What is the treatment for an incomplete pathological fracture?

Treatment of Incomplete Pathological Fractures

Patients with an incomplete pathological fracture require immediate external splintage or immobilization with pain control until a definitive diagnosis is established through imaging and biopsy—internal fixation is absolutely contraindicated before tissue diagnosis. 1

Immediate Management Algorithm

Initial Stabilization

• Apply external splintage or immobilization to the affected area immediately 1
• Initiate multimodal pain control with regular paracetamol as the foundation 2
• Use opioids cautiously, particularly avoiding codeine due to constipation and cognitive dysfunction risk 2
• Avoid NSAIDs in patients with renal dysfunction 2

Critical Diagnostic Workup Before Any Surgical Intervention

The single most important principle: Never perform internal fixation until tissue diagnosis is established, as this significantly increases local recurrence risk. 3

Essential Imaging Studies

• Obtain MRI of the entire affected bone and adjacent joints to assess tumor extent and soft tissue involvement 1
• Perform CT chest/abdomen/pelvis with contrast to identify primary malignancy or metastatic disease 3
• Consider whole-body PET-CT if initial CT is negative to identify occult primary tumors 3

Mandatory Biopsy Protocol

• Perform biopsy of the fracture site before any surgical fixation 3
• Ensure adequate imaging (including MRI) is completed before biopsy 3
• Coordinate biopsy through specialized bone sarcoma multidisciplinary teams for suspected primary bone malignancies 1

Laboratory Evaluation

• Check serum LDH, calcium, alkaline phosphatase, complete blood count, and serum protein electrophoresis 3
• These markers help differentiate between primary bone tumors, metastatic disease, and metabolic bone disorders 3

Definitive Treatment Based on Underlying Pathology

For Primary Bone Sarcomas (Osteosarcoma, Ewing Sarcoma, Chondrosarcoma)

Although pathological fracture is associated with poorer survival and higher local recurrence in osteosarcoma, limb-sparing surgery may still be possible. 1

• Continue external immobilization during neoadjuvant chemotherapy—fractures often heal during this period 1
• Neoadjuvant chemotherapy allows fracture hematoma contraction and facilitates subsequent tumor resection 3
• Perform definitive resection of the tumor and all involved soft tissues after chemotherapy response 1
• Consider adjuvant radiotherapy to decrease local recurrence risk, though this increases limb reconstruction complications 1
• Amputation remains indicated if there is no radiological response to chemotherapy or if resection would not leave a functional limb 1

Special consideration for chondrosarcoma: Pathological fracture may indicate higher tumor grade, and in dedifferentiated chondrosarcoma, amputation may offer better local control rates. 1

For Metastatic Disease or Multiple Myeloma

The 2025 UK guidelines provide the most current framework, while the 2017 NCCN myeloma guidelines offer complementary management principles.

Orthopedic Consultation Criteria

• Seek orthopedic consultation for impending or actual long-bone fractures 1
• Consultation is mandatory for bony compression of spinal cord or vertebral column instability 1

Radiation Therapy Options

• Use low-dose external beam radiotherapy (10-30 Gy) for uncontrolled pain or impending pathologic fracture 1
• Single-fraction radiotherapy (8 Gy) is appropriate for patients with poor performance status and limited life expectancy 1
• Limit radiation fields to minimize impact on stem-cell harvest and future treatment options 1
• Postoperative fractionated radiotherapy is recommended after surgical fixation to prevent prosthesis failure 1

Surgical Intervention for Metastatic Disease

• In patients with good performance status and extremity fractures, orthopedic surgery to fix or prevent complete fracture is preferred 1
• Surgery should be followed by postoperative radiotherapy to improve local control 1
• For patients with extremely short life expectancies, radiotherapy alone may be considered for pain relief, though it does not restore bone stability 1

Systemic Bone-Directed Therapy

• All patients receiving primary myeloma therapy should receive bisphosphonates (pamidronate or zoledronic acid)—this is a Category 1 recommendation 1
• Obtain dental examination before starting bisphosphonate therapy to reduce osteonecrosis of jaw risk 1
• Monitor for renal dysfunction with bisphosphonate use 1
• Zoledronic acid reduces mortality by 16% and extends median overall survival by 5.5 months compared to clodronic acid 1

Vertebral Augmentation Procedures

• Consider vertebroplasty or kyphoplasty for symptomatic vertebral compression fractures 1
• Vertebral augmentation provides rapid analgesia and structural reinforcement more effectively than other measures 1
• Percutaneous thermal ablation (radiofrequency ablation) combined with vertebral augmentation can provide pain relief when radiotherapy cannot be offered or is ineffective 1

For Benign Lesions

• Allow the fracture to heal with conservative management before definitive treatment of the underlying lesion 4
• External immobilization with protected weight-bearing is typically sufficient 4
• Definitive treatment of the benign lesion (curettage, bone grafting) can be performed after fracture union 4

Common Pitfalls to Avoid

Critical Error #1: Performing internal fixation before establishing tissue diagnosis dramatically increases local recurrence risk and may compromise limb salvage in primary bone sarcomas. 1, 3

Critical Error #2: Using dynamic hip screw fixation for pathologic fractures—this is not effective due to lack of bone healing, particularly with planned subsequent radiation. 2

Critical Error #3: Failing to recognize that incomplete pathological fractures in weight-bearing bones require urgent intervention, as lesions encompassing more than 50% of bone diameter are at imminent risk for complete fracture. 5

Critical Error #4: Delaying multidisciplinary team involvement—all patients with suspected primary bone malignancies should have care supervised by a bone sarcoma multidisciplinary team from the outset. 1