basic pathologic fracture

1. Dr Parthasarathy S
Pg Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref:Rockwood and Green’s fractures in adults 8th
edition

2.  Fractures occuring in abnormal weakened
bone during normal activity or after minor
trauma
 Many of these patients have additional
fractures,delayed union or nonunion

3.  Correctable conditions
 Renal osteodystrophy
 Hyperparathyroidism
 Osteomalacia
 Disuse osteoporosis
 Uncorrectable conditions
 Osteogenesis imperfecta
 Polyostotic fibrous dysplasia
 Post menopausal osteoporosis
 Paget disease
 Osteopetrosis

5.  Major health problem for 55% of people >50
years
 80% affected by osteoporosis are women
 Patients >50 yrs of age who sustain a hip
fracture 24% will die within in a year
 One of every two women will have an
osteoporosis related fracture in her lifetime
 Spine,proximal femur,distal femur,distal
radius common locations for pathologic
fracture

6.  50% of tumours can metastasize to skeleton
 Mainly originates from
 breast
 lung
 prostate
 hyroid
 kidney
 Common sites of metastasis
 Spine
 Pelvis
 Ribs
 Skull
 Proximal femur
 Proximal humerus

10.  Osteoporosis in x-rays
 Thin cortex
 Loss of normal trabecular pattern
 Osteomalacia/Hyperparathyroidism in x-rays
 Looser lines(compression side radiolucent lines)
 Calcification of small vessels
 Phalangeal periosteal reaction

11.  Parrish and Murray, 1970
 increasing pain with advancing cortical destruction of
lesions involving >50% of the shaft diameter
 Beals, 1971
 lesions >2.5 cm are at increased risk to fracture
 Murray, 1974
 increased fracture with destruction of > one-third of
the cortex, pain after radiotherapy

12.  Fidler, 1981
% shaft destroyed Incidence Fx (%)
0-25% 0%
25-50% 3.7%
50-75% 61%
>75% 79%
 Conclusion: Patients with tumors destroying
>50% of the diameter of bone require
prophylactic internal fixation

13. Score < 7 no surgery
Score > 7 prophylactic fixation

14.  “Harrington criteria”
>50% of diameter of bone
>2.5 cm
pain after radiation
fracture of the lesser trochanter
 Limitations
only for proximal femur
doesn’t account for tumor biology

15.  Osteoporosis
 insufficiency fractures
 Paget’s disease
 early and late stages; most fractures occur in the
late stage of disease
 Hyperparathyroidism
 dissecting osteitis
 fractures through Brown tumors
Fractures through non-neoplastic bone disease

16.  Radiographic appearance
Thickened cortices
Purposeful trabeculae
Mixed sclerosis/lysis
Bowing deformities
Joint arthrosis
 Fracture
delayed healing
malignant transformation
 Treatment
Osteotomy to correct
alignment
Excessive bleeding
Joint arthroplasty vs. ORIF
Fracture through Pagetic
bone (arrow). Transverse
fracture suggests
pathologic bone.

17.  Adenoma
 Polyostotic disease
 Mental status changes
 Abdominal pain
 Nephrolithiasis
 Polyostotic disease
 mixed radiolucent/radiodense
Mixed
radiodense
and
radiolucent
lesions
Multiple brown tumors
in a patient with primary
hyperparathyroidism

18.  May be secondary to renal
failure
secondary
tertiary
 Treatment
parathyroid adenectomy
ORIF for fracture
correct calcium
Pathologic fracture through
brown tumor (arrow)

19.  Fractures more common in benign tumors (vs
malignant tumors)
 most asymptomatic prior to fracture
 antecedent nocturnal/rest symptoms rare
 most common in children
 humerus
 femur
 unicameral bone cyst, NOF, fibrous dysplasia,
eosinophilic granuloma

20.  Fractures observed more
often in males than females
 May be active or latent
 Almost always solitary
 First two decades
 Humerus and femur most common
sites
Fracture through UBC
“fallen fragment”sign (arrow)
Fractures through benign tumors

21.  Treatment - impending fractures
 observation
 aspiration and injection methylprednisolone,
bone marrow or bone graft
 curetting and bone graft (+/-) internal fixation
 Treatment - fractures
 allow fracture to heal and reassess
 ORIF for femoral neck fractures

