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Pathologic Fractures

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
Fibrous Dysplasia
Benign condition which
normal bone is replaced
by fibrous connective
tissue due to a defect in
osteoblast differentiation
and maturation
Femur and humerus
First and second decades
Not heritable
Fibrous Dysplasia
May be associated with caf au lait spots
and endocrinopathy
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
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 Fracture through Pagetic
bone (arrow). Transverse
Joint arthroplasty vs. ORIF
fracture suggests
pathologic bone.
Hyperparathyroidism

Adenoma
Polyostotic disease
Mixed
Mental status changes radiodense
and
Abdominal pain radiolucent
lesions
Nephrolithiasis
Polyostotic disease
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
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
PMMA no PMMA
Pain relief 97% 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

pre-op pre-op post-op


*pre operative embolization of renal cell mets should be done
Pre-op Post-op
renal cell renal cell
carcinoma carcinoma
Solitary renal cell carcinoma

Soft tissue mass

Permeative lysis
Post-op intercalary
allograft
Thank You

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