Pathologic Fracture Management

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.