PATHOLOGICAL

FRACTURES
MENTOR
Dr. dr. Adrian Khu, Sp. OT, FICS

Presented by:
Maylia Lie (173307020004)
 ANATOMY
■ Bones, from the viewpoint of their gross structure, are classified as :
1) long bones, or tubular bones (e.g. femur)
2) short bones or cuboidal bones (e.g. carpal bones), and
3) flat bones (e.g. scapula). Furthermore, each bone consists of dense
cortical bones (compacta) on the outside and a sponge-like
arrangement of trabecular bone (spongiosa) on the inside
■ A long bone has two parts: the
diaphysis and the epiphysis.

■ The diaphysis is the tubular shaft

that runs between the proximal and
distal ends of the bone

■ The hollow region in the diaphysis is

called the medullary cavity

■ The walls of the diaphysis are

composed of dense and hard
compact bone
■ The medullary cavity has a delicate membranous lining called the
endoteum (end- = “inside”, oste- = “bone), where bone growth, repair
and remodeling occur.
■ The outer surface of the bone is covered with a fibrous membrane
called the periosteum (per- = “around” or “surrounding”)
■ Mature long bone have 3 distinct zones : epiphyseal, metaphyis and
diaphysis.
■ the epiphysis and metaphysis are separated by a fourth zone, known as
the epiphyseal plate, or physis
■ The biomechanical composition of bone is as follows: 30%
organic substances, 60% inorganic (mineral) substances
and 10% water
 DEFINITION
■ A pathological fracture is defined as a fracture through
diseased or abnormal bone, usually resulting from a force
insufficient to produce a fracture in normal bone. It occur
through bone at its weakest point or where the tumor mass
occupies the most space.
 EPIDEMIOLOGY
■ A pathological fracture is one that occurs in bone tissue
that is pathological, weak and remodeled, with altered or
reduced mechanical and viscoelastic properties.

■ 5% of all fracture are pathological fractures due to local or

systemic diseases.

■ Age-related fractures are projected to increase nationally

from 2.1 million in 2005 to over 3 million fractures in
2025, solely in the basis of growh in the elderly population
most at risk.
 GIT disorders and
fragility
Drugs IBD

Infection
Osteomalacia

ETIOLOGY
Endocrinopathies Non-malignant
haematological

Uncommon diseases of
Malignancies bone and connective tissue

Rheumatology
diseases
 CLINICAL FEATURES

■ Pathologic fractures don’t always have symptoms.

Numbness,
tingling or
Bruising, weakness
tenderness
Mild to severe and swelling
pain
CLASSIFICATION OF THE CAUSES
1. According to the nature of the provoking factors involved:
■ Intrinsic processes include conditions such as
osteogenesis imperfecta and bone tumours.
■ extrinsic processes include previous surgical intervention
(biopsy, fixation etc.) and radiotherapy.
2. According to pattern of bone invasion
■ Systemic: such as Osteoporosis, metastatic bone disease,
Metabolic bone disease (hyperparathyroidism).
■ Localized: such as Primary tumors of the bone
3. According to age:
■ Neonate :
Neonatal osteopenia (Mineral deficiency such as calcium and phosphorus),
Osteogenesis imperfecta.
■ Infants and young children:
Bone cyst, Rickets, Osteomyelitis, Disuse
■ Children and adolescents:
Unicameral bone cysts, Nonossifying fibroma, Osteosarcoma, Ewing sarcoma.
■ Adults
Metastases, Giant cell tumor, fibrous dysplasia.
■ Geriatric patients:
Osteoporosis ,Metastases, Hyperparathyroidism
4. According to management:
 Correctable disorders include disuse
osteoporosis, hyperparathyroidism, renal
osteodystrophy, and steroid-induced
osteoporosis.
 Noncorrectable disorders include osteogenesis
imperfecta, Paget disease, rheumatoid arthritis,
and Gaucher disease.
EVALUATION OF THE PATIENT WITH AN IMPENDING OR ACTUAL
PATHOLOGIC FRACTURE

 A comprehensive evaluation of a patient with a lytic

bone lesion or pathologic fracture is essential.
• History:
– Excessive pain at the site of fracture prior to injury.
– Patients with a known primary malignant disease or
metabolic disease.
– A history of multiple fractures.
– Risk factors such as smoking or environmental
exposure to carcinogens.
■ Review of systems: gastrointestinal symptoms, weight loss, flank pain,
hematuria etc..

■ Physical examination: In addition to the standard physical examination

performed for the specific fracture encountered, attention should be
directed to evaluation of a possible soft tissue mass at fracture site or
evidence of primary disease such as lymphadenopathy, thyroid
nodules, breast masses, prostate nodules, rectal lesions, as well as
examination of other painful regions to rule out impending fractures.
 LABORATORY STUDIES
■ Plain x-rays: chest, affected bone, humerus, pelvis, femur,
spine
■ CT scan: chest, abdomen, pelvis.
■ MRI : to evaluate soft-tissue masses and extent of marrow
involvement
■ Laboratory: complete blood count, erythrocyte
sedimentation rate, calcium, phosphate, urinalysis,
prostate-specific antigen, immunoelectrophoresis, and
alkaline phosphatase etc…
■ Biopsy: needle vs. open
 MANAGEMENT
 Initial Stabilization
■ Many patients have bone pain with activity, and it may occur weeks to
months before pathologic fracture.
– When activity-related pain exists with a radiographically
documented destructive lesion, an ambulatory support to reduce
loading should be recommended.
■ Walker
■ 2 crutches
■ Single cane
 General Measures:
■ Control pain.
■ Reduce forces with walking aid or by placing
patient at bed rest.
 Activity:
■ Reduce activity.
– Recommend ambulatory aid.
– If patient is unable to walk, recommend a
wheelchair.
– If unable to control pain, recommend bed rest.
NON OPERATIVE TREATMENT
 Bracing:
■ Bracing of an impending or actual pathologic fracture
should be performed if the patient is not a surgical
candidate. Nonsurgical candidates are those with limited
life expectancies, severe comorbidities, small lesions, or
radiosensitive tumors. Lesions most amenable to bracing
are those in the humeral diaphysis, forearm, and
occasionally the tibia
Prophylactic management

