Pathological fracture

Definition:
Fracture of a diseased
A. Developmental
bone by trivial injury which is i. Ostegenesis
not sufficient to cause fracture imperfecta
of a normal bone ii. Osteopetrosis
iii. Diaphyseal aclasis
iv. Congenital
Cause: pseudoarthrosis
A. Generalized bone disease B. Metabolic
a. Nutritional
1. Osteogenesis imperfecta i. Rickets &
osteomalacia
2. Postmenopausal ii. Scurvey
osteoporosis b. Hormonal
3. Metabolic bone disease i. Hyperparathyroidism
ii. Cushing’s syndrome
4. Myelomatosis iii. Frahlic’s syndrome
5. Polyostotic fibrous c. Atrophic
dysplasia i. Senile/ post
menopausal
6. Paget’s disease osteoporosis
ii. Disuse osteoporosis
B. Local benign conditions C. Infection
a. Bacterial – osteomyelitis
1. Chronic infection i. Specific (TB)
ii. Non-specific
2. Solitary bone cyst b. Parasite
3. Fibrous cortical defect i. Hydatid disease
4. Chondromyxoid fibroma D. Inflammation
a. Granulomatous lesion
5. Aneurysmal bone cyst i. Hostiocytosis X
6. Chondroma E. Tumor
7. Monostotic fibrous a. Cystic and fibrous dysplasia
i. ABC
dysplasia ii. Unicameral bone cyst
iii. Fibrous dysplasia
C. Primary malignant tumours b. Primary
i. Benign
1. Chondrosarcoma 1. Chondroma
2. Chondroblast
2. Osteosarcoma oma
3. Ewing’s tumour 3. Chondromyxo
id fibroma
4. GCT
D. Metastatic tumours ii. Malignant
1. Osteosarcom
Carcinoma in breast, lung, a
kidney, thyroid, colon and 2. Fibrosarcoma
prostate 3. Ewing’s
tumor
4. Multiple
Common sites of myeloma
5. Malignant
pathological fractures fibrous
(A) Neck of femur, histiocytoma
(B) Neck of humerus, c. Secondary
i. From any malignant
(C) Distal end of radius, tumor
(D) Compression fracture of F. Iatrogenic
vertebra, (E) Fracture of ribs i. Through screw holes
after implant removal
ii. During mobilaization
under anaesthesia
iii. Forceful manipulation
iv. Donor site after bone
graft
v. After surgical
treatment of infected
bone
 N.B.
 Renal cell carcinoma has special predilection for
Evaluation of a case of upper end of humerus
 Ca prostate for pelveis (due to common
pathological fracture venous network)
H/O
1. Spontaneous fracture
2. trivial injury
3. Age of the patient
< 20 years - commonly benign bone tumours and cysts.
> 40years - commonly multiple myeloma, secondary
carcinoma and Paget’s
4. Older patients
- previous illnesses
- operations
- Malignant tumour or radiotherapy
5. Younger patient
several previous fractures - osteogenesis imperfecta
6. Gastrectomy
intestinal metabo malabsorption,
chronic alcoholism lic bone
prolonged drug disorde therapy - .
r
Symptom
Loss of weight, pain, a lump, cough or haematuria
[suggest that the fracture may be through a secondary deposit]

Examination
1. Careful evaluation of the affected skeletal region.
2. Palpation of a mass or fracture
3. Detailed neurologic examination of the extremities are
essential.
4. All extremities and the entire spine should be evaluated for
additional lesions or lymphadenopathy, because patients can
have multiple sites of involvement with bone metastasis,
lymphoma, or osteoporosis.
5. careful evaluation of all possible primary sites (breast,
prostate, thyroid)

