Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
31 August 2006

HOW DO WE EXAMINE A BONE?

            The lady was elderly at 86 years of age.  She lived independently and had only one medication that she took to treat high blood pressure.  She returned from an outing one night and missed the top step on her porch.  She fell onto her left side on the concrete porch and broke her left hip.  With this, she was unable to get up.  She rolled into a sitting position on the top step, held on to the railing with both hands and forced herself into a standing position.  But she was then unable to bear any weight on her left leg because of severe pain with even a suggestion of bearing weight.  Very fortunately, she had a cell phone in her purse.  She called her daughter for help and an ambulance was dispatched to her home. 

            She was takien to the hospital where a standard x-ray was done, easily demonstrating the fracture of her left hip.  Fortunately, this type of fracture was easily seen on a standard x-ray.  It was surgically repaired the next morning and she was discharged to the transititional care center for rehabilitation three days later.  She returned home in about two weeks, continued rehabilitation services for about another month before her walking was again near normal.  For this lady, a simple x-ray was all that was needed to see the fracture.

            Another lady, had a similar experience of falling forward, landing on her left side while walking on an uneven sidewalk.  The companion that was with her was able to help her up and continue the walk although with slight discomfort.  Over the course of the next week, the discomfort became much worse and the patient came to the clinic for further evaluation.  A standard x-ray was taken of her hip and the x-ray was normal.  However, because her pain was quite was severe and impairing her walking, this patient was taken to the hospital where a CAT scan of the hip was taken.  A CAT scan is a special kind of x-ray that looks as if there is a cross section of the bone instead of a standard “picture of the bone”.  CAT scans can see cracks that a standard x-ray does not show.  When the CAT scan of this lady’s hip was taken, it demonstrated that she also had a fracture of her hip.  Because the bones were in good alignment, it would theoretically be possible for this lady to avoid weight-bearing for several months and allow the bones to heal.  However, because of her age, this much immobility would be highly likely to lead to major degenerative changes.  Therefore, she also was treated surgically and an artificial hip placed to correct this fracture.  She also recovered in the course of about three weeks returning to normal activity.

            A third patient didn’t have a fall but had developed severe pain in left hip.  After this pain had been present for about a month, she decided it wasn’t really going to go away as she had hoped and she had came to the clinic to seek an answer why her hip was hurting.  A standard x-ray was done and showed no abnormality.  The patient indicated that she had had no fall or accident that might have resulted in the fracture of her hip.  For this lady we did something a little different called a bone scan.  With this technique, a radioactive tracer material is injected intravenously into her arm.  This material is designed so that it will collect in areas where her bone is growing rapidly.  Such places are stress fractures that don’t show on an x-ray or bone tumors where the tumor is eating the bone up rapidly and new bone is being laid down rapidly.  This lady showed high activity in the neck of her left hip. This was highly suggestive that there was malignancy in that bone.  There followed a search where such a tumor might have come from and a mammogram demonstrated a cancer in her breast.  The remainder of her workup looking for other metastases from the breast tumor was negative.  So this lady underwent a resection of the tumor in her breast and a replacement of her left hip.  It is now eighteen months later and she has undergone radiation and chemotherapy in addition to the surgery on her breast.  To this time, there is no evidence of recurrence of her breast tumor or metastases from same.  She indicates that her left hip is normal and she has no symptoms at all there.

            These three ladies are an example of the various ways that we have available to examine a patient’s bones.  A standard x-ray is rather like taking a picture.  But a CAT scan of the bone is like making a cross section and being able to look down on the bone from above.  A bone scan is able to examine the growth activity of the bone and find tumors or other abnormalities before a fracture ever occurs.

            The healthcare professionals at your local clinics are well aware of these various techniques which are very helpful in evaluating a person’s bone pain.  The MRI scan is another type of examination that offers very little help with bones but can see soft tissues attached to the bones.  An MRI scan is very helpful for evaluating pinched nerves in the back or infections that occur in or near bones.  Using these different diagnostic techniques allows the healthcare professionals at your local clinics to find abnormalities that can be surgically corrected or treated medically.