By Jeffrey R. Carlson, MD, MBA, FAAOS, CPE
Pathological fractures are not caused by direct force or trauma to a bone but rather by an underlying disease or condition that compromises its strength. These fractures are not only associated with pre-existing bone tumors or metastatic cancer, but can also be caused by osteoporosis, osteomyelitis, osteogenesis imperfecta, Paget’s Disease, or other pathological reasons. Simple actions, such as a sneeze or bending over, can cause bones, compromised by disease, to fracture. Imagine a senior lady with a vertebral compression fracture due to advanced osteoporosis – this is a good example of a non-cancer pathological fracture.
So that proper treatment can be administered to the patient, pathological fractures must be detected clinically, diagnosed radiologically and the cause determined histologically. Typically, when I see patients for a fracture, x-rays are taken immediately. After clinical H & P, I will review the images with the patient to make them aware of the findings. We will discuss and develop the treatment plan together.
My goals in treating all pathological fractures are to relieve any pain, address any neurological deficits (especially when dealing with fractures of the vertebral column), and stabilize the fracture. For less serious, stable fractures, I can often prescribe bracing, activity modifications, and medications for pain and inflammation. Osteoporotic patients who present with vertebral compression fractures can be scheduled for kyphoplasty, an in-office procedure that places cement inside the shattered vertebrae, giving immediate pain relief and stability.
Sometimes, the imaging reveals a bone tumor or lesion the patient is unaware of. Obviously, this is concerning news for the patient, and this new finding should be presented calmly and clearly. We will develop a plan together for the repair of the fracture and how to get an oncologist involved to discuss what treatment may be needed for the tumor or any other cancerous findings.
Most pathological fractures of long bones will require surgical reduction and internal fixation with rods, plates, wires, pins or screws. Thankfully, most diseases that weaken bones do not impede their ability to heal, so these stabilization procedures provide skeletal integrity and increase function while the patient recovers.
For patients who have end stage metastatic cancer, multiple myeloma and lymphoma, treatment of pathologic fractures should also focus on minimizing morbidity, reducing pain, and increasing QOL and mobility. A recent Swedish study of 1,453 pathological fracture patients published in The Journal of Orthopaedic Surgery and Research found that age, sex, primary tumor type and site were associated with mortality. The study found that surgical reduction of pathological fractures was certainly palliative, but benefits should be weighed against contraindications. Lung cancer was reported as an independent negative predictor of survival, whereas myeloma was a favorable prognostic factor for survival. Lower extremity fractures had a higher morbidity rate than upper extremity fractures. Spinal metastases account for approximately 70% of all bone metastases and are reported most frequently.
Jeffrey R. Carlson, MD, is the President and Managing Partner of Orthopaedic & Spine Center in Newport News, Va. He holds a fellowship in Orthopaedic Trauma surgery and a combined Neurosurgery-Orthopaedic fellowship in complex spine surgery from Brigham and Women’s Hospital in Boston. osc-ortho.com