Approach to Pathologic Fractures in Children

Amy K. Williams; Alexandre Arkader


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

In This Article

Giant Cell Tumors

Giant cell tumors (GCTs) are considered benign but locally aggressive tumors with the potential for pulmonary metastases. Patients who are diagnosed with GCT should have a chest radiograph to evaluate for metastases. If metastases are present, they usually behave in a benign manner. GCT usually is seen in older teens and young adults and involves the epiphysis of long bones after physeal closure. In decreasing order of frequency, these tumors most commonly occur in the distal femur, proximal tibia, proximal humerus, and distal radius. The incidence of pathologic fracture is up to 30%.[21,23–26]

The standard treatment for GCT is curettage and cementation with an adjuvant such as phenol or cryoablation. Deheshi et al.[24] noted that the recurrence rate of GCT in the presence of a pathologic fracture is not necessarily higher than in cases of GCT without fracture. The literature does indicate that the recurrence rate is higher when curettage and grafting is employed rather than resection, but there may be more complications with resection, so functionally, curettage and grafting or adjuvants may still be appropriate.[24,27]

Pathologic fractures associated to GCTs can be nondisplaced and nonarticular; nonarticular, but displaced; or displaced and intraarticular.[1] Nondisplaced fractures may be treated by closed means, and the treatment for the GCT is not altered; for nonarticular but displaced fractures, closed treatment can be attempted, and it is recommended to allow the pathologic fracture to heal before proceeding with definitive treatment. If the fracture cannot be treated by closed means, it is recommended to proceed with open reduction and internal fixation simultaneously along with curettage, ablation, and cementation. If the fracture is intraarticular and a satisfactory open reduction cannot be achieved, partial or complete resection of the joint may be necessary.[1]