Pathologic Fractures in Children

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Pathologic Fracturesin Children

• Steven Frick, MD
• Created March 2004 Revised August 2006

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Pathologic Fracture Fracture through Abnormal
Bone
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Osteopetrosis - failed fixation of femoral neck
fracture. No osteoclasts - No remodeling.
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With every fracture Ask the question - Is this
fracture through NORMAL bone?
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Often Need to Do More than Treat the Fracture

• Orthopaedic surgeon may be the first to have
  opportunity to make the diagnosis. (malignancy,
  metabolic disease, etc.)

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History

• Minor Or No Trauma
• Any Antecedent Pain?
• Night pain?
• Recent Illness?
• Weight loss?
• Fevers?

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History

• Ask about growth and development
• Dietary habits
• kidney disease
• thyroid disease
• Family history

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History

• Ask about prior malignancies, even in the child
• Families will not always volunteer this
  information

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Physical Exam

• Look for soft tissue mass vs. fracture hematoma
• Other systems- skin, lymphatics, solid organs
• Height - weight percentiles

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11 yo - OGS
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Lab Tests

• CBC with differential
• ESR
• Calcium, Phosphorus, Alkaline phosphatase
• Bun/Cr

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RadiographsBe suspicious

• Osteopenia
• Physeal width (rickets)
• Soft tissue calcifications
• Presence of mass
• Any periosteal reaction

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Ennekings 4 Questions

• Where is lesion located?
• What is lesion doing to bone?
• What is bone doing to lesion?
• Are there clues to type of lesion?

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Benign vs. MalignantMankins Criteria

• Size
• Margination
• Cortex
• Soft tissue mass

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Make Diagnosis/Categorize

• Benign Bone Lesion
• Malignant Bone Lesion
• Infection
• Metabolic Bone Disease
• Skeletal Dysplasia
• Neuropathic
• Osteopenia- Disuse
• Overuse

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Unicameral Bone CystUBC

• Metaphyseal
• Proximal humerus, femur
• 3-14 years old
• Males gt females

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UBC Pathologic Fracture

• Fallen leaf sign (or fragment)
• Active adjacent to physis
• tx immobilize
• fx heals cyst persist in 85

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UBC Persistent

• Steroid injections
• Bone marrow injections
• Bone graft substitutes
• Open currettage/graft
• disrupt hydraulics- puncture, screw, wires, rods

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UBC Injection

• 18 ga spinal needle
• C-arm
• Serous fluid, straw colored
• 2nd needle- vent
• Depomedrol 160 mg
• may need multiple injections

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LJ, 8 yo with arm pain when throwing, injected
once with methylprednisolone (multiple sites),
healing at 3 months
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UBC - Risk Factors for Recurrence

• Age lt 10
• male
• active lesions
• large size
• multiloculated
• cyst index (Kaelin)

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UBC
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Aneurysmal Bone CystABC

• Expansile
• Often wider than physis
• Eccentric
• Aggressive at margins

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ABC
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ABC
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ABC
Look for fluid-fluid levels on MRI
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5 yo female with 1 year of hip pain and 4 prior
steroid injections, progressive coxa vara.
Biopsy ABC
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ABC

• Currettage and bone graft
• /- internal fixation
• high recurrence

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Currettage, biopsy consistent with aneurysmal
bone cyst
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1 month after currettage, bone grafting,
valgus/internal fixation, spica immobilization
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Nonossifying Fibroma(NOF)

• Let fracture heal
• most NOFs persist
• assume if fractures once with minimal trauma,
  high risk to fracture again unless bone changes
  with healing
• currettage/bone graft

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10 yo male - running during soccer. NOF fracture
- at 4 weeks underwent allograft DBM / cancellous
bone graft. Healed at 9 mos.
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NOF - Prophylactic Bone Graft?

