REFERAT

PATHOLOGIC FRACTURES

Pembimbing
:
dr. R.M. Tjahja Nurroby, M.kes, Sp.OT (K) Hand

Disusun oleh :
Wan Muhammad Mulkan, S.ked
030.12.277

KEPANITERAAN ILMU KLINIK BEDAH

FAKULTAS KEDOKTERAN UNIVERSITAS TRISAKTI
RSAL DR. MINTOARDJO
PERIODE
JAKARTA, MARET 2018
LEMBAR PENGESAHAN
REFERAT
PATHOLOGIC FRACTURES

Diajukan untuk memenuhi syarat kepaniteraan klinik Ilmu bedah

Periode – 2018
Di Rumah Sakit Angkatan Laut dr. Mintohardjo
 Disusun oleh :
Wan Muhammad Mulkan
030.12.277

Telah diterima dan disetujui oleh dr. T. Nurrobi, Sp.OT(K)Hand,

selaku dokter pembimbing
Departemen Ilmu Bedah RS AL dr. Mintohardjo

Jakarta,

dr. R.M.Tjahja Nurrobi, M.Kes, Sp.OT (K) Hand

KATA PENGANTAR

Puji syukur kehadirat Tuhan Yang Maha Esa karena atas berkat dan rahmat-Nya,
penulis dapat menyelesaikan referat yang berjudul “Pathologic Fractures”. Penulisan Referat
ini dilaksanakan dalam rangka memenuhi sebagian persyaratan salah satu tugas kepaniteraan
ilmu klinik Bedah di Rumah Sakit Angkatan Laut Dr. Mintohardjo periode. Penulisan referat
ini tidak akan selesai tanpa dukungan dan bimbingan berbagai pihak. Oleh karena itu, penulis
mengucapkan terima kasih kepada dr. R.M.Tjahja Nurrobi, M.Kes, Sp.OT (K) Hand selaku
dokter pembimbing yang telah menyediakan waktu, tenaga, dan ilmunya untuk mengarahkan
penulis dalam penyusunan referat ini.
Penulis menyadari bahwa penulisan referat ini masih jauh dari sempurna. Oleh karena
itu, kritik dan saran sangat penulis perlukan demi melengkapi laporan kasus ini. Akhir kata,
semoga Tuhan membalas kebaikan semua pihak dan laporan kasus ini hendaknya membawa
manfaat bagi pengembangan ilmu pengetahuan, profesi, dan masyarakat luas.
 Jakarta, Maret 2018

Wan Muhammad Mulkan S.Ked

DAFTAR ISI

LEMBAR PENGESAHAN
KATA PENGANTAR
DAFTAR ISI
TABEL GAMBAR
BAB I INTRODUCTION
BAB II PATHOLOGIC FRACTURES
2.1 Anatomy
2.2 Definition
2.3 Epidemiology
2.4 Etiology
2.5 Mechanism of Injury
2.6 Risk Factor
2.7 Classification
2.8 Symptoms
2.9 Diagnosis and Investigations
2.10 Treatment
2.11 Preventions
 BAB I
INTRODUCTION

A pathological fracture occurs without adequate trauma and is caused by pre-existent

pathological bone lesion. A bone fracture is a complete or incomplete discontinuity of bone
caused by a direct or indirect force. 5% of all fracture are pathological fractures due to local
or systemic diseases.(1)
Metastatic bone disease from breast, lung, kidney, prostate, thyroid are
haematological malignancies including multiple myeloma are common caused of
pathological fracture. Other causes include endocrinopathies (cushing’s syndrome,
thyrotoxicosis, hyperparathyroidism, diabetes mellitus, male hypogonadism and growth
hormone deficiency), osteomalacia of varied etiology (vitamin D deficiency and resistance,
hypoposphaspataemia, chronic kidney disease, renal tubular acidosis, mineralization
inhibitors, hypophosphatasia, inadequate calcium intake) and drugs (glucocorticoids,
thiazolidinediones, antiepileptic drugs, proton pump inhibitors, antidepressants,
antipsychotics, long term heparin, L-thyroxin overdose and androgen deprivation therapy).
Less common causes are gastrointestinal disorders (celiac disease, inflammatory bowel
disease, gastrointestinal surgery), HIV infection, non-malignant haematological diseases
(thalassemia, systemic mastocytosis) and rheumatological diseases (rheumatoid arthritis,
ankylosing spondylitis and systemic lupus erythomatosus). Uncommon bone diseases like
osteogenesis imperfect, paget’s disease of bone and polyostotic fibrous dysplasia are also
important causes of pathological fracture.(1)
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.(2)

