Pathologic Fractures

• Tumors
• primary
• secondary (metastatic) (most common)
• Metabolic
• osteoporosis (most common)
• Paget’s disease
• hyperparathyroidism
Pathologic Fractures
Benign Tumors
• Fractures more common in benign tumors (vs malignant tumors)
• most asymptomatic prior to fracture
• antecedent nocturnal/rest symptoms rare
• most common in children
• humerus
• femur
• unicameral bone cyst, NOF, fibrous dysplasia, eosinophilic granuloma
Fractures through benign tumors

Unicameral Bone Cyst

• Fractures observed more often in males than

females
• May be active or latent
• Almost always solitary
• First two decades
• Humerus and femur most common sites

Fracture through UBC

“fallen fragment”sign (arrow)
Unicameral Bone Cyst

• Treatment - impending fractures

• observation
• aspiration and injection methylprednisolone, bone marrow or bone graft
• curetting and bone graft (+/-) internal fixation
• Treatment - fractures
• allow fracture to heal and reassess
• ORIF for femoral neck fractures
 Fibroxanthoma

• Most common benign tumor

• Femur, distal tibia, humerus
• Multiple in 8% of patients
(associated with
neurofibromatosis)
• Increased risk of pathologic
fracture in lesions >50%
diameter of bone and >22mm
length
Fibroxanthoma

• Treatment
• observation
• curetting and bone graft for impending fractures
• immobilization and reassess after healing for patients with fracture
 Fibrous Dysplasia

• Solitary vs. multifocal (solitary most common)

• Femur and humerus
• First and second decades
• May be associated withn endocrinopathy
(Albright’s syndrome)
Fibrous Dysplasia

• Treatment
• observation
• curetting and bone graft (cortical structural allograft) to prevent deformity
and fracture (+/-) internal fixation
• expect resorption of graft and recurrence
• pharmacologic—bisphosphonates
Pathologic Fractures
through Primary Malignant Tumors

• Relatively rare (often unsuspected)

• May occur prior to or during treatment
• May occur later in patients with radiation osteonecrosis (Ewing’s,
lymphoma)
• Osteosarcoma, Ewing’s, malignant fibrous histiocytoma,
fibrosarcoma
Pathologic Fractures
Primary Malignant Tumors
• Suspect primary tumor in younger patients with aggressive appearing
lesions
• poorly defined margins (wide zone of transition, lack of sclerotic rim)
• matrix production
• periosteal reaction
• Patients usually have antecedent pain before fracture, especially
night pain
Pathologic Fractures
Primary Malignant Tumors

• Pathologic fracture complicates but does not

mitigate against limb salvage
• Local recurrence is higher
• Survival is not compromised
• Patients with fractures and underlying suspicious
lesions or history should be referred for biopsy
 B

A. Pathologic fracture through MFH

arising in antecedent infarct
A
B. (H&E 100x) Pleomorphic spindled
cells with storiform growth pattern
Pathologic Fractures
Primary Malignant Tumors
• Always biopsy solitary destructive bone lesions even with a history of
primary carcinoma
• Case:
A 62 year-old woman with a history of breast carcinoma presented
with a pathologic fracture through a solitary proximal femoral lesion
 Pre-op Post-

Intermediate grade chondrosarcoma

*fixation of primary bone tumors must not be performed until proper
evaluation has been performed and the diagnosis has been established in
order to prevent potential for spread of tumor.
Pathologic Fractures
Primary Malignant Tumors

• Treatment
• Immobilization
• Traction, ex fix, cast
• staging
• biopsy
• adjuvant treatment (chemotherapy)
• resection/amputation
Fractures through non-neoplastic bone disease

Metabolic Bone Disease

• Osteoporosis
• insufficiency fractures
• Paget’s disease
• early and late stages; most fractures occur in the late stage of disease
• Hyperparathyroidism
• dissecting osteitis
• fractures through Brown tumors
Paget’s Disease
• Radiographic appearance
• Thickened cortices
• Purposeful trabeculae
• Mixed sclerosis/lysis
• Bowing deformities
• Joint arthrosis
• Fracture
• delayed healing
• malignant transformation
• Treatment
• Osteotomy to correct alignment
• Excessive bleeding Fracture through Pagetic
• Joint arthroplasty vs. ORIF bone (arrow). Transverse
fracture suggests
pathologic bone.
Hyperparathyroidism

• Adenoma
• Polyostotic disease
• Mental status changes
Mixed
• Abdominal pain radiodense
• Nephrolithiasis and
radiolucent
• Polyostotic disease
lesions
• mixed radiolucent/radiodense

Multiple brown tumors

in a patient with primary
hyperparathyroidism
 Hyperparathyroidism

• May be secondary to renal

failure
• secondary
• tertiary
• Treatment
• parathyroid adenectomy
• ORIF for fracture
• correct calcium

Pathologic fracture through

brown tumor (arrow)
Fractures in Patients with Metastatic
Disease and Myeloma
• Aside from osteoporosis, most common causes of pathologic fracture
• Fifth decade and beyond
• Appendicular sites: femur and humerus most common
• All metastatic tumors are not treated the same
Not All Mets Created Equal

