A Case of Lower Extremity Weakness with Foot Drop Following Intramedullary Nailing of a Pathologic Femoral Fracture.

Charles A Gusho

doi:10.7759/cureus.6561

Abstract

A 62-year-old woman presented with a pathologic femoral fracture. She underwent bilateral femoral intramedullary nailing (IMN) fixation, and her postoperative course was complicated by worsening lower extremity weakness and foot drop. Lumbar imaging identified vertebral compression fractures with foraminal encroachment. The patient was thereafter started on a radiotherapy regimen and discharged home. Pathologic fractures most commonly occur in the proximal femur. In some patients, contralateral weakness suggests an additional fracture, though it may represent spinal involvement. This case explores multiple current treatment options for pathologic fractures of the femur and spine and suggests that prophylactic endoprostheses may have greater selective benefit than IMN fixation.

Highlights

The incidence of metastatic disease will likely increase in the 20 years with the aging population
Research by Guzik et al identified 122 patients with proximal femoral metastasis who underwent standard or modular endoprosthetic replacement of the proximal femur. Their data highlight a moderate reduction in visual analog scale (VAS) pain scores and improved quality of life at 27 months following surgery, suggesting hip arthroplasty (HA) as a viable treatment option [3]
As was highlighted in research by McLynn et al, the perioperative complication profile has received little attention. In their retrospective study of 332 cases of prophylactic femoral fixation and 288 cases of pathologic fracture fixation, they report that when controlling for disseminated cancer, the odds of experiencing an adverse event, death, or prolonged hospital stay were no greater in prophylactic fixation than in fracture fixation for up to 30 days [4]

Summary

Introduction

The incidence of metastatic disease will likely increase in the 20 years with the aging population. Presented here is a case of bilateral lower extremity weakness following a pathologic femoral fracture secondary to breast metastasis. This patient had weakness from multiple lumbar fractures and delay in spinal MRI permitted the development of worsening weakness and cauda equina compression. The following day, the patient underwent right femoral IMN fixation using a 12 mm x 420 mm titanium cannulated nail Thereafter, she was neurovascularly intact throughout her right lower extremity and postoperative films showed anatomic alignment (Figure 4). Postoperative films showed anatomic alignment (Figure 5) Following the procedure, she was neurovascularly intact throughout her left lower extremity. Severe extensive metastatic disease with pathologic compression fractures of L4 and L5 (arrows) and extensive epidural tumor invasion at L4 and L5 with foraminal neuronal encroachment

Discussion

Conclusions

Findings

Disclosures

Guzik G