Pathological Fractures — Workup

A pathological fracture is defined as a fracture that occurs in bone weakened by an underlying disease process. Unlike traumatic fractures, which occur in normal bone subjected to excessive force, pathological fractures occur when relatively minor trauma or even normal physiological stress is applied to abnormal bone.

Pathological fractures are commonly associated with metabolic bone disorders, infections, and primary or metastatic bone tumors. In orthopaedic practice, metastatic disease is one of the most frequent causes of pathological fractures in adults. Early recognition of a pathological fracture is critical because the underlying disease often requires specific treatment beyond simple fracture fixation.

The evaluation of a pathological fracture requires careful clinical assessment, appropriate imaging studies, and sometimes biopsy to determine the underlying cause. Failure to recognize a pathological fracture can lead to inappropriate treatment and potentially worsen the patient prognosis.

Several conditions can weaken bone and predispose it to fracture. These conditions may be broadly classified into metabolic, neoplastic, infectious, and congenital causes.

Among these causes, metastatic cancer is the most frequent cause of pathological fractures in adults, whereas primary bone tumors and metabolic diseases are more common in younger patients.

Certain bones are more frequently involved in pathological fractures due to their high vascularity and susceptibility to metastatic deposits.

• Femur (especially proximal femur)
• Humerus
• Vertebral bodies
• Pelvis
• Ribs

The proximal femur is a particularly common site for pathological fractures because it bears significant mechanical load during daily activities.

The clinical history and physical examination are crucial in identifying a pathological fracture. Patients often report pain at the site of the lesion prior to the fracture event.

Important Clinical Features

• Pain preceding fracture
• Minimal trauma causing fracture
• History of malignancy
• Night pain
• Systemic symptoms such as weight loss

Pain that occurs at rest or during the night is particularly concerning for an underlying neoplastic process.

Plain radiography is the first step in the imaging evaluation of a suspected pathological fracture. X-rays may reveal characteristic patterns that help identify the underlying pathology.

Additional imaging modalities such as CT scans, MRI, and bone scans may be required to further characterize the lesion.

Advanced imaging studies help determine the extent of disease and identify other skeletal lesions.

• CT scan for cortical bone evaluation
• MRI for soft tissue and marrow involvement
• Bone scan for detection of multiple metastases
• PET scan for staging malignancy

MRI is particularly useful for evaluating the local extent of a bone tumor and its relationship to surrounding soft tissues.

Laboratory tests may help identify metabolic bone diseases or systemic malignancies associated with pathological fractures.

A biopsy is often required when the diagnosis remains uncertain after imaging studies. The biopsy allows histological examination of the lesion and confirmation of the underlying pathology.

It is essential that biopsy procedures are carefully planned because improper biopsy techniques can compromise future surgical treatment.

• Core needle biopsy
• Open biopsy
• Image-guided biopsy

Treatment of pathological fractures involves management of both the fracture and the underlying disease process.

• Stabilization of fracture
• Treatment of underlying tumor or metabolic disorder
• Pain management
• Rehabilitation

In metastatic disease, surgical fixation may be combined with adjuvant therapies such as radiotherapy or chemotherapy.

• Pathological fractures occur in abnormal bone
• Metastatic disease is the most common cause in adults
• Proximal femur is a common site
• Radiographs are the first imaging modality
• Biopsy may be required for diagnosis