pathologic fractures in children joshua klatt, md original author: steven frick, md; march 2004 1st...
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Pathologic Fracturesin ChildrenJoshua Klatt, MD
Original Author: Steven Frick, MD; March 20041st Revision: Steven Frick, MD; August 20062nd Revision: Joshua Klatt, MD; January 2010
Pathologic Fracture =
Fracture through abnormal bone
Pathologic FracturesAbnormal bone lacks normal biomechanic and viscoelastic propertiesIntrinsic processesLocalized - Bone cyst, neoplasm, etc.Systemic - OI, osteopenia, osteopetrosis, rickets, etc.Extrinsic processesRadiation, biopsy, defects after plate removal, etc.
Osteopetrosis - failed fixation of femoral neck fracture. No osteoclasts = No remodeling.
With every fracture: Ask the question - Is this fracture through NORMAL bone?
The orthopaedic surgeon may be the first to have opportunity to make the diagnosis. (malignancy, metabolic disease, etc.)Often Need to Do More than Treat the Fracture
Differ from fractures in normal bone in that one must take into accountEtiologyNatural historyTreatment of underlying abnormalityMust treat both fracture and underlying cause!Often Need to Do More than Treat the Fracture
Minor or no trauma?Less than anticipated for fracture patternAny antecedent pain?Only with activity vs. night painRecent illness?Weight loss?Fevers?History
HistoryAsk about growth and developmentDietary habitsKidney diseaseMay suggest rickets or renal osteodystrophy, etc.Thyroid diseaseFamily historyDysplasias, metabolic disorders, osteoporosis, neuromuscular disorders, etc.
Ask about prior malignancies, even in the child!Families will not always volunteer this informationHistory
Look for soft tissue mass vs. fracture hematomaOther systems- skin, lymphatics, solid organsHeight - weight percentilesPhysical Exam
11 yo - Osteosarcoma
CBC with differentialESRCalcium (ionized), Phosphorus, Alkaline phosphataseBun/CrLab Tests
OsteopeniaPhyseal width (rickets)Soft tissue calcificationsPresence of massAny periosteal reactionRadiographsBe suspicious!
Is pathology Localized and isolated?Polyostotic?Generalized to entire skeletal system?A generalized condition with skeletal manifestations?Radiographs
Where is lesion located?What is lesion doing to bone?What is bone doing to lesion?Are there clues to type of lesion?Ennekings 4 QuestionsEnneking, et al. The surgical staging of MSK sarcoma. JBJS 62-A:1027-1030, 1980.Enneking. A System of Staging MSK Neoplasms. CORR 204:9-24, 1986.
SizeMarginationCortexSoft tissue massBenign vs. MalignantMankins CriteriaGebhardt, Ready & Mankin. Tumors about the knee in children. Clin Orthop 255:86-110, 1980.
Benign bone lesionMalignant bone lesionInfectionMetabolic bone diseaseCategorize/Make DiagnosisSkeletal dysplasia Neuropathic Osteopenia-disuseOveruse
TreatmentUnion best achieved by correcting biomechanical and biological environment
While chemo & radiation slow healing, they provide a beneficial response in presence of rapidly dividing malignant cells
Not true neoplasms, etiology unknownOften loculated and not truly unicameralMost frequently contain serous fluidUsually metaphysealProximal humeral & femoral lesions account for 94% of all lesionsMost in patients 3-14 years old, average age 9Males > females (2:1)Simple Bone Cyst(Unicameral Bone Cyst)Baig & Eady. Unicameral (Simple) Bone Cysts. South Med J. 99(9):966-76, 2006.
Fallen leaf sign (or fragment) is virtually pathognomonicTreatmentFracture heals; cyst persist in 50-90%Humerus - treat fracture, address lesion after fracture is healed, if felt to be necessaryDisplaced proximal femur #s - Open reduction, grafting and rigid fixation, unless very youngPosterior facet #s of the calcaneus - Open reduction, if necessary with grafting and fixationSBC Pathologic Fracture
Controversial!Open ManagementCurettage/graftBone graft substitutesMinimally invasive techniques (injections)Steroid injectionsBone marrow injectionsAll seem to work with similar frequency (~90%)But can be recurrence with any of them!Disrupt hydraulics- puncture, screw, wires, rods, etc.SBC Treatment
18 ga spinal needleC-armSerous fluid, straw colored2nd needle- ventDepo-Medrol 160 mgWatch for immediate drainage from large outflow veinsMay need multiple injectionsSBC Injection
LJ, 8 yo with arm pain when throwing, injected once with methylprednisolone (multiple sites), healing at 3 months
SBC - Risk Factors for RecurrenceOnly reliable predictor of treatment success is age of the patient> 10 yrs heal ~ 90% of time< 10 yrs heal ~ 60% of timeMost cysts tend to heal after skeletal maturityBaig & Eady. Unicameral (Simple) Bone Cysts. South Med J. 99(9):966-76, 2006.Spence et al. Solitary unicameral bone cyst: treatment with freeze-dried crushed cortical-bone allograft. JBJS-A 58:636-41, 1976
ExpansileOften wider than physisEccentricAggressive at marginsAneurysmal Bone Cyst(ABC)Cottalorda & Bourelle, Current treatments of primary ABCs. J Pediatr Orthop B 15:155-67, 2006.
