1. Textbook Reading-Rockwood -Chapter 20 Pathologic Fractures p643-p647

2. Pathologic Fractures Bone weakness with a pre-existing abnormality
Fractures due to low energy injuries.
Distored archetecture and distored bone density

3. Pathologic Fractures
Correctable diseases : renal osteodystrophy, hyperparathyroidism, osteomalacia, and disuse osteoporosis.
Uncorrectable diseases : osteogenesis imperfecta, poly-ostotic fibrous dysplasia, postmenopausal osteoporosis, Paget's disease, and osteopetrosis.

4. Pathologic Fractures
A primary goal in the management of patients with any systemic skeletal disease is to prevent disuse osteoporosis, which may lead to additional pathologic fractures.

5. Pathologic Fractures 10 million Americans > 50 years  osteoporosis
34 million osteomalacia & risk for osteoporosis
1.5 million people  pathologic fracture related to osteoporosis each year
20% elder who sustain a hip fracture die within 1 year
One of every two women > 50 years  osteoporosis-related fracture in lifetime
Other skeletal conditions such as Paget's disease  one million people in USA
20,000 to 50,000 Americans  osteogenesis imperfecta

6. Pathologic Fractures
The American Cancer Society  1.3 million new cancer cases in 2003 50% skeleton metastasis
With improved medical treatment of many cancers  increased prevalence of bone metastasis  increases the chances of pathologic fracture.
The majority of bone metastases originate from cancers  breast, lung, and prostate, followed by the thyroid and kidney.
The most common sites  spine, pelvis, ribs, skull, and proximal long bones.

7. EVALUATION OF THE PATIENT WITH AN IMPENDING OR ACTUAL PATHOLOGIC FRACTURE
Clinical
History
Physical Examination
Laboratory Studies
Associated Medical Problems
Radiographic Workup
Plain X-Rays
Nuclear Medicine Studies
Three-Dimensional Imaging/Angiography
When and How to Biopsy

8. History TABLE 20-1 Evaluation of a Patient with a Lytic Bone Lesion
TABLE Factors Suggesting a Pathologic Fracture

9. TABLE 20-1 Evaluation of a Patient with a Lytic Bone Lesion
History: thyroid, breast, or prostate nodule
Review of systems: gastrointestinal symptoms, weight loss, flank pain, hematuria
Physical examination: lymph nodes, thyroid, breast, lungs, abdomen, prostate, testicles, and rectum
Plain x-rays: chest, affected bone, humerus, pelvis, femur, spine
99mTc bone scan/FDG-PET scan: total body
CT scan: chest, abdomen, pelvis
Laboratory: complete blood count, erythrocyte sedimentation rate, calcium, phosphate, urinalysis, prostate-specific antigen, immunoelectrophoresis, and alkaline phosphatase
Biopsy: needle vs. open
FDG, Fluorine-18 deoxyglucose; PET, positron emission tomography; CT, computed tomography.

10. TABLE 20-2 Factors Suggesting a Pathologic Fracture
Spontaneous fracture
Fracture after minor trauma
Pain at the site before the fracture
Multiple recent fractures
Unusual fracture pattern (banana fracture)
Patient >45 years of age
History of primary malignancy

11. Physical Examination
Careful evaluation of the affected skeletal region Palpation of a mass or fracture and a detailed neurologic examination
All extremities and the entire spine should be evaluated for additional lesions or lymphadenopathy
Careful evaluation of all possible primary sites (breast, prostate, thyroid) and a stool guaiac test

12. Laboratory Studies
Baseline laboratory  CBC/DC, ESR, BUN, SUGAR, liver function, protein, albumin, CA, P, and ALP.
Bone metastases  anemia of chronic disease, hypercalcemia, and increased alkaline phosphatase
U/Amicroscopic hematuria renal cell carcinoma (RCC)

13. Laboratory Studies
Serum and urine protein electrophoreses  multiple myeloma
Thyroid function tests, CEA, CA125, and PSA are serum markers for specific tumors
N-telopeptide and C-telopeptide in serum and urine increased destruction caused by bone metastasis

14. Laboratory Studies
Prostate-specific antigen is a sensitive measurement of prostate cancer : < 10 ng/mL excludes bone metastasis
Remember that serum calcium is a measurement of unbound calcium in the serum, and, therefore, determination of serum protein is necessary to interpret the calcium level.
Correct Ca(mg/dl)=Total Ca(mg/dl)-0.8×[4.0-albumin(g/dl)]。