 often is recommended if the weakened bone state is

detected before the fracture occurs.
■ Impending fracture:
The goals of surgical treatment in a patient with an
impending pathologic fracture are to alleviate pain, reduce
narcotic use, restore skeletal stability, and regain functional
independence.
■ The Mirels system classifies the risk of pathologic fracture based on
scoring four variables on a scale of 1-3: location of lesion, radiographic
appearance, size, and pain. An overall score is calculated, and a
recommendation for or against prophylactic fixation is made.

1 2 3
Location Upper Lower Intertrochan
extremity extremity teric
Radiographic Blastic Mixed Lytic
appearance
Sizea < 1/3 1/3 - 2/3 >2/3
Pain Mild Moderate Functionalb

■ a Size is determined as a fraction of the diameter of the bone.

b Functional pain is defined as severe pain or pain aggravated by limb function .
Fracture Risk % Recommendation
≥9 33-100 Prophylactic fixation is
recommended
=8 15 Clinical judgment should be
used
≤7 <4 Observation and radiation
therapy can be used

Commonly, a lesion is considered to be at risk for fracture if it is painful,

larger than 2.5 cm, and involves more than 50% of the cortex
Advantages of prophylactic management :
Decreased morbidity
Decreased hospital stay
Easier rehabilitation
More immediate pain relief
Faster surgery and less complications
OPERATIVE TREATMENT

■ Goals of surgical intervention are:

– Prevention of disuse osteopenia.
– Mechanical support for weakened or fractured bone to permit the
patient to perform daily activities.
– Pain relief.
– Decreased length and cost of hospitalization.
■ Internal fixation, with or without cement augmentation, is
the standard of care for most pathologic fractures,
particularly long bones. Internal fixation will eventually fail if
the bone does not unite.
■ in the upper limb have traditionally been managed
with bridge plate stabilization
■ intramedullary nailing may be indicated in
humerus shaft fracture.
■ External fixation or cast immobilization usually is
preferred in case of osteomyelitis
■ If bone loss is significant, the defect can be filled
with autogenous bone graft, a vascularized
osseous graft, or bone transport using the Ilizarov
technique.
■ Subtrochnteric and intertrochanteric fracture
treated with reconstruction nail or interlocking
nail.
■ femoral head and neck usually are best treated by
removal of the head and neck and replacement
with a femoral head prosthesis, If the acetabulum
is not involved, a hemiarthroplasty may be
indicated; however, with acetabular involvement,
total hip replacement is required.
■ Single vertebral metastasis with cord compression: Surgery
■ Multiple spinal metastasis : Radiotherapy
■ Diffuse skeletal metastasis with severe pain : Radionuclide
therapy
 Simple bone cysts tend to disappear once decompressed
by the trauma. Treated as any other fracture. In other
words the majority will need simple reduction and a plaster
cast. The exception is a fracture about the proximal femur.
Here open reduction and internal fixation is preferred.
■ Recurrence of a cyst is an indication to do curretage and
bone graft
Amputation may needed in
■ Pathological fracture through a high-grade sarcoma,especially if there
is a poor response to induction chemotherapy → Forequarter
amputation entails surgical removal of the entire upper extremity,
scapula, and clavicle).
■ contamination of soft tissue during biopsy.
■ non healing pathological fracture.
CONTRAINDICATIONS TO SURGICAL MANAGEMENT

■ Contraindications to surgical management of

pathologic fractures are:
– General condition of the patient inadequate to tolerate anesthesia
and the surgical procedure.
– Mental obtundation or decreased level of consciousness that
precludes the need for local measures to relieve pain.
– Life expectancy of <1 month
POST OPERATIVE MANAGEMENT

■ Perioperative antibiotic coverage.

■ Post operative calcium support for healing especially in first week with
taking in consideration a specific conditions such as breast cancer
frequently are hypercalcemic from the high number of bone metastases
and may require detoxification of calcium rather than supplementation.
■ prophylaxis for embolic events.
■ Aggressive postoperative pulmonary toilet.
■ Early mobilization are all instituted as standard treatment
Complications

– Loss of fixation is the most common

complication in the treatment of
pathologic fractures, owing to poor
bone quality.
– Infection
– Delayed wound healing
– Failure to heal
 PROGNOSIS

 After treatment of a pathologic fracture, the bone may or

may not heal. The factors that influence whether healing
will occur include location of the lesion, extent of bony
destruction, tumor histology, type of treatment, and length
of patient survival
■ The prognosis depends entirely on the underlying process.
■ Benign diagnoses: Excellent