Introduction:

I. PATHOLOGIC FRACTURE

DEFINITION
A pathologic fracture is a broken bone that’s caused by a
disease, rather than an injury. Some conditions weaken your
bones, which makes them more likely to break.
Pathological fractures in children can occur as a result of a
variety of conditions, ranging from metabolic diseases and
infection to tumors. Fractures due to benign and malignant bone
tumors should be recognized and managed appropriately by the
treating orthopedic surgeon. The most common benign bone tumors
that cause pathological fractures in children are unicameral
bone cysts, aneurysmal bone cysts, non-ossifying fibromas and
fibrous dysplasia. Non-ossifying fibroma is the most common bone
tumor in kids. It is not a cancer. NOF is benign which means it
is just a collection of abnormal cells that stays where it is
and does not move to other parts of the body.

Causes
In this case, the cause of the client’s pathologic fracture is
related to the Disease Non-ossifying fibroma.

Non ossifying fibroma (NOF) causes bone weakening. When the

bones are weak, there is a high risk for the client to fall,
trip or slip easily and cause bone fracture.
On year 2015 the patient had fracture on his right femur.
Last year, 2016, he suffered from patellar fracture and it was
casted at Philippine orthopedic center. The patient said that he
fell on the second to the last step on the stair. This year,
while he was playing with his cousins he tripped at the garden
hose. That’s why his distal 3rd femur on right side was
fractured. Then they found out that the patient has benign tumor
and lytic lesion that indicates non ossifying fibroma.

From the word itself, ossification means bone formation. Fibroma

means benign tumor that is composed of fibrous or connective
tissue. And Non, other word for not, means that the bone does
not form and it has benign tumor.
Patient’s Profile
Patient’s Name: Patient X
Age: 7 years old
Address: # 4570-I Sampaloc St. Santolan Road, Brgy. Gen Tiburcio
de Leon, Valenzuela City
Birthday: December 9, 2010
Birth Place:
Religion:
Admission Date: November 21, 2017
Admitting Physician: Dr. Dollete
Admitting Diagnosis: Pathologic fracture distal third femur
right probably secondary to Non-ossifying Fibroma
Chief Complaint: Pain on right thigh

Socio-economic Status
Educational Attainment
Family Background
Number of Siblings 3
Birth order 2
Mother’s occupation Housewife
Father’s occupation Seaman
Other sources of income none
Other people in the house Grandmother
Housing
Level
Materials
Other Notes
Family History

Paternal Maternal
(+)Diabetes Mellitus (-)Diabetes Mellitus
(-)Asthma (-)Asthma
(-)Heart Disease (-)Heart Disease
(-)Cancer (-)Cancer

The only pertinent family history in this patient is the

Diabetes Mellitus on the father’s side. The rest of the family
history is unremarkable.

Medical history
(-) Cardiovascular system
(-) Pulmonary system
(-) GIT/GUT
(-) Hematopoietic system
(-) Endocrine system 2015
(-) Neurological System
(-) Allergies  Fracture at the
distal 3rd femur right

2016
 Trauma at Right patellar
Cause: Falling accident
Intervention: Cast

2017
 Re-fracture at the distal 3rd femur right
Cause: Slipping from garden hose
Intervention: Steinmann Pin Insertion

Anatomy and Physiology

Pathophysiology

Non modifiable Modifiable

Sex – Male Age – 7 years old
Recurrent fall
Low body weight – 20 kg
Low Calcium Intake

Non Ossifying Fibroma

 Lytic lesion

Pathologic Fracture

Weakens overall strength of the Right Femur

Increased Risk of Trauma (Fall)

further fracture

Fracture of Distal 3rd of femur, Right

Physical Assessment
Physical Normal Actual Findings Implication
Assessment
INTEGUMENT

SKIN Uniform in color Good skin turgor Normal findings

HAIR Thick, Silky, Black in color, Normal findings

Evenly evenly
Distributed distributed

NAILS Intact with the With good Normal findings

epidermis, pink capillary refill
to brown
appearance
When nails
pressed between
the fingers
(Blanch Test),
 the nails return
to usual color in
less than 4
seconds.
HEAD

