PATHOLOGICAL FRACTURE

&
STRESS FRACTURE

Presenter: Nurul Saadah binti Joraimi

Matric no. : MBBS 0917210
 1)PATHOLOGICAL FRACTURE

“Fracture occurring in an abnormal bone during normal activity or

after minor trauma, aka insufficiency fractures”
 INTRODUCTION

• Pathologic fractures occur in abnormal bone, by which predisposes the

patient for failure during normal activity or after minor trauma.
• Osteoporosis is the commonest cause of pathological fractures.
• Pathological fractures may also occur in bone weakened by benign or
malignant, primary or secondary bone tumors.
• Poor callus formation, slow healing.
• The fracture pattern is also often different: pathological fractures have a
transverse fracture pattern, while higher energy fractures are typically spiral
or comminuted. 
 ETIOLOGY

• Non- neoplastic & neoplastic.

• Non- neoplastic:

Correctable Non- correctable

i. Renal osteodystrophy i. Osteogenesis imperfecta
ii. Hyperparathyroidism ii. Polyostotic fibrous dysplasia
iii. Osteomalacia iii. Postmenopausal
iv. Disuse osteoporosis osteoporosis
iv. Paget disease
v. Osteopetrosis
 • Neoplastic:

Primary Metastatic
i. Primary benign tumor i. Tumors metastasize to bone:
• Breast
• Asymptomatic, commonly seen in • Lung
children • Prostate
• Humerus > Femur • Thyroid
• Kidney
• GCT, SBC, NOF, fibrous ii. Common sites: spine, pelvis, ribs,
dysplasia, eosinophilic granuloma skull, proximal femur, proximal
humerus.
ii. Primary malignant tumor
• Antecedent pain before fracture
• Radiation induced osteonecrosis
in the later period
Osteoporotic fracture - Ulna
• Generalised low bone density - compare the cortical thickness with the normal bone
(inset)
• There is a subtle impacted fracture of the ulna
Pathological fracture - Multiple myeloma

• There is a transverse fracture of the humerus with anterior displacement and

angulation
• The bone appears 'moth-eaten'
Pathological fracture in benign bone lesion

•A fracture line passes through a well defined benign bone lesion - in this case a non-
ossifying fibroma
 FACTORS SUGGESTING PATHOLOGIC #

i. Spontaneous fracture
ii. Fractures after minor trauma
iii. Pain at the site before the fracture (might suggest neoplasm)
iv. Multiple recent fractures (s/o osteogenesis imperfecta)
v. Unusual # patterns
vi. Patient >45 years
vii. History of malignancy
 PATIENT PRESENTATION

i. Pain, swelling and deformity at the fracture site

ii. Constitutional symptoms like loss of appetite, loss of weight, fever, fatigue
iii. Deformities elsewhere in the body due to previous fractures
iv. A lump elsewhere in the body, cough, haemoptysis, haematuria
 EXAMINATION

i. General physical examination: ii. Local examination of fracture site:

• Features specific for certain conditions • Deformity, swelling (either bony or soft
leading to pathological fracture tissue)

• Lymphadenopathy, • An infected sinus, an old scar

• Mass per abdomen or in the pelvis; lump • Location of the fracture – vertebral body #
elsewhere in the body and # at corticocancellous junction in
osteoporosis

iii. Rectal and vaginal examination

 INVESTIGATION

• Radiological & laboratory evaluation

• Bone biopsy (lytic lesion)
1) Laboratory investigations:
• 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
• N- telopeptide & C- telopeptide (bone collagen marker)
Disorder Serum S. Phosphorous S. Alkaline Urine Calcium
Calcium phosphatase

Osteoporosis N N N N

Osteomalacia Low Low High Low

Hyperparathyroidism High Low Normal High

Renal Osteodystrophy Low High High

Pagets disease N N High Hydroxyproline

Myeloma N N N Light chains

2) Radiological investigations: • Radiological appearance of metastatic
lesions:
• Plain radiographs
 Osteoblastic – prostate cancer
• Chest X-ray – lung primary and
metastasis  Osteolytic - Most common; seen
in cancer of lungs, thyroid,
• Bone scan – most sensitive for multiple kidney, and colon
lesions
 Mixed – breast cancer
• CT scan
• Spine involvement is more common,
• MRI – primary tumor
particularly at the pedicle area, where
• PET scan – in metastatic lesions “Winking owl sign” is positive
3) Bone biopsy (for lytic lesion):

• Being done on solitary • Thus these fractures should be stabilized

bone lesion in a patient first and then biopsy undertaken.
with or without hx.
• Biopsy should be obtained from a
• Needle biopsy is definitive when site near but unaffected by fracture.
differentiating carcinoma from
• Site should be as small as
sarcoma with adequate
immunohistochemistry. possible, longitudinally in
line with the extremity.
• When there is pathologic fracture
• Tissues involved in post- biopsy
through the lytic lesion, bleeding can
occur due to early fracture callus. hematoma must be considered as
contaminated.
• Perform C&S for all biopsy to rule out infections that may mimic tumors
on x rays.
• If definitive dx present on frozen sections intra-op , then it’s ideal to fix the
fractures; otherwise must wait for permanent sections.
 ENNEKING’S 4 QUESTIONS

