1.
Pathologic Fractures due to metastasis and its
management
Presented by Dr Pushpendra
JBJS REVIEWS 2023

2.
A pathological facture is one in which a bone is broken,
through an area weakened by pre-existing disease by a degree of
stress, that would have left the normal bone intact.
In other words, a fracture involving “abnormal bone” is a
pathological fracture.
its suspected when fracture occurs:
1.Spontaneously
2.After minor trauma
3. Unusual fracture pattern
4. History of recent several fractures
5. Older patient
6.History of primary malignancy

3.
Etiology :
1.Development disorders of bone :
a) Congenital defects of bone tissue : Osteogenesis imperfecta Osteopetrosis
b) Disorder of cartilage growth : Achondroplasia Diaphysealaclasis (multiple
exostosis) ,Dyschondroplasia (Ollier’s disease)
2.Nutritional and vitamin deficiencies :
Scurvy ,Rickets ,Osteomalacia
3.Hormonal imbalance :
Hyperparathyroidism ,Cushing’s syndrome
Pathological fracture from cortisone treatment
4.Atrophic conditions of bone : Disuse osteoporosis,Senile osteoporosis
5.Infections : Osteomyelitis
6.Cystic disorders : UBC ,ABC ,Non -osteogenic fibroma of bone
Monostotic and polyostotic fibrous dysplasia
7.Paget’s disease of bone

4.
8.Tumors of bone :
a) Primary benign tumours : Chondroma , osteiod osteoma
Benign chondroblastoma Chondromyxoid fibroma
Haemangioma of bone ,Giant cell tumour of bone
b) Malignant tumours :
Osteosarcoma ,Chondrosarcoma ,Fibrosarcoma
Malignant – fibrous histiocytoma
Malignant round cell tumour ,Multiple myelomatosis
c) Metastatic tumours of bone – lungs, prostrate, breast
thyroid, kidney and GI tract,
9.Iatrogenic pathological fracture :
Through screw hole stress protection phenomenon
Through biopsy
After removal of infected bone
Through a donor site for a bone graft

5.
Common cancer and types of metastasis to bone
Osteolytic
•RCC
•Thyroid
•Lung
Mixed
• Breast
85 % of metastases from
Breast, Lung, Prostate
12 % From RCC , Thyroid
3 % GIT
Osteolytic bone disease Osteoblastic bone disease
Osteoblastic
•Breast
•Prostate

6.
Management
A.Investigation
X ray
Ct scan
MRI
LABORATORY STUDIES : Complete haemogram , Peripheral
smear ,Serum glucose Serum albumin ,Serum calcium,
Phosphate , Alkaline phosphatase , LFT , Urine sugar and
albumin

7.
Search for occult primary carcinoma
• Breast - Examination ,Mammography
• Lung – Chest X-ray /HRCT
• Kidney – USG abdo.
• Thyroid – Digital palpation
• Prostate – Serum PSA and Digital prostate examination
• Myeloma profile: ESR ,S. Electrophoresis Bence Jones
Proteins ,
• Skeletal survey – Skull, pelvis, spine
• True cut core needle biopsy
• Bone marrow aspiration and biopsy
• PET scan

8.
B.Treatment…………
Non-operative……. Patients with metastatic bone disease often present
with at least some pain, so decisions on when to offer surgery can be
difficult.That time treated with ……..
1.Radiotherapy
a.External-beam radiotherapy
b.Stereotactic Body Radiotherapy(SBRT)
c.Radiopharmaceuticals : Unsealed source therapy with bone-
seeking Radionueclides
• (Strontium-89, Samarium-153, P-32, Rhenium – 186 are commonly used to
treat bone mets )
• They get concentrated in highly active site of the bone and emit beta-
particles which intern destroy the tumor cells
• It takes 7-14 days to see clinical response and the procedure can be repeated
once in 12 weeks
Multiple painful bony lesion: Hemibody irradiation and Radioneuclide
therapy
GOALS OF TREATMENT is Metastatic Bone tumors: To provide pain-free
maintenance of normal daily function

9.
2.Systemic therapy
A . Hormone therapy (Ca breast and prostate )
B . Chemotherapy(as per medical oncologist and
type of mets)
C . Bisphosphonates : Zolindronic acid
D . Targeted therapy : Denosumab

10.
Mirels criteria to assess risk for impending fracture.
generally recommends prophylactic fixation for scores >8
Damron et al., using Ct based rigidity analysis (CTRA), which is better then Mirel’s scoring
to predict impending pathological fracture……

11.
Operative…
Prophylactic fixation :
Advantages :
• Decreased morbidity
• Decreased hospital stay
• Easier rehabilitation
• Pain relief
• Faster surgery and less complications
• Less blood loss during surgery
Risks :
• Temporary
• Fixation device may eventually fail
• Loss of fixation is the most significant complication

12.
Minimally invasive interventional radiology
specially for spine ,pelvis and hyper vascular mets.
By…
• Ablation(RFA,microwave or with cryogenic agent)
• Reinforce (bone cement)
• Transcatheter arterial embolization (TAE)

13.
55-year/male
H/o pain on left hip and groin region last 4 month which is
significantly increases recently
Past H/o He had an established diagnosis of renal cell
carcinoma with biopsy-proven metastasis to bone 1 year earlier
medical history included anxiety, hypertension, and a left total
nephrectomy
On examination tenderness on the left groin and a painful log roll

14.
Fig.-A The cryoablation probe is placed percutaneously into the lesion. Embolization coil
performed before this portion of the procedure is seen.
Fig.-B After confirming proper placement of the ablation probe, cement is injected. Care is
taken throughout the procedure that the cement is not escaping into the joint space or
adjacent tissues.
Fig. C Final cement pressurization is preformed; interdigitation within the supra-
acetabular trabecular bone is seen

15.
AP x ray of the left hip joint demonstrate
intramedullary cephalomedullary nailing.
Embolization coils can be seen projected in front
of the femur. In the acetabulum, the area that
underwent percutaneous ablation
cementoplasty demonstrates filling of the entire
radiolucent area previously visualized.

16.
Take home massage
• The treatment of patients with impending or
completed pathologic fractures due to
metastasis must be accomplished with
multidisciplinary support to achieve the
greatest success.