Diagnosis of fracture optimizing health system use of medical isotopes and other. Pathological fracture of the proximal femur in osteosarcoma. Probably the most common cause of this is an underlying tumor, either benign or malignant. There is a transverse fracture of the humerus with anterior displacement and angulation. Ir microscopic imaging of pathological states and fracture. Mri evaluation of suspected pathologic fracture at the. Fractures without significant trauma uw radiology university of. Noninvasive prediction of fracture risk in patients with. Veterinary participation in puerto rican crested toad program. Terminology the term pathological fracture is usually reserved for malignancies, either benign.
The proximal femur is emphasized as a template for long bones throughout the skeleton because it is a common site for all three types of atraumatic fractures, but the general principles discussed are broadly applicable throughout the skeleton. There are illdefined lucencies reflective of lytic changes involving the distal shaft, metaphysis and epiphysis of the femur. Distinguishing an acute osteoporotic fracture from a pathologic fracture is more challenging. Although diagnostic imaging has made remarkable progress in recent years, it remains difficult to differentiate acute fractures from old. Everyday things, such as coughing, stepping out of a car, or bending over can fracture a bone thats been weakened by an illness. Results from an imaging study such as plain radiography or spiral ct scan can be compared to a known standard. Skeletal metastases affect up to 85% of breast cancer patients. The aim of this study is to report the outcomes for a cohort of patients with osteosarcoma who presented with and without pathological fractures and to identify the prognostic importance of pathological fracture in predicting outcomes and influences on survival.
The sensitivity and specificity of magnetic resonance imaging mri in the diagnosis of pathological fractures secondary to malignancy are well established and hence became the modality of choice in such cases. Their age range was from 9 to 84 mean age 42 with nine patients under the age of 40 and eight above the age of 40. The dx is metastic disease to bone, likely lung cancer in nature, metastased in subtrochanteric are and femoral neck consistent with possible impending fracture. Talk plan signs or symptoms of a fracture types of fracture and dislocations diagnosis of fracture 3. Right femoral pathological fracture caused by primary bone e. The instrumental software permits straightforward imaging of ir band areas. Types of bone fractures imaging and management lecturio. Learningradiology pathologic, fracture, pathological. Ir microscopic imaging of pathological states and fracture healing of bone.
Pathological fractures commonly occur in abnormal bone. Physical therapists in several other specialties utilize imaging in practice, education, and research including neurologic, sports. Discriminating imaging findings of acute osteoporotic. Final diagnosis and management should be made in the context of appropriate anatomical and functional imaging using a multidisciplinary approach. Percutaneous stabilization of impending pathological fracture of the proximal femur. Twelve patients had a fracture at diagnosis and five developed a fracture after the diagnosis. This is a scenario that often causes confusion, hence its. Pathological fracture is not a predictor of worse survival in this study. Pathological fracture coding in icd10cm icd10monitor. Magnetic resonance imaging mri is the radiological modality of choice for diagnosing pathological fractures in situations of diagnostic uncertainty. Chronic benign fractures especially in the elderly may continue to exhibit imaging signs of micromotion or stress for months to years by displaying some osseous edema or post contrast enhancement. Trauma xray lower limb gallery 1 hip pathological fracture.
Similarly, the initial presentation of a pathologic fracture may be misinterpreted 19, 20, 21, with a missed. In icd10cm there is one code to indicate a personal history. Although there is an overlap in appearances, characteristic imaging features can aid in the distinction between these 2 types of compression fractures. The objectives of our study were to define ct and mri features that distinguish pathologic fractures from stress fractures and to compare the performance of ct and mri with radiography.
Distinguishing stress fractures from pathologic fractures. There is a transverse pathologic fracture white arrows through the lesion. Femurs were examined by ir microscopic imaging 4 weeks after fracture. Feb 22, 2016 bone densitometry can be performed in an attempt to predict the risk of fracture from osteoporosis. Fractures through abnormal bone are called pathological fractures. The followup protocols and imaging schedules were consistent during the period. There is a permeative, lytic, and destructive lesion black arrows in the midshaft of the humerus with endosteal scalloping. Pathological fracture does not confound the diagnosis of musculoskeletal tumours. In a study of 1700 bone tumors of all types, benign and malignant, there were found 160 pathologic fractures.
