Abstract
Introduction Most tumour-related pathological fractures occur in patients with bone metastases.
However, in mostly younger patients, a pathological fracture can be due to both a
benign or a malignant bone tumour. Making the correct diagnosis from among these two
differential diagnoses is enormously important. If the tumour is malignant, treating
the fracture inevitably leads to tumour cell contamination and can significantly worsen
the oncological situation. The aim of this review article is firstly to provide the
reader with diagnostic assistance in the case of suspected pathological fractures,
and secondly to focus on the treatment of pathological fractures occurring with benign
bone tumours.
Methods This is a non-systematic review of the diagnosis and treatment of pathological fractures
in benign bone tumours or tumour-like lesions, based on an electronic PubMed database
search. We also present our own procedures, in particular for ruling out a malignant
bone tumour.
Results and Discussion Whenever a fracture occurs in the absence of sufficient traumatic force, the possibility
of a pathological fracture should always be considered. As well as taking a general
history for a possible primary tumour, it is particularly important to ask the patient
whether they had any pain before the fracture occurred. If the findings from clinical
examination or conventional radiological imaging give rise to suspicion of a pathological
fracture, an MRI of the affected skeletal section with contrast medium should be carried
out before commencing any fracture treatment. A CT scan is also helpful for accurately
assessing bone destruction. If a malignant or locally aggressive benign bone tumour
such as giant cell tumour (GCT) or aneurysmal bone cyst (ABC) cannot be definitively
ruled out through imaging, a biopsy is essential. The bone biopsy must always be carried
out on the assumption that the histological work-up will reveal a malignant bone tumour;
it must therefore be performed according to strict oncological criteria. If the radiological
diagnosis is unambiguous, e. g., a juvenile bone cyst (JBC) or a non-ossifying fibroma
(NOF), conservative treatment of the fracture can be considered, depending on the
location. In the presence of a locally aggressive benign bone tumour such as a GCT
or ABC, curettage of the tumour must be carried out as well as treating the fracture.
With GCT in particular, neoadjuvant therapy with denosumab prior to curettage and
osteosynthesis or en bloc resection of the tumour should be considered, depending
on the extent of the tumour.
Conclusion Pathological fractures, especially in younger patients, should not be overlooked.
Only after a malignant or benign locally aggressive bone tumour has been definitively
ruled out should fracture treatment be performed. In the presence of a locally aggressive
bone tumour, as well as treating the fracture, it is usually necessary to perform
curettage of the tumour – also en bloc resection, where applicable, in the case of
a GCT. Depending on the location, benign, non-aggressive tumours can be treated conservatively
if necessary.
Keywords
fracture - pathological - bone tumor - benign