Symptoms usually present for < 6 monthsLesion may attain considerable size before recognizedCan exist as primary bone lesion (70%) secondary lesion in other osseous conditions (30%)Pelvic lesions account for 50% of all flat bone lesions (~10% total)Treatment is difficult due to inaccessibility and integrity of acetabulumAneurysmal Bone Cyst(ABC)Cottalorda et al. Aneurysmal Bone Cysts of the Pelvis in Children. J Pediatr Orthop. 25:471-5, 2005.
ABCBur, et al. Fluid-fluid levels in a unicameral bone cyst: CT and MR findings. J Comput Assist Tomogr 17:134-6, 1993.Papagelopoulos, et al. Treatment of aneurysmal bone cysts of the pelvis and sacrum. JBJS-A 83:1674-81, 2001.Look for fluid-fluid levels on MRI (however, not especially specific)
5 yo female with 1 year of hip pain and 4 prior steroid injections, progressive coxa vara. Biopsy = ABC
Curettage, biopsy consistent with aneurysmal bone cyst
1 month after curettage, bone grafting, valgus/internal fixation, spica immobilization
Curettage and bone graft+/- internal fixation? Injection of fibrosing agent (Ethibloc, Ethicon, etc.) is controversialHigh recurrence ABCCottalorda & Bourelle, Current treatments of primary ABCs. J Pediatr Orthop B 15:155-67, 2006.Adamsbaum et al. Intralesional Ethibloc injection in primary ABCs. Skeltal Radiol. 32:559-66, 2003.Varshney et al. Is Sclerotherapy Better than Intralesional Excision for treating ABCs. CORR epib 2009.
Nonossifying Fibroma(NOF)Benign, nonosteoid-producing lesionUsually found in metaphyses of long bonesPrediliction for lower extremitiesUsually asymptomaticOften incidental radiographic findingIt is speculated that up to a 1/3 of children may have at least a minor NOF/fibrous cortical defectAlmost always regress by early 20sBetsy et al. Metphyseal fibrous defects. J Am Acad Orthop Surg. 12:89-95, 2004.
Nonossifying Fibroma(NOF)Most treated non-op!Let fracture heal, excellent healing potentialMost NOFs persist after #, but heal by skeletal maturityIf fractures once with minimal trauma, potential risk to fracture again unless bone changes with healingIf necessary, treat with curettage/bone graftBetsy et al. Metphyseal fibrous defects. J Am Acad Orthop Surg. 12:89-95, 2004.
10 yo male - running during soccer. NOF fracture - at 4 weeks underwent allograft DBM / cancellous bone graft. Healed at 9 mos.
NOF - Prophylactic Bone Graft?Are size parameters predictable?Arata and Peterson, JBJS 1981Review of 23 fractures over 50 yearsSuggest tx if greater than 50% diameter, >33 mm lengthEasley and Kneisl, JPO 1997Review of 22 lesions, many without #s, over 25 yearsOnly included large lesions (above criteria)Only 41% had fractures, no refracturesSuggest prophylactic surgery not necessary in manyCriteria for surgery still not well definedArata et al. Pathological fxs through NOFs. JBJS-A. 63:980-8, 1981.Easley & Kneisl. Pathologic fxs through NOFs: is prophylactic treatment warranted? J Pediatr Orthop 17:808-13, 1997.
Fibrous DysplasiaDevelopmental disorder of bone, etiology unclearMay be mutation leading to activation of c-fos oncogene Can be associated with endocrine disorders (McCune-Albright syndrome)Can be mono- or polyostoticUsually affects adolescents and young adultsMany solitary asymp lesions found incidentallyMost do not require interventionIf increased fracture risk, treat with curettage, bone grafting and sometimes internal fixation
Parekh et al. Fibrous Dysplasia. J Am Acad Orthop Surg. 12:303-13, 2004.
Fibrous DysplasiaSurgical treatment for:Progressive lesionsLarge lesions with painPain & deformity suggest microfracturesFailure of conservative treatmentLess successful in:Younger patientsLarger and proximal femoral lesionsPolyostotic disease, esp McCune-Albright syndromeEnneking & Gearen. Fibrous dysplasia of the femoral neck: Treatment by cortical bone-grafting. JBJS-A 68:1415-22, 1986
Fibrous DysplasiaLesions are never eradicated, even with graftingAll grafts are eventually absorbed into dysplastic boneCortical grafts at a much slower rate and therefore recommended for weight-bearing bonesEnneking suggested cortical struts alone for femoral neckFixation in WB bones seems to improve outcome in childrenEnneking & Gearen. Fibrous dysplasia of the femoral neck: Treatment by cortical bone-grafting. JBJS-A 68:1415-22, 1986.Stephenson et al. Fibrous dysplasia: An analysis of options for treatment. JBJS-A 69:400-9, 1987.