Pathological fracture is a violation of the integrity of the bone in the area of its pathological restructuring. It occurs as a result of a minor traumatic effect: a fall from a small height, a non-intense blow or even ordinary muscle tension. The cause of development is osteoporosis, osteomyelitis, malignant and benign neoplasms of bone tissue and some other diseases. Clinical manifestations are usually erased, pain, swelling, limitation of limb function may be observed. The diagnosis is established on the basis of radiography, MRI, CT, scintigraphy, biopsy and other studies. Treatment is more often operative.
M84.4 Pathological fracture not classified elsewhere
Pathological fracture is damage to a bone whose strength is reduced due to some disease or pathological condition. Pathological fracture in osteoporosis, which often occur in elderly and senile people, are of the greatest importance due to their prevalence, probable complications and possible adverse outcome. Most often in clinical practice there are pathological injuries of the vertebrae, femoral neck and distal epiphysis of the radius.
A characteristic feature of this type of damage is the difficulty of consolidation due to pathological changes in bone tissue. Because of this, patients remain immobilized for a long time, which causes the development of bedsores and stagnant pneumonia, the formation of severe contractures, etc. This, as well as the need to remove the tumor in benign and malignant neoplasms, causes a high frequency of surgical interventions. Treatment of pathological fracture, depending on the cause of their occurrence, can be carried out by orthopedic traumatologists and oncologists.
Most often, pathological fracture are complicated by bone neoplasms and fibrous osteodystrophy. According to statistics, pathological violation of bone integrity is observed in 50-60% of solitary cysts. A little less often, traumatic injuries occur with fibrous dysplasia. In Paget’s disease and Recklinghausen’s disease, bones break in 40-50% of cases, in giant cell tumors – in 15% of cases.
- Bone tumors. Among the tumor processes, the first place in the number of such complications is occupied by malignant tumors, while pathological bone damage is more often observed in metastatic processes and less often in primary tumors. A distinctive feature of fractures with metastases is the multiplicity, especially pronounced with injuries to the vertebral bodies. Multiple myeloma metastases are complicated by fractures in 2-3 cases. Less often, pathological fracture are observed in metastases of hypernephroma and cancer, as well as in osteoplastic bone carcinosis. Bone damage in osteoclastic sarcomas is not uncommon. Among benign neoplasms, fractures are most often complicated by chondromes.
- Osteoporosis. Nowadays, due to an increase in life expectancy and a decrease in the motor activity of the “average” person in traumatology and orthopedics, pathological fractures in osteoporosis are becoming increasingly important. Injuries occur more often in postmenopausal women. The integrity of the vertebrae, femoral neck or radius is usually violated. Multiple repeated compression fractures of the vertebrae cause the development of kyphosis. Fractures of the femoral neck cause disability, and in old age in 25-30% of cases end in death due to severe complications.
- Infections. Fractures often occur with echinococcosis and quite rarely – with tuberculosis, osteomyelitis and tertiary syphilis.
- Changes in osteogenesis. Pathological bone fragility is also observed in osteopsatirosis and osteogenesis imperfecta, osteoarthropathies with syringomyelia and spinal cord dryness and osteosclerosis of various genesis.
- Neurological diseases. Bone changes due to neurogenic disorders cause pathological fractures in paresis and paralysis of both traumatic and non-traumatic nature.
Peculiar micro-fractures always occur with osteochondropathies and in most cases – with congenital syphilis and childhood scurvy. Less often, bones break with osteomalacia and rickets and very rarely with hemophilia. A pathological fracture can also be considered a violation of the integrity of the forming bone callus, that is, a recurrence of a traumatic fracture. The integrity of the bone is also often violated in ankylosis, in such cases, the atrophied bone breaks near the joint. Many experts attribute to pathological injuries fractures of the atrophied and ankylosed spine in ankylosing spondylitis.
A distinctive feature of such injuries is the low severity of symptoms compared to ordinary traumatic fractures. Minor or moderate pain and indistinct swelling of the affected segment are possible. In some cases, such fractures become the first manifestation of a pathological process in the bone in people who previously considered themselves healthy. Quite often, a pathological violation of the integrity of the bone is preceded by bone deformities, indefinite spontaneous pain or pain during exercise.
Significant displacement of fragments is observed very rarely. Compression lesions, overhangs, large cracks, indentations and fractures of tubular bones in the form of a telescope often occur (transverse injuries in which the thinned cortical layer of one fragment moves over another bone fragment). Pathological mobility and crepitation in such injuries are absent, hemorrhage may be poorly expressed or not at all expressed. All of the above complicates the diagnosis and causes late treatment of patients to doctors.
The diagnosis is made taking into account complaints, a characteristic history (minor injury), examination data and additional examination methods. Radiography is of the greatest importance. For a more accurate assessment of the condition of bones and surrounding soft tissues, MRI and CT can also be used. If metastases are suspected, scintigraphy is of great importance, which allows detecting metastatic lesions four times more often than conventional radiography. If osteoporosis is suspected, densitometry is indicated. In some cases, the nature of the pathological process can be established only with the help of a biopsy.
Laboratory tests also have a certain diagnostic value. Osteolytic processes are characterized by the release of hydroxypromine, hypercalciuria and hypercalcemia. In osteoplastic lesions, there is a decrease in the level of calcium and an increase in the level of alkaline phosphatase in the blood serum. At the same time, the analysis data in most cases are not specific and can only be considered as an additional diagnostic criterion.
Therapeutic tactics are determined taking into account the underlying disease, as well as the localization and nature of the damage. The purpose of surgical intervention may be to reduce the duration of treatment in a hospital, eliminate pain syndrome, facilitate patient care, early activation of the patient and improve his psychoemotional state, as well as reduce the likelihood of complications: bedsores, thrombophlebitis, trophic ulcers, congestive pneumonia, hypercalcemia, etc.
The method of surgical intervention is chosen taking into account the peculiarities of the pathological process. In benign tumors, resection of the affected area is performed (in some cases, with the replacement of the resulting defect with an allo- or homotransplant) in combination with bone or intraosseous osteosynthesis. With oncological lesions, it is often not an increase in duration that comes to the fore, but an improvement in the patient’s quality of life.
At the same time, with the successful treatment of the underlying disease, pathological fracture, which are a complication of malignant tumors, grow together quite successfully, which also needs to be taken into account when choosing operational tactics. If the joint or the periarticular area is affected, endoprosthetics is performed if possible, if the integrity of the diaphysis is violated, segmental resection is performed in combination with strengthening the damaged area with bone cement or replacement of the defect with a graft. Fragments are fixed using nails, plates, pins, screws or by installing Ilizarov apparatuses.
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