Pathological fracture
Overview
A fracture occurring in bone already weakened by disease - the force required is far less than needed to break healthy bone.
Presentation
•Fracture after minimal or trivial trauma - the defining clinical clue; mechanism does not match injury
•Bone pain - deep, constant, worse at night; may precede fracture by weeks
•Systemic red flags - weight loss, fatigue, anorexia, night sweats suggest underlying malignancy
•Vertebral fracture - acute back pain, height loss, kyphosis; neurological symptoms suggest spinal cord compression
Investigations
🥇 First-line
•Plain X-ray - fracture + lytic/sclerotic lesions, cortical destruction
•Serum calcium, phosphate, ALP, PTH - distinguishes metabolic causes
•FBC, renal function, serum protein electrophoresis, urine Bence Jones protein - screen for myeloma
•Isotope bone scan (Tc-99m) - multiple metastatic deposits; note myeloma may be cold/normal
🥈 Second-line
•MRI - vertebral fractures, spinal cord assessment; mandatory if neurological symptoms
•CT chest/abdomen/pelvis - staging and identifying primary tumour
🏆 Gold standard
•Bone biopsy - histological confirmation when primary unknown
Management
•Treat underlying cause - systemic therapy for myeloma; radiotherapy for painful bone metastases; bisphosphonates or denosumab for bone protection in malignancy/osteoporosis; risedronate or zoledronic acid for Paget's
•Analgesia - WHO ladder; bone pain from malignancy often responds to NSAIDs and bisphosphonates alongside opioids
•Surgical stabilisation - intramedullary nailing for long bone fractures; vertebroplasty or kyphoplasty for vertebral compression fractures in selected patients
•Spinal cord compression - dexamethasone 16 mg/day immediately + urgent MRI spine + neurosurgical/oncological review