Pathologic Fractures

H.T. Temple, MD
Walter W. Virkus, MD
Created March 2004; Revised December 2005, October 2008

Pathologic Fractures
Tumors
primary
secondary (metastatic) (most common)

Metabolic
osteoporosis (most common)
Pagets disease
hyperparathyroidism

Pathologic Fractures
Benign Tumors
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

Fractures through benign tumors

Unicameral Bone Cyst

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 fragmentsign (arrow)

Unicameral Bone Cyst

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

Fibroxanthoma
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

Fibroxanthoma
Treatment
observation
curetting and bone graft for impending
fractures
immobilization and reassess after healing for
patients with fracture

Fibrous Dysplasia
Solitary vs. multifocal
(solitary most common)
Femur and humerus
First and second decades
May be associated with
caf au lait spots and
endocrinopathy (Albrights
syndrome)

Fibrous Dysplasia
Treatment
observation
curetting and bone graft (cortical structural
allograft) to prevent deformity and fracture
(+/-) internal fixation
expect resorption of graft and recurrence
pharmacologicbisphosphonates

Pathologic Fractures
through Primary Malignant
Tumors
Relatively rare (often unsuspected)
May occur prior to or during treatment
May occur later in patients with radiation
osteonecrosis (Ewings, lymphoma)
Osteosarcoma, Ewings, malignant fibrous
histiocytoma, fibrosarcoma

Pathologic Fractures
Primary Malignant Tumors
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

Pathologic Fractures
Primary Malignant Tumors
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

A. Pathologic fracture through MFH

arising in antecedent infarct
A

B. (H&E 100x) Pleomorphic spindled

cells with storiform growth pattern

Pathologic Fractures
Primary Malignant Tumors
Always biopsy solitary destructive bone
lesions even with a history of primary
carcinoma
Case:
A 62 year-old woman with a history of
breast carcinoma presented with a
pathologic fracture through a solitary
proximal femoral lesion

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.

Pathologic Fractures
Primary Malignant Tumors
Treatment
Immobilization
Traction, ex fix, cast

staging
biopsy
adjuvant treatment (chemotherapy)
resection/amputation

Fractures through non-neoplastic bone disease

Metabolic Bone Disease

Osteoporosis
insufficiency fractures

Pagets disease
early and late stages; most fractures occur in the
late stage of disease

Hyperparathyroidism
dissecting osteitis
fractures through Brown tumors

Pagets Disease
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.

Hyperparathyroidism

Adenoma
Polyostotic disease
Mental status changes
Abdominal pain
Nephrolithiasis
Polyostotic disease

Mixed
radiodense
and
radiolucent
lesions

mixed radiolucent/radiodense
Multiple brown tumors
in a patient with primary
hyperparathyroidism

Hyperparathyroidism
May be secondary to renal
failure
secondary
tertiary

Treatment
parathyroid adenectomy
ORIF for fracture
correct calcium
Pathologic fracture through
brown tumor (arrow)

Fractures in Patients with Metastatic

Disease and Myeloma
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

Not All Mets Created Equal

Breast radiosensitive, chemosensitive
Lung moderately radiosensitive, chemo
sensitivity variable
Prostate radiosentive, chemosensitive
Thyroid radiosensitive, chemosensitive
Renal minimally radiosensitive, variable
chemosensitivity

Overall Incidence of Metastases

to Bone at Autopsy

70%
12%
32%
21%

Jaffe, 1958
Clain, 1965
Johnson, 1970
Dominok, 1982

Incidence of Metastases at
Autopsy by Primary Tumor Site
Primary Site
Breast
Lung
Prostate
Hodgkins
Kidney
Thyroid
Melanoma
Bladder

% metastasis to Bone
50-85
30-50
50-70
50-70
30-50
40
30-40
12-25

Incidence of Metastases
60% of patients with early identified cancer
may already have metastases
10-15% of all patients with primary
carcinoma will have radiologic evidence of
bone metastases during course of disease

Route of Metastases
Contiguous
Hematogenous
most common

Destructive lesions in bone from

lung carcinoma (arrows)

Mechanism of Metastases
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

Bone Destruction
Early
most important
osteoclast mediated
(RANK L)

Late
malignant cells may be
directly responsible

Metastases of Unknown Origin

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

Diagnostic Strategy for Patients

with Unknown Primary
History and Physical
Chest X-Ray
Chest CT
Abdominal CT
Biopsy

% Primary Tumor
Identified
8%
43%
15%
13%
8%
Rougraff, 1993

Defects
Cortical defects weaken bone especially in
torsion
Two types
stress riser - smaller than the diameter of bone
open section defect - larger than the diameter of
bone. causes a 90% reduction in load to
failure and demand augmentation and fixation

Impending Pathologic Fracture

61% of all pathologic
fractures occur in the
femur
80% are peritrochanteric
fracture in this area results
in significant morbidity
historic data on impending
pathologic fracture
involves the proximal
femur

Impending Pathologic Fracture

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 > onethird of the cortex, pain after radiotherapy

Impending Pathologic Fracture

Fidler, 1981
% shaft destroyed
0-25%
25-50%
50-75%
>75%

Incidence Fx (%)
0%
3.7%
61%
79%

Conclusion: Patients with tumors destroying

>50% of the diameter of bone require
prophylactic internal fixation

Indication for Prophylactic Internal

Fixation
Harrington criteria

>50% of diameter of bone

>2.5 cm
pain after radiation
fracture of the lesser trochanter

Limitations
only for proximal femur
doesnt account for tumor biology

Harrington, K.D.: Clin. Orthop. 192:

222, 1985

Mirels Scoring System

1

Site
Pain
Lesion
Size

Score
2

upper limb

lower limb

peritrochanteric

mild

moderate

functional

blastic

mixed

lytic

<1/3

1/3-2/3

>2/3

Score < 7 no surgery

Score > 7 prophylactic fixation
Mirels, H.: Clin. Orthop. 249: 256, 1989.