BAB II
2.1 Anatomy
The main function of the musculoskeletal system is to support and protect soft tissues
and to assist with movement. Bones, muscle, tendons, ligament and joints function to
generates and to transfer forces so that to our limbs can be manipulated in three-dimentional
space.(3) The tissue bone is considered from two entirely different points of view: 1)
individual bones are anatomical structures and 2) bone of the entire skeleton collectively is a
physiological organ that is metabolically active.(4)
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.(4)
The structure of a long bone allows for the best visualization of all of the parts of a
bone. 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, which is filled with yellow marrow. The walls
of the diaphysis are composed of dense and hard compact bone.(5)

Figure 1. Anatomy of long 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”). The periosteum contains blood vessels, nerves, and lymphatic vessels that
nourish compact bone. Tendons and ligaments also attach to bones at the periosteum. The
periosteum covers the entire outer surface except where the epiphysis meet other bone joints.
In this region, the epiphysis are covered with articular cartilage, a thin layer of cartilage that
reduces friction and acts as a shock absorber.

Figures 2. Periosteum and endosteum

Mature long bone have 3 distinct zones : epiphyseal, metaphyis and diaphysis. In the
development, the epiphysis and metaphysis are separated by a fourth zone, known as the
epiphyseal plate, or physis.(5)

Epiphysial plate (phisis)

An extremely important zone in human development, the epiphyseal plate is responsible for
longitudinal growth of the skeleton and therefore one’s height and stature.The epiphyseal
plate provides growth in the length of the metaphysis and diaphysis of long bone. Four zone
of ephypisis zone of the epiphyseal plate can be distinguired : (4)
1. The zone of resting cartilage anchors the epiphyseal plate to the epiphysis and contains
immature chondrocytes, as well as delicate blood vessels that penetrate it from the epiphysis
and bring nourishment to the entire plate.
2. The zone of young proliferating cartilage is the site of most active interstitial growth of the
cartilage cells, which are arranged in vertical collumns.
3. The zone of maturing cartilage reveals a progressive enlargement and maturation of the
cartilage cells as they approach the metaphysis. These chondrocytes accumulate glycogen in
their cytoplasm and produce phosphatase which may be involved in the calcification of their
surrounding matrix
4. The matrix of calcifying cartilage is thin and its chondrocytes have died as a result of
calcification of the matrix. This is structurally the weakest zone of the epiphyseal plate. Bone
deposition is active on the metaphyseal side of this zone and as new bone is added to the
calcified cores as cartilage matrix, the metaphysis becomes correspondingly longer.(4)

Figures 3. Histological appearance of an epiphyseal plate

Metaphisis
The metaphysis is a transitional zone between the epiphysis and diaphyis. It is also
characterized by thinner cortical walls with dense trabecular bone. Is is commonly the site of
tendinous attachments to bone. It is a metabolically active region and often supports a fair
amount of bone marrow. The metaphysis is the region where the bone made by the
epiphyseal plate is fine-tuned into its diaphyseal shape.(6)