• Controversial
• Arata and Peterson, JBJS 1981 - gt50 diameter,
  gt33 mm length
• Easley and Kneisl, JPO 1996 - prophylactic
  surgery not necessary in many

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Fibrous Dysplasia

• Weightbearing bones - ORIF or structural graft
• Enneking - cortical struts alone for femoral neck
• cancellous bone graft will remodel into fibrous
  dysplasia, therefore cortical grafts recommended-
  slower to remodel

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14 yo female - fell walking across front yard 3
months of left hip pain - Motrin referred for
path fx through Ewings sarcoma Dx -polyostotic
fibrous dysplasia
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3 Years Postop
Notice resorption of graft and recurrence of
cystic changes in femoral neck. Can have
secondary ABC develop within fibrous dysplasia
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Fibrous Dysplasia

• Consider other sites
• Bone scan, MRI
• For extensive involvement (McCune-Albright)
  consider intramedullary fixation/splinting

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11 yo male fem neck path fx, nondisplaced.
Fibular allograft (neck) and titanium elastic
nails (subtroch and shaft)
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13 yrs old 2 years postop. FD in rt. femur and
tibia. No pain in hip, in karate. Fibular graft
gone - ? Treat Painful tibia. ? nail ?pamidronate
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5 yo - Albrights polyostotic fibrous dysplasia
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Prophylactic Treatment of Fibrous Lesions (NOF
/FD)

• Any mechanical pain?
• Location and size - relative issues
• supracondylar femur, proximal femur more
  worrisome
• pharmacologic approach (pamidronate) for painful
  fibrous dysplasia some reported successes

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Osteogenesis Imperfecta(OI)

• Abnormal type I collagen
• Severe type - multiple fractures prior to
  skeletal maturity
• Lower extremity gt upper extremity
• Femur, tibia, humerus

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OI

• Early onset (fxs prior to walking)- more
  fractures (2x)
• Closed tx- limit immobilization time
• IM fixation often needed

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3 yo OI - multiple fxs Lt femur
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OI
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OI Olecranon Fx
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OI- New Methods

• Minimize disuse osteoporosis
• Early IM fixation
• New design expandable nails
• Alendronate, pamidronate, other bisphosphonates /
  osteoclast inhibitors

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Olliers Disease Enchondromatosis

• Linear masses of cartilage in metaphyseal and
  diaphyseal regions of long bones
• asymmetric, often unilateral
• usually sporadic occurrence
• pathologic fx may occur

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7 yo male - femur fracture jumping on
bed Enchondromatosis femur/tibia/ pelvis Rt LE
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Osteomyelitis

• Infection always in differential
• Pathologic fracture uncommon
• Delayed diagnosis
• Femur, tibia
• Involucrum may be supportive

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Iatrogenic Osteoporosis

• Post-Irradiation
• Steroids
• Chemotherapy (MTX)

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10 yo female ALL - chemotherapy/steroids Fx after
fall from chair. Tx immobilization
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Neuropathic Fractures

• Myelomeningocele, paraplegics, sensory
  neuropathies
• Often mistaken for infection, DVT, tumor

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3 yo with spina bifida - swollen leg Consult
DVT vs. infection? Take an x-ray - healing fx may
look like malignancy
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11 yo male - Duchenne Muscular Dystrophy Hip pain
for 2 months. Disuse fracture/nonunion
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Stress Fractures

• usually through normal bone subjected to abnormal
  stresses
• May be mistaken for more serious pathology (esp.
  longitudinal stress fxs)
• History of recent increased activity
• femur, tibia, fibula

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12 yr old male, activity related pain, training
for baseball, running 6 miles per day, referred
for Ewings sarcoma. Longitudinal femoral stress
fracture
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Stress Fractures

• Can occur through pathologic bone
• Congenital abnormalities, metabolic disorders
  (osteoporosis, osteomalacia)

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Congenital Tibial Dysplasia
Presented at age 10 after fracture from minor
trauma Had bowed legher entire life No other
msk abnormalities
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Malignant Appearing Pathologic Fracture

• Referral to musculoskeletal oncologist
• Requires complete staging
• Biopsy needed - follow proper rules for biopsy
• Avoid fracture callus, notify pathologist of fx
  - biopsy soft tissue mass

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Osteogenic Sarcoma
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Malignant Pathologic Fractures

• May need immediate amputation
• OGS - some fx may heal during neoadjuvant
  chemotherapy
• Ewings - closed immobilization, chemotherapy

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Path fx lesser trochanter Stage IIB MRI - soft
tissue mass posterior
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Ewings sarcoma - allograft-prosthesis composite
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Pediatric Pathologic Fxs

• Be suspicious - scrutinize every fracture film
• Usually benign process
• Make the diagnosis to guide treatment
• Appropriate referral / workup for suspected
  malignancy
• prophylactic treatment for benign lesions on an
  individual basis

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