Download MBBS Orthopaedics PPT 2 Pathological Fractures Lecture Notes

Pathological Fractures

Diagnosis, Pathophysiology and

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treatment.

Learning Objectives

? Understand the biology of Pathological #

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? Diagnostic workup
? Treatment options ?Which is best
? Future areas of development
Pathologic fractures- Introduction

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? Occur in abnormal bone.
? Weakened bone fractures after minor trauma

Recognition, diagnosis, and treatment of the condition

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affecting the bone

Problem Statement
? 10 million Americans have osteoporosis
? 34 million have osteomalacia

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? 55% of people who are 50 years or older.
? Eighty percent of those affected by osteoporosis are women.
? 2 million people sustain a pathologic fracture each year.31 Of patients

over 50 years of age

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? 24% who sustain a hip fracture die within 1 year.
? One of every two women will have an osteoporosis-related fracture

in her lifetime

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Non Metabolic causes?

? 1.4 million new cancer cases
? 50% of these tumors can metastasize to the skeleton.
? With improved medical T/t- patients are living longer.

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? There is an increased prevalence of bone metastasis

Problem Statement-Skeletal metastases

? Considerable morbidity

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? Predispose to pathological fractures.
? Advances in the medical management of malignancy- life expectancy

is increasing

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? Risk of skeletal metastasis- pathological fractures.

Conventional modes of trauma fixation may not be appropriate.
Primary benign or malignant bone

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tumors

? Actual or impending pathologic fractures
? Requires a multidisciplinary approach
? Different principles applied to fracture fixation.

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Factors Suggesting a Pathologic Fracture

? Spontaneous fracture
? Fracture after minor trauma

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? Pain at the site before the fracture
? Multiple recent fractures
? Unusual fracture pattern ("banana fracture")*
? Patient older than 45 years
? History of primary malignancy

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Evaluation

? History: thyroid, breast, or prostate nodule
? Review of systems: gastrointestinal symptoms, weight loss, flank pain,

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hematuria

? Physical examination: lymph nodes, thyroid, breast, lungs, abdomen,

prostate, testicles, rectum

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Investigations

? Plain x-rays: chest, affected bone (additional sites as

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directed by bone scan findings)

? 99mTc total body bone scan (FDG-PET scan

lymphoma)

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? CT scan with contrast: chest, abdomen, pelvis
Labs

? Complete blood count,ESR

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? S .calcium, phosphate
? Urinalysis
? PSA, immuno-electrophoresis, and alkaline phosphatase
? Biopsy: needle versus open
Where is the lesion?

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? Epiphysis vs. metaphysis vs. diaphysis
? Cortex vs. medullary canal
? Long bone (femur, humerus) vs. flat bone (pelvis, scapula)

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Where is the lesion?

? Epiphysis vs. metaphysis vs. diaphysis
? Cortex vs. medullary canal
? Long bone (femur, humerus) vs. flat bone (pelvis, scapula)

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What is the lesion doing to the bone?

? Bone destruction (osteolysis)

? Total

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? Diffuse

? Minimal

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What is the lesion doing to the bone?

? Bone destruction (osteolysis)

? Total

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? Diffuse

? Minimal
What is the bone doing to the lesion?

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? Well-defined reactive rim- Benign or slow growing

? Intact but abundant periosteal reaction-Aggressive

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? Periosteal reaction that cannot keep up with tumor (Codman triangle)

? Highly malignant

What is the bone doing to the lesion?

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? Well-defined reactive rim- Benign or slow growing

? Intact but abundant periosteal reaction-Aggressive

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? Periosteal reaction that cannot keep up with tumor (Codman triangle)

? Highly malignant
What are the clues to the tissue type within the

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lesion?

Calcification

Bone infarct/cartilage tumor

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Ossification

Osteosarcoma/osteoblastoma

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Ground-glass appearance

Fibrous dysplasia
Evaluate
Analysis

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? Epiphysis
? Medulla
? Neck femur
? Destruction- total osteolysis

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? No bony reaction

Mirel's Classification

Component 1 2 3

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Site upper limb Lower limb Peritrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Size < 1/3 1/3 to 2/3 > 2/3

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Systemic Non ?Neoplastic Causes?

Correctable conditions

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? Renal osteodystrophy

? Hyperparathyroidism

? Osteomalacia

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Uncorrectable conditions

? Osteogenesis imperfecta

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? Polyostotic fibrous dysplasia

? Postmenopausal osteoporosis

? Osteopetrosis.

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Benign Causes?

? Benign tumours - unicameral

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bone cyst, ABC,GCT.
B/L Neck femur- Osteomalacia
Goal- Metastatic bone disease

? Palliation

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? Pain relief
? Restoration of function
? Improvement in quality of life.

Inappropriate treatment can lead to

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fixation failure

Problem Statement

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? Most common site for skeletal metastases- axial skeleton
? Most pathological fractures -long bones

? Two-thirds -femur

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? Proximal Humerus- most others
Impending Fractures?

? Osteolytic lesions
? Lesions larger than 25 mm

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? Areas subject to high anatomical stress
? Resorption exceeding more than 50?75% of the original bone

diameter.

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Morbidity?

? Pain
? Hypercalcaemia
? Reduced mobility

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? Fractures of lower limb- mobility
? Fractures of the upper limb can compromise functional independence


End-stage of the malignant disease?