• Breast – radiosensitive, chemosensitive

• Lung – moderately radiosensitive, chemo sensitivity variable
• Prostate – radiosentive, chemosensitive
• Thyroid – radiosensitive, chemosensitive
• Renal – minimally radiosensitive, variable chemosensitivity
Overall Incidence of Metastases to Bone at
Autopsy

• 70% Jaffe, 1958

• 12% Clain, 1965
• 32% Johnson, 1970
• 21% Dominok, 1982
Incidence of Metastases at Autopsy by
Primary Tumor Site

Primary Site % metastasis to Bone

Breast 50-85
Lung 30-50
Prostate 50-70
Hodgkin’s 50-70
Kidney 30-50
Thyroid 40
Melanoma 30-40
Bladder 12-25
Incidence of Metastases

• 60% of patients with early identified cancer may already have

metastases

• 10-15% of all patients with primary carcinoma will have radiologic

evidence of bone metastases during course of disease
 Route of Metastases

• Contiguous

• Hematogenous
• most common

Destructive lesions in bone from

lung carcinoma (arrows)
Mechanism of Metastases
• Release of cells from the primary tumor
• Invasion of efferent lymphatic or vascular
channels
• Dissemination of cells
• Endothelial attachment and invasion at
distant site
• Angiogenesis and tumor growth at distant site

Metastatic carcinoma
In body pedicle junction
Bone Destruction

• Early
• most important
• osteoclast mediated
• (RANK L)
• Late
• malignant cells may be directly responsible
Metastases of Unknown Origin

• 3-4% of all carcinomas have no known primary site

• 10-15% of these patients have bone metastases
Diagnostic Strategy for Patients with
Unknown Primary
% Primary Tumor
Identified
History and Physical 8%
Chest X-Ray 43%
Chest CT 15%
Abdominal CT 13%
Biopsy 8%

Rougraff, 1993
Defects

• Cortical defects weaken bone especially in torsion

• Two types
• stress riser - smaller than the diameter of bone
• open section defect - larger than the diameter of bone…. causes a 90%
reduction in load to failure and demand augmentation and fixation
Impending Pathologic Fracture

• 61% of all pathologic

fractures occur in the femur
• 80% are peritrochanteric
• fracture in this area results
in significant morbidity
• historic data on impending
pathologic fracture involves
the proximal femur
Impending Pathologic Fracture
• Parrish and Murray, 1970
• increasing pain with advancing cortical destruction of lesions involving
>50% of the shaft diameter
• Beals, 1971
• lesions >2.5 cm are at increased risk to fracture
• Murray, 1974
• increased fracture with destruction of > one-third of the cortex, pain after
radiotherapy
Impending Pathologic Fracture

• Fidler, 1981
% shaft destroyed Incidence Fx (%)
0-25% 0%
25-50% 3.7%
50-75% 61%
>75% 79%

• Conclusion: Patients with tumors destroying >50% of the diameter

of bone require prophylactic internal fixation
Indication for Prophylactic Internal
Fixation
• “Harrington criteria”
• >50% of diameter of bone
• >2.5 cm
• pain after radiation
• fracture of the lesser trochanter
• Limitations
• only for proximal femur
• doesn’t account for tumor biology

Harrington, K.D.: Clin. Orthop. 192:

222, 1985
Mirels Scoring System
Score
1 2 3
Site upper limb lower limb peritrochanteric

Pain mild moderate functional

Lesion blastic mixed lytic

Size <1/3 1/3-2/3 >2/3

Score < 7 – no surgery

Score > 7 – prophylactic fixation
Mirels, H.: Clin. Orthop. 249: 256, 1989.
Adjuvant Treatment

• Radiation
• Radiation alone
• Complete pain relief in 50%
• Partial pain relief in 35%
• Radiofrequency ablation
• Chemotherapy
• Hormone treatment
• Bisphosphonates
Adjuvant Treatment

• Radiation
• Radiation alone
• Complete pain relief in 50%
• Partial pain relief in 35%
• Radiofrequency ablation
• Chemotherapy
• Hormone treatment
• Bisphosphonates
Radiation Therapy

• Overall 85% response rate

• Median duration of pain relief 12-15 weeks
• Tumor necrosis followed by collagen proliferation, woven bone
formation, and replacement by lamellar bone
• Recalcification by 2-3 months
• More than half respond within 1-2 weeks
• Various dose and fractionization schedules
Radiation Therapy

• Townsend, et al., Journal of Clinical Oncology, 1994

• 64 surgical stabilization procedures, 35 with post-op
radiation, 29 with no radiation
• Functional use of extremity, avoidance of revision surgery,
and survival time increased in radiation group
Radiotherapy
Pre XRT Post XRT
Prostate
CA Prostate
CA
Treatment Objectives in Metastatic Disease
• Decrease pain
• Restore function
• Maintain/restore mobility
• Limit surgical procedures
• Minimize hospital time
• Early return to function (immediate weightbearing)
Pathologic Fracture Survival

• 75% of patients with a

pathologic fracture will
be alive after one year
• the average survival is ~
21 months
 Survival Time

