Updated: 9/28/2021

Impending Fracture & Prophylactic Fixation

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  • Criteria for prophylactic fixation
    • Several methods exist to predict the risk of pathologic fracture. These include
      • the presence of significant functional pain
      • > 50% destruction of cortical bone
      • formal staging systems
        • Harington's criteria
        • Mirels' criteria
    • Prophylactic fixation is preferred to fixation of actual pathological fracture due to
      • shorter operative time
      • decreased morbidity
      • quicker recovery
  • Harington's criteria
    • Haringtons' Criteria 
      • > 50% destruction of diaphyseal cortices
      • > 50-75% destruction of metaphysis (> 2.5 cm)
      • Permeative destruction of the subtrochanteric femoral region
      • Persistent pain following irradiation
  • Mirels' criteria
    • Mirels' classification
      • score > 8 suggests prophylactic fixation
      • size of lesion is expressed as a fraction of the cortical thickness. 
    • Mirels' criteria
      Score
      1
      2
      3
      Site
      Upper limb
      Lower limb
      Peritrochanteric
      Pain
      Mild
      Moderate
      Functional
      Lesion
      Blastic
      Mixed
      Lytic
      Size
      < 1/3
      1/3 to 2/3
      > 2/3
  • Treatment algorithm
    • Obtain tissue diagnosis
      • unless patient has a known primary neoplasm with bone biopsy proven skeletal metastasis, the treating surgeon should biopsy the lesion in question
        • biopsy may require separate incision than the incision used for IM nailing of bone
        • if biopsy suggests primary neoplasm of bone (like sarcoma) that may benefit from neoadjuvant chemo/radiotherapy then close wound and refer to local sarcoma center prior to surgical stabilization
          • surgical treatment of primary sarcoma will contaminate entire bone with sarcoma and affect ability to perform limb-salvage surgery
    • Radiation therapy
      • indications
        • painful lesion with Mirels' score =< 8
    • Surgical fixation
      • do not proceed with fixation until primary neoplasm of bone has been ruled out with biopsy
      • goals of fixation
        • maximize ability for immediate mobilization and weight-bearing
        • protect the entire bone in setting of systemic or metastatic disease
        • optimize implant choice in the context of the patient's overall prognosis
      • type of fixation depends on location of lesion and type of disease
        • humerus
          • proximal humerus lesions
            • endoprosthesis
          • diaphysis
            • intramedullary nail
            • resection and intercalary spacer
            • plates and screws (less preferred)
          • distal humerus lesions
            • flexible nails
            • elbow replacement
        • femur
          • peritrochanteric lesions
            • intramedullary nail
          • femoral neck and head lesions
            • hemiarthroplasty
    • Postoperative radiation
      • following surgery refer the patient to radiation oncology for post-operative radiotherapy treatment to
        • decrease pain
        • slow progression
        • treat remaining tumor burden not removed at surgery

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(OBQ13.170) A 52-year-old female with metastatic breast carcinoma presents with moderate left shoulder pain. Figures A through C are radiographs, CT scan and bone scan images of her shoulder. Examination reveals mild tenderness but no swelling around the proximal humerus. Examination is negative for other causes of shoulder pain. According to the Mirels' scoring system, what is the most appropriate next step in treatment?

QID: 4805
FIGURES:
1

Observation is appropriate because her Mirels' score is 4.

32%

(1061/3300)

2

Radiation therapy is appropriate because her Mirels' score is 6.

55%

(1828/3300)

3

Prophylactic internal fixation with a proximal humeral locking plate is appropriate because her Mirels' score is 8.

4%

(133/3300)

4

Prophylactic fixation with an intramedullary nail is appropriate because her Mirels' score is 7.

4%

(142/3300)

5

Proximal humeral replacement is appropriate because her Mirels' score is 8.

3%

(99/3300)

L 4 B

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(OBQ07.242) A 75-year-old man is brought to the ER after a fall. He complains of right leg pain, and a radiograph is shown in Figure A. Prior to operative fixation of the fracture, biopsy and staging procedures reveal that this is a metastatic lesion. Which of the following primary cancer diagnoses is associated with the shortest life expectancy following pathologic fracture?

QID: 903
FIGURES:
1

Lung

87%

(2250/2599)

2

Thyroid

3%

(73/2599)

3

Prostate

1%

(36/2599)

4

Breast

1%

(24/2599)

5

Renal

8%

(207/2599)

L 1 B

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(OBQ05.13) An elderly female has just been diagnosed with lung cancer. If her cancer metastasizes to bone, what is the most common site of subsequent pathologic fracture?

QID: 50
1

Proximal femur

53%

(693/1304)

2

Distal femur

1%

(13/1304)

3

Proximal humerus

2%

(30/1304)

4

Humeral shaft

1%

(9/1304)

5

Thoracic spine

42%

(553/1304)

L 4 D

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