Pathological fractures

Pathological fractures by Dr. Bipul Borthakur

1. PATHOLOGICAL FRACTURE Dr . B.Borthakur ( Prof .) Dept.of Orthopaedics, SMCH

2. INTRODUCTION Definition: Fracture occurring in an abnormal bone during normal activity or after minor trauma 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 Neoplasm – Primary or metastatic Metabolic disease Renal osteodystrophy Hyperparathyroidism Osteomalacia Infection – osteomyelitis (chronic, tubercular) Osteoporosis – Age related, Post-menopausal, Disuse Osteonecrosis

6. ETIOLOGY Defects in normal bone repair mechanisms 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 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 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?

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

15. 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

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

17. 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

18. TREATMENT – Of fracture Goals of surgical intervention Prevention of disuse osteopenia Mechanical support Pain relief Decreased length and cost of hospital stay Fracture fixation +/- Bone cement augmentation Intramedullary nails or plates: load bearing than load sharing Arthroplasty for intra-articular fractures Decompression and stabilization of vertebral compression fractures

19. TREATMENT – Of fracture Prophylactic fixation Decreased morbidity Shorter hospital stay Easier rehabilitation Pain relief Faster and less complicated surgery Decreased surgical blood loss

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

21. 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 therapy after surgical wound healing

22. THANK YOU