• Poor prognostic factors 6 mos % 1 yr % 3 yrs %

• Presentation with metastatic disease Breast 89 78 48

• Short time from initial diagnosis to Prostate 98 83 57
first met
Lung 50 22 3
• Visceral mets
• Non-small cell lung cancer Renal 51 51 40
 Healing of Path Fractures

• Healing rate of pathologic fractures

• Myeloma- 67%
• Renal- 44%
• Breast- 37%
• Lung- 0%
Fracture Healing

• 129 patients
• overall rate = 35%
• 74% for patients surviving > 6 months
• radiotherapy <30 GY did not adversely affect fracture healing

Gainor, B.J.: CORR 178: 297, 1983

Pathologic Fracture Treatment

• Biopsy especially for solitary lesions

• Nails versus plates versus arthroplasty
• plates, screws and cement superior for torsional loads
• interlocked nails stabilize entire bone
• Cement augmentation
• Radiation/chemotherapy/bisphosphonates
• Aggressive rehabilitation
Indications for Surgical Treatment

• Ratio of survival time to surgical recovery time

• Ability to ambulate
• Ability to use extremity
• Capacity to return to full function
• Pain not controlled by analgesics
• Location of disease – high risk area
 Indications for ORIF/IMN

• Diaphyseal lesion
• Good bone stock
• Histology sensitive to
chemo/radiation
• Impending fractures
• Poor prosthetic options
 Indications For Replacement

• Periarticular disease
• Fracture after radiation
• Failed fixation
• Renal cell ca
Pathologic Fracture Treatment

• Periarticular fractures, especially around the hip are

more appropriately treated with arthroplasty
• Periacetabular fractures
• protrusio shell,
cement, arthroplasty
• saddle prosthesis
• Structural
allograft-prosthesis
composite
Cement

PMMA no PMMA
Pain relief 97% 83%

Ambulation 95% 75%

Fixation failure 2 cases 6 cases

Haberman, E.T: CORR, 169: 70, 1982

Resection for Pathologic and Impending
Pathologic Fractures

• Radiation and chemotherapy resistant tumors

• renal
• thyroid
• melanoma
• occasionally lung
• Solitary metastases (controversial)
Renal Cell Carcinoma

pre-op pre-op post-op

*pre operative embolization of renal cell mets should be done
Pre-op Post-op
renal cell renal cell
carcinoma carcinoma
Solitary renal cell carcinoma

Soft tissue mass

Permeative lysis
• Post-op intercalary
allograft
Renal Cell
• Kollender, et al., Journal of Urology, 2000
• 45 lesions treated with wide or marginal resection
• 91% with pain relief, 89% with good/excellent functional
outcome
• Les, et al., CORR, 2001
• 41 renal cell patients treated with intralesional excision,
37 treated with marginal or wide resection
• Re-operation recommended for 41% in group I, 3% in
Group II
• Median survival 20 months in group I, 35 months in
group II
Renal Cell

• Wedin, et al., CORR 1999

• 228 metastatic lesions treated with endoprosthetic or
osteosynthesis
• 24% failure rate in renal cell lesions
• 20% failure rate in diaphyseal and distal femur lesions
• 14% failure rate for osteosynthesis, 2% for endoprosthesis
Complications

• Infection
• malnutrition
• hematomyelopoetic suppression
• Hemorrhage
• vascular tumors ( renal and thyroid)
• Tumor recurrence
• Failure of fixation
• Thromboembolic disease
Embolization

• Hypervascular tumors
• Renal cell carcinoma
• Thyroid carcinoma
• Pheochomocytoma
Pre embolization Post embolization

Pre-operative embolization can prevent

hemorrhage with intra-lesional surgery
Summary

• Diagnosis and treatment requires a multidisciplinary approach

• Aggressive surgical treatment relieves pain, restores function, and
facilitates nursing care
• Biopsy all solitary lesions or refer appropriately
• Understand tumor biology and tailor treatment
References
• Mirels H. Metastatic disease in long bones. A
proposed scoring system for diagnosing impending
pathologic fractures. Clin Orthop 1989; 249:256
• Gainor BJ, Buchert P. Fracture healing in metastatic
bone disease Clin Orthop 1983; 176:297-302.
• Eckardt JJ, et.al. Endoprosthetic reconstructions for
bone metastases. Clin Orthop 2003; 415:S254-262.
References

• Ward WG, et.al. Metastatic disease of the femur:

surgical treatment. Clin Orthop 2003; 415:S230-244
• Kelly CM, et.al. Treatment of metastatic disease of
the tibia. Clin Orthop 2003; S219-219
• van der Linden YM, et.al. Simple radiographic
parameter predicts fracturing in metastatic femoral
bone lesions:results from a randomized trial.
Radiotherapy and Oncology 2003; 69: 21-31
References

• Singletary SE, et.al. A role for curative surgery in the treatment of

selected patients with metastatic breast cancer. Oncologist 2003;
214-251
• Wedin R. Surgical treatment for pathologic fracture. Acta
Orthopaedica Scandinavica 2001; 72: 1-29
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