PATHOLOGICAL FRACTURE PREPARED BY AIDROOS ALAIDROOS SUPERVISED BY ASSOCIATE PROFESSORO AHMED ABDO

DEFINITION A pathological fracture is defined as a fracture through diseased or abnormal bone, usually resulting from a force insufficient to produce a fracture in normal bone. It occur through bone at its weakest point or where the tumor mass occupies the most space.

Epidemiology: Approximately 1.5 million people sustain a pathologic fracture annually in America.

ANATOMY AND PHYSIOLOGY OF MUSCULOSKELETAL SYSTEM Skeletal Organization Axial skeleton 80 bones Head, thorax, and spine Appendicular skeleton 126 bones Upper extremities Lower extremities

Bone is a living tissue made predominantly of protein collagen (which provides a strong yet malleable framework) and calcium phosphate (a mineral that ensures strengthening of the framework). Bones are continuously being renewed through a process called bone remodeling, involving bone resorption and bone formation.

Bone Structure Diaphysis Epiphysis End of a long bone Metaphysis Between epiphysis and diaphysis Growth plate Medullary canal Contains bone marrow Periosteum Fibrous covering of diaphysis Cartilage Connective tissue that provides a smooth articulation surface for other bones

Skeletal Tissue and Structure functions Give the body its structural form Protect vital organs Promote efficient movement despite the forces of gravity Store salts and other materials needed for metabolism Produce red blood cells

Bone Aging Birth to adult (0–20) Transition from flexible to firm bone Adult to elderly (40+) Reduction in collagen matrix and calcium salts Diminution of bone strength Spinal curvature

CLASSIFICATION OF THE CAUSES 1.According to the nature of the provoking factors involved: Intrinsic processes include conditions such as osteogenesis imperfecta and bone tumours. extrinsic processes include previous surgical intervention (biopsy, fixation etc.) and radiotherapy.

2.According to pattern of bone invasion Systemic: such as Osteoporosis, metastatic bone disease, Metabolic bone disease (hyperparathyroidism). Localized: such as Primary tumors of the bone.

3.According to age : Neonate : Neonatal osteopenia (Mineral deficiency such as calcium and phosphorus), Osteogenesis imperfecta. infants and young children : bone cyst, Rickets, Osteomyelitis, Disuse

Children and adolescents : Unicameral bone cysts, Nonossifying fibroma, Osteosarcoma, Ewing sarcoma. Adults : Metastases, Giant cell tumor, fibrous dysplasia. Geriatric patients : osteoporosis,Metastases, Hyperparathyroidism.

4.According to management:  Correctable disorders include disuse osteoporosis, hyperparathyroidism, renal osteodystrophy, and steroid- induced osteoporosis.  Noncorrectable disorders include osteogenesis imperfecta, Paget disease, rheumatoid arthritis, and Gaucher disease.

EVALUATION OF THE PATIENT WITH AN IMPENDING OR ACTUAL PATHOLOGIC FRACTURE AA comprehensive evaluation of a patient with a lytic bone lesion or pathologic fracture is essential. History: Excessive pain at the site of fracture prior to injury. Patients with a known primary malignant disease or metabolic disease. A history of multiple fractures. Risk factors such as smoking or environmental exposure to carcinogens.

Review of systems: gastrointestinal symptoms, weight loss, flank pain, hematuria etc.. Physical examination : In addition to the standard physical examination performed for the specific fracture encountered, attention should be directed to evaluation of a possible soft tissue mass at fracture site or evidence of primary disease such as lymphadenopathy, thyroid nodules, breast masses, prostate nodules, rectal lesions, as well as examination of other painful regions to rule out impending fractures.

LABORATORY STUDIES Plain x-rays: chest, affected bone, humerus, pelvis, femur, spine CT scan: chest, abdomen, pelvis. MRI : to evaluate soft-tissue masses and extent of marrow involvement Laboratory: complete blood count, erythrocyte sedimentation rate, calcium, phosphate, urinalysis, prostate-specific antigen, immunoelectrophoresis, and alkaline phosphatase etc… Biopsy: needle vs. open

MANAGEMENT IInitial Stabilization Many patients have bone pain with activity, and it may occur weeks to months before pathologic fracture. When activity-related pain exists with a radiographically documented destructive lesion, an ambulatory support to reduce loading should be recommended. Walker 2 crutches Single cane

 General Measures: Control pain. Reduce forces with walking aid or by placing patient at bed rest. Activity: Reduce activity. Recommend ambulatory aid. If patient is unable to walk, recommend a wheelchair. If unable to control pain, recommend bed rest.

Nursing: Assess patient and recommend general measures: Walking aid Activity reduction

NON OPERATIVE TREATMENT BBracing: Bracing of an impending or actual pathologic fracture should be performed if the patient is not a surgical candidate. Nonsurgical candidates are those with limited life expectancies, severe comorbidities, small lesions, or radiosensitive tumors. Lesions most amenable to bracing are those in the humeral diaphysis, forearm, and occasionally the tibia

Prophylactic management  often is recommended if the weakened bone state is detected before the fracture occurs. Impending fracture: The goals of surgical treatment in a patient with an impending pathologic fracture are to alleviate pain, reduce narcotic use, restore skeletal stability, and regain functional independence.

