In the Name of God Dr. A. Borjian Isfahan University of Medical Science

Pathologic fracture

 Benign tumors  Malignant primary tumors  Mtastatic tumors

Pathologic Fx:  A pathologic Fx is defined, Fx occur in Abnormal Bone  Bone lack of normal biomechanical and viscoelastic properties  Weakened bone predispose the patient to failure in normal activity or after minor trauma.

Pathologic fracture (Incidence) :  Osteoprosis most common condition associated with pathologic Fx  10 million American>50 have osteoprosis  34 million have osteomalacia and at risk devalping osteoporosis  1.5 million sustain P. Fx related to osteoprosis eah year

Classification:  Intrinsic:  Osteopenia of osteogensis imperfect & Replacement of Bone with tumor  Extrinsic: Lessen the inherent structural integrity of bone  Radiation or hole in bone  Localize  Bone cyst  Generalize  Osteopetrosis  Correctable  Rickets  Un correctable  Metastatic cancer  In normal bone  Vascular foramina

Classification: A: Correctable disease:  Renal osteodystrophy  Hyper parathyroidism  Osteomalacia  Disuse osteoprosis

Classification: B: Uncorrectable disease:  Osteogesis imperfecta  Polyostatic fibrous dysplasia  Postmonoposal osteoprosis  Paget disease  Osteo petrosis

Pathologic fracture:  Fx callus may not form normally  healing slowly  Increase incidence of nonunion & delay union

 Diagnoses has been made on clinical finding History History Physical examination Physical examination Xray Xray Laboratory finding Laboratory finding Often the history is most helpful Often the history is most helpful

Evaluation of a pediatric patient  Age of patient  Location of the lesion Epiphysis- metaphysis- diaphysis Epiphysis- metaphysis- diaphysis  What is the lesion doing to the bone  Zone of transition  Pathern of lesion  What is the bone doing to the lesion  Periosteal response  Lytic- blastic- calsified- osified- ground glass

Table 6-2

Table 6-3

Benign tumor

U.B.C:  Radiolucent centric fluid filled cystic  70% proximal Humerus or femor,  75% present with pathologic Fx,  if diameter of cyst 85% or more  pathologic Fx

Complication patho Fx:  Malunion  Growth arrest  Osteo necrosis  Collapse of articular surface

Treatment:  Undisplace Fx I. Traction II. Curtage & Bone graft (autograft or allograft)  Displace Fx or Unstable Fx Internal fixation + curettage & bone graft Internal fixation + curettage & bone graft

Classification for treatment of proximal femur:

Malignant tumors:  Osteosarcoma  Chondrosarcoma  lymphoma

lymphoma

 Lymphoma Primary or secondary Primary or secondary  Sixth and seven decades  Male/female = 1.5/1  Femor pelvic spine ribs

Lymphoma  Chief complain Localized pain Localized pain Swelling Swelling Nerve root or cord compression Nerve root or cord compression

lymphoma  X ray Diaphysial Diaphysial Illdefined Illdefined Bone distraction Bone distraction Permeative apperance Permeative apperance Ticking of cortex Ticking of cortex Periosteal reaction rarely seen Periosteal reaction rarely seen

 Radiogarph can be normal  Bone scan  MRI

 Staging CBC CBC Serom chemistry Serom chemistry Bone scan Bone scan CT (chest abdomen pelvic) CT (chest abdomen pelvic) Bone marrow biopsy Bone marrow biopsy

patology Patology?

 Prognosis Primary 55% 5-year survival Primary 55% 5-year survival Secondary <25% Secondary <25%

 Treatment Chemotherapy Chemotherapy Radiotherapy Radiotherapy surgury surgury

Case 1

Case 2

Case 3

Osteosarcoma:  Osteosarcom & Ewing 10% pathologic Fx  Colse treatment in cast (After Biopsy)  Neoadjuvan chemotherapy  Surgery (Limbsalvage or amputation)

Chondrosarcoma:  Middle age or older adult  Proximal femor most common for P. Fx  Serious mistake with metastatic carcinoma  Displace Fx  amputation

Chondrosarcoma:

Lymphoma

Metastatic tumor  Metastatic carcinoma most common malignancy treated by orthopedic surgeon  8000 sarcoma every year.  1.3 million carcinoma  50-80% carcinoma have bone metastase at time of death.

