FRACTURES (PATHOLOGICAL)

Almost any malignant tumor can occasionally metastasize to bone, but osteolytic deposits most prone to collapse or fracture are from carcinomas of:

• Breast

• Lung

• Kidney

• Thyroid

Bone metastases are usually painful but pathological fractures can occur when there has been no preceding pain. The axial skeleton and proximal long bones are most commonly affected. (see Bone Metastases, Bone Pain)

The aims of treatment are:

• Pain relief

• To preserve mobility whenever possible

• To facilitate nursing care

Assessment – There is pain, deformity and bony crepitus on movement. In a fractured neck of femur the leg is shortened and externally rotated.

X-ray is important to confirm the diagnosis, to plan treatment and to assess the texture of surrounding bone.

First aid – Straighten the limb immediately if there is a marked deformity. Give analgesia as required. The patient is usually frightened and needs reassurance.

Conservative treatment includes analgesia, external splinting, skin traction, and local injection.

Analgesics are only required if there is pain at rest. Pain on movement will not respond to analgesics and is managed by stabilizing the fracture.

«  If the patient is too ill to consider surgical fixation, the aim of management is to stabilize the fracture and reduce pain enough for the patient to be nursed in comfort.

Skin traction can very effectively reduce pain, sometimes with a muscle relaxant such as diazepam to reduce muscle spasm. In a patient with a poor prognosis this may be all that is required to relieve pain. A weight of about 5lb to 8lb (a catheter bag filled with water) is usually sufficient.

Local injection into the fracture site using a long needle can sometimes abolish pain for several days. Use 10ml 0.5% bupivacaine with 80mg (2ml) methylprednisolone.

Surgery – Internal fixation is the treatment of choice whenever possible. Immediate referral to an orthopedist is indicated, with a view to prompt treatment and early discharge of the patient.

Radiotherapy – The presence of metal or cement does not interfere with subsequent palliative radiotherapy, which will result in healing of the fracture eventually in about 50% of cases (although pain relief is achieved even in the absence of healing). The usual dose is 2,500cGy in 5 treatments over 2 weeks.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.