J Korean Orthop Assoc.  2011 Jun;46(3):250-255. 10.4055/jkoa.2011.46.3.250.

Pathologic Fracture in Radiation-induced Osteosarcoma Misdiagnosed as Delayed Femoral Neck Fracture

• Chun YS
• Han CS
• Kwak SJ
• Huh DB

• KMID: 2185464
• DOI: http://doi.org/10.4055/jkoa.2011.46.3.250

Abstract

Secondary osteosarcoma has a relatively higher incidence in middle aged persons than in children. Radiation-induced osteosarcoma occurs in approximately 1% of patients who have been treated with more than 2,500 cGy. The time interval from radiation to onset of secondary osteosarcoma is approximately 10 to 15 years. A 51-year-old female who have been treated with radiation for angiomyxoma was hospitalized due to right hip pain. She had a minor trauma 2 weeks prior to hospitalization. A day before hospitalization, she experienced a second trauma by fall, and then, severe hip pain developed. A radiograph of the patient showed femoral neck fracture with sclerotic change of fractured margin. We diagnosed the patient as having a neglected femoral neck fracture and treated it with closed reduction using cannulated screw fixation. At 6 months post-surgery, the patient had residual pain of the right hip and we could find overproduced callus at the fracture site. Through further evaluation, we diagnosed this as secondary osteosarcoma with pulmonary metastasis. We report this case to make a warning about a misdiagnosed osteosarcoma as a simple femoral neck fracture.

Keyword

femoral neck fracture; pathologic fracture; secondary osteosarcoma; radiotherapy; misdiagnosis

MeSH Terms

Bony Callus
Child
Diagnostic Errors
Female
Femoral Neck Fractures
Femur Neck
Fractures, Spontaneous
Hip
Hospitalization
Humans
Incidence
Middle Aged
Myxoma
Neoplasm Metastasis
Osteosarcoma

Figure

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  Figure 1 Initial anteroposterior radiograph shows a transcervical femoral neck fracture with modest displacement in Garden type 3. Sclerotic change is seen at the fracture site. No periosteal reaction is found and any other findings looked like mass are not observed.

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  Figure 2 Postoperative radiograph (A) and radiograph made 4 months after surgery (B) show internal fixation with three cannulated screws at right femoral neck. In the radiograph made 4 months after surgery(B), no evidence of union is found. Blurring mixed with calcification around the fracture site is seen. Anteroposterior radiograph made 6 months after surgery (C) shows overpruded callus. There is loss of cortical and cancellous bony architecture with destructive and heterogenous shadow.

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  Figure 3 Bone scintigraphy images show asymmetrical intensed increased uptake in right femoral head, neck and proximal portion.

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  Figure 4 T2WI MRI shows increased signal intensities (A) and GD inhanced MRI shows fuzzy enhancements (B) at the gluteal muscles, vastus muscles and adductor muscles.

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  Figure 5 Histology shows tumor cells with anaplastic, some are giant, numerous atypical mitoses. Some tumor cells are included in the osteoid-like matrix (H&E, ×400).

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