Adjuvant Treatment
Radiation
Radiation alone
Complete pain relief in 50%
Partial pain relief in 35%

Radiofrequency ablation
Chemotherapy
Hormone treatment
Bisphosphonates

Adjuvant Treatment
Radiation
Radiation alone
Complete pain relief in 50%
Partial pain relief in 35%

Radiofrequency ablation
Chemotherapy
Hormone treatment
Bisphosphonates

Radiation Therapy
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

Radiation Therapy
Townsend, et al., Journal of Clinical Oncology,
1994
64 surgical stabilization procedures, 35 with post-op
radiation, 29 with no radiation
Functional use of extremity, avoidance of revision
surgery, and survival time increased in radiation group

Radiotherapy
Pre XRT
Prostate
CA

Post XRT
Prostate
CA

Bisphosphonates
Long-term prevention of skeletal
complications of metastatic breast cancer
with pamidronate: Protocol 19 Aredia Breast
Cancer Study Group
Hortobagyi, et al. Journal of Clinical Oncology,
1998

Zoledronic acid reduces skeletal-related

events in patients with osteolytic
metastases
Berenson, et al. Cancer 2001

Treatment Objectives in Metastatic Disease

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

Pathologic Fracture Survival

75% of patients with a
pathologic fracture
will be alive after one
year
the average survival is
~ 21 months

Survival Time
Poor prognostic
factors
Presentation with
metastatic disease
Short time from initial
diagnosis to first met
Visceral mets
Non-small cell lung
cancer

6 mos % 1 yr %

3 yrs %

Breast

89

78

48

Prostate

98

83

57

Lung

50

22

Renal

51

51

40

Healing of Path Fractures

Healing rate of pathologic fractures
Myeloma- 67%
Renal- 44%
Breast- 37%
Lung- 0%

Fracture Healing

129 patients
overall rate = 35%
74% for patients surviving > 6 months
radiotherapy <30 GY did not adversely
affect fracture healing
Gainor, B.J.: CORR 178: 297, 1983

Pathologic Fracture Treatment

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

Indications for Surgical Treatment

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

Indications for ORIF/IMN

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

Indications For Replacement

Periarticular disease
Fracture after radiation
Failed fixation
Renal cell ca

Pathologic Fracture Treatment

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

Cement
Pain relief

PMMA
97%

no PMMA
83%

Ambulation

95%

75%

Fixation failure

2 cases

6 cases

Haberman, E.T: CORR, 169: 70, 1982

Resection for Pathologic and

Impending Pathologic Fractures
Radiation and chemotherapy resistant
tumors

renal
thyroid
melanoma
occasionally lung

Solitary metastases (controversial)

Renal Cell Carcinoma

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

Pre-op
renal cell
carcinoma

Post-op
renal cell
carcinoma

Solitary renal cell carcinoma

Soft tissue mass

Permeative lysis

 Post-op intercalary
allograft

Renal Cell
Kollender, et al., Journal of Urology, 2000
45 lesions treated with wide or marginal resection
91% with pain relief, 89% with good/excellent
functional outcome

Les, et al., CORR, 2001

41 renal cell patients treated with intralesional excision,
37 treated with marginal or wide resection
Re-operation recommended for 41% in group I, 3% in
Group II
Median survival 20 months in group I, 35 months in
group II

Renal Cell
Wedin, et al., CORR 1999
228 metastatic lesions treated with endoprosthetic or
osteosynthesis
24% failure rate in renal cell lesions
20% failure rate in diaphyseal and distal femur lesions
14% failure rate for osteosynthesis, 2% for
endoprosthesis

Complications
Infection
malnutrition
hematomyelopoetic suppression

Hemorrhage
vascular tumors ( renal and thyroid)

Tumor recurrence
Failure of fixation
Thromboembolic disease

Embolization
Hypervascular tumors
Renal cell carcinoma
Thyroid carcinoma
Pheochomocytoma

Pre embolization

Post embolization

Pre-operative embolization can prevent

hemorrhage with intra-lesional surgery

Summary
Diagnosis and treatment requires a
multidisciplinary approach
Aggressive surgical treatment relieves pain,
restores function, and facilitates nursing care
Biopsy all solitary lesions or refer appropriately
Understand tumor biology and tailor treatment

References
Mirels H. Metastatic disease in long bones. A
proposed scoring system for diagnosing impending
pathologic fractures. Clin Orthop 1989; 249:256
Gainor BJ, Buchert P. Fracture healing in
metastatic bone disease Clin Orthop 1983;
176:297-302.
Eckardt JJ, et.al. Endoprosthetic reconstructions
for bone metastases. Clin Orthop 2003; 415:S254262.

References
Ward WG, et.al. Metastatic disease of the femur:
surgical treatment. Clin Orthop 2003; 415:S230244
Kelly CM, et.al. Treatment of metastatic disease
of the tibia. Clin Orthop 2003; S219-219
van der Linden YM, et.al. Simple radiographic
parameter predicts fracturing in metastatic femoral
bone lesions:results from a randomized trial.
Radiotherapy and Oncology 2003; 69: 21-31

References
Singletary SE, et.al. A role for curative
surgery in the treatment of selected patients
with metastatic breast cancer. Oncologist
2003; 214-251
Wedin R. Surgical treatment for pathologic
fracture. Acta Orthopaedica Scandinavica
2001; 72: 1-29

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