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Pathological Fracture

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.


Presentation

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 [1]. Common anatomical sites for pathological fractures include the femur, vertebrae, humerus, and tibia [2] [3]. Pain related to a fracture that onsets without an injury or trauma raises suspicion of a pathological fracture [4]. 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 [3].

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]
Lymphadenopathy
  • […] trado-medical practitioners may undergo malignant transformation from chronic irritation and pursue an aggressive course with significant morbidity and mortality as illustrated in the patient with pathological fracture and a huge matted ipsilateral inguinal lymphadenopathy[ncbi.nlm.nih.gov]
Poor Oral Hygiene
  • This condition can lead to impairment of speech and eating, malnutrition, poor oral hygiene, and difficulty with dental treatment. Its prevalence in patients with head and neck cancer ranges from 5% to 38%.[ncbi.nlm.nih.gov]
Osteoporosis
  • Causes of bone abnormalities include osteoporosis, malignant or non-malignant tumors, infection, and some inherited bone disorders.[symptoma.com]
  • Codes M80 Osteoporosis with current pathological fracture M80.0 Age-related osteoporosis with current pathological fracture M80.00 Age-related osteoporosis with current pathological fracture, unspecified site M80.00XA …… initial encounter for fracture[icd10data.com]
  • Note: If the patient has a history of a pathological fracture that has healed, first code the osteoporosis and then the history of pathological fracture due to osteoporosis.[provider.healthalliance.org]
  • However none of these series exclusively focus on cases with severe osteoporosis with cortices as thin as found in our patient.[webmedcentral.com]
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]
  • 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.[orthopedics.about.com]
Torticollis
  • METHODS: A case of pathological fracture of the odontoid process with torticollis diagnosed with LCH of the odontoid process and C2 body and involving right femur in early childhood is presented. A histopathological study showed LCH.[ncbi.nlm.nih.gov]
Babinski Sign
  • Neurologic examination revealed mild occipital neuralgia, difficulty with movements of the cranium, hyperactive deep tendon reflexes, but no Babinski sign.[ncbi.nlm.nih.gov]
Radiculomyelopathy
  • 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]

Workup

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) [5]. 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.

Imaging tests:

  • 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 [6].
  • 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 [7].
  • 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 [8] [9] [10] [11] [12].
  • 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 [13]:

  • 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) [14]. Most bone biopsies are performed by fine-needle aspiration. Other methods of obtaining a sample for bone biopsy includes surgical excision.

Multilocular Cyst
  • In multivariate analysis, ballooning of bone, cyst in long bone, male sex, thin cortical thickness and multilocular cyst were significant adverse prognostic factors for pathological fractures at presentation.[ncbi.nlm.nih.gov]

Treatment

  • The mean VAS score decreased from 7.1 (range, 4-9) before treatment to 1.6 (range, 0-6), 1 month after treatment, and to 1.4 (range 0-6) 6 months after treatment.[ncbi.nlm.nih.gov]
  • Conservative treatment may be alternatively attempted; however, it is not usually employed. Here, we report a successful conservative treatment of ORN associated with pathologic fracture.[ncbi.nlm.nih.gov]
  • Different treatments are available to improve muscle length and function.[ncbi.nlm.nih.gov]
  • After exploration and sequestrectomy in combination with antibiotic treatment, osteolysis with a pathological fracture developed.[ncbi.nlm.nih.gov]
  • As there are limited data in the literature regarding treatment of fractures in these patients, it is important to notify the outcome of conservative treatment of pathological fractures in patients with primary hyperoxaluria type I.[ncbi.nlm.nih.gov]

Prognosis

  • Abstract Hypercalcemia and osteolytic bone lesion are important complications in the prognosis of patients with adult T cell leukemia/lymphoma (ATL).[ncbi.nlm.nih.gov]
  • The prognosis for patients at this stage continues to be poor due to limited effective treatment. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes, kidney, bone marrow and adrenals.[ncbi.nlm.nih.gov]
  • OUTCOMES: The patient died in 83 days after the surgery, and the survival time from the symptoms started to the end was only 11 months, which showed a rapid progress and poor prognosis of EAS.[ncbi.nlm.nih.gov]
  • Abstract Opinion remains divided as to whether the development of pathological fracture affects the prognosis of patients with an osteosarcoma of the extremities.[ncbi.nlm.nih.gov]
  • The prognosis is poor with a mean survival of less than 2 years. [ 12 ]. Conclusion Bone metastases, which may reveal biliary carcinoma, are aggressive, progress rapidly and are the sign of a poor prognosis. Conflict of interest statement None.[em-consulte.com]

