By Dr. Ujjal Rajbongshi, Junior resident, Dept of Orthopaedics, SMCH, Silchar

1. PATHOLOGICAL
FRACTURE
Moderator – Dr. A. K. Sipani
Prof and HOD, Dept of Orthopaedics, SMCH
Presented by- Dr. Ujjal Rajbangshi
1st year PGT, Dept of Orthopaedics, SMCH

2. INTRODUCTION
 Definition: Fracture occurring in an abnormal bone during normal
activity or after minor trauma
 Many of these patients have multiple fractures, delayed union or non-
union
 Age: >50 years
 Gender: Females > Males, (attributed to osteoporosis)
 Common sites: Spine, proximal femur, distal femur, distal radius.

3. ETIOLOGY
 Neoplasm – Primary or metastatic
 Metabolic disease
Renal osteodystrophy
Hyperparathyroidism
Osteomalacia
 Infection – osteomyelitis (chronic, tubercular)
 Osteoporosis – Age related, Post-menopausal, Disuse
 Osteonecrosis

4. ETIOLOGY
 Defects in normal bone repair mechanisms
Osteogenesis imperfecta
Polyostotic fibrous dysplasia
Paget disease
Osteopetrosis
 Iatrogenic causes – surgical defect

5. ETIOLOGY – Primary tumors
 Primary benign tumors
Asymptomatic, commonly seen in children
Humerus > Femur
SBC, ABC, NOF, fibrous dysplasia, eosinophilic granuloma
 Primary malignant tumors – relatively rare
Antecedent pain before fracture
Radiation induced osteonecrosis in the later period

6. ETIOLOGY – Metastatic disease
 Tumors commonly metastasize
to bone
Breast
Lung
Prostate
Thyroid
Kidney
 Common sites of metastasis
Spine
Pelvis
Ribs
Skull
proximal femur
Proximal humerus.

7. HISTORY
 Spontaneous fracture after minor trauma
 Pain at the site before the fracture - neoplasm
 Recent multiple fractures – s/o osteogenesis imperfecta
 Unusual # patterns
 Chronic alcoholism, prolonged drug therapy, intestinal malabsorption
 History of malignancy and any surgeries related to malignancy

8. PATIENT PRESENTATION
 Pain, swelling and deformity at the fracture site
 Loss of appetite, loss of weight, fever, fatigue
 Deformities elsewhere in the body due to previous fractures
 A lump elsewhere in the body, cough, haemoptysis, haematuria

9. EXAMINATION
 General physical examination
Features specific for certain conditions leading to pathological fracture
Lymphadenopathy, liver enlargement
Mass per abdomen or in the pelvis; lump elsewhere in the body
 Local examination of fracture site
Deformity, swelling (either bony or soft tissue)
An infected sinus, an old scar
Location of the fracture – vertebral body # and # at corticocancellous
junction in osteoporosis
 Rectal and vaginal examination

10. INVESTIGATIONS
 Radiological investigations
Plain radiographs
Chest X-ray – lung primary and mets
Bone scan – most sensitive for multiple lesions
CT scan
MRI – primary tumor
PET scan – in metastatic lesions
 Other useful tests: Gastrointestinal series, Endoscopy,
Mammography and CT chest, abdomen and pelvis

13. INVESTIGATIONS
 Radiological appearance of metastatic lesions
Osteoblastic – prostate cancer
Osteolytic - Most common; seen in cancer of lungs, thyroid, kidney, and
colon
Mixed – breast cancer

14. INVESTIGATIONS
 Laboratory evaluation
CBC, DLC, PBS, ESR
Chemistry panel – Serum Ca, Ph, Albumin, globulin, ALP
Urine routine
Serum and urine protein electrophysis
24hr urine hydroxyproline – Paget disease
 Specific tests – TFT, CEA, PTH, PSA
 Biopsy of local lesion before or at the time surgical fixation of fracture

15. TREATMENT
 Initial care of the patient
Reduce and immobilize the fracture
 Definitive treatment of the fracture
 Treatment of the underlying pathology

16. TREATMENT – Of fracture
 Non-operative treatment: Bracing
Limited life expectancies
Severe comorbidities
Small lesions
Radiosensitive tumors
 Common location - humerus shaft, forearm, tibia
 Weight bearing should be limited

17. TREATMENT – Of fracture
 Goals of surgical intervention
Prevention of disuse osteopenia
Mechanical support
Pain relief
Decreased length and cost of hospital stay
 Fracture fixation +/- Bone cement augmentation
Intramedullary nails or plates: load bearing than load sharing
Arthroplasty for intra-articular fractures
Decompression and stabilization of vertebral compression fractures

19. TREATMENT – Of fracture
 Prophylactic fixation
Decreased morbidity
Shorter hospital stay
Easier rehabilitation
Pain relief
Faster and less complicated surgery
Decreased surgical blood loss

20. TREATMENT – Of pathology
 Multidisciplinary approach which medical and surgical oncologists
Look for primary tumor
Surgical excision of primary tumor
 Treatment of metabolic bone disorders
 Post-operative chemo or radiotherapy for both bone and primary
lesions
Radiation therapy after surgical wound healing

21. THANK YOU