Approach to Pathologic Fractures in Children

Amy K. Williams; Alexandre Arkader


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

In This Article

Malignant Bone Tumors and Metastases

The two most common primary tumors of long bones in the pediatric population are Ewing sarcoma and osteogenic sarcoma. Because of the aggressive nature of these lesions and associated bone destruction, pathologic fracture may occur and poses a treatment challenge. Historically, the presence of a pathologic fracture would preclude limb salvage procedures because of the possibility of dissemination of tumors cells through fracture hematoma (Figure 4). However, more recent studies have shown that pathologic fracture may affect local recurrence but not survival rates[44–46] and that limb sparing surgery is possible as long as wide resection can be obtained after fracture healing.

Figure 4.

(A and B) Anteroposterior and lateral radiographs of the femur of a 6-year-old boy with a pathologic fracture secondary to osteogenic sarcoma. (Printed with permission from Children's Orthopaedic Center, CHLA, Los Angeles, CA).

In 2012, Xie et al.[47] compared two cohorts of patients, one with a pathologic fracture undergoing limb salvage and neo-adjuvant chemotherapy and one without pathologic fracture undergoing the same treatment course. The 3- and 5-year survival did not differ significantly between the two groups. The rates of local recurrence and metastasis also were not significantly different. In addition, in 2010, Ferguson et al.[48] showed that the presence of a pathologic fracture did not preclude limb salvage, and it did not increase local recurrence rates.

Pathologic fracture also can occur after limb salvage, especially when a bone graft is used, in particular massive allografts. The incidence approaches 15% in most series.[49–51] Several different techniques for enhanced fixation and stability have been described, including adding an intramedullary rod to the allograft.[49,51]