2.

1 Imaging

X-ray examination is mandatory. Remember the rule of twos:

 Two views: a fracture or a dislocation may not be seen on a single x-ray lm; at least two
views (anteroposterior and lateral) must be obtained.
 Two joints: the joints above and below the fracture must always be included on the x-ray
images; they may be dislocated or fractured.
 Two limbs: a pre-existing constitutional abnormality may be mistakenly attributed to the
recent injury; and in children, the appearance of immature epiphyses may confuse the
diagnosis of a periarticular fracture. X-rays of the uninjured limb are essential for
comparison.
 Two injuries: severe force often causes injuries at more than one level. Thus, with fractures
of the calcaneum or femur it is important also to x-ray the pelvis and spine.
 Two occasions: some fractures are notoriously dif cult to detect soon after injury, but
another x-ray examination a week or two later may show the lesion. Common examples
are undisplaced fractures of the distal end of the clavicle, the scaphoid, the femoral neck
and the lateral malleolus, and also stress fractures and

2.2 Pathological Fractures

When abnormal bone gives way this is referred to as a pathological fracture. The causes are
numerous and varied (Table 23.1). Often the diagnosis is not made until a biopsy is examined.
Clinical features

Bone that fractures spontaneously or after trivial injury must be regarded as abnormal until
proved otherwise. Under the age of 20 years the common causes are benign bone tumours and
cysts. Over the age of 40 years the common causes are metabolic bone disease, myelomatosis,
secondary carcinoma and Paget’s disease. Ask about previous illnesses or operations: a history of
gastrointestinal disease, chronic alcoholism or prolonged corticosteroid therapy should suggest a
metabolic bone disorder; a malignant tumour, no matter how long ago it occurred, may be the
source of a late metastatic lesion.

Local signs of bone disease should not be missed. General examination may show features
suggestive of hypercortisonism or Paget’s disease, or generalized tissue wasting due to malignant
disease.

X-rays

Understandably, the fracture itself attracts most attention. But the surrounding bone must also be
examined and features such as cyst formation, cortical erosion, abnormal trabeculation and
periosteal thickening should be sought. The type of fracture, too, is important: vertebral
compression fractures may be due to severe osteoporosis or osteomalacia, but they can also be
caused by skeletal metastases or myeloma. Radio- isotope scans may reveal deposits elsewhere
in the skeleton, where further imaging studies can be concentrated.

Special investigations

Investigations should include a full blood count, erythrocyte sedimentation rate, protein
electrophoresis and tests for metabolic bone disease. Urinalysis may reveal blood from a tumour
or Bence–Jones protein.

Biopsy

Some lesions are so typical that a biopsy is unnecessary (solitary cyst, fibrous cortical defect,
Paget’s disease). Others are more obscure and a biopsy is essential for diagnosis. If open
reduction of the fracture is indicated, the biopsy can be done at the same time; otherwise a
definitive procedure should be arranged.

Treatment (see also Chapter 9)

The principles are the same as for other fractures, though the choice of method will be in
uenced by the condition of the bone. The underlying pathological disorder may also need treatment
in its own right.
Generalized bone disease

In most of these conditions (including Paget’s disease) the bones fracture more easily, but they
heal quite well provided the fracture is properly immobilized. Internal xation is therefore advisable
(and for Paget’s disease almost essential); this also reduces the risk of re-fracture. Patients with
osteomalacia, hyperparathyroidism, renal osteodystrophy and Paget’s disease may need systemic
treatment as well.

Local benign conditions

Fractures through benign cyst-like lesions usually heal quite well and they should be allowed to
do so before tackling the underlying lesion. Treatment is therefore the same as for simple fractures
in the same area, although in some cases it will be necessary to take a biopsy before immobilizing
the fracture. When the bone has healed, the tumour can be dealt with by curettage or local excision.

Primary malignant tumour

The fracture may need splinting but this is merely a prelude to definitive treatment of the tumour,
which by now will have spread to the surrounding soft tissues. The prognosis depends on the type
of tumour. Limb-sparing surgery is often possible with modern endoprosthetic replacements.

Metastatic tumours

Metastasis is a frequent cause of pathological fracture in older people. Breast cancer is the
commonest source and the femur the commonest site. Nowadays cancer patients (even those with
metastases) often live for several years and effective treatment of the fracture will vastly improve
their quality of life. Preoperatively, imaging studies should be performed to detect other bone
lesions; these may be amenable to ‘prophylactic’ xation.

Fracture of a long-bone shaft should be treated by internal fixation; intramedullary nails are more
suitable than plates and screws and, if necessary, the site is also packed with acrylic cement. This
may be followed by local irradiation.

Fracture near a bone end can often be treated by excision and prosthetic replacement, especially
in the case of femoral neck fracture.

Pathological compression fractures of the spine

cause severe pain. This is due largely to spinal instability and treatment should include operative
stabilization. If there are clinical or imaging features of actual or threatened spinal cord or cauda
equina compression, the affected segment should be decompressed; postoperative irradiation may
also be needed.
Referensi:
1. Apley AG, Solomon L. Apley’s system of orthopaedics and fractures. 4th ed. London:
Hodder Arnold. 2014. P.330.
2. Apley AG, Solomon L. Apley’s system of orthopaedics and fractures. 4th ed. London:
Hodder Arnold. 2014. P.335.