15. TABLE 20-3 Disorders Producing Osteopenia
Laboratory Value
Serum Calcium
Serum Phosphorus
Serum Alkaline Phosphatase
Urine
Osteoporosis
Normal
Normal Ca
Osteomalacia
Normal to low
Normal to high
Low Ca
Hyperparathyroidism
High Ca
Renal osteodystrophy
Low
High
Paget's disease
Very high
Hydroxyproline
Myeloma
Protein

16. Associated Medical Problems
Pain unable to ambulate or perform daily activities
Spinal fractures  neurologic deficits
Prolonged bedrest  predisposing hypercalcemia
40% hypercalcemia related to malignancy lung, breast, kidney, and genitourinary tract

17. Associated Medical Problems
Hypercalcemia  poor prognosis  60% : survive < 3 months, and only 20% 1 year
No reliable correlation between the hypercalcemia and skeletal involvement
Lung ca  hypercalcemia without obvious bone metastases
Multiple myeloma or breast cahypercalcemia with extent of bone metastases

18. TABLE 20-4 Signs and Symptoms of Hypercalcemia
Neurologic: headache, confusion, irritability, blurred vision
Gastrointestinal: anorexia, nausea, vomiting, abdominal pain, constipation, weight loss
Musculoskeletal: fatigue, weakness, joint and bone pain, unsteady gait
Urinary: nocturia, polydypsia, polyuria, urinary tract infections

19. Radiographic Workup -Plain X-Rays
Evaluate a destructive bone lesion or pathologic fracture  plain x-ray in two planes.
Diagnostic clues  osteopenia, periosteal reaction, cortical thinning, Looser's lines, and abnormal soft tissue shadows

20. Radiographic Workup -Plain X-Rays
Osteomalacia or hyperparathyroidism  looser's lines (compression-side radiolucent lines), calcification of small vessels, and phalangeal periosteal reaction.
Osteoporosis  thin cortices and loss of the normal trabecular pattern.

21. Radiographic Workup -Plain X-Rays
Osteolytic or osteoblastic lesion  tumor  inactive, active, or aggressive.
Small osteolytic lesions without endosteal or periosteal reaction  inactive or minimally active (benign) primary bone tumors.
Cortex erosion but are contained by periosteum  active benign or low-grade malignant bone tumors

22. Radiographic Workup -Plain X-Rays
Large lesions that destroy the cortex  aggressive, malignant lesions
Permeative or moth-eaten pattern of cortical destruction highly suggestive of malignancy
> 45 years & destructive bone lesions  metastatic carcinoma , multiple myeloma and lymphoma
Solitary bone lesion  primary bone tumor  chondrosarcoma, malignant fibrous histio-cytoma, or osteosarcoma

23. Radiographic Workup -Plain X-Rays
Osteolytic destruction is most common  lung, thyroid, kidney, and colon
Osteoblastic with sclerosis  metastatic prostate cancer
Metastatic breast cancer  mixed osteolytic and osteoblastic

24. osteolytic & osteoblastic

25. TABLE 20-5 Evaluation of Plain X-rays
Question
Option
Interpretation
1. Where is the lesion?
Epiphysis vs metaphysis vs diaphysis
Cortex vs medullary canal
Long bone (femur, humerus) vs flat bone (pelvis, scapula)
2. What is the lesion doing to the bone?
Bone destruction (osteolysis)
   -Total
   -Diffuse
   -Minimal
3. What is the bone doing to the lesion?
Well-defined reactive rim
Benign or slow-growing
Intact but abundant periosteal reaction
Aggressive
Periosteal reaction that cannot keep up with tumor (Codman's triangle)
Highly malignant
4. What are the clues to the tissue type within the lesion?
Calcification
Bone infarct/cartilage tumor
Ossification
Osteosarcoma/osteoblastoma
Ground glass
Fibrous dysplasia

26. Thank you for attention.

27. Rockwood Chapter 20 Pathologic fractures P.648~652
Report: R3 范姜治澐

28. Plain X-Rays Generalized osteopenia Periosteal reaction
Cortical thinning
Looser's lines (compression-side radiolucent lines)
Abnormal soft tissue shadows

29. Question Option Interpretation Where is the lesion?
Epiphysis vs metaphysis vs diaphysis Cortex vs medullary canal Long bone (femur, humerus) vs flat bone (pelvis, scapula)
Codman's triangle
What is the lesion doing to the bone?
Bone destruction (osteolysis)    -Total    -Diffuse    -Minimal
What is the bone doing to the lesion?
Well-defined reactive rim Intact but abundant periosteal reaction Periosteal reaction that cannot keep up with tumor (Codman's triangle)
What are the clues to the tissue type within the lesion?
Calcification Ossification Ground glass
Bone infarct/cartilage tumor Osteosarcoma/osteoblastoma Fibrous dysplasia