Diaphysis
In the middle of long bones is the diaphysis, a segment of thick cortical bone with a
minimal amount of trabecular bone. It is often smaller in diameter than metaphyseal and
epiphyseal bone; because its thick cortical layer is extremely strong, it does not require a
large diameter to distribute its load. The central portion is the least dense area of the bone and
is known as the intramedullary canal. The area of the bone inside the cortex is continuous
throughout an entire bone and is known as the endosteal area.(6)
Diaphyseal bone’s primary function is structural: it gives the skeleton much of its
length and providing much of the surface area for muscular and tendinous attachment.(6)

Bone cells and tissue

Bone certains a relative small number of cells entrenched in a matrix of collagen
fibers that provide a surface for inorganic salt crystals to adhere. These salt crystals form
when calcium phosphate and calcium carbonate combine to create hydroxyapatite, which
incorporates other inorganic salts like magnesium hydroxide, fluoride, and sulfate as it
crystallizes, or calcifies, on the collagen fibers. The hydroxyapatite crystals give bones their
hardness and strength, while the collagen fibers give them flexibility so that they are not
brittle. Although bone cells compose a small amount of the bone volume, they are crucial to
the function of bones. Four types of cells are found within bone tissue: osteoblasts,
osteocytes, osteogenic cells, and osteoclasts.(5)

Figure 4. Bone cells

The osteoblast is the bone cell responsible for forming new bone and is found in the
growing portions of bone, including the periosteum and endosteum. Osteoblasts, which do
not divide, synthesize and secrete the collagen matrix and calcium salts. As the secreted
matrix surrounding the osteoblast calcifies, the osteoblast become trapped within it; as a
result, it changes in structure and becomes an osteocyte, the primary cell of mature bone and
the most common type of bone cell. Each osteocyte is located in a space called a lacuna and
is surrounded by bone tissue. Osteocytes maintain the mineral concentration of the matrix via
the secretion of enzymes. Like osteoblasts, osteocytes lack mitotic activity. They can
communicate with each other and receive nutrients via long cytoplasmic processes that
extend through canaliculi (singular = canaliculus), channels within the bone matrix.(5)
The dynamic nature of bone means that new tissue is constantly formed, and old,
injured, or unnecessary bone is dissolved for repair or for calcium release. The cell
responsible for bone resorption, or breakdown, is the osteoclast. They are found on bone
surfaces, are multinucleated, and originate from monocytes and macrophages, two types of
white blood cells, not from osteogenic cells. Osteoclasts are continually breaking down old
bone while osteoblasts are continually forming new bone. The ongoing balance between
osteoblasts and osteoclasts is responsible for the constant but subtle reshaping of bone.(5)

Cell type Function Location

Osteogenic cells Develop into osteoblast Deep layers of the periosteum and the
marrow
Osteoblasts Bone formation Growing portions of bone, including
periosteum and endosteum
Osteocytes Maintain mineral concentration Entrapped in matrix
of matrix
Osteoclasts Bone resorption Bone surfaces and at sites of old,
injured, or unneeded bone
Table 1. review the bone cells, their function and locations(5)

Compact bone
Compact bone is the denser, stronger of the two types of bone tissue. It can be found
under the periosteum and in the diaphyses of long bones, where it provides support and
protection.(5)
The microscopic structural unit of compact bone is called an osteon, or Haversian
system. Each osteon is composed of concentric rings of calcified matrix called lamellae
(singular = lamella). Running down the center of each osteon is the central canal, or
Haversian canal, which contains blood vessels, nerves, and lymphatic vessels. These vessels
and nerves branch off at right angles through a perforating canal, also known as Volkmann’s
canals, to extend to the periosteum and endosteum.(5)
The osteocytes are located inside spaces called lacunae (singular = lacuna), found at
the borders of adjacent lamellae. As described earlier, canaliculi connect with the canaliculi
of other lacunae and eventually with the central canal. This system allows nutrients to be
transported to the osteocytes and wastes to be removed from them.(5)

