Pathologic Fractures - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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Pathologic Fractures

Pathologic Fractures

• Tumors
  • primary
  • secondary (metastatic) (most common)
• Metabolic
  • osteoporosis (most common)
  • Paget’s 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, fibroxanthoma, fibrous dysplasia, eosinophilic granuloma

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)

Fractures through benign tumors

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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

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 café au lait spots and endocrinopathy (Albright’s 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
  • pharmacologic—bisphosphonates

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

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

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

Pathologic Fractures

Primary Malignant Tumors

• Treatment
  • immobilization
  • staging
  • biopsy
  • adjuvant treatment (chemotherapy)
  • resection/amputation

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

Fractures through non-neoplastic bone disease

Paget’s 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 (^) Fracture through Pagetic bone (arrow)

Hyperparathyroidism

• Adenoma
• Polyostotic disease
• Mental status changes
• Abdominal pain
• Nephrolithiasis
• Polyostotic disease
  • mixed radiolucent/radiodense Multiple brown tumors in a patient with primary hyperparathyroidismDocsity.com

Hyperparathyroidism

• May be secondary to renal

failure

• secondary
• tertiary
• Treatment
• parathyroid adenectomy
• ORIF for fracture
• correct calcium

Pathologic fracture through brown tumor (arrow) Docsity.com

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

Overall Incidence of Metastases to

Bone at Autopsy

• 70% Jaffe, 1958
• 12% Clain, 1965
• 32% Johnson, 1970
• 21% Dominok, 1982

Incidence of Metastases at Autopsy by

Primary Tumor Site

Primary Site % metastasis to Bone Breast 50-85 Lung 30-50 Prostate 50-70 Hodgkin’s 50-70 Kidney 30-50 Thyroid 40 Melanoma 30-40 Bladder 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

Destructive lesions in bone from lung carcinoma (arrows)

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