Pathologic Fracture Management

Pathologic Fracture Management

Prepared by Dr. Alper DUNKI

Pathological fractures occur in structurally weakened bone, most commonly due to metastatic disease, but also from primary tumors or metabolic bone disorders. Management begins with accurate diagnosis, staging, and biopsy planning before any surgical fixation.
The femur, pelvis, and spine are typical sites, with lung, breast, thyroid, renal, and prostate cancers being leading causes.
Predictive tools such as Harrington criteria, Mirel’s score, and CT-based structural rigidity analysis guide the need for prophylactic fixation.

1. Definition and Overview

• A pathologic      fracture is a break in bone caused by abnormal weakening of bone      structure, usually due to benign or malignant lesions.
• The      core principle of management: accurate diagnosis and staging of the      underlying pathology before surgical fixation.
• These      fractures reflect compromised skeletal biomechanics, most      frequently secondary to metastatic disease, though they may arise      from primary sarcomas, benign lesions, or metabolic bone      disorders.

2. Etiology and Epidemiology

• Metastatic      bone disease accounts for the majority of pathologic fractures in      adults.
• The      five cancers most likely to metastasize to bone: lung, breast, thyroid,      renal, and prostate.
• Spine,      pelvis, and proximal femur are the most common sites.
• In      patients >40 years, a metastatic fracture is ~500 times more common     than a primary sarcoma-related one.
• Approximately      8% of patients with bone metastases will experience a pathologic      fracture during the disease course

3. Pathophysiology

• Osteolytic      lesions: Tumor-induced activation of osteoclasts via RANKL      signaling → bone resorption.
• Osteoblastic      lesions: Mediated by endothelin-1, stimulating abnormal bone      formation.
• Biomechanical      weakness arises from cortical destruction or cavitary defects that      reduce the bone’s load-bearing capacity.
• Result:      fractures occur during normal or minimal stress

4. Clinical Presentation and Evaluation

• Symptoms:     Chronic or progressive pain, swelling, reduced function, or a sudden  increase in pain after minimal trauma.
• May      present with systemic signs of malignancy (weight loss, fatigue,  hypercalcemia).
• Imaging      protocol:
  • Plain       radiographs of the entire affected bone.
  • CT       of chest/abdomen/pelvis for staging.
  • Bone       scintigraphy for osteoblastic lesions or skeletal survey for myeloma.
  • MRI      for soft tissue or neurovascular involvement.
  • PET/CT     for systemic evaluation.
• Laboratory      workup: CBC, metabolic panel, calcium, alkaline phosphatase, ESR, urinalysis, PSA, CEA, and serum/urine electrophoresis to identify possible      myeloma or metastasis.
• Biopsy    should be performed only after staging, adhering to strict      oncologic principles to avoid contamination

5. Classification and Prediction of Impending Fractures

• Impending  fracture: Bone so weakened that fracture is likely with normal activity.
• Harrington Criteria (1980):
  • 50%   cortical destruction
  • Lesion >2.5 cm
  • Persistent  pain after radiotherapy
  • Lesser  trochanter fracture → Indicates need for prophylactic fixation
• Mirel’s  Classification (1989):
  • Considers       site, pain, lesion type, and size.
  • Score       ≥8 → Prophylactic fixation recommended.
• CT-based  Structural Rigidity Analysis (CTRA):
  • A  modern quantitative alternative; superior predictive value for femoral fractures

6. General Treatment Principles

• Management  goals:
  • Stabilize  the fracture
  • Restore  function and mobility
  • Control  pain
  • Prevent  further complications
  • Address  underlying malignancy

• Treatment  strategy depends on:
  • Primary pathology (benign vs. malignant)
  • Expected survival
  • Healing potential of the lesion
  • Patient activity level and comorbidities

7. Surgical Management – Core Principles

• Surgical  fixation must follow comprehensive oncologic workup and biopsy.
• Implant  choice principles:
  • Favor  load-sharing constructs over purely load-bearing.
  • Implant  should outlast expected survival.
  • Bypass  lesion by at least two cortical diameters.
  • Allow  immediate postoperative stability and early mobilization.
• Cement  augmentation enhances fixation in poor-quality bone.
• Material  considerations:
  • Titanium:   MRI-compatible, lower modulus of elasticity, suited for benign lesions.
  • Stainless  steel:  Stronger, preferred in metastatic lesions but produces imaging       artifacts.
  • Carbon-fiber  (CFR-PEEK): Radiolucent, MRI-compatible, high fatigue strength –       emerging as optimal for oncologic fixation

8. Lesion-Specific Management

A. Impending Fractures

• Prophylactic  fixation before fracture reduces morbidity, surgical complexity, and      blood loss.
• Indicated  when Mirel ≥8 or biomechanical analysis supports instability.
• Elective  stabilization allows easier postoperative rehabilitation

