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.
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.
Venting, drilling holes in the distal femur.
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.