Investigation
1. CBC with ESR – ESR – infective 9. protein electrophoresis- MM
& malignancy 10. Tumor markers
TC, DC – Non specific 11. tests for syphilis
infection
Eosinophilia – TB
Hb% - MM, Malignancy
2. Urine - R/E Haematuria - RCC
Bence jones protein – MM
3. S. Calcium
Metabolic and hormonal disease
4. S. Phosphate -
5. S. Alkaline phospatase - Any cause that increases osteoblastic
activity
6. S. Acid Phosphatase - Ca prostate
7. Blood urea
8. S. Creatinine - Renal disease
Radiology
1. Shows whether it is localized or generalized disease
2. Features such as cyst formation, cortical erosion, abnormal
trabeculation and periosteal thickening
 Geographical lesion – Benign
 Moth-eaten lesion – Intermediate
 Permeative lesion – Malignant
3. X-ray of other bones, the lungs and the urogenital tract may
be necessary to exclude malignant disease.
CT Scan & MRI
1. CT scan – Better Extent of
visualization of bone pathological
2. MRI - Better lesion
visualization of soft tissue
Bone scan
Important in revealing or excluding other deposits.
Biopsy
1. Some lesions are so typical that a biopsy is unnecessary
solitary cyst, fibrous cortical defect, Paget’s disease
2. Others are more obscure and a biopsy is essential for
diagnosis.
Depends on type of lesion
 Benign – Excisional biopsy
 Malignant – Incisional biopsy
Management:
Generalized bone disease
 In most of these conditions bones fracture more easily, but
they heal quite well provided the fracture is properly
immobilized.
 Internal fixation is therefore advisable
 Patients with osteomalacia, hyperparathyroidism, renal
osteodystrophy and Paget’s disease will need systemic
treatment as well.

Local benign conditions

 Fractures through benign cyst like lesions usually heal
quite well and they should be allowed to do so before tackling
the local lesion.
 Treatment is therefore the same as for simple fractures
in the same area,
 In some cases it will be necessary to take a biopsy
before immobilizing the fracture.
  When the bone has healed, the tumour can be dealt
with by curettage or local excision.

Primary malignant tumour

The fracture may need splinting but this is merely a prelude to
definitive treatment of the tumour, which by now will have spread to
the surrounding soft tissues. The prognosis is almost always very
poor.

Metastatic tumours
 Metastasis is a frequent cause of pathological fracture in older
people.
 Breast cancer is the commonest source and
 the femur the commonest site.

Fracture of a long-bone shaft

Should be treated by internal fixation;
if necessary the site is also packed with acrylic cement.
implant will function as a load-bearing and not a load-sharing
device; intramedullary nails are more suitable than plates and
screws.

Fracture near a bone end

can often be treated by excision and prosthetic replacement;
this is especially true of femoral neck fractures. Preoperatively,
imaging studies should be performed to detect other bone lesions;
these may be amenable to prophylactic fixation. Once the wound
has healed, local irradiation should be applied to reduce the risk of
progressive osteolysis.

Pathological compression fractures of the spine

Cause severe pain. This is due largely to spinal instability and
treatment should include operative stabilization. If there are
either clinical or imaging features of actual or threatened spinal cord
or cauda equina compression, the segment should also be
decompressed.
Postoperative irradiation is given as usual. With all types of
metastatic lesion, the primary tumour should be investigated and
treated as well.

Alternative:
A. Generalized disease:
1. Conservative treatment of the primary
disease
2. Immobilazation of fracture by Bracing or
Internal fixation accordingly
 3. Mobilization as early as possible
B. Localised lesion
1. Initially immobilization for a certain period
2. Radiotherapy in malignant lesion
3. Fixation – Internal or external
a. Indication for internal fixation
i. If fracture is painful in
immobilization
ii. If External fixation is inefficient
iii. When dissemination is
suspected
iv. If pathological fracture is
hormone dependent.
e.g – Ca breast, Ca prostate
b. Choice of implant is static IM nailing
Advantage
i. Protect a large enough
segment of bone
ii. Provide mechanical and
rotational stability
Disadvantage
ii. Dissemination of the disease
iii. Ionization of metal if
radiotherapy is given
iv. Implant will be barrier to the
radiotherapy
Prophylactic nailing; Indication
i. Pure lytic lesion
ii. Endoosteal cortical
erosion > 50%
iii. In case of femur > 2.5
cm lysis
4. Curettage and bone graft – In benign lesion
5. Prosthetic replacement
6. Amputation
a. Indication
i. Failure of all measures taken
previously to control
pathological fracture
ii. Infected bone with loss of large
segment where reconstruction is
not possible
iii. Highly malignant lesion with
large lesion
Collected from different books

