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PATHOLOGIC FRACTURE

Introduction

A pathologic fracture occurs when a bone that has been weakened from an underlying disease or condition breaks secondary to minimal traumatic force that would not normally lead to a facture. There are many conditions that can cause pathologic fractures, but enchondromas are by far the most common. Enchondromas are the most frequently seen bone tumors of the hand, with incidence rates highest in the ulnar metacarpals and proximal phalanges—especially the little finger. There is no consensus on the optimal treatment of pathologic fractures of the hand and wrist, but both the fracture itself and underlying cause must be addressed.1-3

Pathophysiology

  • Pathologic fractures occur when some type of disease process has weakened a bone, which eventually fractures after experiencing a minor trauma. In most cases, these traumatic events would not otherwise cause a fracture in healthy bone.1
  • In the hand, pathologic fractures are most commonly associated with benign bone tumors, but a wide range of other possibilities exist.
    • Solitary enchondromas are the most common bone tumors of the hand. They typically affect small tubular bones and more commonly involving the ulnar digits, and more than half present with pathologic fractures.
    • Other causes of pathologic fractures include aneurysmal bone cysts, giant cell bone tumors, epidermal inclusion bone cysts, multiple myeloma, fibrous dysplasia, Paget disease, Ewing sarcoma, inflammation or infection, cryosurgery, and radiation therapy and metastatic lesion of the bone.1,3

Related Anatomy

  • Metacarpals
  • Phalanges
  • Medullary bone

Incidence and Related Conditions

  • Bony tumors of the hand account for ~5% of all benign and malignant tumors of the skeleton, with 96% being benign. Approximately 35-65% of these are enchondromas.4
  • Up to 40% of enchondromas involve the hand, with the ulnar metacarpals and proximal phalanges being most commonly affected.4
    • The little finger is the most common site of enchondroma-related fractures in the hand.2
  • Among all pathologic fractures related to tumors, 23% occur in the hand, with 81% resulting from enchondromas.1

Other tumors that can lead to pathologic fractures include:

  • Giant cell tumor
  • Giant cell reparative granuloma
  • Aneurysmal bone cyst
  • Brown tumor of hyperparathyroidism
  • Multiple myeloma
  • Fibrous dysplasia
  • Paget disease
  • Ewing sarcoma

 

ICD-10 Codes

  • PATHOLOGIC FRACTURE

    Diagnostic Guide Name

    PATHOLOGIC FRACTURE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    PATHOLOGIC FRACTURE DUE TO    
    - NEOPLASTIC DISEASE    
     - RADIUS M84.534_M84.533_ 
     - ULNA M84.532_M84.531_ 
     - HAND M84.542_M84.541_ 
    - OSTEOPOROSIS, AGE-RELATED    
     - FOREARM M80.032M80.031_ 
     - HAND M80.042_M80.041_ 
    PATHOLOGIC FRACTURE NEC, CHRONIC FRACTURE    
    - RADIUS M84.434_M84.433_ 
    - ULNA M84.432_M84.431_ 
    - HAND M84.442_M84.441_ 
    - FINGER(S) M84.445_M84.444_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY M84.4, M84.5 AND M80
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Pathologic Fracture
  • Nondisplaced pathologic fracture (AP view) of the right ring finger proximal phalanx (arrow) secondary to an expanding enchondroma (E).
    Nondisplaced pathologic fracture (AP view) of the right ring finger proximal phalanx (arrow) secondary to an expanding enchondroma (E).
  • Nondisplaced pathologic fracture (lateral view) of the left long finger middle phalanx (arrow) secondary to an enchondroma (E).
    Nondisplaced pathologic fracture (lateral view) of the left long finger middle phalanx (arrow) secondary to an enchondroma (E).
  • Left handed carpenter was nailing a small board while pushing the board in place with his right long finger when he felt a pop followed by pain and swelling at the base of the long finger. X-ray shows a RCL pathologic avulsion fracture (arrow) secondary to an enchrondroma. (E). Insert shows oblique view.
    Left handed carpenter was nailing a small board while pushing the board in place with his right long finger when he felt a pop followed by pain and swelling at the base of the long finger. X-ray shows a RCL pathologic avulsion fracture (arrow) secondary to an enchrondroma. (E). Insert shows oblique view.
Symptoms
Pain
Deformity
Swelling and ecchymosis
Loss of function
Typical History

