Approach to Pathologic Fractures in Children

Amy K. Williams; Alexandre Arkader


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

In This Article

Aneurysmal Bone Cysts

Aneurysmal bone cysts (ABCs) are benign but at times locally aggressive tumors that present as a well-defined, eccentric, expansile, blood-filled cystic lesion. They usually occur in the metaphyseal region of long bones or in the posterior elements of the spine.[1] In order of decreasing frequency, sites involved include the femur, tibia, spine, humerus, pelvis, and fibula.[11,12]

Pathologic fractures occur in 11–35% of patients with ABCs of the long bones.[1,9,13–15] The humerus and femur are the most frequently fractured long bones.[1,13–15] Conservative treatment is not recommended for pathologic fractures associated with ABC, as the lesion lacks the ability of spontaneous healing. The exception is a lesion that clinically and radiographically resembles a UBC, making the diagnosis challenging. UBCs also can be erroneously tagged as ABCs during the acute phase of a pathologic fracture.

Intralesional curettage has a recurrence rate of up to 30%.[1,9,16,17] Some authors have recommended the use of adjuvant therapy, such as phenol or cryosurgery. The use of a high-speed burr coupled with curettage has been shown to decrease recurrence rates, even without a surgical adjuvant. Gibbs et al.[16] reported local control of almost 90% achieved with curettage and the use of a high-speed burr. Dormans et al.[18] described a "four-step approach" to ABCs; after a biopsy and frozen section confirms the diagnosis, the tumor is curetted and a high-speed burr is used to extend the margins; electrocautery is then used to aid in identifying further tumor pockets and to cauterize residual tumor. Phenol is the adjuvant, and bone grafting fills the defect. Recurrence rates are around 15%.