Question

55-year-old man who complains of a ground level fall with midshaft femur pain. you begins to assess vital signs as you examine the patient’s leg. The middle anterior portion of the thigh appears mildly swollen and is tender on palpation. The left leg appears to be shorter than the right with mild external rotation. Neurovascular is intact distal to the injury with decreased range of motion due to pain. The patient is working hard to keep the leg still. You partner reports vital signs as follows: pulse 110, easily felt and regular, respirations of 22, unlabored and regular, blood pressure in a lying position is 134/88, pulse oximeter waveform matches his pulse and shows saturations of 97% on room air. He Glasgow score is 15. you ask about about his medical history. he said he has had HIV for the last 12 years. He reports his HIV has been managed well with very few complications. In other history he states he has had increased anxiety and stress the last 12 months from relationship problems with his partner. He states he has “always had dyspepsia” but an upper GI scope two years ago reported no cancer. He states he has been relatively healthy considering the HIV except for an ache deep in his groin for the last three weeks. He reports the following medications: antiretroviral therapy x3, lansoprazole, alendronate, vitamin D, and supplemental calcium. When asked about the alendronate, he states he is participating in an HIV bone protection study for the last seven years.

What additional assessment, history or diagnostic information should done in prehospital ?

This seems to be unusual that a relatively young and healthy individual would experience an atypical femur fracture. What in his history or his current medications would contribute to this type of fracture?

What are two specific patient education or counseling points patients taking a biphosphonate need?

Answer 1

-additional assessment

- is required in the case of his dyspepsia because dyspepsia is common in gastric cancer

-it is necessary to take patients family history to assess inherited bone disorders

- xray,CT or MRI SCAN help to diagnose the condition better ;pathological fracture present as a chalkstic fracture in long bones,and appear as a transverse fracture nearly 90 degrees to the long axis of the bone

-check for the chances of simple bone cyst

Apathological fracture is a broken bone that is caused by a disease rather than an injury

everday activities can fracture a bone that weakened by an illness

stress facture; may occure in normal or metabolically weakened bones caused by reprtitive stress or force,often from overuseStress fracture also associated with prolonged use of some medications example-biphosphonate

Anxiety related fracture-men with probable anxiety score greater than 11 had an increased risk of fracture

ANTIRETROVIAL THERAPY -Much attention has been paid to emerging complications of hiv infection in patients receiving potent antiretrovial treatment . Although the major focus has been on cardiovascular issues and metabolic disorders.there is also an emerging issue of potentially increased risk of bone problems as patients live longer

BISPHOSPHONATES

They are primary agents in the current pharmacological arsenal against osteoclast -medicated bone loss due to osteoporosis.prolonged use of bisphosponate increase the risk of stress fracture in patients thigh or hip[femoral fracture]

Inform to docter if develop any new pain in thighs

should not take medication if patient have kidney diseases,low calcium ,inability to stand or site

do not take medication if patient have any difficulty swallowing or heart burn

do not take medication if you are breast feeding or pregnant