Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 2 Pathological Fractures Lecture Notes
Pathological Fractures
Diagnosis, Pathophysiology and
treatment.
Learning Objectives
? Understand the biology of Pathological #
? Diagnostic workup
? Treatment options ?Which is best
? Future areas of development
Pathologic fractures- Introduction
? Occur in abnormal bone.
? Weakened bone fractures after minor trauma
Recognition, diagnosis, and treatment of the condition
affecting the bone
Problem Statement
? 10 million Americans have osteoporosis
? 34 million have osteomalacia
? 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
? 24% who sustain a hip fracture die within 1 year.
? One of every two women will have an osteoporosis-related fracture
in her lifetime
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.
? There is an increased prevalence of bone metastasis
Problem Statement-Skeletal metastases
? Considerable morbidity
? Predispose to pathological fractures.
? Advances in the medical management of malignancy- life expectancy
is increasing
? Risk of skeletal metastasis- pathological fractures.
Conventional modes of trauma fixation may not be appropriate.
Primary benign or malignant bone
tumors
? Actual or impending pathologic fractures
? Requires a multidisciplinary approach
? Different principles applied to fracture fixation.
Factors Suggesting a Pathologic Fracture
? Spontaneous fracture
? Fracture after minor trauma
? Pain at the site before the fracture
? Multiple recent fractures
? Unusual fracture pattern ("banana fracture")*
? Patient older than 45 years
? History of primary malignancy
Evaluation
? History: thyroid, breast, or prostate nodule
? Review of systems: gastrointestinal symptoms, weight loss, flank pain,
hematuria
? Physical examination: lymph nodes, thyroid, breast, lungs, abdomen,
prostate, testicles, rectum
Investigations
? Plain x-rays: chest, affected bone (additional sites as
directed by bone scan findings)
? 99mTc total body bone scan (FDG-PET scan
lymphoma)
? CT scan with contrast: chest, abdomen, pelvis
Labs
? Complete blood count,ESR
? S .calcium, phosphate
? Urinalysis
? PSA, immuno-electrophoresis, and alkaline phosphatase
? Biopsy: needle versus open
Where is the lesion?
? Epiphysis vs. metaphysis vs. diaphysis
? Cortex vs. medullary canal
? Long bone (femur, humerus) vs. flat bone (pelvis, scapula)
Where is the lesion?
? Epiphysis vs. metaphysis vs. diaphysis
? Cortex vs. medullary canal
? Long bone (femur, humerus) vs. flat bone (pelvis, scapula)
What is the lesion doing to the bone?
? Bone destruction (osteolysis)
? Total
? Diffuse
? Minimal
What is the lesion doing to the bone?
? Bone destruction (osteolysis)
? Total
? Diffuse
? Minimal
What is the bone doing to the lesion?
? Well-defined reactive rim- Benign or slow growing
? Intact but abundant periosteal reaction-Aggressive
? Periosteal reaction that cannot keep up with tumor (Codman triangle)
? Highly malignant
What is the bone doing to the lesion?
? Well-defined reactive rim- Benign or slow growing
? Intact but abundant periosteal reaction-Aggressive
? Periosteal reaction that cannot keep up with tumor (Codman triangle)
? Highly malignant
What are the clues to the tissue type within the
lesion?
Calcification
Bone infarct/cartilage tumor
Ossification
Osteosarcoma/osteoblastoma
Ground-glass appearance
Fibrous dysplasia
Evaluate
Analysis
? Epiphysis
? Medulla
? Neck femur
? Destruction- total osteolysis
? No bony reaction
Mirel's Classification
Component 1 2 3
Site upper limb Lower limb Peritrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Size < 1/3 1/3 to 2/3 > 2/3
Systemic Non ?Neoplastic Causes?
Correctable conditions
? Renal osteodystrophy
? Hyperparathyroidism
? Osteomalacia
Uncorrectable conditions
? Osteogenesis imperfecta
? Polyostotic fibrous dysplasia
? Postmenopausal osteoporosis
? Osteopetrosis.
Benign Causes?
? Benign tumours - unicameral
bone cyst, ABC,GCT.
B/L Neck femur- Osteomalacia
Goal- Metastatic bone disease
? Palliation
? Pain relief
? Restoration of function
? Improvement in quality of life.
Inappropriate treatment can lead to
fixation failure
Problem Statement
? Most common site for skeletal metastases- axial skeleton
? Most pathological fractures -long bones
? Two-thirds -femur
? Proximal Humerus- most others
Impending Fractures?
? Osteolytic lesions
? Lesions larger than 25 mm
? Areas subject to high anatomical stress
? Resorption exceeding more than 50?75% of the original bone
diameter.
Morbidity?
? Pain
? Hypercalcaemia
? Reduced mobility
? Fractures of lower limb- mobility
? Fractures of the upper limb can compromise functional independence
End-stage of the malignant disease?
