Notes

Spiral fractures rarely occur unless violence has taken place. It is due to a twisting of the arm causing the almost pathognomonic finding.
In a case of obvious elderly abuse, social services must be notified
Given the findings of obvious, moderately differentiated carcinoma, definitive treatment can be recommended with radical vulvectomy and groin node dissection. Only microinvasive squamous cell carcinoma of the vulva can be treated by wide local excision, but it is a diagnosis that is only made after pathology evaluation of a small (<2 cm), well-differentiated lesion, with invasion <1.0 mm. Squamous cell carcinoma is the most common vulvar malignancy and may arise in the setting of chronic irritation from lichen sclerosus.
Squamous cell carcinoma accounts for approximately 90% of vulvar cancers. Patients commonly present with a lump and they commonly have a long-standing history of pruritus.
With lichen sclerosus, the skin appears thin, inelastic and white, with a “crinkled tissue paper” appearance. Paget’s disease of the vulva is associated with white plaque-like lesions and poorly demarcated erythema, not a discrete mass (pagets: vulva is fiery red mottled background with whitish hyperkeratotic areas.) Verrucous carcinoma has cauliflower-like lesions.
This presentation is classic for human papilloma virus (HPV) related vulvar intraepithelial neoplasia (multicentric brown-pigmented papules are noted on the perineum, perianal region and labia minora). Melanoma would be unlikely to be multifocal and warts have a characteristic verrucous appearance, although pigmentation can occur. Molluscum, a poxvirus, is characterized by multiple shiny non-pigmented papules with a central umbilication.
The finding of a mass in the Bartholin gland is highly suspicious for malignancy and requires excision/biopsy, especially in a post-menopausal women. age >40, then biopsy
Vulvar Itraepithelial Neoplasia III should be treated with local superficial excision. It is inappropriate to do radical surgery in this setting as cancer has not been diagnosed.
Given the multifocality of the vulvar dysplasia (VIN 2), laser treatment is the best choice. Treatment with TriChloroAcetic acid is recommended for treatment of warts and not VIN.