Download - P03 ped pathologic fxs
Pathologic Fractures in Children
Steven Frick, MD
Pathologic Fracture =
Fracture through Abnormal Bone
Osteopetrosis - failed fixation of femoral neck fracture. No osteoclasts - No remodeling.
With every fracture
Ask the question -
Is this fracture through NORMAL bone?
•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
•Minor Or No Trauma•Any Antecedent Pain?•Night pain?•Recent Illness?•Weight loss?•Fevers?
History
History
• Ask about growth and development• Dietary habits• kidney disease• thyroid disease• Family history
•AskAsk about prior malignancies, even in the child•Families will not always volunteer this information
History
•Look for soft tissue mass vs. fracture hematoma•Other systems- skin, lymphatics, solid organs•Height - weight percentiles
Physical Exam
11 yo - OGS
•CBC with differential•ESR•Calcium, Phosphorus, Alkaline phosphatase•Bun/Cr
Lab Tests
•Osteopenia•Physeal width (rickets)•Soft tissue calcifications•Presence of mass•Any periosteal reaction
RadiographsBe Suspicious
•Where is lesion located?•What is lesion doing to bone?•What is bone doing to lesion?•Are there clues to type of lesion?
Enneking’s 4 Questions
•Size•Margination•Cortex•Soft tissue mass
Benign vs. MalignantMankin’s Criteria
•Benign Bone Lesion•Malignant Bone Lesion•Infection•Metabolic Bone Disease•Skeletal Dysplasia •Neuropathic •Osteopenia- Disuse•Overuse
Make Diagnosis/Categorize
•Metaphyseal•Proximal humerus, femur•3-14 years old•Males > females
Unicameral Bone CystUBC
•Fallen leaf sign (or fragment)•Active= adjacent to physis•tx= immobilize•fx heals; cyst persist in 85%
UBC Pathologic Fracture
•Steroid injections•Bone marrow injections•Bone graft substitutes•Open currettage/graft•disrupt hydraulics- puncture, screw, wires, rods
UBC Persistent
•18 ga spinal needle•C-arm•Serous fluid, straw colored•2nd needle- vent•Depomedrol 160 mg•may need multiple injections
UBC Injection
LJ, 8 yo with arm pain when throwing, injected once with methylprednisolone (multiple sites), healing at 3 months
UBC - Risk Factors for Recurrence
• Age < 10• male • “active” lesions• large size• multiloculated• cyst index (Kaelin)
UBC
•Expansile•Often wider than physis•Eccentric•Aggressive at margins
Aneurysmal Bone CystABC
ABC
ABC
ABC
5 yo female with 1 year of hip pain and 4 prior steroid injections, progressive coxa vara
•Currettage and bone graft•+/- internal fixation•high recurrence
ABC
Currettage, biopsy consistent with aneurysmal bone cyst
1 month after currettage, bone grafting, valgus/internal fixation, spica immobilization
Nonossifying Fibroma(NOF)
• Let fracture heal• most NOF’s persist• assume if fractures once with minimal
trauma, high risk to fracture again unless bone changes with healing
• currettage/bone graft
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?
• Controversial• Arata and Peterson, JBJS 1981 - >50%
diameter, >33 mm length• Easley and Kneisl, JPO 1996 - prophylactic
surgery not necessary in many
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
14 yo female - fell walking across front yard
3 months of left hip pain - Motrin
referred for “path fx through Ewing’s sarcoma”
Dx -polyostotic fibrous dysplasia
3 Years Postop
Fibrous Dysplasia
• Consider other sites• Bone scan, MRI• For extensive involvement (McCune-
Albright) consider intramedullary fixation/splinting
11 yo male – fem neck path fx, nondisplaced. Fibular allograft (neck) and titanium elastic
nails (subtroch and shaft)
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
5 yo - Albright’s polyostotic fibrous dysplasia
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 – role?
•Abnormal type I collagen •Severe type - multiple fractures prior to skeletal maturity•Lower extremity > upper extremity•Femur, tibia, humerus
Osteogenesis Imperfecta(OI)
•Early onset (fxs prior to walking)- more fractures (2x)•Closed tx- limit immobilization time•IM fixation often needed
OI
3 yo OI - multiple fxs Lt femur
OI
OI – Olecranon Fx
•Minimize disuse osteoporosis•Early IM fixation•Alendronate, pamidronate, other bisphosphonates / osteoclast inhibitors
OI- New Methods
Ollier’s Disease Enchondromatosis
• Linear masses of cartilage in metaphyseal and diaphyseal regions of long bones
• asymmetric, often unilateral• usually sporadic occurrence • pathologic fx may occur
7 yo male - femur fracture jumping on bed
Enchondromatosis femur/tibia/ pelvis Rt LE
•Infection always in differential•Pathologic fracture uncommon•Delayed diagnosis•Femur, tibia•Involucrum may be supportive
Osteomyelitis
•Post-Irradiation•Steroids•Chemotherapy (MTX)
Iatrogenic Osteoporosis
10 yo female ALL - chemotherapy/steroids
fx after fall from chair. Tx = immobilization
•Myelomeningocele, paraplegics, sensory neuropathies•Often mistaken for infection, DVT, tumor
Neuropathic Fractures
3 yo MMC - swollen leg Consult = DVT vs infection?
Take an xray - healing fx may look like malignancy
11 yo male - Duchenne Muscular Dystrophy
Hip pain for 2 months. Disuse fracture/nonunion
•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
Stress Fractures
12 yr old male, activity related pain, training for baseball, running 6 miles per day, referred for Ewing’s sarcoma.
Longitudinal femoral stress fracture
Stress Fractures
• Can occur through pathologic bone• Congenital abnormalities, metabolic
disorders (osteoporosis, osteomalacia)
Congenital Tibial Dysplasia
Presented at age 10 after fracture from minor trauma
Had “bowed leg”her entire life
No other msk abnormalities
•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
Malignant Appearing Pathologic Fracture
Osteogenic sarcoma
Malignant Pathologic Fractures
• May need immediate amputation• OGS - some fx may heal during
neoadjuvant chemotherapy• Ewing’s - closed immobilization,
chemotherapy
Path fx lesser trochanter
Stage IIB
MRI - soft tissue mass posterior
Ewings sarcoma - allograft-prosthesis composite
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
•Unicameral Bone Cysts (UBC)•Nonossifying Fibromas•Aneurysmal Bone Cyst (ABC)
Benign Bone Lesions
•Rickets•Renal Osteodystrophy•Hyperparathyroidism•Cushing’s
Metabolic Bone Disease
Malignant Bone Lesions
• Osteogenic Sarcoma• Ewing’s Sarcoma• Leukemia/Lymphoma
•Fibrous Dysplasia•Osteogenesis Imperfecta•Ollier’s Disease•Osteopetrosis
Skeletal Dysplasias
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