Etiology

  • BACKGROUND: Primary hyperparathyroidism revealed by a pathological fracture is very uncommon; in the majority of cases the discovery of lytic bone lesions on imaging examinations evokes in the clinician first a neoplastic etiology and a metabolic origin[ncbi.nlm.nih.gov]
  • Abstract Treatment of mandibular pathological fractures differs according to etiology. Closed reduction with intermaxillary fixation is usually performed when fractures occur as a result of osteomyelitis.[ncbi.nlm.nih.gov]
  • 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).[symptoma.com]
  • Pathophysiology : Although there are many potential etiologies for weakened bone manifesting as pathological fractures, it is simple to divide it into three categories with common etiologies: 1) Metabolic bone disease- eg.[learn.pediatrics.ubc.ca]
  • […] manifestations due to the underlying etiology.[icd10data.com]

Epidemiology

  • Benger U: Epidemiological changes over 30 years in an urban population. In Thesis Lund University, Lund Sweden; 1987. 3. Praemer A, Furner S, Rice D: Musculoskeletal condition in the United States.[webmedcentral.com]
  • Proximal humeral fractures Epidemiology 4-5% of all fractures. Mechanism of injury Usually after a fall on to an outstretched hand from standing height.[patient.info]
  • The epidemiology of peripheral fractures. Bone . 1996. 18:209S-13S. Pedrazzoni M, Abbate B, Verzicco I, Pedrazzini A, Benatti M, Cervellin G.[emedicine.medscape.com]
  • Epidemiology and Etiology Compared to the total number of fractures excluding osteoporotic and insufficiency fractures pathological fractures are of rare occurence. In the current literature.[musculoskeletalkey.com]
  • PubMed Google Scholar Cummings SR, Melton LJ: Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002, 359 (9319): 1761-7. 10.1016/S0140-6736(02)08657-9.[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology : Although there are many potential etiologies for weakened bone manifesting as pathological fractures, it is simple to divide it into three categories with common etiologies: 1) Metabolic bone disease- eg.[learn.pediatrics.ubc.ca]
  • Lyons A, Ghazali N (2008) Osteoradionecrosis of the jaws: Current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg 46: 653-660.[omicsonline.org]

Prevention

  • Among the various materials that have been used to prevent early reformation of the physeal bar (fat, silastic, cartilage), Peterson recommended the use of Cranioplast, as this material can prevent bar reformation, and it is radiolucent because it does[ncbi.nlm.nih.gov]
  • OBJECTIVE: To evaluate the feasibility and effectiveness of computed tomography (CT)-guided percutaneous screw fixation plus cementoplasty (PSFPC), for either treatment of painful metastatic fractures or prevention of pathological fractures, in patients[ncbi.nlm.nih.gov]
  • In such cases, earlier surgical intervention has the potential to prevent permanent neurological deficit and disability and to maintain function and quality of life.[ncbi.nlm.nih.gov]
  • This method shows a versatile potential for the prediction of pathological fracture and might aid in judging the optimal treatment to prevent fracture. Copyright 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V.[ncbi.nlm.nih.gov]
  • Locate a Children's outpatient physical therapy location near you Locate a Children's sports medicine physical therapy location near you Here are a few tips to help prevent a fracture.[childrensortho.com]

References

Article

  1. American Academy of Orthopaedic Surgeons: "Fractures." National Institute on Aging: "Falls and Fractures." University of Iowa Hospitals & Clinics: "Fracture types."
  2. Sim FH. Metastatic bone disease of the pelvis and femur. Instr Course Lect. 1992;41:317-27.
  3. Hu YC, Lun DX, Wang H. Clinical features of neoplastic pathological fracture in long bones. Chin Med J. 2012;125:3127-32.
  4. 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.
  5. Brickles J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am. 2009; 91:1503-16.
  6. Fayad LM, Kamel IR, Kawamoto S, et al. Distinguishing stress fractures from pathologic fractures: a multimodality approach. Skeletal Radiol. 2005;34:245-59.
  7. 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.
  8. 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.
  9. 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.
  10. Herneth AM, Philipp MO, Naude J, et al. Vertebral metastases: assessment with apparent diffusion coefficient. Radiology. 2002;225:889-94.
  11. 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.
  12. 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.
  13. 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.
  14. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 1989;256-64.

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Last updated: 2018-06-22 01:55