From the Guidelines
For a patient with metastatic breast cancer to the bone with lytic lesions in the left humerus acting as a humeral fracture, a Sarmiento brace (functional humeral brace) is the best splint option. This orthosis encircles the arm and provides circumferential support while allowing elbow and shoulder movement. The brace should extend from just below the axilla to above the elbow, with padding at pressure points. It should be worn continuously until fracture healing occurs, typically 6-12 weeks, with regular follow-up to assess alignment and healing. The Sarmiento brace is preferred because it provides adequate immobilization of the fracture site while maintaining functional use of the arm, which is particularly important in cancer patients to preserve quality of life and independence. Additionally, this type of brace accommodates soft tissue swelling and allows for easy inspection of the skin. For pain management during initial application, appropriate analgesia should be provided, and orthopedic oncology consultation is recommended to evaluate for potential prophylactic surgical fixation, as pathologic fractures often have delayed or poor healing with conservative management alone 1.
Key Considerations
- The use of bisphosphonates, such as pamidronate or zoledronic acid, may be beneficial in reducing skeletal-related events and pathologic fractures in patients with metastatic breast cancer to the bone 1.
- However, the primary focus for the patient's current condition is immobilization and stabilization of the fracture site, making the Sarmiento brace the most appropriate choice.
- Regular follow-up and monitoring of the patient's condition are crucial to ensure proper healing and to address any potential complications that may arise.
Additional Recommendations
- A dental examination with preventive dentistry intervention is recommended before treatment with intravenous bisphosphonates, and dental procedures during treatment with intravenous bisphosphonates should be avoided if possible 1.
- Serum creatinine monitoring before each dose of bisphosphonate is administered, and dose reduction or discontinuation if renal function is reduced, is necessary to minimize the risk of renal toxicity 1.
From the Research
Treatment Options for Metastatic Breast Cancer to the Bone
- The presence of metastatic lesions in bone disrupts the normal bone microenvironment and upsets the fine balance between the key components, leading to a vicious cycle that further promotes bone destruction and tumor progression 2.
- Various therapeutic options are available for bone metastases of breast cancer, including local therapies such as surgery, radiation therapy, and radiofrequency ablation (RFA), together with systemic therapies such as endocrine therapy, chemotherapy, monoclonal antibody-based therapy, bone-enhancing therapy, and radioisotope therapy 2.
Management of Lytic Lesions in the Humerus
- Lytic lesions from bone metastases are associated with a poor prognosis and significant morbidities that include fracture and debilitating pain 3.
- For patients with lytic metastatic lesions to the humerus, external beam irradiation is effective as a means of pain control and halting bone destruction 4.
- Impending and complete diaphyseal fractures can be treated effectively with either intramedullary nail fixation or plate fixation, and rigid fixation is optimal to allow patients to begin immediate unrestricted activities using the upper extremity 4.
Splinting Options for Humeral Fractures
- There is no specific evidence on the best splint for a patient with metastatic breast cancer to the bone with lytic lesions in the humerus.
- However, the use of intramedullary nail fixation or plate fixation can provide rigid fixation and allow for immediate unrestricted activities using the upper extremity 4.
- The choice of splint or fixation method may depend on the individual patient's needs and the extent of the bone destruction, and should be determined by a healthcare professional in consultation with the patient 4, 5, 6.