? Probably limits of medical management
? Half of patients who undergo surgery for a pathological fracture will
die within 6 months
Poor Prognosis
? Visceral metastases
? Haemoglobin level less than 7g%
? Lung cancer
73 Yrs Breast Ca right hip pain
Mirel's Classification
Component 1 2 3
Site upper limb Lower limb Peritrochanteric
Pain Mild Moderate Functional
Lesion Blastic Mixed Lytic
Size < 1/3 1/3 to 2/3 > 2/3
Primary bone malignancy with #
? Sarcomas -1% of all malignant tumours
? Osteosarcoma followed by chondrosarcoma and Ewing's
sarcoma.
? The incidence of fractures in osteosarcoma
? 5-10%
Cause of Fracture ?
? Underlying malignancy-bone destruction
? Biopsy induced weakness
? Radiotherapy induced necrosis
? Chemotherapy induced osteoporosis
Patient presents with Solitary Mets
? Suspicious bone lesion or pathological fracture
? Absence of known malignancy
? Expeditious cautious approach must be undertaken.
Fixation should be avoided until a definitive
diagnosis is established
Metastatic disease
? More common than primary bone tumours
? More than 50% of all primary cancers ?Mets
? Breast, lung, prostate, kidney and thyroid
? Pathological fractures - 30% of patients
Facilities/Expertise not available
? Early referral
? Immobilised in a cast/ traction
? External fixation -pins should be placed outside the pathological
segment of bone.
Biopsy?
Does this patient require a biopsy?
? Necessary for tissue diagnosis
? Carefully planned-Needle biopsy
? Definitive treatment in mind
? Pathologist involvement is best
Treatment- Principles
? Prophylactic fixation of impending fractures.
? Stabilisation or reconstruction of bones affected by pathological
fracture
? Spinal disease- decompression and mechanical stabilisation
Management of metastatic pathological
fractures
? The prognosis should exceed the anticipated recovery time from
surgery
? Intervention should address all areas of weakened bone/ weaken
subsequently
? Construct employed - allow immediate full weight-bearing.
? All patients should be considered for post-operative radiotherapy.
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
plate fixation.
? Cemented arthroplasty is preferred to uncemented.
Post-operative radiotherapy is indicated for almost all patients-
negatively affect bone ingrowth in uncemented prostheses
Pathological fractures of the femoral
neck
? Most common site in the appendicular skeleton.
? 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
Cemented
Peritrochanteric fractures
? Plate and screw osteosynthesis, augmented with
cement.
? Cephalo-medullary nails- good choice
Biomechanical advantage of a centro medullary position-
resists medialisation seen in DHS
Metastatic Renal Ca-EPR
Metastatic Breast Ca- Nailing 2 yrs later
Subtrochanteric and diaphyseal
femoral fractures
? Locked cephalomedullary nails
? Safe, effective and reliable, provide pain relief
? Allows early postoperative mobilisation and weight-
bearing
Pathological Femur diaphysis-
Renal Ca
The distal femur
? Retrograde nailing
? Curettage and internal
fixation augmented with
PMMA
? Endoprosthetic replacement
The humerus
? Second most common long bone site
? Proximal 1/3 and diaphysis frequently
affected
? Endoprosthetic replacement or locking
plate with cement aug
? Cemented, long stem prosthesis spanning
the diaphysis is ideal
EndoprostHetic Replacement
Humerus -Diaphyseal
? Intramedullary nailing
? Plate and screw fixation (with or without cement augmentation)
Advantages
? Plate fixation avoids violation of the rotator cuff
Disadvantages
? Risks damage to the radial nerve
? Fails to protect as much humeral length
? Leads to stress risers
Multiple myeloma- IF Final
result
The tibia
? Rare ?(4.4%)
? Proximal tibia- curettage, PMMA augmentation and
locking plate fixation.
? Endoprosthetic replacement- necessitates major soft
tissue reconstructive procedures
? Gastrocnemius flaps and split skin grafting
Tibial diaphysis/Distal
? Locked antegrade intramedullary nailing is preferred +- augmented
with cement.
? Distal tibial involvement- curettage and internal fixation with cement
augmentation
Renal Cell Ca with
distal tibial mets
Nonoperative Treatment?
? Not a surgical candidate -Bracing.
? Limited life expectancies
? Severe comorbidities
? Small lesions
? Radiosensitive tumors
Amputation
? Failure of internal fixation with painful non-union
? Local recurrence, involvement of the skin, soft tissues and
neurovascular structures
? Severe lymphoedema, post-radiation neuropathy and fibrosis
Radiotherapy
? Vital adjunct in patients with metastatic disease
? 90% of patients can expect some pain relief
? 50?60% experiencing complete pain relief.
Entire surgical field should be the default position and considered in
every case.
Medical therapy
? Bisphosphonates
? Denosumab
? Chemotherapy
? Radiopharmaceuticals
? Hormonal therapy
Future-Intercalary Prosthesis
Carbon fiber Nail
Favorable mechanical properties
Eases radiation therapy
Evaluation of fracture healing
Evaluate progression or relapse
This post was last modified on 07 April 2022