Presentation on pathological fractures, diagnosis and its management

1. PATHOLOGICAL
FRACTURE
Dr. Bipul Borthakur
Silchar medical college, Assam

2. INTRODUCTION
• Definition: Fracture occurring in an abnormal bone during normal activity or
after minor trauma
• Also known as Insufficiency fractures
• Many of these patients have multiple fractures, delayed union or non-union
• Age: >50 years
• Gender: Females > Males, (attributed to osteoporosis)
• Common sites: Spine, proximal femur, distal femur, distal radius.

3. CORRECTABLE CONDITIONS
• RENAL OSTEODYSTROPHY
• HYPERPARATHYROIDISM
• OSTEOMALACIA
• DISUSE OSTEOPOROSIS

4. UNCORRECTABLE CONDITIONS
• OSTEOGENESIS IMPERFECTA
• POLYOSTOTIC FIBROUS DYSPLASIA
• POST MENOPAUSAL OSTEOPOROSIS
• PAGET DISEASE
• OSTEOPOROSIS

5. ETIOLOGY
• Infective – Chronic osteomyelitis
• Neoplasm – Primary or metastatic
• Metabolic diseases of bone – Rickets, Osteomalacia, renal osteodystrophy
• Osteoporosis – Age related, Post-menopausal, Disuse
• Osteonecrosis

6. ETIOLOGY
• Developmental disorders of bone
• Osteogenesis imperfecta
• Polyostotic fibrous dysplasia
• Paget disease
• Osteopetrosis
• Iatrogenic causes – surgical defect

7. ETIOLOGY – PRIMARY TUMORS
• Primary benign tumors
• Asymptomatic, commonly seen in children
• Humerus > Femur
• GCT, SBC, ABC, NOF, fibrous dysplasia, eosinophilic granuloma
• Primary malignant tumors – relatively rare
• Antecedent pain before fracture
• Radiation induced osteonecrosis in the later period

8. ETIOLOGY – METASTATIC DISEASE
• Tumors commonly metastasize to
bone
• Breast
• Lung
• Prostate
• Thyroid
• Kidney
• Common sites of metastasis
• Spine
• Pelvis
• Ribs
• Skull
• proximal femur
• Proximal humerus.

9. FACTORS SUGGESTING PATHOLOGICAL #
• Spontaneous fracture
• Fracture after minor trauma
• Pain at the site before the fracture - neoplasm
• Recent multiple fractures – s/o osteogenesis imperfecta
• Unusual # patterns (banana fracture)
• Patients older than 45 years
• Chronic alcoholism, prolonged drug therapy, intestinal malabsorption
• History of malignancy and any surgeries related to malignancy

10. PATIENT PRESENTATION
• Pain, swelling and deformity at the fracture site
• Constitutional symptoms like loss of appetite, loss of weight, fever, fatigue
• Deformities elsewhere in the body due to previous fractures
• A lump elsewhere in the body, cough, haemoptysis, haematuria

11. EXAMINATION
• General physical examination
• Features specific for certain conditions leading to pathological fracture
• Lymphadenopathy, liver enlargement
• Mass per abdomen or in the pelvis; lump elsewhere in the body
• Local examination of fracture site
• Deformity, swelling (either bony or soft tissue)
• An infected sinus, an old scar
• Location of the fracture – vertebral body # and # at corticocancellous junction in
osteoporosis
• Rectal and vaginal examination

12. INVESTIGATION
• Radiological investigations
• Plain radiographs
• Chest X-ray – lung primary and metatasis
• Bone scan – most sensitive for multiple lesions
• CT scan
• MRI – primary tumor
• PET scan – in metastatic lesions
• Other useful tests: Gastrointestinal series, Endoscopy, Mammography and
CT chest, abdomen and pelvis

13. EVALUATION OF PLANE RADIOGRAPHS
• WHERE IS THE LESION?
• WHAT IS THE LESION DOING TO THE BONE?
• WHAT IS THE BONE DOING TO THE LESION?
• WHAT ARE THE CLUES TO THE TISSUE TYPE
WITHIN THE LESION?

16. INVESTIGATIONS
• Spine involvement is more common, particularly at the pedicle area, where
“Winking owl sign” is positive

17. INVESTIGATIONS
• Radiological appearance of metastatic lesions
• Osteoblastic – prostate cancer
• Osteolytic - Most common; seen in cancer of lungs, thyroid, kidney, and colon
• Mixed – breast cancer

18. INVESTIGATIONS
• Laboratory evaluation
• CBC, DLC, PBS, ESR
• Chemistry panel – Serum Ca, Ph, Albumin, globulin, ALP
• Urine routine
• Serum and urine protein electrophysis
• 24hr urine hydroxyproline – Paget disease
• Specific tests – TFT, CEA, PTH, PSA
• Biopsy of local lesion before or at the time surgical fixation of fracture

19. TREATMENT
• Initial care of the patient
• Reduce and immobilize the fracture
• Definitive treatment of the fracture
• Treatment of the underlying pathology

20. TREATMENT – OF FRACTURE
• Non-operative treatment: Bracing
• Limited life expectancies
• Severe comorbidities
• Small lesions
• Radiosensitive tumors
• Common location - humerus shaft, forearm, tibia
• Weight bearing should be limited

21. TREATMENT – OF FRACTURE
• Goals of surgical intervention
• Prevention of disuse osteopenia
• Mechanical support
• Pain relief
• Decreased length and cost of hospital stay

22. TREATMENT – OF FRACTURE
• Fracture fixation +/- Bone cement augmentation / bone grafting
• Intramedullary nails or plates: load bearing than load sharing
• Arthroplasty for intra-articular fractures
• Decompression and stabilization of vertebral compression fractures
• Bone graft may be autologous or allograft; may end up with an
unpredectable outcome, whereas bone cement gives immediate
structural support

23. TREATMENT – OF FRACTURE
• Prophylactic fixation
• Decreased morbidity
• Shorter hospital stay
• Easier rehabilitation
• Pain relief
• Faster and less complicated surgery
• Decreased surgical blood loss

24. INDICATIONS OF PROPHYLACTIC
FRACTURE FIXATION
• HARRINGTON’S CRITERIA
1. >50% diameter of the bone
2. >2.5 cm
3. Pain after radiation
4. Fracture of lesser trochanter
• LIMITATIONS
1. ONLY FOR PROXIMAL FEMUR
2. DOESN’T ACCOUNT FOR TUMOR BIOLOGY

25. TREATMENT – OF PATHOLOGY
• Multidisciplinary approach which medical and surgical oncologists
• Look for primary tumor
• Surgical excision of primary tumor
• Treatment of metabolic bone disorders
• Post-operative chemo or radiotherapy for both bone and primary
lesions
• Radiation and chemotherapy usually should be started after soft tissue
healing, which takes 2-3 weeks

26. THANK YOU