HEAD Rounded, Symmetrical, no Normal findings

Symmetrical, palpable masses
Normocephalic

SKULL No nodules or No nodules and Normal findings

masses and masses palpable
depressions when
palpate

FACE Smooth and has Symmetrical, no Normal findings

uniform presence of
consistency and nodules
with no presence
of nodules or
masses

EYES AND VISION

EYEBROWS Hair is evenly Symmetrically Normal findings

distributed, aligned
symmetrically
aligned and
showed equal
movements

EYELASHES Equally Equally Normal findings

distributed and distributed
curled slightly
outward.

EYELIDS Skin intact with No Normal findings

no discharges and discoloration,
no discoloration. symmetrical,
Lids close blinks
symmetrically and involuntarily
blinks
involuntary.

Bulbar
EYES conjunctiva Symmetrical, no Normal findings
appeared edema, moist,
 transparent with the sclera
few capillaries appeared white,
evident. the pupils
Sclera appeared constrict in
white. response to
No edema or light and dilate
tearing of the when looking at
lacrimal gland. far objects.
Cornea is
transparent,
smooth and shiny
and the details
of the iris are
visible.
The pupils of the
eyes are black
and equal in
size. The iris is
flat and round.
PERRLA (pupils
equally round
respond to light
accommodation),
illuminated and
non-illuminated
pupils
constricts.
Pupils constrict
when looking at
near object and
dilate at far
object. Pupils
converge when
object is moved
towards the nose.

EARS AND The Auricles are

HEARING symmetrical and
has the same
EARS color with his Symmetrical, Normal findings
facial skin. The clean, no foul
auricles are odor, and no
aligned with the discharges
outer canthus of
eye. When
palpating for the
texture, the
auricles are
 mobile, firm and
not tender. The
pinna recoils
when folded.
During the
assessment of
Watch tick test,
the client was
able to hear
ticking in both
ears.

NOSE AND The nose appeared

SINUSES symmetric,
straight and
NOSE uniform in color. Symmetrical, Normal findings
There was no clean and no
presence of discharges.
discharge or
flaring. When
lightly palpated,
there were no
tenderness and
lesions

The lips of the

client are
uniformly pink;
moist, symmetric
and have a smooth
MOUTH texture. The No lesions, Normal findings
client was able moist,
to purse his lips symmetrical.
when asked to
whistle.

There are no
discoloration of
the enamels, no
retraction of
gums, pinkish in
color of gums
TEETH AND GUMS The buccal mucosa 1 extracted Normal findings
of the client tooth and 5
appeared as teeth with
uniformly pink; cavities, no
moist, soft, more
 glistening and abnormalities
with elastic noted.
texture.
The tongue of the
client is
centrally
positioned. It is
pink in color,
moist and
slightly rough.
There is a
presence of thin
whitish coating.
The smooth
palates are light
pink and smooth
while the hard
palate has a more
irregular
texture.
The uvula of the
client is
positioned in the
midline of the
soft palate.

The neck
muscles are equal
in size. The
client showed
coordinated,
smooth head
movement with no
NECK discomfort. Symmetrical, no Normal findings
The lymph nodules
nodes of the palpated.
client are not
palpable.
The trachea
is placed in the
midline of the
neck.
The thyroid
gland is not
visible on
inspection and
the glands ascend
during swallowing
but are not
visible.
 The jugular
veins are not
visible.

The chest wall is

intact with no
tenderness and
masses. There’s a
full and
THORAX,LUNGS symmetric
AND ABDOMEN expansion and the
thumbs separate
LUNGS OR 2-3 cm during The chest is not Normal findings
CHEST deep inspiration protruded, no
when assessing tenderness and
for the masses noted.
respiratory The chest wall
excursion. The is intact.
client manifested No crackles
quiet, rhythmic sounds heard.
and effortless
respirations.
The spine is
vertically
aligned. The
right and left
shoulders and
hips are of the
same height

There were no
visible
pulsations on the
aortic and
pulmonic areas.
There is no
presence of
heaves or lifts.

