Pathological Fracture – Causes, Symptoms & Treatment
A pathological fracture is a bone break caused by an underlying bone disease, often occurring without significant external force or trauma.
Things worth knowing about "Pathological fracture"
A pathological fracture is a bone break caused by an underlying bone disease, often occurring without significant external force or trauma.
What is a Pathological Fracture?
A pathological fracture is a bone fracture that occurs as a result of an underlying disease that has weakened the bone structure, rather than from a significant traumatic event. Because the bone is already compromised by a pre-existing condition, even minor stress, everyday movements, or in some cases no apparent force at all can cause the bone to break. Pathological fractures are clinically important because they often signal a serious underlying medical condition that requires prompt evaluation and treatment.
Causes
Pathological fractures can arise from a variety of conditions that weaken bone integrity:
Osteoporosis
Osteoporosis is the most common cause of pathological fractures worldwide. As bone density decreases with age or due to other factors, bones become brittle and prone to fracture. The spine, hip, and wrist are particularly vulnerable.
Bone Metastases
Cancers that commonly spread to bone – including breast, prostate, lung, kidney, and thyroid cancer – can form bone metastases. These lesions weaken the affected bone locally, making fractures in areas such as the femur, spine, or humerus more likely.
Primary Bone Tumors
Both benign and malignant primary bone tumors, such as osteosarcoma, Ewing sarcoma, enchondroma, and bone cysts, can compromise bone strength to the point of fracture.
Bone Infections
Osteomyelitis, a bacterial or fungal infection of bone tissue, can destroy bone structure locally and significantly increase fracture risk.
Metabolic Bone Diseases
Conditions such as Paget's disease of bone, hyperparathyroidism, osteomalacia, and chronic kidney disease disrupt normal bone metabolism and reduce mechanical bone strength.
Other Causes
- Long-term use of corticosteroids (medication-induced osteoporosis)
- Prior radiation therapy to bone (radiation osteonecrosis)
- Rare genetic disorders such as osteogenesis imperfecta (brittle bone disease)
Symptoms
The symptoms of a pathological fracture are similar to those of a traumatic fracture but often occur without a clear injury event:
- Sudden, severe pain at the fracture site
- Swelling, tenderness, or bruising over the affected area
- Limited range of motion or inability to bear weight
- Visible deformity or abnormal bone alignment
- In vertebral fractures: acute back pain, loss of height, or development of a stooped posture (kyphosis)
- In severe cases: neurological symptoms such as numbness, weakness, or paralysis due to nerve compression
It is worth noting that patients often experience a period of increasing local pain before the fracture occurs, which may reflect the progression of the underlying bone disease.
Diagnosis
Diagnosing a pathological fracture involves both confirming the fracture and identifying the underlying cause:
- X-ray: Initial imaging to visualize the fracture and any existing bone abnormalities
- Computed Tomography (CT): Provides detailed structural information about the fracture and surrounding tissue
- Magnetic Resonance Imaging (MRI): Particularly useful for detecting tumors, metastases, and bone marrow involvement
- Bone scintigraphy: Whole-body scan to detect additional bone lesions
- Blood tests: Including bone turnover markers, tumor markers, calcium levels, and complete blood count
- Biopsy: Tissue sampling for histological confirmation when a tumor or malignancy is suspected
Treatment
Treatment of a pathological fracture must address both the fracture itself and the underlying condition:
Conservative Management
Stable fractures, particularly those due to osteoporosis, may be managed conservatively with immobilization, pain management, and targeted treatment of the underlying disease (e.g., bisphosphonates, calcium, and vitamin D supplementation).
Surgical Treatment
Surgical stabilization is frequently required. Common approaches include:
- Osteosynthesis: Internal fixation using nails, plates, or screws
- Endoprosthesis: Joint replacement, particularly for hip fractures
- Vertebroplasty / Kyphoplasty: Minimally invasive stabilization of vertebral fractures using bone cement
Oncological Therapy
When fractures are related to cancer, fracture treatment is combined with systemic therapies such as chemotherapy, radiation therapy, or bone-targeted agents like bisphosphonates (e.g., zoledronic acid) or RANK-L inhibitors (e.g., denosumab) to reduce the risk of further skeletal complications.
Rehabilitation
Physiotherapy and rehabilitation are essential after treatment to restore mobility, prevent further fractures, and maintain the patient's quality of life.
References
- Coleman, R.E. et al.: Bone health in cancer: ESMO Clinical Practice Guidelines. Annals of Oncology, 2020;31(12):1650–1663.
- Kanis, J.A. et al.: European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporosis International, 2019;30(1):3–44.
- Rougraff, B.T.: Pathologic Fractures. In: Orthopaedic Knowledge Update, American Academy of Orthopaedic Surgeons (AAOS), 2021.
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