Missed pathological femoral neck fracture undergoes spontaneous healing

Abstract

Pathologic fractures are common complications of metastatic bone disease in patients with breast cancer. Fractures involving the proximal femur generally cause significant pain that is exacerbated by ambulation. Due to excessive stress on the weight-bearing hip joint, these fractures present a significant burden on the quality of life among patients. Here we describe a case of a 38-year-old female patient who was found to have a pathologic fracture of the proximal femur missed on imaging studies that underwent spontaneous union. Pathologic fractures rarely heal on their own, since a tumor at the fracture site interferes with bone healing and most fractures have to be managed with surgical intervention. Fractures can be missed on imaging studies in the setting of extensive metastatic disease. Physicians should be cognizant of this fact and maintain a high level of suspicion to recognize fractures with unusual presentations where patients may not present with the typical findings of acute onset of pain and inability to ambulate or bear weight.

Keywords: Pathological fracture; bone metastases; breast cancer.

Fig. 1

Initial images. (A) Pelvis AP radiograph obtained in 2018 due to left hip pain, no fracture is noted on the exam. Subsequent PET-CT scan obtained in 2019 for disease surveillance, intense uptake with SUV of 13.34 noted in the proximal left femur (B) along mixed lytic-sclerotic lesion in the proximal left femur (C) and femoral neck fracture (arrow) better visualized on the axial view (D).

Fig. 2

Radiograph AP pelvis (A) and lateral (B) left femur obtained in 2019 showing extensive metastatic disease of the bony pelvis with minimally displaced pathologic fracture (arrow) of the sub capital region of the left femoral neck.

Fig. 3

Radiograph AP pelvis (A) demonstrating a normal femoral neck-shaft angle on the right and a decreased one on the left femoral neck (blue lines). PET-CT scan images obtained at the same time (2019), coronal (B) and axial view (C) showing new bone formation along the previously seen fracture line (arrow).

Fig. 4

Surveillance PET-CT scan obtained a year after the presentation to the oncology orthopedic service (2020), coronal (A) and axial view (B) depicting the left femoral neck healed fracture (arrow) that remained in a stable position.