The majority of neoplastic pathologic fractures are caused secondary to metastatic disease rather than primary bone tumors
- Fracture due to underlying weakned bone
- May be due to malignancy or metabolic bone disease
- Osteolytic lesions of bone occur secondary to tumor-induced activation of osteoclasts by upregulation of RANK ligand
- Osteoblastic lesions occur secondary to endothelin 1, which is secreted by the tumour
- Osteoblastic: Breast, Prostate
- Osteolytic: RCC, Thyroid, Lung
- Mixed: Breast
- Cancer - primary and secondary e.g. lung, breast, thyroid, renal, and prostate
- Infection e.g. Osteomyelitis
- Inherited bone disorders, Bone cyst
- Paget's disease, Scurvy, Rickets, Osteomalacia
- Achondroplasia, Diaphysealaclasis (multiple exostosis)
- Dyschondroplasia (Ollier’s disease)
- Hyperparathyroidism, Cushing’s syndrome
- Pathological fracture from cortisone treatment
- Frohlich’s syndrome (hypopituitarism)
- Disuse osteoporosis and Senile osteoporosis
- Suspect if a fracture occurs:
- After minor trauma
- Unusual fracture pattern
- History of recent several fractures
- Older patient
- History of primary malignancy
- Patients may or may not report B symptom - weight loss, fevers, etc
- Bone pain preceded the fracture
- Limb swelling predating fracture
- Marked post-fracture swelling.
- Cystic abnormality of the humerus on X-ray.
- History of malignancy, particularly metastatic.
- Paget's disease of bone with development of malignancy
- FBC Anaemia, Raised ESR - malignancy, myeloma
- Raised Calcium - malignancy
- Plasma protein electrophoresis, Urinary light chains, Bone marrow biopsy
- CT Chest abdomen and pelvis
- Urinalysis : Haematuria and Bladder/Renal cancer
- Prostate – Serum PSA, Digital prostate examination
- Bone scan for increased uptake
- CT for lytic lesions
- Breast exam, mammogram
- DEXA scan if osteoporosis and fragility fracture
- Myeloma screen: Bone marrow examination, Bence-Jones proteins, Serum and urine electrophoresis, Skeletal Survey - X-ray skull, spine and pelvis
- Tumor markers: Ca 125, Ca 19.9, CEA
- Thyroid – Digital palpation
- MRI: Marrow disease, Epidural and nerve root, compression can be
detected, Localize the disease.
- Bone scan: Increased accumulation in the bone - hot lesion. Cold scan with Myeloma and some breast, Flare phenomenon – increased number of lesions
in the case of effective therapy
- Stress fracture: Cortical disruption and/or weakening of bony architecture secondary to repetitive micro-trauma or overuse.
- Paget’s disease: Metabolic disorder resulting in mixed blastic/lytic lesions of bone.
- Avascular necrosis: Local ischemia to a region of bone resulting in tissue death.
- Benign fracture: Cortical disruption secondary to mechanical failure of bone without evidence of malignancy.
- Infection: The presence of foreign microorganisms invading and multiplying within a bone leading to bone erosion and damage
- Manage pain, Avoiding the fracture, Bone stabilization, NSAIDs
- Systemic therapy
- Hormone therapy : Ca breast and prostate
- Bisphosphonates : Zolindronic acid
- Targeted therapy : Denosumab
- Radiotherapy: External-beam radiotherapy, Stereotactic Body Radiotherapy(SBRT), Radiopharmaceuticals : Unsealed source therapy with bone-seeking radionuclides
- If suspicious the patient may require referral to a physician who can investigate
- This may be a care of the elderly physician or Hospitalist
- May require operative management - nails etc