Our purpose was to investigate chronological changes in radiological findings after ovf and to identify discriminators of acute versus older. The current multidisciplinary treatment program for osteosarcoma. Pathologic fractures of the long bones occur in 1743% of patients with. Pathologic fractures occur in 8% to 30% of patients with bone metastases.
The radiograms showed an undisplaced left scaphoid fracture, coming through a welllimited lytic lesion. Additional crosssectional imaging with ct or mri as well as scintigraphy and pet scanning is often performed for further evaluation. The xray examination showed a right proximal femoral fracture, with multiple. If a patient is admitted to treat the pathological fracture rather than osteoporosis, the fracture should be sequenced first, followed by the code for osteoporosis. Paget disease, osteopetrosis, although the term insufficiency fracture is probably more correct 4. It can be used in the setting of generalized metabolic bone disease e. This leads to suspicions of fractures associated with a malignant lesion in the femoral neck and described as pathological fracture. Prediction of pathological fracture in the proximal femora. Imaging, diagnosis, prognosis noninvasive prediction of fracture risk in patients with metastatic cancer to the spine brian d. Ir imaging showed that the mineral level was enhanced in estrogentreated samples. Seven patients had metastatic disease at diagnosis.
In addition, the crystals were largermore perfect in the treated specimens. A magnetic resonance imaging mri was planned for the following week, and it showed a diffuse t1 hyposignal of the scaphoid bone, potentially indicating an enchondroma. Nonetheless, diagnostic challenges remain, particularly in acutestage fractures, which often show aggressive. Studies reported contradictory results for the prognostic significance of a pathological fracture in osteosarcoma patients. A fracture that would not otherwise occur were it not for pathological weakening of the bone due to osteoporosis, metastasis, infection, metabolic disorders or. Mar 16, 2016 a pathological or fragility fracture is defined as a fracture sustained due to trauma no more severe than a fall from standing height, with the break occurring under circumstances that would not cause a fracture in a normal, healthy bone. Pathological fractures in predicting clinical outcomes for patients. The imaging education manual is produced by the imaging special interest group of the orthopaedic section, apta. The role the pathologic fracture plays in the symptomatology varies with the type of tumor. Pathologic fractures caused by pbt and mbt may be differentiated by a few specific radiographic and ct imaging features, though mri was poor for characterization of the underlying lesion. The x rays show a mass expanding the 3rd metatarsal. Prediction of pathological fracture in patients with.
Background please read the sections on benign versus aggressive lesions chapter 49 and bone metastases chapter 53. Oct 30, 2017 a pathologic fracture is a broken bone thats caused by a disease, rather than an injury. Mri evaluation of suspected pathologic fracture at the extremities. Imaging differentiation of pathologic fractures caused by. These data demonstrate the utility of ir spectroscopic imaging for the study of pathological states of hard tissue. Review of the imaging features of benign osteoporotic and. Oct 10, 2014 appropriate treatment of osteoporotic vertebral fractures ovf requires knowledge of the age of the fracture. Pathologic fracture radiology rsna publications online. Role of imaging in fractures muhammad bin zulfiqar pgr ii simsshl new radiology department 2. Introduction to trauma xray pathological fractures. Pathological fractures were more frequent among patients with bone metastases at the time of diagnosis of lung cancer 24.
A pathologic fracture is usually diagnosed through an xray, which can help the doctor locate the specific location of the crack or break. Pathological fractures in predicting clinical outcomes for. Dx for impending fracture orthopedic coding ask an expert. The chronic pressure effects on the adjacent metatarsal.
The differential diagnosis at such a stage can also include a variety of malignancies including osteosarcoma and ewings sarcoma. Does the use of magnetic resonance imaging scan in occult and. Fluoroscopy and conebeam ctguided fixation by internal. Prediction of pathological fracture in the proximal femora with bone lesions using a ct scanbased finite element method yusuke kawabata1, kosuke matsuo2, hiroyuki ike, md 2, tomoyuki saito, md, phd. Conservative treatment of a pathologic fracture of the scaph. A pathologic fracture is a broken bone thats caused by a disease, rather than an injury. To describe pretreatment imaging features of pathologic fractures caused by primary bone tumors pbts and metastatic bone tumors mbts and determine if radiographic or crosssectional features can differentiate the underlying pathologies associated with the fractures. Although xray will reveal most fractures, subtle fractures, including those in skeletally immature children, and some stress fractures may not be visible immediately on xray.