A. Patient with multiple metastases Common causes for

and limited life span - treatment is
aimed at relief of pain, splint the bone,
regaining immediate mobility
B.Femoral, tibial and humeral fractures
are nailed where possible
C.Prophylactic stabilisation should be
considered in patients with metastases
where there has been
- cortical bone destruction of 50
% or
- a femoral lesion longer than 2.5
cm,
- pathological fracture of the lesser
trochanter
- persistent pain after irradiation
planning the management of
patients with a pathologic fracture and
systemic skeletal disease,
it is best to separate the underlying diseases into
Correctable and
Uncorrectable conditions.
pathological fractures
Local disorders
a. Metastatic carcinoma
Common sites
• Vertebral bodies
(thoracic/lumbar).
• Proximal half of femoral shaft.
• Proximal half of humerus.
b. Bone cyst of a long bone.
Generalized disorders
a. Senile osteoporosis
Common sites affected are:
• Thoracic or lumbar vertebral
body.
• Neck or trochanteric region of
femur.
b. Paget’s disease of bone
• Shaft of tibia or femur

Correctable diseases include Uncorrectable

diseases include
renal osteodystrophy, osteogenesis imperfecta,
hyperparathyroidism, poly-ostotic fibrous dysplasia
osteomalacia, postmenopausal osteoporosis
disuse osteoporosis. Paget's disease
osteopetrosis.

Factors Suggesting a Pathologic Fracture A primary is to prevent disuse

Spontaneous fracture osteoporosis, which may lead
Fracture after minor trauma to additional pathologic
Pain at the site before the fracture fractures.
Multiple recent fractures
Unusual fracture pattern (“banana fracture”)
Patient >45 years of age
History of primary malignancy

Evaluation of Plain X-rays

1. Where is the Epiphysis vs metaphysis vs

lesion? diaphysis
Cortex vs medullary canal
Long bone (femur, humerus)
vs flat bone (pelvis, scapula)
2. What is the Bone destruction
lesion doing to the (osteolysis)
bone? -Total
-Diffuse
-Minimal
3. What is the bone Well-defined reactive rim Benign or slow growing
doing to the lesion? Intact but abundant Aggressive
periosteal
reaction Highly malignant
Periosteal reaction that
cannot keep up with tumor
(Codman's triangle)
4. What are the Calcification Bone infarct/cartilage
clues to the tissue Ossification tumor
type within the Ground glass Osteosarcoma /
lesion? osteoblastoma
Fibrous dysplasia

Impending pathological fracture: a lesion is considered to be at risk for fracture

if it is painful, larger than 2.5 cm, and involves more than 50% of the cortex

Assessment of risk of pathological fracture

In case of metastasis:
 Fracture risk as the load-bearing requirement of the bone divided by its
load-bearing capacity.
The load-bearing requirement
depends on the patient's age, weight, activity level, and ability to
protect the site.
The load-bearing capacity
depends on the amount of bone loss, modulus of the remaining
bone, and location of the defect with respect to the type of load
applied.

 Patients treated with prophylactic stabilization of an impending fracture

fare better than those treated after a fracture:
1. shorter hospitalization (average 2 days),
2. discharge more likely (40%),
3. more immediate pain relief,
4. faster and less complicated surgery, less blood loss,
5. quicker return to premorbid function,
 6. improved survival, and fewer hardware complications.
N.B - Elective stabilization also allows the medical oncologist and surgeon to
coordinate operative
treatment and systemic chemotherapy

The goals of surgical treatment in a patient with an impending

pathologic fracture are
1. To alleviate pain,
2. reduce narcotic use,
3. restore skeletal stability, and
4. regain functional independence

Factors included in the decision-making are

(a) life expectancy of the patient,
(b) patient comorbidities,
(c) extent of the disease,
(d) tumor histology,
(e) anticipated future oncologic treatments, and
(f) degree of pain.
N.B - Patients with a life expectancy of < 6 weeks may not gain significant
benefit from major
reconstructive surgery.