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? Probably limits of medical management
? Half of patients who undergo surgery for a pathological fracture will

die within 6 months

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Poor Prognosis
? Visceral metastases
? Haemoglobin level less than 7g%
? Lung cancer

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73 Yrs Breast Ca right hip pain
Mirel's Classification

Component 1 2 3

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Site upper limb Lower limb Peritrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Size < 1/3 1/3 to 2/3 > 2/3

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Primary bone malignancy with #

? Sarcomas -1% of all malignant tumours
? Osteosarcoma followed by chondrosarcoma and Ewing's

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sarcoma.

? The incidence of fractures in osteosarcoma

? 5-10%

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Cause of Fracture ?

? Underlying malignancy-bone destruction
? Biopsy induced weakness
? Radiotherapy induced necrosis

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? Chemotherapy induced osteoporosis

Patient presents with Solitary Mets

? Suspicious bone lesion or pathological fracture

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? Absence of known malignancy
? Expeditious cautious approach must be undertaken.

Fixation should be avoided until a definitive

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diagnosis is established
Metastatic disease

? More common than primary bone tumours
? More than 50% of all primary cancers ?Mets

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? Breast, lung, prostate, kidney and thyroid
? Pathological fractures - 30% of patients

Facilities/Expertise not available

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? Early referral
? Immobilised in a cast/ traction
? External fixation -pins should be placed outside the pathological

segment of bone.

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Biopsy?

Does this patient require a biopsy?
? Necessary for tissue diagnosis
? Carefully planned-Needle biopsy

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? Definitive treatment in mind
? Pathologist involvement is best

Treatment- Principles

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? Prophylactic fixation of impending fractures.
? Stabilisation or reconstruction of bones affected by pathological

fracture

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? Spinal disease- decompression and mechanical stabilisation
Management of metastatic pathological

fractures
? The prognosis should exceed the anticipated recovery time from

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surgery

? Intervention should address all areas of weakened bone/ weaken

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subsequently

? Construct employed - allow immediate full weight-bearing.
? All patients should be considered for post-operative radiotherapy.

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Bone cement -role

? Percutaneously -prevent vertebral collapse
? Lone stabilisation device in cases of focal disease following curettage
? Important augment for internal fixation including intramedullary or

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plate fixation.

? Cemented arthroplasty is preferred to uncemented.

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Post-operative radiotherapy is indicated for almost all patients-

negatively affect bone ingrowth in uncemented prostheses

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Pathological fractures of the femoral

neck

? Most common site in the appendicular skeleton.

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? Preferred strategy -HRA or THR.
? Cemented long-stem femoral implants is the workhorse.
? Bypass the distal part of the lesion by two bone diameters.

Metastatic Ca Lung- Bipolar

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Cemented


Peritrochanteric fractures

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? Plate and screw osteosynthesis, augmented with

cement.

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? Cephalo-medullary nails- good choice

Biomechanical advantage of a centro medullary position-

resists medialisation seen in DHS

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Metastatic Renal Ca-EPR


Metastatic Breast Ca- Nailing 2 yrs later

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Subtrochanteric and diaphyseal

femoral fractures

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? Locked cephalomedullary nails
? Safe, effective and reliable, provide pain relief
? Allows early postoperative mobilisation and weight-

bearing

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Pathological Femur diaphysis-

Renal Ca

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The distal femur

? Retrograde nailing
? Curettage and internal

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fixation augmented with

PMMA

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? Endoprosthetic replacement


The humerus

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? Second most common long bone site
? Proximal 1/3 and diaphysis frequently

affected

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? Endoprosthetic replacement or locking

plate with cement aug

? Cemented, long stem prosthesis spanning

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the diaphysis is ideal


EndoprostHetic Replacement

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Humerus -Diaphyseal

? Intramedullary nailing
? Plate and screw fixation (with or without cement augmentation)

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Advantages
? Plate fixation avoids violation of the rotator cuff
Disadvantages
? Risks damage to the radial nerve
? Fails to protect as much humeral length

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? Leads to stress risers


Multiple myeloma- IF Final

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result

The tibia

? Rare ?(4.4%)

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? Proximal tibia- curettage, PMMA augmentation and

locking plate fixation.

? Endoprosthetic replacement- necessitates major soft

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tissue reconstructive procedures

? Gastrocnemius flaps and split skin grafting

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Tibial diaphysis/Distal

? Locked antegrade intramedullary nailing is preferred +- augmented

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with cement.

? Distal tibial involvement- curettage and internal fixation with cement

augmentation

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Renal Cell Ca with

distal tibial mets
Nonoperative Treatment?

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? Not a surgical candidate -Bracing.
? Limited life expectancies
? Severe comorbidities
? Small lesions

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? Radiosensitive tumors

Amputation

? Failure of internal fixation with painful non-union

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? Local recurrence, involvement of the skin, soft tissues and

neurovascular structures

? Severe lymphoedema, post-radiation neuropathy and fibrosis

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Radiotherapy

? Vital adjunct in patients with metastatic disease
? 90% of patients can expect some pain relief
? 50?60% experiencing complete pain relief.

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Entire surgical field should be the default position and considered in

every case.

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Medical therapy

? Bisphosphonates
? Denosumab
? Chemotherapy

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? Radiopharmaceuticals
? Hormonal therapy

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Future-Intercalary Prosthesis

Carbon fiber Nail

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Favorable mechanical properties

Eases radiation therapy

Evaluation of fracture healing

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Evaluate progression or relapse