Practical Input on Bone Tumor Imaging: Pathological Fracture, Risk Features, and When to Contact Orthopaedics

Abstract

Awareness of risk factors associated with impending fracture and its radiologic appearance allows early diagnosis, supports prophylactic surgical treatment, and prevents the multiple complications of a pathologic fracture. Because the femur is the most common long bone affected by metastatic bone lesions, we address this clinically relevant site in this review. The key to early detection of risky bone lesions is familiarity with the possible clinical presentation, biomechanical effects of the anatomical site (femoral head and neck, intertrochanteric zone, proximal diaphysis), and the lesion types (lytic, blastic, or mixed). Awareness of the possible treatment strategies depending on the characteristics just listed allows high-quality targeted reporting.

Keywords

risk factors - pathologic fracture - femoral head - early detection - diaphysis - lesion - lytic

• References

• 1 Nooh A, Goulding K, Isler MH. , et al. Early improvement in pain and functional outcome but not quality of life after surgery for metastatic long bone disease. Clin Orthop Relat Res 2018; 476 (03) 535-545
• 2 Damron TA, Morgan H, Prakash D, Grant W, Aronowitz J, Heiner J. Critical evaluation of Mirels' rating system for impending pathologic fractures. Clin Orthop Relat Res 2003; ;(415, Suppl): S201-S207
• 3 Jawad MU, Scully SP. In brief: classifications in brief: Mirels' classification: metastatic disease in long bones and impending pathologic fracture. Clin Orthop Relat Res 2010; 468 (10) 2825-2827
• 4 Aufranc OE, Jones WN, Bierbaum BE. Pathological fracture of the femoral neck. JAMA 1968; 206 (01) 120-123
• 5 Casadei R, Ruggieri P, Ferraro A, Mercuri M. Indications for the treatment of pathologic fracture in tumors of bone. Chir Organi Mov 1996; 81 (01) 21-30
• 6 Harrington KD. Impending pathologic fractures from metastatic malignancy: evaluation and management. Instr Course Lect 1986; 35: 357-381
• 7 Hipp JA, Springfield DS, Hayes WC. Predicting pathologic fracture risk in the management of metastatic bone defects. Clin Orthop Relat Res 1995; ; (312) 120-135
• 8 Harrington KD. New trends in the management of lower extremity metastases. Clin Orthop Relat Res 1982; ; (169) 53-61
• 9 Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; ;(249) 256-264
• 10 Benca E, Patsch JM, Mayr W, Pahr DH, Windhager R. The insufficiencies of risk analysis of impending pathological fractures in patients with femoral metastases: a literature review. Bone Rep 2016; 5: 51-56
• 11 Roodman GD. Mechanisms of bone metastasis. N Engl J Med 2004; 350 (16) 1655-1664
• 12 van der Linden YM, Kroon HM, Dijkstra SP. , et al; Dutch Bone Metastasis Study Group Simple radiographic parameter predicts fracturing in metastatic femoral bone lesions: results from a randomised trial. Radiother Oncol 2003; 69 (01) 21-31
• 13 Fidler M. Incidence of fracture through metastases in long bones. Acta Orthop Scand 1981; 52 (06) 623-627
• 14 Sternheim A, Giladi O, Gortzak Y. , et al. Pathological fracture risk assessment in patients with femoral metastases using CT-based finite element methods. A retrospective clinical study. Bone 2018; 110: 215-220
• 15 Menck H, Schulze S, Larsen E. Metastasis size in pathologic femoral fractures. Acta Orthop Scand 1988; 59 (02) 151-154
• 16 Sivasundaram R, Shah S, Ahmadi S. , et al. The biomechanical effect of proximal tumor defect location on femur pathological fractures. J Orthop Trauma 2013; 27 (08) e174-e180
• 17 Haidukewych GJ. Metastatic disease around the hip: maintaining quality of life. J Bone Joint Surg Br 2012; 94 (11, Suppl A): 22-25
• 18 Behnke NK, Baker DK, Xu S, Niemeier TE, Watson SL, Ponce BA. Risk factors for same-admission mortality after pathologic fracture secondary to metastatic cancer. Support Care Cancer 2017; 25 (02) 513-521
• 19 Blank AT, Lerman DM, Patel NM, Rapp TB. Is prophylactic intervention more cost-effective than the treatment of pathologic fractures in metastatic bone disease?. Clin Orthop Relat Res 2016; 474 (07) 1563-1570
• 20 Li S, Peng Y, Weinhandl ED. , et al. Estimated number of prevalent cases of metastatic bone disease in the US adult population. Clin Epidemiol 2012; 4: 87-93