Approach to Pathologic Fractures in Children

Amy K. Williams; Alexandre Arkader

Disclosures

Curr Orthop Pract. 2013;24(3):260-266. 

In This Article

Conclusion

After critically evaluating the literature relating to the subject of pathologic fractures in the pediatric population, it can be concluded that to determine the correct course of treatment, the type of tumor, patient characteristics, and the pattern of the fracture must all be considered in concert.

For most benign latent and active lesions, the appropriate treatment usually is conservative management of the fracture. With certain lesions, it is necessary to consider the weight-bearing capacity of the involved extremity to determine whether internal fixation will be required. Many benign lesions are asymptomatic, and a fracture may be the first and only indication of a lesion. While many benign lesions have characteristic radiographic appearances, a biopsy may be warranted unless the diagnosis can be made with absolute certainty from imaging.

As curettage and grafting is an important step in management of benign lesions associated with pathologic fracture, the appropriate grafting material as well as the appropriate adjuvants must be chosen to best heal both the lesion and the fracture. Unfortunately, the literature at this time does not offer a consensus on which graft material and adjuvants should be used to fill the voids left by curettage. Adjuvants such as cyroablation, phenol, and polymethylmethacrylate have been shown to be effective.

For malignant lesions, the current literature disputes the previously held notion that pathologic fracture precludes limb salvage surgery. As long as wide margins can be obtained, the evidence shows that overall survival does not significantly differ between patients who have pathologic fracture and those who do not, as long as they have received appropriate neo-adjuvant chemotherapy. Amputation continues to play an important role in the treatment of these lesions, but only when appropriate margins cannot be achieved or when the excision will render the salvaged limb nonfunctional (Figure 5). In cases of malignancy, all factors related to the individual patient and his or her tumor must be carefully considered before making the determination of whether limb salvage is appropriate, but limb salvage should not be ruled out solely on the basis of the presence of a pathologic fracture.

Figure 5.

(A and B) The patient in Figure 4 (A and B) after limited open reduction and internal fixation of the femur. (C–F) MRI of the same patient showing the extent of the soft-tissue contamination. This patient ultimately needed a hip disarticulation. (Printed with permission from Children's Orthopaedic Center, CHLA, Los Angeles, CA).

Pediatric musculoskeletal tumors of both benign and malignant nature may be associated with pathologic fractures, and these injuries and lesions must be carefully evaluated on a case-by-case basis by using a multisystem approach with great attention to detail.

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