Figure 5. Diagram of Compact Bone

Spongy (Cancellous) Bone
Like compact bone, spongy bone, also known as cancellous bone, contains osteocytes
housed in lacunae, but they are not arranged in concentric circles. Instead, the lacunae and
osteocytes are found in a lattice-like network of matrix spikes called trabeculae (singular =
trabecula). The trabeculae may appear to be a random network, but each trabecula forms
along lines of stress to provide strength to the bone. The spaces of the trabeculated network
provide balance to the dense and heavy compact bone by making bones lighter so that
muscles can move them more easily. In addition, the spaces in some spongy bones contain
red marrow, protected by the trabeculae, where hematopoiesis occurs.(5)

Figure 7. Diagram of Spongy Bone

Anatomy of Axial Skeleton

The skeleton is divided into 2 anatomic regions: axial and appendicular. The
appendicular skeleton comprises the extremities, which are paired mirror images of each
other. The axial skeleton is the central structural core of the body. The auditory ossicles and
the hyoid bone are nonstructural, nonextremity bones that are used in sensation, phonation,
and swallowing; they do not fit well into either category.(6)
The axial skeleton includes the bones of the skull, cervical vertebrae, thoracic
vertebrae, ribs, sternum, lumbar vertebrae, and the sacrum and coccyx (see the image below).
Some authors consider the bones of the pelvis to be axial, although they properly belong to
the appendicular skeleton.(6)
 Figure 8. Human Skeleton

The skull is made of many interdigitating flat bones with numerous sinuses, foramina,
and features; detailed discussion of these features is beyond the scope of this article. The
main joints of the skull are the articulations between the mandible and skull and the
articulation between C1 and the base of the skull. The skull’s primary purpose is to house the
brain and sensory organs. The bones of the skull also allow mastication, swallowing,
phonation, and numerous other vital functions.(6)
The cervical spine is made up of 7 vertebrae (see the first and second images below).
C1 and C2 are highly specialized and are given unique names: atlas and axis, respectively
(see the third image below). C1 and C2 form a unique set of articulations that provide a great
degree of mobility for the skull. C1 serves as a ring or washer that the skull rests upon the
dens or odontoid process of C2. Approximately 50% of flexion extension of the neck happens
between the occiput and C1; 50% of the rotation of the neck happens between C1 and C2.(6)

Figure 9. Human spine from C1 to sacrum

The lumbar spine is the next mobile segment of the spine, typically consisting of 5
large vertebrae with classic features, including body, pedicles, lamina, spinous processes,
facet joints, and lateral processes (see the image below). The lumbar spine is mobile with all
articulations, contributing to flexion-extension, bending, and rotation. The lumbar spine
allows truncal mobility.
The lumbar spine connects to the sacrum through the L5-S1 articulation (see the images
below). The wedge-shaped sacrum is a fused set of sacral vertebrae. Its primary purpose is to
transfer the load from the spine to the pelvis. This happens through the extremely strong and
immobile sacroiliac joints. The sacrum also houses the sacral nerve roots from the terminal
end of the spinal canal. At the end of the sacrum is the coccyx, which is the vestigial remnant
of the tail.

Upper Extremity
The upper extremities are mirrored paired structures. The upper extremity starts at the
shoulder girdle and extends to the finger tips. The shoulder girdle consists of the scapula and
the clavicle (see the first and second images below). The clavicle is an S-shaped bone that
provides a strut on which the shoulder girdle articulates. It originates at the sternoclavicular
joint and terminates at the acromioclavicular joint.

Figure 8. Shoulder girdle, composed of clavicle and scapula

The scapula is a multifunctional bone. Its body (the wide and flat medial portion) is
the site of origin of the rotator cuff muscles. Additionally, the scapula articulates with the
chest wall to give the shoulder a greater net motion that could be achieved with just
glenohumeral motion. The body of the scapula then turns into the neck and flattens into the
shallow glenoid cavity.(6)
The glenoid cavity is the socket of the ball-and-socket joint of the shoulder (the
glenohumeral joint). It is a deficient socket, being very flat. Accordingly, the soft tissue
labrum, ligaments, and muscular attachments are crucial in stabilizing this joint.(6)
In addition, the scapula has a process that protrudes superiorly and another that
protrudes anteriorly. These are called the acromion and the coracoid, respectively, and both
serve 2 functions. The primary function is soft tissue attachment: the deltoid to the acromion
and the conjoint tendon to the coracoid. The secondary function is secondary stabilization of
the glenohumeral joint.(6)