22.  Most common benign tumor
 Femur, distal tibia, humerus
 Multiple in 8% of patients
(associated
with
neurofibromatosis)
 Increased risk of pathologic
fracture in
lesions >50%
diameter of bone and
>22mm
length

23.  Treatment
 observation
 curetting and bone graft for impending fractures
 immobilization and reassess after healing for
patients with fracture

24.  Solitary vs. multifocal (solitary
most common)
 Femur and humerus
 First and second decades
 May be associated with café
au lait spots and endocrinopathy
(Albright’s syndrome)

25.  Treatment
 observation
 curetting and bone graft (cortical structural
allograft) to prevent deformity and fracture
(+/-) internal fixation/replacement arthroplasty
 expect resorption of graft and recurrence
 pharmacologic—bisphosphonates

26.  Relatively rare (often unsuspected)
 May occur prior to or during treatment
 May occur later in patients with radiation
osteonecrosis (Ewing’s, lymphoma)
 Osteosarcoma, Ewing’s, malignant fibrous
histiocytoma, fibrosarcoma

27.  Suspect primary tumor in younger patients
with aggressive appearing lesions
 poorly defined margins (wide zone of transition,
lack of sclerotic rim)
 matrix production
 periosteal reaction
 Patients usually have antecedent pain before
fracture, especially night pain

28.  Pathologic fracture complicates but does not
mitigate against limb salvage
 Local recurrence is higher
 Survival is not compromised
 Patients with fractures and underlying
suspicious lesions or history should be
referred for biopsy

29. A
B
A. Pathologic fracture through MFH
arising in antecedent infarct
B. (H&E 100x) Pleomorphic spindled
cells with storiform growth pattern

30.  Always biopsy solitary destructive bone
lesions even with a history of primary
carcinoma

31. Pre-op Post-
Intermediate grade chondrosarcoma
*fixation of primary bone tumors must not be performed until proper
evaluation has been performed and the diagnosis has been established in
order to prevent potential for spread of tumor.

32.  Treatment
 Immobilization
 Traction, ex fix, cast
 staging
 biopsy
 adjuvant treatment (chemotherapy)
 resection/amputation

33.  Aside from osteoporosis, most common
causes of pathologic fracture
 Fifth decade and beyond
 Appendicular sites: femur and humerus most
common
 All metastatic tumors are not treated the
same

34.  Breast – radiosensitive, chemosensitive
 Lung – moderately radiosensitive, chemo
sensitivity variable
 Prostate – radiosentive, chemosensitive
 Thyroid – radiosensitive, chemosensitive
 Renal – minimally radiosensitive, variable
chemosensitivity

35.  Contiguous
 Hematogenous
 most common
Destructive lesions in bone from
lung carcinoma (arrows)

36.  Release of cells from the
primary tumor
 Invasion of efferent lymphatic or
vascular channels
 Dissemination of cells
 Endothelial attachment and
invasion at distant site
 Angiogenesis and tumor growth
at distant site
Metastatic carcinoma
In body pedicle junction

37.  Early
 most important
 osteoclast mediated
 (RANK L)
 Late
 malignant cells may be directly
responsible

38.  3-4% of all carcinomas have no known primary
site
 10-15% of these patients have bone metastases

39. % Primary Tumor
Identified
History and Physical 8%
Chest X-Ray 43%
Chest CT 15%
Abdominal CT 13%
Biopsy 8%
Rougraff, 1993

40.  Radiation
 Radiation alone
 Complete pain relief in 50%
 Partial pain relief in 35%
 Radiofrequency ablation
 Chemotherapy
 Hormone treatment
 Bisphosphonates

41.  Overall 85% response rate
 Median duration of pain relief 12-15 weeks
 Tumor necrosis followed by collagen
proliferation, woven bone formation, and
replacement by lamellar bone
 Recalcification by 2-3 months
 More than half respond within 1-2 weeks
 Various dose and fractionization schedules

42.  Competitive inhibitor of RANKL receptor
 Decrease in the time to skeletal related events as
well as decrease in the rate of these events in
patients with bone metastasis
 Osteoporosis
 Bone pain & hypercalcemia