1. Where is the lesion? 3. What is the bone doing to the lesion?

• Epiphysis/ Metaphysis/ Diaphysis • Well defined reactive rim-
• Cortex/ Medullary canal (benign/slow growing)
• Long bone/ Flat bone • Intact but abundant
periosteal reaction
2. What is the lesion doing to the (Aggressive)
bone? • Periosteal reaction that cannot
keep up with tumor (Malignant)
• Osteolysis : Total/ Diffuse/ Minimal
4. What are the clues to the tissue type within the lesion?
• Calcification (Bone infarct/ Cartilage tumor)
• Ossification (Osteosarcoma/ Osteoblastoma)
• Ground glass appearance (Fibrous dysplasia)
 TREATMENT

i. Initial care of the patient:

• Reduce and immobilize the fracture

ii. Definitive treatment of the fracture

iii. Treatment of the underlying pathology
Treatment of fracture:

• Non surgical (bracing)

 Limited life expectancies
 Severe comorbidities
 Small lesions
 Radiosensitive tumors
• Common location (humerus shaft, forearm, tibia)
• Weight bearing should be limited
• For surgical, intramedullary device or • Proximal, total humeral endoprosthesis.
modular prosthesis provides better
• Humerus shaft- locked intramedullary
stability.
nails, intercalary allograft.
• Bone cement-
• Distal humerus- flexible intramedullary
 Increases the strength of fixation
nail, bicondylar fixation, resection with
 Should not be used to replace segment modular distal femur reconstruction.
of bone
• Radius/ Ulna- Flexible rods, rigid
• Goal should be to stabilize as plate fixation, radial head resection,
much of the bone as possible. curettage.
• Prophylactic fixation:
 Decreased morbidity
 Shorter hospital stay
 Easier rehabilitation
 Pain relief
 Faster and less complicated surgery
 Decreased surgical blood loss
• Must obey Harrington’s criteria
• Harrington’s criteria:
 >50% cortical bone destruction
 lesion >2.5 cm in size
 pathological avulsion fracture of the
lesser trochanter
 Functional pain after radiation therapy​
• Limitations:
 Only for proximal femur
 Doesn’t account for tumor
biology
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 and chemotherapy usually should be started after soft tissue healing,
which takes 2-3 weeks
 2) STRESS FRACTURE

“partial or complete fracture of a bone as a result of sub-maximal

loading.”
 EPIDEMIOLOGY /ETIOLOGY

• Up to 20% of all sports medicine clinic injuries may be related to stress

injuries.
• Stress fractures are more common in weight-bearing than non-weight bearing
limbs. Stress fractures of the tibia, metatarsals, and fibula are the most
frequently reported sites.
• Shin splints is the most common form of early stress injury.
• The location of stress injuries varies by sport; ulna is the upper extremity bone
most frequently affected.
Extrinsic factor:

i. Track athletes - Navicular, tibia, and metatarsals

ii. Distance runners - Tibia and fibula
iii. Dancers - Metatarsals
iv. Military recruits- Calcaneus and metatarsals
Intrinsic factor:

i. Low bone density

ii. Sex: female > male
iii. History of stress fracture
iv. Hormonal status: late menarche (>15 years of age), oligo or amenorrhea
v. BMI < 19
vi. Low energy availability and/or eating disorder
vii. Systemic medical conditions that affect metabolic and/or nutritional status, such as thyroid
dysfunction
viii. Inadequate calcium and vitamin D intake
ix. Increase in training volume or intensity, a change in technique or surface, or an alteration of footwear.
 PATHOGENESIS

Rapid increases in the frequency, duration, or intensity of an athletic activity without adequate periods of rest

Disrupts normal bone remodeling

Osteoclast-mediated bone resorption in the Haversian canals and interstitial lamellae

Small cracks appear at the cement lines of the Haversian systems, which propagate into microfractures

New bone formation occurs as a result of increased periosteal osteoblastic activity.

 CLINICAL PRESENTATION

i. Pain with activity which subsides with rest.

ii. Pain that gradually worsens over time when continuing the aggravating
activity.
iii. Swelling and tenderness may also be present around the area of pain.
iv. Provocative tests such as pain on hopping can be helpful when establishing a
dx of femoral stress fracture.
 INVESTIGATION

i. X Ray
ii. Scintigraphy
iii. MRI
iv. CT Scan
1) X-RAY

• Normal : 1st 2-3 wks after

onset of symptoms
• Periosteal response : 3 months after
onset of symptoms.
• Periosteal bone formation, sclerosis,
endosteal callus, and a frank fracture
line.

The initial AP radiograph of the A follow-up AP radiograph of the

right foot in a pt with a stress # 2nd right foot in a pt with a stress # of
metatarsal, which appears normal. the 2nd metatarsal, which shows a
periosteal reaction (arrow)
2) SCINTIGRAPHY
• Sensitive method
• It detects the osteoblastic activity associated
with remodeling.
• Acute stress fractures are depicted as discrete,
localized, areas of increased uptake of a Tc- 99m
• Lacks specificity.
3) MRI
• Both sensitive and specific
• It is extremely sensitive in the detection of
pathophysiological soft-tissue, bone and
marrow changes associated with stress
fractures
• Soft tissue- collection in infection, mass in
tumor can be well visualized
4) CT Scan

• Disruption in normal cortical pattern is better seen then x-ray

• Less sensitive then MRI or Bone scan
 PREVENTION

• Training errors - most frequent culprit and should be corrected.

• Assessment of the type and condition of the running shoes. Viscoelastic
insoles may help reduce the incidence of lower-extremity stress fractures.
• Education – parents, coaches, military personnel
• Female athletes – alerted , eating disorders, hormonal abnormalities.
 TREATMENT

• Early detection, ample rest

• Surgical treatment is needed for certain fractures (cases of delayed union or
failed non-operative treatment)