A Ambispective Cohort Study On Tumorous Pathological Fractures Of Extremity

Objective To review the diagnosis and treatment of tumorous long bone pathological fractures of extremity in a cohort study. Methods From August 2002 to August 2009,143 consecutive hospitalized patients suffered pathological fracture were enrolled, including 82 males and 61 females aging from 2.4 to 82 years. The upper extremities were affected in 46 cases, the lower extremity in 92 cases, and multiple fractures in five cases. Of 143 cases,135 were identified as complete fractures, and eight as impending fractures. Fractures were classified into long bone fractures and other bone fractures, including long bones with 127 cases (femurs in 79 cases, humerus in 28 cases, tibia in 11 cases, fibulas in 2 cases, ulnas in 3 cases and radiuses in 4 cases), fingers in 11 cases and multiple bone fractures in 5 cases. Among all long bone fractures, tumor type of 100 cases were checked and confirmed, including 96 single bone fractures (63 affecting femurs,20 humeri,5 tibias, and 8 other long bones) and four multiple bone fractures. Among the tumors causing pathological fracture,32 cases were of metastases,25 cases primary malignant tumors,28 cases benign tumors, and 15 cases giant cell tumors; the others suffered from parathyroid tumors in 6 cases, enchondroma in 11 cases, and unidentified origins in 26 cases. The forces causing fractures were reviewed retrospectively, and whether they had precursory symptoms such as local pain before fracture were indentified as well. Misdiagnosis and mistreatment were classified, and remediated measures were followed. The diagnosis and treatment of pathological fractures were retrospectively reviewed. Results All the patients were followed up from six to 56 months with an average of 26 months. All the forces resulting in fractures were subjected to four classifications:spontaneous in 29 cases, functional activity in 44 cases, minor injuries in 59 cases, traumatic injuries in 11 cases.90 patients had local precursory symptoms such as local pain before fracture happened. Among single long bone fractures, the forces resulting in fractures included spontaneous in 18 cases, functional activities in 29 cases, minor injuries in 46 cases, and traumatic injuries in 7 cases.76 patients complained of discomforts such as pain at fracture location before fracture happening. In 13 cases with metastases, the resection of mass was followed by reconstruction with prosthesis but no local recurrences.16 patients with metastases were treated with intramedullary nail, however,2 cases recurred and 2 cases died. Operative management was rejected in 3 cases.13 cases with osteosarcoma were treated with limb sparing operation,4 cases amputation, all of which had no relapses but with lung metastases in 3 patients.3 cases with malignant fibrous histiocytoma underwent tumor resection and followed by reconstruction with prosthesis.2 cases were subjected to amputation, however, one of which was misdiagnosed at first visit and died at last follow-up.7 cases of giant cell tumor underwent curettage and allograft transplantation,2 cases recurred,2 cases were widely resected with prosthetic reconstruction with no relapse. The other 8 cases of giant cell tumor with aggressive characters were used tumor wide resection and prosthetic replacement with no local recurrence. Enchondroma in 11 cases were curetted and transplantation with allograft with good results.6 cases of PTPH were accepted parathyroid tumor resection with fracture spontaneous healed.16 cases experienced misdiagnosis with average delay time of 10 weeks.1 cases of bone osteosarcoma loosed limb salvage opportunity and had to have amputation.2 cases of malignant fibrous histiocytoma experienced mistreatment, 1case died and 1 cased amputated. Conclusion Pathological fractures should be highly suspected in minor injury and/or local precursory symptoms patients. Treatment of pathological fractures should consider multiple factors such as specific tumor character, fracture locations, age, extent of fracture dislocation, and sensitivity to neo-adjuvant treatment. It is a better way to choose arthroplasty for fractures adjacent to joints. Pathological fractures should be highly understood to decrease misdiagnosis and mistreatment.