A pathological fracture occurs when a bone breaks due to a weakness in the structure caused by an abnormality or disease process. Causes of bone abnormalities include osteoporosis, malignant or non-malignant tumors, infection, and some inherited bone disorders.
Patients with a pathological fracture will present with symptoms similar to any fractured bone: swelling or bruising, deformity, pain in the area of fracture that is worsened with mobility or application of pressure, and loss of function of the injured area . Common anatomical sites for pathological fractures include the femur, vertebrae, humerus, and tibia  . Pain related to a fracture that onsets without an injury or trauma raises suspicion of a pathological fracture . Additionally, fractures in patients with pre-existing conditions such as metastatic cancer, advanced stage lung or breast cancer, Paget disease, osteoporosis/osteopenia, history of solid organ transplantation, chronic kidney disease may also indicate a pathological fracture.
A pathological fracture should always be included in the differential when patients with known bone metastases or a history of cancer complain of sudden onset of pain, even without swelling, deformity, or immobility. Pathological fractures of the thoracic or lumbar spine often present with pain upon sitting or standing. On the other hand, pathological spine fractures, particularly at the mid-back (the thoracic/lumbar junction), may present with pain when the patient is in a recumbent position. Cervical spine pathological fractures cause pain upon extension and flexion of the neck .
Entire Body System
- Severe Pain
: A 53-year-old white woman was admitted to the Massachusetts General Hospital complaining of severe pain in the right hip. The patient had twisted the right leg in moving to answer the telephone a few hours before admission. [jamanetwork.com]
pain or pain aggravated by limb function. [roentgenrayreader.blogspot.com]
Surgery is normally reserved for those with severe pain, weakness, or inability to feel their arms or legs. [emedicinehealth.com]
pain and acute loss of function. [healio.com]
Liver, Gall & Pancreas
- Bone Disorder
Causes of bone abnormalities include osteoporosis, malignant or non-malignant tumors, infection, and some inherited bone disorders. [symptoma.com]
This process is most commonly due to osteoporosis, but may also be due to other pathologies such as: cancer, infection (such as osteomyelitis), inherited bone disorders, or a bone cyst. [en.wikipedia.org]
Causes of weakened bone include osteoporosis, tumors, infection, and certain inherited bone disorders. And these are just a few causes; there are dozens of diseases and conditions that can lead to a pathologic fracture. [verywellhealth.com]
- Limitation of Neck Movement
The neck pain was resolved, and there was no limitation in neck movement. Immobilization and systemic chemotherapy with close observation are adequate for the management of patients despite the unstable pathological fracture of the odontoid process. [ncbi.nlm.nih.gov]
Between January 2002 and September 2006, 17 patients with cervical radiculomyelopathy caused by metastasis-induced pathologic fractures were selected for anterior corpectomy. [ncbi.nlm.nih.gov]
- Hyperactive Deep Tendon Reflexes
Neurologic examination revealed mild occipital neuralgia, difficulty with movements of the cranium, hyperactive deep tendon reflexes, but no Babinski sign. [ncbi.nlm.nih.gov]
Workup of pathological fracture consists of a medical history (e.g., history of present illness, smoking history and other risk factors for lung, bladder, renal cancers, osteoporosis, previous fractures) . Laboratory and imaging tests can help identify the cause of the pathological fracture (e.g., metastatic disease or benign condition). A bone biopsy will provide a definitive diagnosis.
- A plain radiograph is the first test for the evaluation of bone integrity. A pathological fracture due to metastatic disease appears as a lytic lesion of the involved bone on plain radiograph films. About 10% of pathological fractures are not detected by plain radiographs .
- Computed tomography (CT) scans are performed in patients with suspected metastatic disease to search for primary tumors, and in patients with known metastatic disease to assess overall disease burden. CT scans are very accurate for assessment of bone cortex integrity, which aids in the diagnosis of a pathological fracture .
- Magnetic resonance imaging (MRI) is more sensitive and more specific than CT for the detection of bone metastases. A well-defined low signal T1-weighted abnormality around the fracture is indicative of an underlying tumor. Advanced MRI techniques such as diffusion-weighted MR imaging and dynamic contrast-enhanced imaging allow differentiation between metabolic insufficiency fractures and pathologic fractures     .
- Integrated 18F-labeled fluorodeoxyglucose-positron emission tomography (PET) with computed tomography (PET/CT) scanning may also help differentiate the type of pathological fractures.
Laboratory tests :
- Serum alkaline phosphatase - Typically elevated with metastatic disease involving bone lesions; it is indicative of osteoblastic response (bone destruction). It may not be elevated in lytic tumors (e.g., plasma cell myelomas) in contrast with the raised levels in Paget disease, benign fractures, and endocrine diseases.
- Serum protein electrophoresis
- Urinalysis, urine protein electrophoresis
- Calcium level
A bone biopsy can be performed to determine the etiology of a pathological fracture (malignancy vs. insufficiency/benign disease process) . Most bone biopsies are performed by fine-needle aspiration. Other methods of obtaining a sample for bone biopsy includes surgical excision.
- American Academy of Orthopaedic Surgeons: "Fractures." National Institute on Aging: "Falls and Fractures." University of Iowa Hospitals & Clinics: "Fracture types."
- Sim FH. Metastatic bone disease of the pelvis and femur. Instr Course Lect. 1992;41:317-27.
- Hu YC, Lun DX, Wang H. Clinical features of neoplastic pathological fracture in long bones. Chin Med J. 2012;125:3127-32.
- Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008; 90:1407-13.
- Brickles J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am. 2009; 91:1503-16.
- Fayad LM, Kamel IR, Kawamoto S, et al. Distinguishing stress fractures from pathologic fractures: a multimodality approach. Skeletal Radiol. 2005;34:245-59.
- Nazarian A, Entezari V, Zurakowski D, et al. Treatment Planning and Fracture Prediction in Patients with Skeletal Metastasis with CT-Based Rigidity Analysis. Clin Cancer Res. 2015;21:2514-9.
- Baur A, Stäbler A, Brüning R, et al. Diffusion-weighted MR imaging of bone marrow: differentiation of benign versus pathologic compression fractures. Radiology. 1998;207:349-56.
- Spuentrup E, Buecker A, Adam G, et al. Diffusion-weighted MR imaging for differentiation of benign fracture edema and tumor infiltration of the vertebral body. Am J Roentgenol. 2001;176:351-8.
- Herneth AM, Philipp MO, Naude J, et al. Vertebral metastases: assessment with apparent diffusion coefficient. Radiology. 2002;225:889-94.
- Byun WM, Jang HW, Kim SW, et al. Diffusion-weighted magnetic resonance imaging of sacral insufficiency fractures: comparison with metastases of the sacrum. Spine (Phila Pa 1976). 2007;32:E820-4.
- Karchevsky M, Babb JS, Schweitzer ME. Can diffusion-weighted imaging be used to differentiate benign from pathologic fractures? A meta-analysis. Skeletal Radiol. 2008;37:791-5.
- Orita Y, Sugitani I, Matsuura M, et al. Prognostic factors and the therapeutic strategy for patients with bone metastasis from differentiated thyroid carcinoma. Surgery. 2010;147:424-31.
- Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 1989;256-64.