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Pathologic Fractures. H.T. Temple, MD Walter W. Virkus, MD Created March 2004; Revised December 2005, October 2008. Pathologic Fractures. Tumors primary secondary (metastatic) (most common) Metabolic osteoporosis (most common) Paget’s disease hyperparathyroidism.

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pathologic fractures

Pathologic Fractures

H.T. Temple, MD

Walter W. Virkus, MDCreated March 2004; Revised December 2005, October 2008

pathologic fractures1
Pathologic Fractures
  • Tumors
    • primary
    • secondary (metastatic) (most common)
  • Metabolic
    • osteoporosis (most common)
    • Paget’s disease
    • hyperparathyroidism
pathologic fractures benign tumors
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
unicameral bone cyst

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 cyst1
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
  • 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
  • Treatment
    • observation
    • curetting and bone graft for impending fractures
    • immobilization and reassess after healing for patients with fracture
fibrous dysplasia
Fibrous Dysplasia
  • Solitary vs. multifocal (solitary most common)
  • Femur and humerus
  • First and second decades
  • May be associated with café au lait spots and endocrinopathy (Albright’s syndrome)
fibrous dysplasia1
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
Pathologic Fracturesthrough 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
Pathologic FracturesPrimary 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 tumors1
Pathologic FracturesPrimary 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


  • Pathologic fracture through MFHarising in antecedent infarct
  • (H&E 100x) Pleomorphic spindledcells with storiform growth pattern


pathologic fractures primary malignant tumors2
Pathologic FracturesPrimary 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



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 tumors3
Pathologic FracturesPrimary Malignant Tumors
  • Treatment
    • Immobilization
      • Traction, ex fix, cast
    • staging
    • biopsy
    • adjuvant treatment (chemotherapy)
    • resection/amputation
metabolic bone disease

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
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
    • Joint arthroplasty vs. ORIF

Fracture through Pagetic

bone (arrow). Transverse fracture suggests pathologic bone.

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


Multiple brown tumors

in a patient with primary


  • May be secondary to renal


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

Pathologic fracture through brown tumor (arrow)

fractures in patients with metastatic disease and myeloma
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
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
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
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
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
Route of Metastases
  • Contiguous
  • Hematogenous
    • most common

Destructive lesions in bone from

lung carcinoma (arrows)

mechanism of metastases
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
Bone Destruction
  • Early
    • most important
    • osteoclast mediated
    • (RANK L)
  • Late
    • malignant cells may be directly responsible
metastases of unknown origin
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
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

  • 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
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 fracture1
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 fracture2
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
Indication for ProphylacticInternalFixation
  • “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
Mirels Scoring System


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
Adjuvant Treatment
  • Radiation
    • Radiation alone
      • Complete pain relief in 50%
      • Partial pain relief in 35%
  • Radiofrequency ablation
  • Chemotherapy
  • Hormone treatment
  • Bisphosphonates
adjuvant treatment1
Adjuvant Treatment
  • Radiation
    • Radiation alone
      • Complete pain relief in 50%
      • Partial pain relief in 35%
  • Radiofrequency ablation
  • Chemotherapy
  • Hormone treatment
  • Bisphosphonates
radiation therapy
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 therapy1
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

Post XRT






  • “Long-term prevention of skeletal complications of metastatic breast cancer with pamidronate: Protocol 19 Aredia Breast Cancer Study Group”
      • Hortobagyi, et al. Journal of Clinical Oncology, 1998
  • “Zoledronic acid reduces skeletal-related events in patients with osteolytic metastases”
      • Berenson, et al. Cancer 2001
treatment objectives in metastatic disease
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
Pathologic Fracture Survival
  • 75% of patients with a pathologic fracture will be alive after one year
  • the average survival is ~ 21 months
survival time
Survival Time
  • Poor prognostic factors
    • Presentation with metastatic disease
    • Short time from initial diagnosis to first met
    • Visceral mets
    • Non-small cell lung cancer
healing of path fractures
Healing of Path Fractures
  • Healing rate of pathologic fractures
    • Myeloma- 67%
    • Renal- 44%
    • Breast- 37%
    • Lung- 0%
fracture healing
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
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
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
Indications for ORIF/IMN
  • Diaphyseal lesion
  • Good bone stock
  • Histology sensitive to chemo/radiation
  • Impending fractures
  • Poor prosthetic options
indications for replacement
Indications For Replacement
  • Periarticular disease
  • Fracture after radiation
  • Failed fixation
  • Renal cell ca
pathologic fracture treatment1
Pathologic Fracture Treatment
  • Periarticular fractures, especially around the hip are more appropriately treated with arthroplasty
  • Periacetabular fractures
    • protrusio shell,

cement, arthroplasty

    • saddle prosthesis
    • Structural





Pain relief 97% 83%

Ambulation 95% 75%

Fixation failure 2 cases6 cases

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

resection for pathologic and impending pathologic fractures
Resection for Pathologic and Impending Pathologic Fractures
  • Radiation and chemotherapy resistant tumors
    • renal
    • thyroid
    • melanoma
    • occasionally lung
  • Solitary metastases (controversial)
renal cell carcinoma
Renal Cell Carcinoma




*pre operative embolization of renal cell mets should be done

solitary renal cell carcinoma
Solitary renal cell carcinoma

Soft tissue mass

Permeative lysis

renal cell
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 cell1
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
  • Infection
    • malnutrition
    • hematomyelopoetic suppression
  • Hemorrhage
    • vascular tumors ( renal and thyroid)
  • Tumor recurrence
  • Failure of fixation
  • Thromboembolic disease
  • Hypervascular tumors
    • Renal cell carcinoma
    • Thyroid carcinoma
    • Pheochomocytoma

Pre embolization

Post embolization

Pre-operative embolization can preventhemorrhage with intra-lesional surgery

  • 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
  • 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, Endoprosthetic reconstructions for bone metastases. Clin Orthop 2003; 415:S254-262.
  • Ward WG, Metastatic disease of the femur: surgical treatment. Clin Orthop 2003; 415:S230-244
  • Kelly CM, Treatment of metastatic disease of the tibia. Clin Orthop 2003; S219-219
  • van der Linden YM, Simple radiographic parameter predicts fracturing in metastatic femoral bone lesions:results from a randomized trial. Radiotherapy and Oncology 2003; 69: 21-31
  • Singletary SE, 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
thank you
Thank You

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