HEART The abdomen of Normal cardiac Normal findings

the client has an and respiratory
unblemished skin rate noted
and is uniform in
color. The
abdomen has a
symmetric
 contour. There
were symmetric
ABDOMEN movements caused Symmetrical, no Normal findings
associated with tenderness and
client’s masses palpated
respiration.

EXTREMITIES
Client’s able to
MUSCLE resist force when Firm, no masses Normal findings
STRENGTH strength is palpated.
tested, there is
visible
contraction but
no movement is
noted when arm is
moved against the
direction of pull
in the muscle.

There were no
JOINTS swelling, No tenderness Normal findings
tenderness and palpated
joints move
smoothly.

Both arms are

ARMS present Both arms Normal findings
Symmetrical,
both arms are
present
both legs are
LEGS present symmetrical with Abnormal
external fixator findings
at right leg

BACK
Firm and Not
BUTTOCKS soggy Firm and not Normal findings
soggy
2-3 inches
GENITALS Normal in size Normal findings
No foul odor and
ANUS discharges No discharges Normal findings
noted
Clinical laboratory
Hematology Department
Component Reference Range
Red Blood Cells 5.20 4.0-6.0x10^12/L
Haemoglobin Mass 131 Male 140-180
Hematocrit 0.41 0.37-0.57
Leucocyte Count 11.60 4.8-10.8x10^9/L

DIFFERENTIAL COUNT
 Segmenters 0.86  0.40 – 0.74
 Lymphocytes 0.09  0.19 – 0.48
 Monocytes 0.03  0.03 – 0.09
 Eosinophils 0.01  – 0.07
 Basophils 0.01  – 0.02
Reticulocytes
Platelet Count 341 150 – 450
x10^9/L
CRP Non
Reactive < 6 mg/L
Semi-Quantitative CRP <6

Component Reference Range

Indices
MCV 82 – 92 ft
78 28 – 32 pg
MCH 32 – 38 %
25 0 – 10 mm/hr
MCHC 5 – 15 mins
32 1 – 7 mins
ESR (Westergen)
8  11 -15 seconds
Clotting Time (Lee and white)
6’00”
Bleeding Time (Ivy’s Method)  22 – 45 seconds
3’00”
COAGULATION STUDIES
 Prothrombin time
11.1
 PT % Activiy
100
 PT INR
0.82
 Activated PTT
35.1

Clinical Microscopy Urinalysis

Physical Characteristics
Color: Yellow Transparency
Clear
pH: 6 Specific Gravity 1.020
Chemical Test:
Glucose Negative Protein
Negative
Microscopic Findings
Cells:
RBC – 0-1/hpf
Pus Cells 0-2/hpf
Epithelial Cells – Rare
Bacteria – Rare
Mucus Threads - +1
Clinical Chemistry Department
Test S1 Result Reference Range S1 Unit
Alkaline 625 H <270 U/L
Phosphatase
SLDH 236.07 <248 U/L
SGOT/AST 18.82 <40 U/L
SGPT/ALT 22.73 <46 U/L
Total Calcium 2.42 2.15-2.57 Mmol/L

LABORATORY RESULT
ABO BLOOD GROUP
Rh Group: B POSITIVE

FINDINGS:

 Overriding fracture with comminution is evident along the

distal thirds diaphysis of the femur. There is anterior
displacement if the distal fracture fragment.
 Adjacent hypodensities and strandings are present
IMPRESSION:

 Complex fracture with surrounding inflammatory changes and

edema, right distal femur shaft.
X-RAY SECTION:
Result of Examination
Chest X-ray

 Both lungs are clear

 Heart is normal in size and configuraton
 Aorta is unremarkable
 Both costophrenic sulci and hemi diaphragms are intact
 Visualized osseous structures are unremarkable
IMPRESSION:
Normal Chest X-ray
  Comminuted fracture of the distal 3rd of the femur on a
background or well defined lytic lesion with short zone of
transition (possibly a bone cyst)

Signs and symptoms

Prior to admission

 Client is complaining of pain in his right leg