FRAKTUR PATOLOGIS

DEFENISI
• Fraktur yang terjadi pada tulang yang abnormal, yang
dihasilkan dari suatu trauma ringan yang biasanya tidak akan
menyebabkan fraktur pada tulang yang normal.
• Fraktur patologis terjadi pada bagian tulang yang paling
lemah atau dimana terdapat massa tumor.
• Tulang merupakan jaringan yang secara dominan
tersusun atas collagen protein (pembentuk kerangka
yang kuat namun rapuh) dan Calcium Phosphate
(mineral yang menguatkan kerangka).
• Tulang secara terus menerus diperbaharui melalui
proses yang disebut bone remodeling, mencakup
resorpsi tulang dan pembentukan tulang.
Klasifikasi Fraktur Patologis
Berdasarkan faktor penyebab
Proses intrinsic termasuk kasus osteogenesis
imperfecta dan tumor tulang
Proses extrinsic termasuk riwayat operasi
sebelumnya (biopsy, fiksasi tulang, dan
sebagainya) dan radioterapi
Berdasrkan pola penyebaran ke tulang
Pada penyakit sistemik seperti Osteoporosis,
Penyakit Metastasis Tulang, penyakit metabolic
(hiperparatiroid)
Penyebaran secara local seperti pada primary
bone tumor.
Berdasarkan usia
Pada neonates seperti Neonatal Osteopenia (penyakit defisiensi mineral
seperti calcium dan phosphor), dan Osteogenesis Imperfecta
Pada bayi dan anak anak : penyakit Riketsia, Osteomyelitis, bone cyst
Pada remaja : Unicameral bone cyst, non ossifying fibroma, Osteosarcoma,
dan Ewing Sarcoma
Pada orang dewasa : Metastasis tulang, Giant Cell Tumor, Fibrous Dysplacia
Penderita usia tua : Osteoporosis, metastasis, hiperparatidroid
Berdasarkan penatalaksanaan fraktur
Kelainan yang dapat diperbaiki termasuk osteoporosis akibat
extremitas yang tidak digunakan, hiperparatiroid, renal
osteodystrophy, dan osteoporosis yang dipicu oeh penggunaan
steroid
Kelainan yang tidak dapat diperbaiki seperti Osteogenesis
Imperfecta, Paget disease, Rheumatoid Arthritis, dan Gaucher
disease
Pemeriksaan pasien dengan Fraktur patologi atau dengan Impending
pathological fracture

Pemeriksaan secara berkesinambungan

diperlukan pada pasien dengan lytic bone lesion atau
pada asien dengan fraktur patologis.
Riwayat penyakit:
Nyeri hebat pada daerah fraktur yang sebelumnya mengalami
cedera
Pasien dengan penyakit malignant atau pada penderita penyakit
metabolic
Riwayat fraktur multiple
Faktor resiko, seperti merokok atau paparan dengan zat karsinogen
Gejala Sistemik:
Gejala gejala gastrointestinal, kehilangan
berat badan nyeri pada daerah pinggang atau
hematuria.
Pemeriksaan Fisik
Selain pemeriksaan fisik standar yang dilakukan pada kasus
fraktur, harus diperhatikan adanya kemungkinan adanya
massa jaringan lunak pada daerah fraktur atau adanya
penyakit seperti lymphadenopathy, tiroid, massa pada
payudara, pembesaran prostat, serta pemeriksaan pada
daerah lainnya untuk menyingkirkan resiko impending fracture.
Plain X-Ray: X-ray thorax, humerus, pelvis, femur, tulang belakang, dan
pada tulang yang sakit
CT-Scan: Thorax, abdomen, dan pelvis
MRI: untuk mengevaluasi massa soft tissue dan kemungkinan penyebaran
ke sum sum tulang
Laboratorium: Pemeriksaan darah lengkap, Laju endap darah, Calcium,
Phosphate, urinalisa, Prostate specific antigen, immunoelectrophoresis, dan
alkali fosfatase.
Biopsy : Open Biopsi dan Biopsi jarum
Penanganan

Penanganan Awal
Kebanyakan penderita mengeluh nyeri tulang pada saat
beraktivitas, dan berlangsung selama beberapa minggu sampai
menahun sebelum timbul adanya fraktur patologis
Apabila terdapat nyeri pada saat beraktivitas disertai adanya
lesi destruksi pada gambaran radiologi, dibutuhkan alat bantu
untuk mengurangi beban tubuh seperti Walker atau tongkat
Penanganan secara umum
mengendalikan nyeri, dan meengurangi beban dengan
menggunakan alat bantu berjalan atau dengan tirah baring
Aktivitas:
mengurangi aktivitas dengan penggunaan alat bantu. Apabila
pasien tidak dapat berjalan, disarankan untuk menggunakan kursi
roda, dan apabila pasien tidak dapat mengendalikan rasa nyeri
disarankan untuk tirah baring
Penanganan Non Operatif
Bracing
• apabila pasien tidak memenuhi syarat untuk dilakukan penanganan
Operative, Bracing merupakan pilihan untuk penanganan fraktur
patologis maupun impending fracture.
• Syarat untuk terapi Non Operative yaitu pasien dengan angka
harapan hidup kecil, angka kematian tinggi, lesi yang kecil, atau
pada penderita yang berespons dengan radioterapi
Profilaksis
Direkomendasikan jika tulang yang melemah ditemukan terlebih
dahulu sebelum terjadinya fraktur patologis.
Penanganan Impending fracture:
Tujuan terapi operative pada pasien dengan impending pathologic
fracture adalah untuk menghilangkan nyeri, mengurangi
penggunaan obat narkotik, mengembalikan stabilitas tulang, dan
mengembalikan fungsi.
Operative treatment
Tujuan dari pembedahan:
- Mencegah disuse osteopenia
- Mechanical support untuk tulang yang lemah atau tulang yang patah agar penderita dapat
menjalankan aktivitas sehari hari
- Meredakan nyeri
- Mengurangi lama rawat dan biaya rumah sakit
Internal fiksasi, dengan atau tanpa penggunaan semen, merupakan standard untuk kasus
fraktur patologis, terutama pada tulang panjang. Internal fiksasi tidak berhasil apabila tulang
tidak menyambung.
Komplikasi
- Fiksasi tulang yang gagal merupakan komplikasi tersering,
akibat buruknya keadaan tulang
- Infeksi
- Lamanya penyembuhan luka
- Kegagalan penyembuhan
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.
BASICS
Approximately 1.5 million people sustain a pathologic fracture annually in America.
Bone is a living tissue made predominantly of protein collagen (which provides a
strong yet malleable framework) and calcium phosphate (a mineral that ensures
strengthening of the framework).
Bones are continuously being renewed through a process called bone remodeling,
involving bone resorption and bone formation.
CLASSIFICATION OF 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 .
CLASSIFICATION OF CAUSES
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
CLASSIFICATION OF CAUSES
3. According to age:

 Children and adolescents:

Unicameral bone cysts, Nonossifying fibroma, Osteosarcoma, Ewing
sarcoma.
 Adults: Metastases, Giant cell tumor, fibrous dysplasia.
 Geriatric patients:
osteoporosis ,Metastases, Hyperparathyroidism.
CLASSIFICATION OF CAUSES
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.
EVALUATION
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.
EVALUATIONS
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
MANAGEMENT
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.
CLASSIFICATION
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
Location Upper
extremi
Radiographic Blastic
appearance
Sizea < 1/3
Pain Mild
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 Ris
≥9

=8

≤7

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.
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
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