Arm
The only bone of the arm is the humerus. This bone starts with a ball-and-socket type
joint at the glenohumeral articulation and terminates at the elbow in a hingelike joint (see the
images below). The humerus is a long tubular bone. Its proximal portion allows highly
mobile motion at the shoulder. Its shaft has numerous muscular attachments for muscles
controlling shoulder motion and elbow motion. There are even muscles acting distal to
forearm that attach on the humerus and cross multiple joints.(6)

Figure 9. Humerus

Forearm
The forearm is made up of the radius and the ulna (see the images below). The ulna is
the principal weight-bearing articulation at the elbow through the olecranon. The radius is the
principal weight-bearing articulation at the wrist. The load is transitioned between the 2
through the syndesmotic interosseous ligament. The anatomy of the radius and ulna allow
pronation and supination of the wrist.(6)
 Figure 10. Bone of for arm

Wrist

The wrist comprises 7 bones: scaphoid, lunate, triquetrum, pisiform, trapezoid, trapezium,
capitate, and hamate (see the images below). The bones are divided into 2 rows: proximal and
distal.(6)

Figure 11. Carpal bones, metacarpals and phalanges

All of the bones of the wrist are small and unique in shape. The scaphoid, lunate,
triquetrum, and pisiform make up the proximal row and primarily articulate with the distal
radius. This complex articulation accounts for a high proportion of wrist flexion/extension
and radial/ulnar deviation. The proximal row and distal row are intimately connected and
have multiple ligamentous structures to stabilize them. The metacarpals articulate with the
distal row.(6)

Lower Extremity
The lower extremities are mirrored paired structures. The lower extremity starts at the
pelvis and extends to the toes.(6)

Hip bone
The os coxae, or hip bone, is occasionally (and incorrectly) considered part of the axial
skeleton. It is a fusion of 3 bones bilaterally (6 total): ilium, ischium, and pubis.(6)
The ilium is a large, curving flat-type bone that connects the sacrum to the pelvic
girdle. It has a very broad area of muscle attachment and many palpable bony prominences,
such as the anterior superior iliac spine (ASIS). The ischium attaches to the ilium at the
acetabulum and makes up the bony floor of the pelvis. It also has many muscular and
ligamentous attachments. It is the bone that one sits on when seated.(6)

The pubis also connects to the ilium and ischium at the acetabulum and forms the
superior anterior portion of the ring. The anterior midline bony prominence that can be
palpated represents the pubic bones coming together in the front at the symphysis pubis.(6)
The 3 bones are fused and contribute to the acetabulum, a cup-shaped fossa that is the
socket of the ball-and-socket hip joint (see the image below). In addition to the spine, the hip
bone is the most important source of bone marrow in adult life.(6)

Figure 12. sacrum, ischium and pubis

Femur

The femur (see the images below) is the longest and strongest of the human bones.
Proximally, the femur is the ball of the ball-and-socket joint of the hip (a highly congruent
joint). The femoral head is grossly spherical in nature, permitting a great deal of joint motion
in all planes. It has a tenuous blood supply and is sensitive to avascular necrosis.(6)
The femoral head is attached to the femur through the femoral neck. The femoral neck
is angled approximately 135 degrees in the coronal plane and approximately 20-30 degrees in
the sagittal plane relative to the femoral shaft, with allowances for lateral offset of the shaft.
This orientation gives the muscles working around this joint much more power, because of
their extended lever arm.(6)
The femoral shaft is long and tubular, with a gentle bow in the anteroposterior
direction. It terminates at the femoral condyles, which make up half of the knee joint. It takes
an immense amount of force to break a femur in a healthy individual; fracture of this bone is
a marker of severe trauma.(6)

