a solitary osseous lesion is identified, metastatic disease is the most common culprit in patients over age 40, but primary lesions are still possible. Despite possible oligometastatic disease, wide surgical resection and reconstruction may confer a survival benefit in some scenarios. Quinn et al review the treatment options of metastatic bone disease in the spine and extremities and emphasize the importance of considering quality of life and return to function in determining the appropriate surgery. For metastatic humeral diaphyseal lesions, they recommend plate fixation with cement or intramedullary nailing (with or without cement). Intercalary replacement is recommended for large segmental bone loss. Scolaro et al review the management of extremity pathologic fractures and highlight the importance of tissue diagnosis prior to surgical intervention. For upper extremity metastatic pathologic fractures, they emphasize the importance of early rigid stability using PMMA cement or wide resection with intercalary reconstruction. Figure A demonstrates a diaphyseal humerus fracture through a permeative lesion. Incorrect Answers: Answer 1: The patient requires a formal diagnostic evaluation due to the presence of a pathologic lesion. Answer 2: Intramedullary nailing through a potential primary bone lesion could result in spreading the tumor and eventual amputation, therefore, it is important to perform a diagnosis and staging in this patient with no history of cancer. Answer 3: Tissue diagnosis is important prior to definitive surgical intervention. If this is a primary bone lesion, then ORIF may be an inappropriate treatment. Answer 5: While osteomyelitis might be on the differential, metastatic disease should be considered and evaluated.
3.4
(8)
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