Prediction of pathologic fracture risk of the femur after. Distinction of long bone stress fractures from pathologic. Data were analysed with r statistical software r foundation, vienna, austria. Chang,1 vahid entezari,1 david zurakowski,2 and leroy m. The optimum threshold to predict pathological fracture was 85% of total body. The term pathological fracture is usually reserved for malignancies, either benign or malignant, although it has been used in the setting of osteomyelitis. The bone texture is abnormal in this patient with a known malignancy indicating a pathological fracture.
Such knowledge may assist radiologists in raising the possibility of a pbt as the cause of a pathologic fracture. The arm was temporarily immobilized in a belowelbow cast. The majority of fractures are simple and the result of trauma. Pathological fracture definition of pathological fracture. The underlying abnormality may be malignant or nonmalignant in nature. A logistic regression model was developed using patient variables collected from a prospectively collected database. Pathological fractures are fractures that occur in abnormal bone. Some conditions weaken your bones, which makes them more likely to break. The xray will also allow the doctor to examine the severity of the injury and make the proper plans for treatment. The study group included 22 patients who developed a radiation. Jul 30, 2014 the sequencing of osteoporosis and pathological fracture depends on the circumstances of admission. Pathological fracture through metastatic lesion, with known cancer diagnosis. The similar bone destruction and multiple pathological fractures could also be seen. Ct is the imaging technique of choice to identify pathological fractures.
A fracture that would not otherwise occur were it not for pathological weakening of the bone due to osteoporosis, metastasis, infection, metabolic disorders or other systemic or local disease. Imaging features and management of stress, atypical, and. Nov, 2018 with fluoroscopy and conebeam ct needle guidance, percutaneous fixation by internal cemented screw is an effective and safe method to decrease pain and opioid use in patients with cancer who have. Diagnosis of fracture optimizing health system use of. Jul 02, 2019 get an overview of the classic fractures and learn more about the definition, epidemiology, classification and types of bone fracture. Imaging of suspected fracture usually begins with plain radiography xray. Introduction a pathologic fracture through a bone tumor is the most dramatic clinical presentation in musculoskeletal oncology. Pathologic fractures are not associated only with malignant or aggressive bone tumors. Prediction of pathological fracture in patients with metastatic disease. Pathological fractures from benign tumours icm robertson feb.
Procedure was a prophylactic intramedullary nailing right femur cpt 27187. Among the exostoses, we have seen no instance in which the fracture has occurred from the disease, although it is possible in cases in which there is a history of trauma sufficient to cause a fracture in a normal bone. Patients with significant loss of bone density can be given treatment to enhance bone deposition. Seventeen patients underwent treatment for a pathological fracture of the proximal femur due to osteosarcoma. Pathologic fracture an overview sciencedirect topics. The aim of this study was to investigate if the risk of pathological fracture can be predicted with the proportion of body weight that can be put through the affected leg in patients with. Although plain radiography is the primary screening technique for evaluating suspected pathologic fractures, conventional magnetic resonance imaging mri is the most preferred modality as it demonstrates superior resolution in bone marrow lesion. In the patient with a pathologic fracture without a known cancer diagnosis, the surgeon should inform the pathologist, who will ensure that the tissue is processed appropriately to permit a full diagnostic workup that could identify the primary tumor site if possible. A fracture of the femoral neck is accompanied by avulsion of the greater trochanter. Interrupted periosteal reaction codman triangle is demonstrated at the distal femoral shaft above the fracture site. The xray a and mri examination bd of the patients femurs, showed a pathological fracture the arrowhead on the right femur with multiple lowdensity. Pathological fractures arise in bones weakened by disease osteoporosis is the most common cause of pathological fractures high force is required to fracture a normal bone, but diseased bones may fracture as a result of low impact trauma.