The Mirels system classifies the risk of pathologic fracture based on scoring four variables on a scale of 1- 3: location of lesion, radiographic appearance, size, and pain. An overall score is calculated, and a recommendation for or against prophylactic fixation is made. a Size is determined as a fraction of the diameter of the bone. b Functional pain is defined as severe pain or pain aggravated by limb function. 321 Intertrochan teric Lower extremity Upper extremity Location LyticMixedBlasticRadiographic appearance >2/31/3 - 2/3< 1/3Size a Functional b ModerateMildPain

Recommendation%Fracture Risk Prophylactic fixation is recommended ≥9 Clinical judgment should be used 15=8 Observation and radiation therapy can be used <4≤7 Commonly, a lesion is considered to be at risk for fracture if it is painful, larger than 2.5 cm, and involves more than 50% of the cortex Advantages of prophylactic management :  Decreased morbidity  Decreased hospital stay  Easier rehabilitation  More immediate pain relief  Faster surgery and less complications

OPERATIVE TREATMENT Goals of surgical intervention are: Prevention of disuse osteopenia. Mechanical support for weakened or fractured bone to permit the patient to perform daily activities. Pain relief. Decreased length and cost of hospitalization. Internal fixation, with or without cement augmentation, is the standard of care for most pathologic fractures, particularly long bones. Internal fixation will eventually fail if the bone does not unite.

in the upper limb have traditionally been managed with bridge plate stabilization intramedullary nailing may be indicated in humerus shaft fracture. External fixation or cast immobilization usually is preferred in case of osteomyelitis If bone loss is significant, the defect can be filled with autogenous bone graft, a vascularized osseous graft, or bone transport using the Ilizarov technique.

Subtrochnteric and intertrochanteric fracture treated with reconstruction nail or interlocking nail. femoral head and neck usually are best treated by removal of the head and neck and replacement with a femoral head prosthesis, If the acetabulum is not involved, a hemiarthroplasty may be indicated; however, with acetabular involvement, total hip replacement is required.

Single vertebral metastasis with cord compression: Surgery Multiple spinal metastasis : Radiotherapy Diffuse skeletal metastasis with severe pain : Radionuclide therapy  Simple bone cysts tend to disappear once decompressed by the trauma. Treated as any other fracture. In other words the majority will need simple reduction and a plaster cast. The exception is a fracture about the proximal femur. Here open reduction and internal fixation is preferred. Recurrence of a cyst is an indication to do curretage and bone graft

 Amputation may needed in Pathological fracture through a high-grade sarcoma,especially if there is a poor response to induction chemotherapy → Forequarter amputation entails surgical removal of the entire upper extremity, scapula, and clavicle). contamination of soft tissue during biopsy. non healing pathological fracture.

CONTRAINDICATIONS TO SURGICAL MANAGEMENT Contraindications to surgical management of pathologic fractures are: General condition of the patient inadequate to tolerate anesthesia and the surgical procedure. Mental obtundation or decreased level of consciousness that precludes the need for local measures to relieve pain. Life expectancy of <1 month

POST OPERATIVE MANAGEMENT Perioperative antibiotic coverage. Post operative calcium support for healing especially in first week with taking in consideration a specific conditions such as breast cancer frequently are hypercalcemic from the high number of bone metastases and may require detoxification of calcium rather than supplementation. prophylaxis for embolic events. Aggressive postoperative pulmonary toilet. Early mobilization are all instituted as standard treatment

complications Loss of fixation is the most common complication in the treatment of pathologic fractures, owing to poor bone quality. Infection Delayed wound healing Failure to heal

Special Therapy  Radiotherapy Often used after pathologic fractures are treated surgically. Specific indications include: Metastatic bone disease Multiple myeloma Lymphoma Palliate symptoms Diminish lesion size Prevent advancement of lesion Painful lesion  Radiotherapy delay soft tissue healing and should not be administered until 10 to 21 days postoperatively.

 Physical Therapy  Used before and after surgery: Before surgical stabilization Instruct patient on protected weightbearing with walking aid After stabilization Instruct patient on use of walking aid Begin program to regain strength

FFollow-up Protected weightbearing until fracture union occurs Patients are followed at 1-month intervals until the fracture heals. Plain radiographs are used to assess healing (In general, ~6-10 weeks, depending on the fracture pattern and the amount of bone loss).

AAfter treatment of a pathologic fracture, the bone may or may not heal. The factors that influence whether healing will occur include location of the lesion, extent of bony destruction, tumor histology, type of treatment, and length of patient survival The prognosis depends entirely on the underlying process. Benign diagnoses: Excellent

Malignant diagnoses: Metastases (uniformly fatal, median survival) Lung, kidney: 6-12 months Breast, prostate: months Myeloma: Median survival, 3-5 years Lymphoma: 60-80% survival at 5 years Osteosarcoma: 60-70% survival at 5 years

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