Pathological fractures occur through an abnormal focal area of bone, which can be malignant or non-malignant. Common sites of bone metastases that cause pathological fractures are the spine, pelvis, ribs, skull, proximal femur and humerus. Diagnosis involves imaging like x-rays, CT, MRI and bone scans to identify the fracture line and assess the extent of involvement. Treatment depends on factors like life expectancy, severity of symptoms, and includes options like bracing, radiation, bisphosphonates, or surgery to stabilize and relieve pain. The goals of surgical treatment are early stabilization to improve function and survival.

1. Dr.SAYF ALDEEN HUSSAM
ORTHOPEDIC TRAINEE
BAGHDAD MEDICAL CITY

2.  Pathological fractures are fractures that occur in abnormal bone.
Although the term can be used in the setting of a generalized
metabolic bone disease, it is usually reserved for fractures
through a focal abnormality. The abnormality may be malignant
or non-malignant in nature.

3.  Uncorrectable
• Osteogenesis imperfecta
• Polyostotic fibrous dysplasia
• Postmenopausal
• Paget disease
• Osteopetrosis
Systemic- non neoplastic:
 Correctable
• Renal osteodystrophy
• Hyperparathyroidism
• Osteomalacia
• Disuse osteoporosis

4.  Common sites of metastasis
– Spine
– Pelvis
– Ribs
– Skull
– proximal femur
– Proximal humerus
 Neoplastic:
 Common metastatic cancers
– Breast
– Lung
– Prostate
– thyroid
– kidney
Or noncancerous tumors and cysts

5.  Pain – most common preceding fracture, night pain, constant dull
in nature, aggravated by activity
 Constitutional symptoms – anorexia, night sweats, weight loss,
fatigue
 Previous history of cancer
 Exposur to Carcinogen – smoking, radiation, occupational toxins

6.  Spontaneous fracture
 Fracture due to Minor trauma
 Pain at site preceeding fracture
 Multiple recent fractures
 Age > 45 yr.s
 Prior history of malignancy
 Unusual # patterns

7.  Debilitating pain
 Immobility
 Neurologic deficits – spine metastasis
 Anaemia
 Hypercalcemia

8.  CBC – anemia of chronic disease
 Calcium – elevated
 Alkaline phosphatase – elevated, non specific
 Tumor markers – PSA, CEA, CA125, TFTs
 N-telopeptide + C-telopeptide –are markers of bone collagen
breakdown measured in serum and urine.
-Measure the overall extent of bone involvement
- Assess the response of the bone to bisphosphonate treatment

9.  plain radiograph: Imaging Findings
-Fracture line extending through a destructive lesion in the bone
Usually transverse in direction
-Surrounding bone may demonstrate
-Endosteal scalloping
-Cortical destruction
-Permeative pattern
-Frequently associated with a soft tissue mass

10. We should answer the Enneking's Four Questions for Bony Lesions
1. Where is the lesion located? Epiphysis , metaphysis , diaphysis
2. What is the lesion doing to the bone? transitional zone
3. What is the bone doing to the lesion? periosteal reaction
4. Dose anything suggest histology ? Calcification , ossification

12. Fracture through a large
metaphyseal Non
Ossifying Fibroma

14. Radiographs demonstrated an
osteolytic lesion with sclerotic
margins, mild expansion, and
central calcification

15.  CT scans:
-Most sensitive for detecting bone destruction
-Determines extent of cortical involvement
-Also used to search for primary lesion in pelvis, abdomen or chest

16. CT scan showing Pathological
fracture in giant cell tumor
at distal femoral condyle

17.  MRI:
-Most sensitive for assessment of the anatomic extent of a lesion
-Most adequate for spinal metastases to determine neurologic
structure involvement
-Can determine extraosseous spread of a mass

18. T1 MRI demonstrated a hypointense
marrow-infiltrating lesion involving the T1
vertebral body

19.  Bone scanning:
 Technetium-99m (99m Tc) bone scanning
Most commonly used radionuclide
 Sensitive for detection of occult lesions
 Assessment of the biologic activity of lesions
 Identification of other sites
 Assessing response to therapy

20.  Principles of the Open Incisional Biopsy:
1- use longitudinal incision in the extremities allows for extension of
the incision for definitive management
2-Approach do not expose neurovascular structures
3-release tourniquet prior to wound closure
4-Biopsy perform through the involved compartment of the tumor
5- if using a drain, bring drain out of the skin in line with surgical
incision allows drain site to be removed with definitive surgery
6-Cultures for all biopsy to rule out infections that may mimic tumors
on x rays

21.  Mirel’s criteria useful to determine which lesions at high risk of
fracture and need Prophylactic stabilization
 A score of 8 or more is an indication for prophylactic stabilisation

22. 1-Shorter hospital stay
2-More immediate pain relief
3-Faster and less complex surgery
4-Quicker return to premorbid function
5-Improved survival
6-Fewer hardware complications

23.  Non operative management:
 Bisphosphonates – inhibits bone resorption by reduce
osteoclasts activity , shown to reduce risk of skeletal metastasis
 Hematological – correction of anemia, coagulopathy, DVT
prophylaxis
 Treat Hypercalcemia – hydration, calcium restriction,
bisphosphonates
 Analgesia

24.  Radiation – most useful in spinal metastases
-Used to reduce pain secondary to bone metastases
-Halts progression of bony destruction
-Allows healing of an impending pathologic fracture
-Postoperative local tumor control

25.  Bracing:
 indications
-Patients with limited life expectancies
- severe comorbidities
- small lesions, or radiosensitive tumors
 Upper extremity lesions particularly amenable for bracing
 Adjuvant radiotherapy of susceptible tumors is required

26.  Operative:
 Indications of surgery
1-Progression of disease after radiation
2- Neurologic compromise caused by bony impingement
3- Radio resistant tumor within the spinal canal
4- Impending fracture
5-Spinal instability caused by a pathologic fracture
6-Progressive deformity

27.  Principles of surgery:
 Intramedullary device provides better stability.
 Use Bone cement:
– Increases the strength of fixation
– Should not be used to replace segment of bone
 Goal should be to stabilize as much of the bone as possible.
 Need Durable, weight bearing implants
 Bone graft less useful due to prolonged healing time