The local bone lesion can be treated with

 Nonsurgical management (radiation, functional bracing, and
bisphosphonates) or surgical stabilization with or without resection.
 Medical treatment with bisphosphonates has decreased the incidence of
pathologic fractures by inhibition of osteoclast-mediated bone destruction
 Postoperatively, external beam radiation is used as an adjuvant local
treatment unless the metastatic lesion is completely resected

After treatment for a pathologic fracture, the bone may or may not heal. The
factors are
1. location of the lesion,
2. extent of bony destruction,
3. tumor histology,
4. type of treatment, and
5. length of patient survival.

Principles of treatment in metastatic pathological fracture:

 Fixation device used will be load-bearing because only 30%
to 40% of pathologic fractures unite even after radiation treatment
 An intramedullary device or modular prosthesis provides
more definitive stability.
 Polymethylmethacrylate (PMMA) is often used to increase
the strength of the fixation, but it should not be used solely to replace a
segment of bone.
 When an intramedullary device is indicated, the entire
femur, humerus, or tibia should be treated with a statically locked nail
 Autogenous bone graft is not generally used in the
treatment of extremity fractures from metastatic bone disease. Segmental
allografts are also rarely indicated because they require a prolonged healing
time.
 When a prosthesis is used to replace a joint affected by a
metastatic lesion or pathologic fracture, it should be cemented into the host
bone.
 For femoral lesions, a reconstruction nail is used to stabilize
the femoral neck even if no lesion is present at the time of surgery.
 RCC – resistant to chemotherapy and radiation therapy
when they spread to the skeleton
i. they tend to progress despite standard medical
treatment and external beam radiation
ii. Depending on the patient's expected lifespan and
location of the lesion, open treatment with thorough curettage of
metastatic RCC followed by intramedullary fixation and PMMA will
decrease the tumor burden
 Metastatic cancers that are hypervascular put
the patient at risk for life-threatening intraoperative hemorrhage if precautions
are not taken eg RCC

Metastasis

 Patients who present with a pathologic fracture are often medically

debilitated and require multidisciplinary care.
 In addition to an orthopaedic surgeon, the comprehensive team includes a
medical oncologist, radiation oncologist, physical/occupational therapist, and
psychologist/psychiatrist.
 Nutrition is of particular concern; serum prealbumin should be measured
and improved if it is low. This may require the addition of enteral or parenteral
hyperalimentation perioperatively.
 Patients may have relative bone marrow suppression and will require
adequate replacement of blood products.
 Perioperative antibiotic coverage, prophylaxis for embolic events,
 Aggressive postoperative pulmonary toilet, and
 Early mobilization are all instituted as standard treatment.

Nonoperative Treatment
Use Bracing for Nonsurgical candidates are
 limited life expectancies,
 severe comor-bidities,
 small lesions,
 radiosensitive tumors
 The use of a fracture brace works well for lesions in the upper
extremity. the humeral diaphysis, forearm, and occasionally the tibia
 Limit weightbearing on the affected extremity.
 A braced lesion may heal with or without radiation therapy.
 If a patient has multiple lesions requiring the use of all extremities
to ambulate, surgical stabilization will provide better support than a brace.

Proximal Humerus fracture

Treated with proximal humeral replacement or intramedullary
fixation.
 Intramedullary locked device with multiple proximal screws - If substantial
bone is available
 Methylmethacrylate may be required to supplement the fixation.
 Cemented proximal humeral endoprosthesis - if extensive destruction of
the proximal humerus or a fracture leaving minimal bone for fixation,
resection of the lesion and reconstruction with it
a. The goal of a proximal humeral replacement is pain relief and local control of
the tumor; range of motion and stability are often limited because of poor soft
tissue attachments to the construct.
b. Postoperative radiation therapy is used in cases when intralesional treatment is
performed.

Humeral Diaphysis
Treated with locked intramedullary fixation or an intercalary metal
spacer
 Intramedullary nail provide mechanical and rotational stability
 PMMA improves implant stability and supplements poor bone quality when
used with stabilization.
 Intercalary spacers offer a modular reconstructive option after resection of
large diaphyseal lesions
used in segmental defects and cases of failed fixation caused by
progressive disease.
can be used after complete resection of a metastatic lesion in the
humeral diaphysis, minimizing blood loss in hypervascular lesions
and often alleviating the need for postoperative radiation.
provide immediate stable fixation, excellent pain relief, and early
return of function
 Drawbacks of Plate fixation - extensive exposure of the humerus and the
inability to protect the entire bone. With disease progression, plate fixation
of the humerus is at risk of failure.