Metastatic tumor:  Breast  Prostate  Lung  Kidney  Thyroid  Gastro intestinal

Evaluation of patient with lytic bone lesion I. History: Thyroid, breast or prostate nodule Thyroid, breast or prostate nodule II. Review of system: Gastrointestinal symptom, weight loss, flank pain, hematuria Gastrointestinal symptom, weight loss, flank pain, hematuria III. Physical examination: Lymph nocles, thyroid, breast, lungs, abdomen, prostate, teslicle and rectum Lymph nocles, thyroid, breast, lungs, abdomen, prostate, teslicle and rectum

Evaluation of patient with lytic bone lesion: IV.Plain X-Ray: IV.Chest, affected bone, humerus, pelvis, femur, spine V.In affected bone (osteopenia, periostal reaction cortical thinning, looser line) VI.Breast & Prostate  Blastic VII.Kidney & Thyroid  Lytic VIII.Lung  Mixed IX.Isolated avulsion Fx lesser trochanter If lesion distal to elbow or knee lung cancer is most likely primary lesion

Evaluation of patient with lytic bone lesion V. Bone scan 99 MTC 99 MTC Pet Scan (Positron emission tomography) gold standard in metabolic imaging Pet Scan (Positron emission tomography) gold standard in metabolic imaging FDG (Fluorine- 18 deoxy glucose) FDG (Fluorine- 18 deoxy glucose) Pet CT. Scan (higher sensivity) & Specificity than pet scan for detection of malignant bone lesion) Pet CT. Scan (higher sensivity) & Specificity than pet scan for detection of malignant bone lesion) VI. CT. Scan (Chest- Abdomen- Pelvis) VII. Laboratory: CBC, ESR, Ca-P, UA, PSA, Alkphos, Immunoelectrotherosis, carcino embryonic antigen, CA 125, N-Telopeptide & C- Telopheptide CBC, ESR, Ca-P, UA, PSA, Alkphos, Immunoelectrotherosis, carcino embryonic antigen, CA 125, N-Telopeptide & C- Telopheptide

Associated Medical problem: (Patient with bone metastase): I. Pain II. Pathologic Fx III. Anemia IV. Hypercalcemia

When and how to biopsy:  Staging study  Needle or open incisional a. Carcinoma from sarcoma b. Contamination from open biopsy  Biopsy of site un affected by Fx  Even if a patient has a known history of carcinoma a biopsy of first site

Impending pathologic Fx: Bone metastases are painful Fiddler:  If 50-75% cortical involvement  moderate to severe pain  After prophylactic internal fixation  no or slight pain

Goals of surgical treatment:  Alleviate pain  Reduce narcotic use  Restore skeletal stability  Regain functional independence

Impending fracture (Risk of Fx):  Pain not respond to radiation  Lesion greater than 2.5 cm  Lesion destroy >50% cortex  Avulsion Fx of lessen trochonter

 Scoring 7 or lower  Irradiated  Scoring 8 or higher  prothylatic internal fixation before irradiation

Benefit of fixation:  Shorter hospitalization (average 2 days)  More immediate pain relief  Less blood loss  Return to premorbid function  Fewer hardware complication

Treatment: A. General treatment I. Cytotoxic agent II. Hormone therapy III. Radioactive iodine IV. Biphosthonate: a)Prevent new metastase b)Inhibit osteoclast resorbtion V. Most metastatic carcinoma sensitive radiation except kidney cancer

Pathologic Fx B. Local treatment 1. Fixation stable 2. Tumor should be debulk 3. Reconstricle durable 4. Cavity filled with PMMA

Treatment:  Pathologic Fx of femoral head & neck rarely head  For head & neck  cemented prosthesis  Hemi arthroplasty versus total hip  When adjacent lesion in subtrochantrick or proximal diaphysis  long stem femoral

Treatment (Inter trochantric):  DHS  high rate of failure even use PMMA + radiation Standard choice:  Cephalomedulary nail (Head & Neck bone)  Prosthesis (Severe destruction)

Sub trochontric:  Subject to force of up 4-6 weight  Static locked intramedullary  Extensive bone destruction  modular proximal prosthesis

Conclusion  The most common cause for a pathologic fracture is osteoporosis or osteomalacia.  Patients with osteoporosis or osteomalacia require evaluation and management of the underlying disorder  Patients more than 45 years of age with a pathologic fracture or lytic lesion are much more likely to have metastatic bone disease than a primary bone tumor.  The prognosis for patients with metastatic bone disease is improving because of early recognition and better adjuvant treatment; therefore, many patients will live more than 2 years.

conclusion  Do not immediately assume that a lytic lesion or pathologic fracture is from metastatic disease. A thorough workup and possible biopsy are required.  Prophylactic fixation for impending fractures from metastatic disease is technically easier for the surgeon and allows a quicker patient recovery.  The mirels scoring system is available to guide the treatment of an impending fracture from metastatic bone disease.

conclusion  Femoral neck fractures from metastatic bone disease require a cemented hip prosthesis, because internal fixation has a high rate of failure with disease progression.  When surgery is required for metastatic disease to the spine, decompression and stabilization with internal fixation are generally necessary.  Surgical reconstruction for pathologic fractures should be durable enough to allow immediate weightbearing and last throughout the patient’s expected lifespan.

 A pathologic fracture through a primary malignant bone tumor is treated much differently than a fracture through a metastatic lesion.  Treatment of a patients with pathologic fractures requires the presence of a multidisciplinary team composed of orthopaedic surgeons, medical oncologists, radiation oncologists, endocrinologists, radiologists, pathologists, pain specialists, nutritionists, physical therapists, and psycholog

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