43.  Decrease pain
 Restore function
 Maintain/restore mobility
 Limit surgical procedures
 Minimize hospital time
 Early return to function (immediate
weightbearing)

44.  Biopsy especially for solitary lesions
 Nails versus plates versus arthroplasty
 plates, screws and cement superior for torsional
loads
 interlocked nails stabilize entire bone
 Cement augmentation
 Radiation/chemotherapy/bisphosphonates
 Aggressive rehabilitation

45.  Ratio of survival time to surgical recovery
time
 Ability to ambulate
 Ability to use extremity
 Capacity to return to full function
 Pain not controlled by analgesics
 Location of disease – high risk area

46.  Diaphyseal lesion
 Good bone stock
 Histology sensitive to
chemo/radiation
 Impending fractures
 Poor prosthetic options

47.  Periarticular disease
 Fracture after
radiation
 Failed fixation
 Renal cell ca

48.  Periarticular fractures, especially around
the hip are more appropriately treated
with arthroplasty
 Periacetabular fractures
protrusio shell,
cement, arthroplasty
saddle prosthesis
Structural
allograft-prosthesis
composite

49. PMMA no PMMA
Pain relief 97% 83%
Ambulation 95% 75%
Fixation failure 2 cases 6 cases
Haberman, E.T: CORR, 169: 70, 1982

50.  Radiation and chemotherapy resistant tumors
 renal
 thyroid
 melanoma
 occasionally lung
 Solitary metastases (controversial)

51. pre-op pre-op post-op
*pre operative embolization of renal cell mets should be done

52.  Post-op intercalary
allograft

53.  Infection
malnutrition
hematomyelopoetic suppression
 Hemorrhage
vascular tumors ( renal and thyroid)
 Tumor recurrence
 Failure of fixation
 Thromboembolic disease

54.  Hypervascular tumors
 Renal cell carcinoma
 Thyroid carcinoma
 Pheochomocytoma

55. Post embolizationPre embolization
Pre-operative embolization can prevent
hemorrhage with intra-lesional surgery

56.  Any process that reduces bone strength predisposes
a patient to a pathologic fracture during normal
activity or after minimal trauma.
 It must be recognized as a pathologic fracture if the
patient is to be treated properly.
 The most common cause for a pathologic fracture is
osteoporosis or osteomalacia.
 Patients with osteoporosis or osteomalacia require
evaluation and management of the underlying
disorder.
 Patients older than 40 years of age with a pathologic
fracture through a discrete bone lesion are much
more likely to have metastatic bone disease than a
primary bone tumor.

57.  The prognosis for patients with metastatic
bone disease is improving because of early
recognition and better adjuvant treatment;
therefore, many patients will live longer
than 2 years.
 Do not immediately assume that a lytic
lesion or pathologic fracture is from
metastatic disease. A thorough workup and
possible biopsy are required.
 Prophylactic fixation for impending (vs.
actual) fractures from metastatic disease is
technically easier for the surgeon and allows
a quicker patient recovery.
 The Mirels’s scoring system is available to
guide the treatment of an impending
fracture from metastatic bone disease.

58.  Femoral neck fractures caused by metastatic
bone disease require a cemented hip
prosthesis, as internal fixation has a high
rate of failure with disease progression.
 An isolated fracture of the lesser trochanter
is usually a sign of a metastatic femoral neck
lesion with impending fracture.
 When surgery is required for metastatic
disease to the spine, decompression and
stabilization with internal fixation are
generally necessary.
 Surgical reconstruction for pathologic
fractures should be durable enough to allow
immediate weight bearing and last the
patient’s expected life span.

59.  A pathologic fracture through a primary
malignant bone tumor is treated much
differently than a fracture through a
metastatic lesion.
 The treating surgeon should keep in mind
with proper surgery there is a chance for
long-term cure.
 Treatment of patients with pathologic
fractures requires the presence of a
multidisciplinary team comprises orthopedic
surgeons, medical oncologists, radiation
oncologists,endocrinologists, radiologists,
pathologists, pain specialists, nutritionists,
physical therapists, and psychologists/
psychiatrists.