Patella
The patella (see the image below) is essentially a giant sesamoid bone. It lies within
the tendon of the quadriceps femoris and moves the tendon away from the center of joint
rotation to give the muscles a greater mechanical ability to move the joint in extension. The
patella can be subjected to as much as 8 times a person's body weight when the knee is
actively in use. It has the thickest articular cartilage of any bone and rides in a groove
between the medial and lateral femoral condyles (known as the trochlea).(6)

Tibia
The tibia (see the images below), commonly referred to as the shin bone, starts
proximally as a wide, nearly flat surface called the tibial plateau, with which the femoral
condyles articulate to form the knee joint. Because the condyles are rounded and the plateau
is minimally concave, this joint is inherently unstable and requires multiple soft tissue
supporting structures for stability. The knee joint mostly flexes and extends but does allow
some internal and external rotation.(6)
The tibial shaft is triangular and strong and, like the femur, has a slight bow. It
terminates at the ankle joint, where the tibia forms a flat weight-bearing portion of the ankle
(the plafond) and the medial stabilizer of the joint (the medial malleolus).(6)
 Figure 13. Tibia and Fibula

Fibula
The fibula is an interesting bone, in that it bears no weight but nonetheless has crucial
functions in knee and ankle articulation. At the knee, the fibular head articulates (minimally)
with the proximal tibia and is crucial for the attachment of soft tissues, including the lateral
collateral ligament (LCL), for knee stability.(6)
The midshaft of the fibula has muscular attachments but is not essential and is often
harvested if vascularized bone autografts are needed for reconstructions. The distal end
makes up the strong tibiofibular joint and the lateral aspect of the ankle joint. The fibula and
tibia are tightly connected through a set of strong soft tissue ligaments called the syndesmotic
complex.(6)

Talus
The talus has 2 distinct regions: body and head. These are connected through the talar
neck. The body has a large superior dome that fits inside the box made up of the fibula, the
tibial plafond, and the medial malleolus. This joint is what is considered the ankle joint (see
the images below); it allows dorsiflexion and plantar flexion of the foot.(6)
 On the underside of the talar body and head is a series of complex articulations with
the calcaneus; these are known as the subtalar joints. The subtalar joints allow inversion and
eversion of the hind foot. The talar head articulates with the navicular to form one of the
hindfoot-midfoot connections.(6)

Calcaneus
The calcaneus (see the image below) is a large, uniquely shaped bone. It makes up the
remainder of the articulations with the midfoot and subtalar joint.
The calcaneus is the location of the calcaneal (Achilles) tendon attachment and
therefore is where the muscles act to achieve plantar flexion of the foot. It also is the only
bony component of the heel and therefore is subject to fracture in falls or trauma when a
person lands on his or her feet. The calcaneus is the proximal extent of the soft tissue
"windlass" mechanism that makes up the arch of the foot and is a common site of pain in
disorders such as plantar fasciitis.(6)

Figure 14. Calcaneus

Biochemistry and physiology of bone as an organ

The biomechanical composition of bone is as follows: 30% organic substances, 60%
inorganic (mineral) substances and 10% water.
a. Organic substances
The organic component of bone includes the bone cells as well as the organic
intercellular substance, or matrix. Collagen fibers and non-collagenous proteins
constitute more than 95% of the organic matrix, which also contains small quantities
of reticular fibrils and amorphous substances (including hyaluronic acid and
chondroitin sulfate). The osteocytes constitute only 2% of the organic matrix
b.

1. Approach to Pathological Fracture-Physician’s Perspective

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929546/
3. https://www.intechopen.com/books/biomechanics-in-applications/biomechanics-of-
musculoskeletal-injury
4. Buku dr. herman
5. https://opentextbc.ca/anatomyandphysiology/chapter/6-3-bone-structure/
6. https://emedicine.medscape.com/article/1948532-overview#a2
7.