Distal Humerus
Treated with flexible intramedullary nails, bicondylar plate fixation
or resection with modular distal humeral reconstruction.
 Flexible nails, inserted in a retrograde manner through
ability to span the entire humerus, excellent functional recovery,
and preservation of the elbow joint.
 PMMA in the lesion gain rotational stability.
 Orthogonal plate fixation combined with PMMA can provide a stable elbow.
but not protect the proximal humerus against a future metastatic lesion or
fracture.
 A distal humeral resection and modular endoprosthetic reconstruction of
the elbow is the best option for massive bone loss involving the condyles
Femur
 Proximal third involved in 50% of cases with the intertrochanteric region
accounting for 20% of cases.
 Metastatic disease to the femur is the most painful of all bone metastases,
because of the high weight bearing stresses through the proximal region.
 High incidence of failure if traditional fracture fixation devices

Femoral Neck
 Pathologic fractures of femoral head and neck rarely heal, and the
neoplastic process tends to progress
 The procedure of choice is a cemented replacement prosthesis
 Hemiarthroplasty versus a total hip replacement depends on the presence
of acetabular involvement.
 All tumor tissue should be curetted from the femoral canal before
implanting the prosthesis.
 When there are adjacent lesions in the subtrochanteric region or proximal
diaphysis, a long-stemmed cemented femoral component should be used for
prophylactic fixation distally, avoiding a future pathologic fracture through a
distal lesion and allowing full weight-bearing postoperatively.
 When there are no additional lesions femoral stem is controversial.
Intertrochanteric Region
The standard of care is intramedullary fixation or prosthetic replacement
 The choice depends on the extent of the lesion and whether it is
radiosensitive.
 Intramedullary reconstruction device - If bone with sufficient strength
remains and local control is likely to be achieved with postoperative external
beam radiation, It allow the patient the highest level of function.
 A cephalomedullary nail protects the femoral neck and is used for all
metastatic lesions or pathologic fractures of the femur when an intramedullary
device is indicated.
 Cemented calcar-replacing prosthesis - If the destruction is more
extensive.

Subtrochanteric Region
This region of the femur is subjected to forces of up to four to six times
body weight.
Statically locked intramedullary fixation with or without PMMA
will stabilize the area and provide weightbearing support
statically locked but the lesion can fracture later causing shortening
of the femur.
Modular proximal femoral prosthesis
reserved for cases with extensive bone destruction or used for
failed internal fixation
It can also be used when a wide resection is necessary for a
pathologic fracture through a primary bone sarcoma.
There is an increased risk of dislocation and abductor mechanism
weakness with a mega prosthesis, but this should not prevent its
use in patients with radioresistant or locally aggressive tumors.
A bipolar head is used to provide more stability if the acetabulum is
not involved with metastatic disease. Excellent pain relief and local
tumor control can be obtained after tumor resection and
reconstruction.

Femoral Diaphysis
 Treated most effectively with a statically locked cephalomedullary
nail, with or without PMMA
 Plate fixation, although more rigid, will not protect a large enough segment
of bone
 Cephalomedullary nail fixation protects the entire bone and is technically
simple,
A trochanteric or piriformis entry point can be used, and the canal is slowly
overreamed 1.0 to 1.5 mm to avoid high impaction forces during rod
placement. Because the device will be load-bearing if the fracture does not
unite, the largest possible diameter nail should be used.

Supracondylar Femur
 Depends on extent of local bone destruction and the presence of additional
lesions in proximal femur.
 Treatment is challenging due to frequent comminution & poor bone stock
especially in older patients.
 Options include lateral locking plate fixation supplemented with
PMMA or a modular distal femoral prosthesis
 A retrograde nail has the drawback of potentially seeding the knee joint
with tumor while failing to provide fixation to the femoral neck region.
 The locking plate provides stable fixation after curettage and cementation
of the metastatic lesion.
 The modular endoprosthesis is the optimal choice for local control when
there is massive destruction of the femoral condyles, because it allows the
lesion to be resected en bloc