Pathological Fracture

Scenario

You are the SPR in Trauma and Orthopaedic on call and are called by A+E to assess a patient who has right thigh pain. The following plane film radiograph has been obtained.

Screenshot-2022-04-27-at-06.48.13

These are AP and Lateral plane film radiograph of a patients Left hip and proximal femur. There is a circumferential lytic lesion within the proximal femoral shaft the lesion occupies 1/3rd the width of the shaft. There is a narrow zone of transition. 

I would take a full history and examine the patient. Pertinent history would be:

  • Chest/prostate/breast/kidney/thyroid symptoms
  • Site, onset, character, radiation, time course, exacerbating and alleviating features of the pain.
  • Weight loss, fatigue and other constitutional symptoms

Examination of potential sources of primary.

Investigations would include: Routine bloods (FBC, U+Es, LFTs, Clotting, Tumour markers), Orthogonal views including full length femur, CT Chest Abdomen and Pelvis +/- bone scan +/- MRI.

Refer to MDT

There are two criteria to determine the need for prophylactic fixation: Harington’s criteria and Mirels’ criteria.

Mirel’s criteria

Score

1

2

3

Site

Upper limb

Lower limb

Peritrochanteric

Pain

Mild

Moderate

Functional

Lesion

Blastic

Mixed

Lytic

Size

<1/3

1/3 to 2/3

>2/3

Scores greater than 8 suggest prophylactic fixation should be undertaken.

  • 8 = 15%
  • 9 >33%

 

Harrington Criteria

  • >50% cortical bone destruction
  • Lesion >2.5cm in size
  • Pathological avulsion fracture of the lesser trochanter
  • Functional pain after radiation therapy

I would treat the patient with an intramedullary nail. Intraoperatively I would send reaming samples for histology.

Lead (PB) – Kettle (KTL)

P – Prostate (sclerotic)

B – Breast (mixed)

K – Kidney/Renal

T – Thyroid

L – Lung

I would treat the patient with an intramedullary nail. Intraoperatively I would send reaming samples for histology. Given the nature of these tumours to bleed I would liaise with interventional radiology or vascular for pre-operatively embolization.

This patient would need to be referred to the regional tumour centre.

Spine > Proximal femur > Humerus

Immediate full weightbearing

Protect patient from periprosthetic/pathological fractures

Implant doesn’t require revision

Patient survives surgery

Area between normal bone and pathological tissue. Narrow zone of transitions implies it is a benign lesion. A wide zone of transition implies it is a metastatic lesion.