1. H.T. Temple, MD Created March 2004; Revised December 2005
Pathologic Fractures
H.T. Temple, MD Created March 2004; Revised December 2005

2. Pathologic Fractures Tumors Metabolic primary
secondary (metastatic) (most common)
Metabolic
osteoporosis (most common)
Paget’s disease
hyperparathyroidism

3. 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, fibroxanthoma, fibrous dysplasia, eosinophilic granuloma

4. 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 fragment”sign (arrow)

5. 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

6. 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

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

8. Fibrous Dysplasia Solitary vs. multifocal (solitary most common)
Femur and humerus
First and second decades
May be associated with café au lait spots and endocrinopathy (Albright’s syndrome)

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

10. 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 (Ewing’s, lymphoma)
Osteosarcoma, Ewing’s, malignant fibrous histiocytoma, fibrosarcoma

11. 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
Patients usually have antecedent pain before fracture, especially night pain

12. 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

13. Pathologic fracture through MFH arising in antecedent infarctB
Pathologic fracture through MFH arising in antecedent infarct
(H&E 100x) Pleomorphic spindled cells with storiform growth pattern A

14. 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

15. Intermediate grade chondrosarcoma
Post-
Pre-op
Intermediate grade chondrosarcoma
*fixation of primary bone tumors is not done without other tumor treatment due to potential for spread of tumor

16. Pathologic Fractures Primary Malignant Tumors
Treatment
immobilization
staging
biopsy
adjuvant treatment (chemotherapy)
resection/amputation

17. Metabolic Bone Disease
Fractures through non-neoplastic bone disease
Metabolic Bone Disease
Osteoporosis
insufficiency fractures
Paget’s disease
early and late stages; most fractures occur in the late stage of disease
Hyperparathyroidism
dissecting osteitis
fractures through brown tumors

18. Paget’s Disease Radiographic appearance Fracture Treatment
Thickened cortices
Purposeful trabeculae
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)

19. Mixed radiodense and radiolucent lesions
Hyperparathyroidism
Adenoma
Polyostotic disease
Mental status changes
Abdominal pain
Nephrolithiasis
mixed radiolucent/radiodense
Mixed radiodense and radiolucent lesions
Multiple brown tumors
in a patient with primary
hyperparathyroidism

20. Hyperparathyroidism May be secondary to renal failure Treatment
tertiary
Treatment
parathyroid adenectomy
ORIF for fracture
correct calcium
Pathologic fracture through brown tumor (arrow)

21. 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

22. Overall Incidence of Metastases to Bone at Autopsy
70% Jaffe, 1958
12% Clain, 1965
32% Johnson, 1970
21% Dominok, 1982

23. Incidence of Metastases at Autopsy by Primary Tumor Site
Primary Site % metastasis to Bone
Breast
Lung
Prostate
Hodgkin’s
Kidney
Thyroid
Melanoma
Bladder

24. 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

25. Route of Metastases Contiguous Hematogenous most common
Destructive lesions in bone from
lung carcinoma (arrows)

26. 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

27. Bone Destruction Early Late most important osteoclast mediated
(RANK L)
Late
malignant cells may be directly responsible

28. Metastases of Unknown Origin
3-4% of all carcinomas have no known primary site
10-15% of these patients have bone metastases

29. Diagnostic Strategy for Patients with Unknown Primary
% Primary Tumor Identified
History and Physical 8%
Chest X-Ray 43%
Chest CT %
Abdominal CT 13%
Biopsy 8%
Rougraff, 1993

30. 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

31. 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

32. 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 > one-third of the cortex, pain after radiotherapy

33. Impending Pathologic Fracture
Fidler, 1981
% shaft destroyed Incidence Fx (%)
0-25% 0%
25-50% 3.7%
50-75% 61%
>75% 79%
Conclusion: Patients with tumors destroying >50% of the diameter of bone require prophylactic internal fixation

34. 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
doesn’t account for tumor biology
Harrington, K.D.: Clin. Orthop. 192: 222, 1985

35. Mirels Scoring System Score 1 2 3
Site upper limb lower limb peritrochanteric
Pain mild moderate functional
Lesion blastic mixed lytic
Size <1/3 1/3-2/3 >2/3
Based on a retrospective study of 78 pts with metastatic disease to long bones. 27 patients fractured within 6 months. Their mean Mirels score was 10 while those without fracture had a score of < 7.
Score < 7 – no surgery
Score > 7 – prophylactic fixation
Mirels, H.: Clin. Orthop. 249: 256,

36. Radiotherapy
All tumor defects that meet the criteria for internal fixation do not require surgery
>50% of diameter of bone
>2.5 cm
pain after radiation
fracture of the lesser trochanter
Tumor biology is variable - some lesions are very sensitive to radiotherapy

37. Radiotherapy
Pre XRT
Prostate CA
Post XRT
Prostate CA

38. Goals of Surgery in Treating Patients with Pathologic Fractures
Relieve pain
Restore function
Facilitate nursing care

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

40. 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
Aggressive rehabilitation

41. Renal Cell Carcinoma pre-op pre-op post-op
*pre operative embolization of renal cell mets should be done

42. 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

43. 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

44. Cement PMMA no PMMA Pain relief 97% 83% Ambulation 95% 75%
Fixation failure 2 cases 6 cases
Haberman, E.T: CORR, 169: 70, 1982

45. Post-op renal cell carcinoma
Pre-op renal cell carcinoma

46. Resection for Pathologic and Impending Pathologic Fractures
Radiation and chemotherapy resistant tumors
renal
thyroid
melanoma
occasionally lung
Solitary metastases (controversial)

47. Solitary renal cell carcinoma
Soft tissue mass
Permeative lysis

48. Post-op intercalary allograft

49. Complications Infection Hemorrhage Tumor recurrence
malnutrition
hematomyelopoetic suppression
Hemorrhage
vascular tumors ( renal and thyroid)
Tumor recurrence
Failure of fixation
Thromboembolic disease

50. Embolization Hypervascular tumors Renal cell carcinoma
Thyroid carcinoma
Pheochomocytoma

51. Pre embolization Post embolization
Pre-operative embolization can prevent hemorrhage with intra-lesional surgery

52. 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

53. 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:
Eckardt JJ, et.al. Endoprosthetic reconstructions for bone metastases. Clin Orthop 2003; 415:S

54. References
Ward WG, et.al. Metastatic disease of the femur: surgical treatment. Clin Orthop 2003; 415:S
Kelly CM, et.al. Treatment of metastatic disease of the tibiaa. Clin Orthop 2003; S
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

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

56. Thank You
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