B. Completed Pathologic Fractures

• Fracture  healing potential varies by tumor type:
  • Multiple myeloma – 67%
  • Renal carcinoma – 44%
  • Breast carcinoma – 37%
  • Lung carcinoma – 0%
• Thus,  implant strategy is tailored to tumor biology:
  • Myeloma:      plates/screws or intramedullary devices.
  • Lung  carcinoma: wide resection or endoprosthesis.
• Renal  cell carcinoma metastases → wide excision when feasible; improves      5-year survival (4.8 vs. 1.3 years).
• Preoperative  embolization is crucial for highly vascular lesions (renal, thyroid)      to minimize intraoperative blood loss

9. Surgical Site–Specific Strategies

Upper Extremity

• Proximal  humerus: arthroplasty (hemi, total, or reverse) or endoprosthesis
• Diaphysis: locked intramedullary nail or plate fixation
• Distal humerus: dual plating or total elbow replacement

Lower Extremity

• Femoral  head/neck: hemiarthroplasty, total hip replacement, or endoprosthesis.
• Subtrochanteric/diaphyseal:  cephalomedullary nailing
• Distal  femur: locking plate or retrograde nail (avoid tumor spread)
• Proximal  tibia: locking plate or modular endoprosthesis

Pelvis

• Small lesions: radiation or radiofrequency ablation.
• Load-bearing  fractures: fixation with screws ± cement.
• Peri-acetabular lesions: Managed per Harrington classification, from curettage + cement (Type I) to acetabular reconstruction (Type IV).

Spine

• Most  common metastatic site.
• Surgery   aims for stabilization, decompression, and palliation.
• Tokuhashi score guides decision-making:
  • 9       → operative
  • ≤5       → palliative care

10. Adjuvant and Systemic Therapy

Radiation Therapy

• Adjuvant  or postoperative use to prevent local progression.
• Radiosensitive:  myeloma, lymphoma, prostate, breast.
• Radioresistant:  renal, thyroid, sarcoma, melanoma.
• Single-fraction 8 Gy provides similar pain control to multiple fractions.
• Complications: delayed wound healing, infection, radiation-induced fractures

Chemotherapy

• Used   for chemosensitive tumors (e.g., sarcomas, myeloma).
• Administered  neoadjuvantly or adjuvantly.
• Decision based on ECOG performance status and overall prognosis

11. Postoperative and Rehabilitation Care

• Goals:  early mobilization, pain control, and return to function.
• Anticoagulation:  recommended postoperatively, especially for lower limb surgery.
• Physical  therapy: begins immediately to maximize function.
• Bisphosphonates or denosumab:  reduce risk of skeletal-related events (SREs) —      including fractures, spinal cord compression, and hypercalcemia.
• Without  therapy, SREs occur in >50% of metastatic breast or prostate cancer      patients.
• Benefits must be balanced against risks: hypocalcemia, osteonecrosis of the jaw,      and atypical fractures

12. Complications and Prognosis

• Mechanical: fixation failure, implant loosening, periprosthetic fracture.
• Infectious:   wound infection, sepsis, prosthetic infection.
• Systemic:  venous thromboembolism, pulmonary cement embolism (BCIS).
• BCIS:   hypoxia and hypotension due to cement pressurization—reported in up to 75%      of oncologic arthroplasty patients.
• Prognosis depends primarily on primary tumor biology and extent of metastasis.
• Example:  6-month survival — prostate (98%), breast (89%), renal (51%), lung (50%)

13. Interprofessional Collaboration and Patient Education

• Multidisciplinary management is essential — orthopedic oncology, radiology, pathology,      medical and radiation oncology, and palliative care.
• Preoperative  coordination ensures accurate diagnosis, staging, and risk optimization.
• Patient education should emphasize early reporting of bone pain and the benefit of prophylactic stabilization.
• The overarching aim is early stabilization, mobilization, and durable      reconstruction that outlasts patient survival

References

1. Rizzo SE, Kenan S. Pathologic Fractures. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.

2. Fields RC, Beauchamp CP, Srinivasan S, et al. Management of pathological fractures: current consensus. Knee Surg Sports Traumatol Arthrosc. 2024;32(3):1125-1135.

3. Boussouar S, Pasche C, Bluemke DA, et al. A tailored approach for appendicular impending and pathologic fractures from metastatic bone disease. Cancers (Basel). 2022;14(4):893.

4. Conti A, Bertolo F, Boffano M, et al. Pathological hip fracture in the elderly: review and proposal of an algorithm. Lo Scalpello J. 2020;34:128-136.