A typical patient is a 37-year-old, left-handed woman who had been experiencing significant pain and swelling in the little finger of her left hand for the past 3 days. Upon presentation, she did not recall a specific traumatic incident that led to her symptoms, but did explain that her job as a chef did require heavy lifting and upon questioning she recalled bumping her left hand hard against the kitchen corner. The initial evaluation revealed that the woman had an enchondroma in her left little finger, and the frequent lifting had led to a pathologic fracture of the proximal phalanx.  The fracture was allowed to heal.  A couple of months later the patient underwent an elective curettage and bone grafting which ultimately healed uneventfully.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify the underlying pathology (diagnosis) causing the pathologic fracture or impending fracture is the primary and most important goal.
  • Recognize a fracture as a pathologic fracture or potential pathologic fracture
  • Treat the fracture
  • Treat the underlying pathology
Conservative
  • It is essential to diagnose the underlying condition that caused the pathologic fracture before any treatment decisions are made. 
  • Although solitary enchondromas are the most common type of pathologic fracture, there are no clear guidelines or a consensus regarding optimal management strategies. However, many experts advise delaying surgery until union of the pathologic fracture secondart to an enchrondroma has been achieved, unless the joint is involved, in which case early surgery is maybe indicated.1
  • When conservative treatment is indicated, immobilization using either a splint, cast or orthotic device may be utilized to allow the fracture to heal. This may or may not be followed by additional treatments.1,3
Operative
  • The goals of treatment for enchondromas with pathologic fractures are tumor removal and fracture stabilization, and because it is technically difficult to remove a tumor and stabilize a fracture in one procedure, the fracture is usually allowed to heal before tumor removal and bone grafting.5
  • It is generally agreed that curettage should be the minimum intervention for pathologic fractures. This may be performed alone or accompanied by autograft or allograft, calcium phosphate bone cement, or some type of fixation.1,2
  • Fractures associated with giant cell tumors of bone may require more aggressive treatments, such as en bloc resection, to reduce the risk of recurrence.1
  • Amputation is advisable in cases of chondrosarcoma associated with pathologic fracture, unless a thorough, wide resection can be carried out.1
  • Preoperative chemotherapy plus surgery and/or radiation is indicated for Ewing sarcoma.1
  • If a pathologic fracture involves a joint, early surgical management is needed to protect joint surfaces and preserve range of motion.2
CPT Codes for Treatment Options

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Complications
  • Postoperative extensor adhesion
  • Stiffness
  • Infection
  • Loss of ROM
  • Fracture displacement
  • Nonunion
Outcomes
  • In one review of 40 enchondroma cases in which 63% presented with pathologic fractures, only 5 patients were treated nonsurgically, but they experienced the most satisfactory outcomes overall.6
  • Another study reviewed 16 pathologic fractures associated with enchondromas and found a higher complication rate with immediate curettage and bone grafting (67%) compared with delayed treatment after fracture healing (10%). Researchers concluded that it may be best to delay treatment whenever possible.7
  • After curettage, there is no convincing evidence that adding autograft or bone cement to fill large bony voids improves the final result, although cement may be more effective in treating malignant tumors like multiple myeloma.1
Key Educational Points
  • In managing these injuries, it is essential to perform a thorough work-up to identify the underlying disease (diagnosis) process responsible for the fracture. It is also important to establish a treatment algorithm based on the extent of damage caused by the tumor.3
  • Most solitary enchondromas are undiagnosed until a pathologic fracture occurs with swelling and pain or an X-ray is taken for other reasons.5
  • There is reasonable evidence to suggest that delaying surgery while the pathologic fracture heals will lead to better outcomes with fewer complications.1
  • While some studies show that early ORIF and grafting can work and while curettage alone or with bone substitutes can work, allowing the fracture to heal followed by delayed curettage with autogenous bone grafting remains a reasonable treatment recommendation for a pathologic fracture secondary to a enchondroma.
  • Rarely a enchondroma will heal completely during fracture healing. 
References

Cited

  1. Haase SC. Treatment of pathologic fractures. Hand Clin2013;29(4):579-84. PMID: 24209955
  2. Hagiwara H, Nishimura T, Yamamura M, et al. Pathologic Fractures Extended to the Metacarpal Head Related with Enchondromas at the Metacarpal Neck. J Hand Surg Asian Pac Vol2017;22(3):384-387. PMID: 28774255
  3. Heaton D, Alexander H, Trumble TE. Missed Pathologic Fracture From Multiple Myeloma. J Hand Surg Am2015;40(7):1501-3. PMID: 26043801
  4. Gaulke R. The distribution of solitary enchondromata at the hand. J Hand Surg Br2002;27(5):444-5. PMID: 12367543
  5. Zheng H, Liu J, Dai X, Schilling AF. Modified technique for one-stage treatment of proximal phalangeal enchondromas with pathologic fractures. J Hand Surg Am;39(9):1757-60.PMID: 25106766
  6. Noble J, Lamb DW. Enchondromata of bones of the hand. A review of 40 cases. Hand1974;6(3):275-84. PMID: 4609850
  7. Ablove RH, Moy OJ, Peimer CA, Wheeler DR. Early versus delayed treatment of enchondroma. Am J Orthop (Belle Mead NJ)2000;29(10):771-2. PMID: 11043959

New Articles

  1. Hagiwara H, Nishimura T, Yamamura M, et al. Pathologic Fractures Extended to the Metacarpal Head Related with Enchondromas at the Metacarpal Neck. J Hand Surg Asian Pac Vol2017;22(3):384-387. PMID: 28774255
  2. Heaton D, Alexander H, Trumble TE. Missed Pathologic Fracture From Multiple Myeloma. J Hand Surg Am2015;40(7):1501-3. PMID: 26043801

Review

  1. Heaton D, Alexander H, Trumble TE. Missed Pathologic Fracture From Multiple Myeloma. J Hand Surg Am2015;40(7):1501-3. PMID: 26043801
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