30. Osteomalacia or hyperparathyroidism
Looser’s line
Calcification of small vessels
Phalangeal periosteal reaction
Osteoporosis
Thin cortices
loss of the normal trabecular pattern without other abnormalities

31. Osteolytic or osteoblastic lesion
Inactive
Small osteolytic lesions surrounded by a rim of reactive bone
Without endosteal or periosteal reaction
Active
Lesions that erode the cortex but are contained by periosteum
Aggressive
Large lesions that destroy the cortex
“moth-eaten”

32. Multiple myeloma and lymphoma
Most destructive bone lesions in patients more than 45 years of age of metastatic carcinoma followed by them
A solitary bone lesion should be fully evaluated to rule out a primary bone tumor
chondrosarcoma,
malignant fibrous histiocytoma
osteosarcoma

33. Bone metastasis Osteolytic lung, thyroid, kidney, and colon
Osteoblastic
with sclerosis
Prostate
Mixed
Breast

34. Tumor cells secrete factors that interact with host cells in the bone microenvironment and affect the cycle of normal bone turnover
An isolated avulsion of the lesser trochanter is almost always pathologic
A cortical lesion in adults is usually a metastasis

35. Nuclear Medicine Studies
Technetium bone scintigraphy
detects osteoblastic activity
Multiple myeloma, occasional metastatic RCC are falsely negative on bone scan
Fluorine-18 deoxyglucose
Positron emission tomography (PET) scanning
Gold stadard recently in metabolic imaging
PET/computed tomography (CT) scanning had higher sensitivity and specificity

36. Magnetic resonance imaging (MRI) is not generally used
Useful in the evaluation of patients with spinal metastasis
Standard angiogram is still useful when embolizing feeding tumor vessels in vascular lesions
Metastatic RCC
Multiple myeloma

37. Search for a primary lesion
examination of the breast, thyroid, and prostate
chest x-ray and CT scans of the chest, abdomen, and pelvis
mammogram
skeletal survey including skull films (MM)
PET

38. A solitary bone lesion in a patient with or without a history of cancer should be biopsied
Needle biopsy
differentiating a carcinoma from a sarcoma
Immunohistochemical staining
Fracture should be stabilized initially with traction or a cast

39. Cultures should always be sent
Incisional biopsy
site unaffected by the fracture
as small as possible
longitudinal fashion
hemostasis
Cultures should always be sent

40. Intraoperative frozen section
surgical treatment of the pathologic fracture
best to wait for the permanent sections before definitively treating the tumor and fracture

41. IMPENDING PATHOLOGIC FRACTURES
X-ray appearance of the lesion
Patient's symptoms
50% to 75% cortical involvement
Significant pain relief after prophylactic fixation
Painful, larger than 2.5 cm, and involves more than 50% of the cortex

42. Classification Mirels developed a scoring system
presence or absence of pain, and the
size,
location
radiographic appearance
Lesions scoring 8 or higher require prophylactic internal fixation before irradiation

43. Prophylactic stabilization
shorter hospitalization (average 2 days)
discharge more likely (40%)
immediate pain relief
faster and less complicated surgery
less blood loss
quicker return to premorbid function
improved survival
fewer hardware complications

44. Goals of surgical treatment
alleviate pain
reduce narcotic use
restore skeletal stability
regain functional independence

45. Decision-making for operation
life expectancy of the patient
patient comorbidities
extent of the disease
tumor histology
anticipated future oncologic treatments
degree of pain

46. TREATMENT OPTIONS FOR PATIENTS WITH METASTATIC OR SYSTEMIC DISEASE
Local bone lesion can be treated with
nonsurgical management (radiation, functional bracing, and bisphosphonates)
surgical stabilization with or without resection
large lytic lesions at risk for fracture
existing pathologic fractures
Pathologic long bone fractures
overall rate of fracture healing: 34%
74% survived > 6 months
Fractures due to MM were most likely to heal

47. Load-bearing fixation device are prefered
Ideal reconstruction
Allow immediate weight-bearing
Not require revision
Load-bearing fixation device are prefered
Poor healing rate, 30~40%
IM device, modular prosthesis
PMMA
increase the strength of the fixation
improves the bending strength of a fixation

