Download MBBS Orthopaedics PPT 2 Pathological Fractures Lecture Notes

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