Pathologic fractures create a serious morbidity in patients with metastatic bone disease. Proactive treatments designed to prevent pathologic fractures before they occur lead to the best outcomes.
This article will critically review the literature and provide guidelines for estimating fracture risk that are useful for orthopedic surgeons.
Pathologic fractures create a serious morbidity in patients with metastatic bone disease. Orthopedic surgeons who treat patients with metastatic skeletal lesions should focus on proactive treatments designed to prevent pathologic fractures before they occur. Prevention of pathologic fractures result in better patient outcome, lower cost, and less difficult operative procedures. For this reason, it is critical to identify both patients and skeletal lesions that are at increased risk of pathologic fracture. The goal of this review is to establish a systematic screening tool and treatment algorithm that orthopedic surgeons can easily apply to their patients in order to optimize the management of metastatic skeletal disease.
Unlike fractures of normal bone, pathologic fractures occur during normal activity or minor trauma due to weakening of the bone by disease. Conditions associated with pathologic fractures include underlying metabolic disorders, primary benign tumors, and primary and metastatic malignant tumors (q) . The most common condition associated with pathologic fractures is osteoporosis(q). This review will focus on the evaluation of fractures that occur secondary to bone destruction by metastatic cancer. Prevention of pathologic fractures is superior to treatment after the fact. Some of the advantages that have been cited include shorter hospital stays(R,A); easier rehabilitation and nursing with more rapid restoration of function (U,V,K,R); easier radiotherapy treatment (R,A.); more immediate pain relief (U,V,K,R,A); and faster and less complicated surgery (R,A).
In order to determine which patients require prophylactic fixation to prevent pathologic fracture, it is necessary to perform an accurate and reliable risk evaluation. Many different characteristics have been proposed as important criteria for determining risk of fracture. These include type of cancer; type of treatment; size of the lesion; location of the lesion; whether the lesion is lytic or blastic; and symptoms due to the lesion. In addition, some have proposed a detailed biomechanical analysis based on finite element modeling. the use of biomechanics to predict fracture. This article will critically review the literature and provide guidelines for estimating fracture risk that are useful for orthopedic surgeons.
