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Pathologic Fracture

- See:
      - Pathologic Hip Frx
      - Metastatic Tumors to Bone

- Discussion:
    - fractures which occur from low energy injuries which occur thru an area of bone weakness with a pre-existing abnormality;
    - injured area demonstrates distored archetecture and distored bone density;
    - Diff Dx:
             - Fibrous Dysplasia
             - Fibrous Histiocytoma
             - Gaucher's Disease
             - Giant Cell Tumor of Bone
             - Metastatic Tumors to Bone (most common)
             - Metastatic Breast Cancer:
             - Multiple Myeloma
             - Nonossifying fibroma
             - Osteogenesis Imperfecta
             - Osteomalacia
             - Osteomyelitis:
             - Osteoporosis
             - Osteopetrosis
             - Pagets Disease
             - Renal Osteodystrophy
             - Simple Bone Cyst / Unicarmeral

- Management:
    - Labs:
           - serum lab studies will help rule out systemic conditions;
           - Sed Rate
           - CBC
           - Serum Calcium
    - Skeletal Survey: (helps rule out pending frx in axial skeleton, femurs, and humeri);
    - Bone Scan
           - may reveal other bone lesions which are not evident from radiographs;
           - note that some tumors such as multiple myeloma do not show increased uptake on bone scans;
    - Biopsy:
           - performed thru fine needle or open biopsy;
           - culture for Osteomyelitis

- Prophylactic Management
prophylactic nailing of femoral lytic lesions:
- scoring system of risk (Mirels (1989))
- based on 4 characteristics: tumor location, associated pain, type of lesion (either lucent, mixed, or blastic), and lesion size;
- tumor is scored from 1 to 3 in each category and a total score is obtained that correlates to fracture risk;
- prophylactic fixation is advised for lesions with scores of higher than 8, and consideration for stabilization is considered for scores of 8.
- references:
- Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures.
- Critical evaluation of Mirels' rating system for impending pathologic fractures.

                     - Metastatic bone disease: the requirement for improvement in a multidisciplinary approach.
                     - Mirels' Rating for Humerus Lesions is Both Reproducible and Valid.
                     - Comparative analysis of risk factors for pathological fracture with femoral metastases.

Orthopaedia. Metastatic bone lesions (pathological fractures)

- Fracture Management:
           - in the study by Duffy GP, et al, authors evaluated the functional results, rates of union, and complications associated w/ vascularized free fibular
                  transfer combined with autografting for the treatment of nonunions in previously irradiated bone;
                  - 17 patients w/ 18 vascularized free fib transfers + autografting for treatment of nonunion of a frx in previously irradiated bone were include;
                  - 8 patients had a bone neoplasm and nine, a soft-tissue neoplasm;
                  - dx: ewing sarcoma in 4; lymphoma, MFH, and rhabdomyosarcoma in two patients each; and cavernous hemangioma, metastatic
                          breast carcinoma, reticulum-cell sarcoma, myxosarcoma, hemangiopericytoma, and fibrosarcoma in one patient each.
                  - all patients received radiation therapy;
                  - average dose was 5564 centigray;
                  - average interval between the radiation therapy and the original fracture was 111 months;
                  - fracture was in the femur in thirteen patients, in the humerus in three, and in the tibia in one;
                  - all patients had operative or nonoperative treatment, or both, of the initial fracture, and two had iliac-crest bone-grafting after
                          the initial open reduction and internal fixation procedure;
                  - all fibular transfers were applied as onlay grafts because no nonunion was associated with a large segmental defect;
                  - cancellous autogenous bone graft was used as an additional graft at proximal and distal junctions of graft w/ bone and at fracture site in all patients;
                  - 16 of the 18 fracture sites united, after an average of 9.4 months (range, three to twenty-four months);
                  - 13 patients had an excellent result, one had a good result, two had a fair result, and one had a failure of treatment;
                  - authors suggest that microvascular fibular transfer + autografting is appropriate for difficult nonunions associated with previously irradiated bone.
           - references:
                  - Fractures following limb-salvage surgery and adjuvant irradiation for soft-tissue sarcoma.

Pathologic fracture risk in rehabilitation of patients with bony metastases.

Stabilization and prosthetic replacement in difficult fractures and bone tumors.

Skeletal sequelae of radiation therapy for malignant childhood tumors.

Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures.

Treatment of pathologic fractures of the distal femur with the Zickel supracondylar nail.

Treatment of pathologic fracture of the humerus.

Pathological fractures in patients who have amyloidosis associated with dialysis. A report of five cases.

Reconstruction nailing for pathological subtrochanteric fractures with coexisting femoral shaft metastases.

Predicting pathologic fracture risk in the management of metastatic bone defects.

Inferior Vena Cava Filters Prevent Pulmonary Emboli in Patients with Metastatic Pathologic Fractures of the Lower Extremity.