48. Autogenous bone graft Segmental allografts Not generally used
Rarely indicated
Require a prolonged healing time

49. Cemented prosthesis IM nailing
Prophylactically stabilization of entire bone
Femur, humerus, or tibia
Reconstruction nail for stabilize the femoral neck

50. Hypervascular metastatic cancers
RCC
Thyroid ca MM
Tourniquet
Preoperative angiographic embolization
within 36 hours

51. Nonoperative treatment
limited life expectancies
severe comorbidities
small lesions
radiosensitive tumors
Patients should limit weightbearing on the affected extremity

52. Upper Extremity Fractures
20% bone metastasis
50% in the humerus
Benefits to quality of life – operation prefered

53. Scapula/Clavicle Nonoperative treatment immobilization radiation
medical management

54. Proximal Humerus humeral head or neck proximal humeral replacement
pain relief and local control of the tumor
range of motion and stability are often limited
intramedullary fixation
cement may be required

55. Humeral Diaphysis locked intramedullary fixation
Intercalary metal spacer
After complete resection of a metastatic lesion
minimizing blood loss
alleviating the need for postoperative radiation
Plate fixation of the humerus is at risk of failure

56. Distal Humerus flexible intramedullary nails bicondylar plate fixation
resection with modular distal humeral reconstruction

57. Forearm/Hand Unusual Often from the lung, breast, and kidney
Radius and ulna
Flexible rods or rigid plate fixation
Radial head
Resection
Hand
curettage, internal fixation, and cementation
Amputation

58. Rockwood and Green’s fractures in adults
Chapter 20
Pathologic Fractures P
Kristy L. Weber
Presented by R3 Meng-huang Wu

59. Humeral Diaphysis IM nailing Intercalary Metal spacer
Mechanical and rotational stability
PMMA augment
Intercalary Metal spacer
Modular reconstruction in segmental defects or large bone loss
Minimize blood loss
Alleviate post op RT
Plate fixation with cement
Extensive exposure
Inability to protect the entire bone
Risk of failure

60. Distal Humerus Flexible intramedullary nails
Bicondylar plate fixation with cement
Resection with modular distal humeral reconstruction
massive bone loss involving the condyles
Curettage of the distal humeral lesion
open reduction in fracture
use PMMA

61. Flexible intramedullary nails
Ease of insertion: retrograde via bilat. entry point
span the entire humerus
excellent functional recovery
preservation of the elbow joint

62. Forearm/Hand Radius and ulna Radial head Hand Distal or extensive
Metastases distal to the elbow are unusual
lung, breast, and kidney
Radius and ulna
flexible rods or rigid plate fixation
Radial head
resection
Hand
Intralesional curettage, internal fixation, and cementation
Distal or extensive
amputation

63. Pelvic/Acetabular Fractures
Bony pelvis
Many bone metastases or pathologic fractures do not affect weight-bearing; not require surgical intervention.
Lesions of the iliac wing, superior/inferior pubic rami, or sacroiliac region.
Insufficiency fractures caused by osteoporosis: protected weight-bearing until the pain diminishes

64. Periacetabular lesions
Affect ambulatory status and often present a difficult surgical problem
CT scans with 3D reconstructions

65. Harrington classification
the location and extent of the defect
Class I
Minor acetabular defects
Intact lateral cortices and superior and medial walls
Conventional cemented acetabular component

66. Class II
Major acetabular defects with a deficient medial wall and superior dome.
Antiprotrusio device or medial mesh

67. Class III
massive defects with deficient lateral cortices and superior dome.
Acetabular cage
The massive bony defect is filled with PMMA
A cemented PE cup

68. Class IV pelvic discontinuity
resection and reconstruction using a saddle prosthesis
satisfactory pain relief and function: 70% to 75%
Complications: 20% to 30% of cases
trabecular metal, tantalum

69. Lower Extremity Fractures
Femur: most common
The proximal 1/3 is involved in 50% of cases with the intertrochanteric region accounting for 20% of cases.
Most painful of all bone metastases
Alter the quality of a patient's life and threaten an individual's level of independence.
Painful lesion:
Prophylactically stabilized whenever possible
high incidence of subsequent fracture and the comparative ease of the operation.

70. Femoral Neck Rarely heal and tends to progress
High incidence of failure if traditional fracture fixation devices

71. Cemented replacement prosthesis
Treatment of choice
THR?: acetabular involvement
All tumor tissue should be curetted from the femoral canal
Adjacent lesions in the subtrochanteric region or proximal diaphysis
long-stemmed cemented femoral component
Cement side effect vs stability