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]

  Surgery is normally reserved for those with severe pain, weakness, or inability to feel their arms or legs. [emedicinehealth.com]

  Functional b a Size is determined as a fraction of the cortical thickness. b Functional pain is defined as severe pain or pain aggravated by limb function. [roentgenrayreader.blogspot.com]

  According to the evaluation of Dijkstra et al, 3 an objective pain scale was classified as none (no pain, 0 points), mild (no pain with analgesics, 1 point), moderate (controllable pain with analgesics, 2 points), and severe (no relief of pain even with [healio.com]

• Abdominal Mass

  The most common presenting features are abdominal pain and palpable abdominal masses. Pathological fractures of the spine presenting as bilateral lower leg weakness are exceptionally rare. [ncbi.nlm.nih.gov]

• Anhidrosis

  Congenital insensitivity to pain with anhidrosis (CIPA) is a rare hereditary sensory and autonomic neuropathy (HSAN) characterized by pain, self-mutilating behaviour, anhidrosis and recurrent hyperthermia. [ncbi.nlm.nih.gov]

• Bone Disorder

  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 bone abnormalities include osteoporosis, malignant or non-malignant tumors, infection, and some inherited bone disorders. [symptoma.com]

  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]

• 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]

• 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) [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]

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]

Hypercalcemia and osteolytic bone lesion are important complications in the prognosis of patients with adult T cell leukemia/lymphoma (ATL). [ncbi.nlm.nih.gov]

Treatment and prognosis Pathological fractures are feared by oncologists because they may cause immobilization of their patients, especially when the spine or lower extremities are affected. [radiopaedia.org]

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 is often [ncbi.nlm.nih.gov]

[…] manifestations due to the underlying etiology. [icd10data.com]

The etiology is unknown, and is more common in adults. The clinical manifestations are heterogeneous due to histiocytic infiltration of multiple systems. [scielo.org.co]

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]

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]

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]

Epidemiology of Fractures in Children Incidence 42% of the boys and 27% of the girls sustain at least one fracture from 0 to 16 years of age. Each year 1.6% to 2.1% of all the children sustain a fracture. [boneandspine.com]

In order to establish an efficient IMP, it is important to know the epidemiology of pathogens, as well the mechanisms used by the different control methods to be pooled for managing the disease ( Dik et al ., 2002 ). [onlinelibrary.wiley.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]

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]

[…] vessels Injury to muscles and tendons Injury to joints Injury to viscera Local Infection Compartment syndrome Others Avascular necrosis Shortening Joint stiffness Sudeck's dystrophy Osteomyelitis Ischaemic contracture Myositis ossificans Osteoarthritis Pathophysiology [en.wikipedia.org]

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]

Some patients have preventative fixation to prevent bony fracture from occurring. [autoaccident.com]

The brace helps support the back and prevents bending forward, which removes pressure from the fractured vertebrae. If the fracture is caused by osteoporosis, treatment of the osteoporosis can help prevent additional fractures. [columbiaspine.org]

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]

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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.