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H.T. Temple, MD
Created March 2004; Revised December 2005
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
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)
matrix production
periosteal reaction
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
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-
Pathologic Fractures
Primary Malignant Tumors
Treatment
immobilization
staging
biopsy
adjuvant treatment (chemotherapy)
resection/amputation
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
Bowing deformities
Joint arthrosis
Fracture
delayed healing
malignant transformation
Treatment
Osteotomy to correct alignment
Excessive bleeding
Joint arthroplasty vs. ORIF
Hyperparathyroidism
Adenoma
Polyostotic disease
Mental status changes
Abdominal pain
Nephrolithiasis
Polyostotic disease
mixed radiolucent/radiodense
Mixed
radiodense
and
radiolucent
lesions
Hyperparathyroidism
May be secondary to renal
failure
secondary
tertiary
Treatment
parathyroid adenectomy
ORIF for fracture
correct calcium
Pathologic fracture through
brown tumor (arrow)
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
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
% 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
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
Incidence Fx (%)
0%
3.7%
61%
79%
Limitations
only for proximal femur
doesnt account for tumor biology
Harrington, K.D.: Clin. Orthop. 192:
222, 1985
Score
2
upper limb
lower limb
peritrochanteric
mild
moderate
functional
blastic
mixed
lytic
<1/3
1/3-2/3
>2/3
Radiotherapy
All tumor defects that meet the criteria for
internal fixation do not require surgery
Radiotherapy
Pre XRT
Prostate
CA
Post XRT
Prostate
CA
Pathologic Fracture
Survival
75% of patients with a
pathologic fracture
will be alive after one
year
the average survival is
~ 21 months
Cement augmentation
Radiation/chemotherapy
Aggressive rehabilitation
post-op
pre-op
pre-op
*pre operative embolization of renal cell mets should be done
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
Cement
Pain relief
PMMA
97%
no PMMA
83%
Ambulation
95%
75%
Fixation failure
2 cases
6 cases
Pre-op
renal cell
carcinoma
Post-op
renal cell
carcinoma
renal
thyroid
melanoma
occasionally lung
Post-op intercalary
allograft
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
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 tibiaa. 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 raole 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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