Pathological fractures in children

Abstract

Pathological fractures in children can occur as a result of a variety of conditions, ranging from metabolic diseases and infection to tumours. Fractures through benign and malignant bone tumours should be recognised and managed appropriately by the treating orthopaedic surgeon. The most common benign bone tumours that cause pathological fractures in children are unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological fractures through a primary bone malignancy are rare, these should be recognised quickly in order to achieve better outcomes. A thorough history, physical examination and review of plain radiographs are crucial to determine the cause and guide treatment. In most benign cases the fracture will heal and the lesion can be addressed at the time of the fracture, or after the fracture is healed. A step-wise and multidisciplinary approach is necessary in caring for paediatric patients with malignancies. Pathological fractures do not have to be treated by amputation; these fractures can heal and limb salvage can be performed when indicated.

Keywords: Benign; Bone tumour; Children; Malignancy; Pathological fracture; Sarcoma.

Fig. 1

Radiographs of a 16-year-old male patient, a) at presentation, showing a pathological fracture of the left humerus through a unicameral bone cyst, b) at two months after treatment in a sling with interval healing, c) and d) after percutaneous curettage and bone grafting, respectively, and e) at two years post-operatively, showing a healed cyst.

Fig. 2

Diagrams showing the classification system for the treatment of pathological fractures of the proximal femur associated with bone cysts in children (adapted with permission from Dormans JP, Pill SG. Fractures through bone cysts: unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002;51:457–467).

Fig. 3

Imaging in a 14-year-old male patient with a sudden onset of right hip pain, a) and b) radiographs at presentation, showing a Shepherd deformity and pathological fracture of the proximal femur, c) an axial CT scan showing the fracture, d) a bone scan, used to rule out polyostotic fibrous dysplasia, showing that it was confined to the right proximal femur, e) after proximal femoral osteotomy to correct the deformity and fixation with intramedullary nail, and f) at two months post-operatively showing healing of the fracture and osteotomies, at which point the patient had no pain.

Fig. 4

Imaging in a 15-year-old female patient, a) radiograph at presentation, showing a pathological fracture through a malignant-appearing lesion of the proximal femur, b) coronal STIR T₁-weighted post-contrast MRI showing the fracture, associated haematoma and soft-tissue mass, after which a biopsy confirmed a diagnosis of Ewing sarcoma. The patient underwent six weeks in traction (c) and six further weeks in a spica cast (d). After neoadjuvant chemotherapy, the fracture healed (e) and patient underwent a wide resection of a proximal femoral mass with endoprosthetic replacement (f).