Pathologic Fracture: Symptoms, Types, Causes and Treatment

Pathologic fractures are breaks in bones that occur due to underlying disease processes rather than as a result of healthy bone being subjected to normal trauma. Recognizing, classifying, and managing these fractures involves understanding their unique features, underlying causes, and tailored treatments. This comprehensive article will walk you through the symptoms, types, causes, and modern management strategies for pathologic fractures, drawing on evidence from recent clinical research.

Symptoms of Pathologic Fracture

Pathologic fractures often present differently from typical traumatic fractures. Understanding their symptoms is crucial for timely diagnosis and effective treatment. These fractures may occur with minimal or no trauma, and they are frequently preceded by warning signs related to the underlying bone abnormality.

Symptom	Description	Typical Scenarios	Source(s)
Pain	Persistent, localized bone pain	Before or at fracture onset	1 3 6 8
Swelling	Localized swelling or soft tissue mass	At fracture site	4 8
Minor Trauma	Fracture after mild/no injury	Spontaneous or low-impact	1 6
Functional Loss	Reduced mobility or limb use	Post-fracture	3 8 11

Table 1: Key Symptoms of Pathologic Fracture

Persistent Pain and Local Prodromes

One of the hallmark symptoms is ongoing, localized pain at the site of the affected bone. This pain often precedes the fracture and may be mistakenly attributed to minor injuries, especially in children or older adults with underlying disease. In nearly half of cases, patients experience noticeable local symptoms—such as pain or swelling—before the fracture actually occurs, which is a critical clue for early detection 1 3 6.

Swelling and Soft Tissue Changes

Localized swelling is another frequent symptom, sometimes accompanied by a palpable mass. In certain cases, especially with tumors, the swelling may be firm or associated with soft tissue abnormalities visible on imaging studies 4. These features can help differentiate pathologic fractures from simple traumatic fractures.

Fracture After Minor or No Trauma

A defining feature of pathologic fractures is that they often occur after minimal or no trauma. Patients may report breaking a bone during normal activities—such as standing, walking, or low-impact movements—raising suspicion for underlying bone weakness 1 6. This is particularly true in elderly patients or those with known cancer.

Functional Loss

After the fracture, affected individuals often experience significant loss of function in the involved limb. This may manifest as inability to bear weight, move the limb, or perform daily activities. In severe cases, this can result in rapid loss of independence and mobility 3 8 11.

Types of Pathologic Fracture

Pathologic fractures are classified based on their etiology, location, and the nature of the underlying bone disease. Understanding these distinctions aids in diagnosis and informs the optimal treatment strategy.

Type	Key Features	Common Locations	Source(s)
Neoplastic	Due to benign or malignant bone tumors	Long bones (femur, humerus, tibia)	1 3 4 6
Metabolic	Resulting from metabolic bone diseases	Vertebrae, long bones	6 7
Infectious	Secondary to bone infection (osteomyelitis)	Variable	6 7
Insufficiency	Normal stress on abnormal bone	Weight-bearing bones	2 5 7

Table 2: Main Types of Pathologic Fracture

Neoplastic Pathologic Fractures

These are the most widely recognized types and occur when bone is weakened by tumors—either primary (originating in bone) or secondary (metastatic from other sites like breast, prostate, or kidney) 1 4 6. Benign tumors (e.g., unicameral bone cysts, non-ossifying fibromas) and malignant tumors (e.g., osteosarcoma, multiple myeloma) can both predispose bone to fracture, though the prognosis and treatment differ significantly 3 6.

Metabolic Pathologic Fractures

Metabolic bone diseases, such as osteoporosis, rickets, and osteomalacia, make bones susceptible to fractures even under normal stress. These fractures are especially common in the elderly and can occur in both the spine and long bones 6 7.

Infectious Pathologic Fractures

Osteomyelitis and other bone infections can erode bone tissue, making it fragile and prone to breaking. Though less common than neoplastic or metabolic causes, infections should always be considered, particularly in children or immunocompromised patients 6 7.

Insufficiency Fractures

Insufficiency fractures are a subset of pathologic fractures where normal physiological stress causes a break in bone with decreased resistance due to underlying disease. These are distinct from fatigue (stress) fractures, which occur in healthy bone under abnormal stress 2 5.

Causes of Pathologic Fracture

The root causes of pathologic fractures are diverse, ranging from tumors to systemic illnesses and local bone disorders. Identifying the underlying cause is essential for developing a targeted treatment plan.

Cause	Description	Example Conditions	Source(s)
Bone Tumors	Benign or malignant neoplastic processes	Osteosarcoma, metastases	1 4 6 8
Metabolic Disorders	Disorders affecting bone metabolism	Osteoporosis, rickets	6 7
Infection	Destruction of bone by pathogens	Osteomyelitis	6 7
Genetic Diseases	Inherited bone fragility	Osteogenesis imperfecta	7

Table 3: Main Causes of Pathologic Fracture

Bone Tumors

Tumors are the leading cause of true pathologic fractures. These include both primary bone cancers (such as osteosarcoma and Ewing sarcoma) and metastatic cancers (commonly from breast, prostate, kidney, and lung) 1 4 6 8. Benign tumors can also weaken bone sufficiently to cause fractures, especially in children (e.g., unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas) 3 6.

Metabolic Bone Diseases

Conditions like osteoporosis, osteomalacia, and rickets change the normal bone architecture, reducing its strength. These diseases are especially prevalent in elderly populations and increase fracture risk even with minimal trauma 6 7.

Infectious Causes

Chronic bone infections, such as osteomyelitis, can erode bone and predispose it to pathological breaks. These fractures often occur in children or patients with compromised immune systems 6 7.

Genetic and Congenital Disorders

Inherited diseases like osteogenesis imperfecta ("brittle bone disease") significantly increase the risk for pathologic fractures, often presenting in childhood 7.

Treatment of Pathologic Fracture

Treatment of pathologic fractures is complex and must be individualized, taking into account the type of fracture, underlying cause, patient health status, and prognosis. A multidisciplinary approach is often required.

Treatment	Indication	Approach Summary	Source(s)
Nonoperative	Stable, benign lesions; low risk	Immobilization, observation	3 6 8
Surgery - Fixation	Unstable fracture, weight-bearing bone, malignancy	Plates, nails, prostheses, cement	8 10 11 12
Adjuvant Therapy	Malignant or metastatic disease	Chemotherapy, radiotherapy	11 12
Lesion-Specific	Based on underlying pathology	Sclerotherapy, curettage, resection	3 6 12

Table 4: Treatment Strategies for Pathologic Fracture

Nonoperative Management

For fractures through benign lesions—especially in children—nonoperative management (casting or splinting) is often successful. Union is typically predictable, though the underlying lesion may require further intervention after healing 3 6 8. For example, nonossifying fibroma and fibrous dysplasia often heal well with conservative therapy, but close follow-up is necessary to monitor for deformity or recurrence.

Surgical Treatment

Surgical intervention is indicated when the fracture is unstable, affects a weight-bearing bone, or is associated with malignancy. Internal fixation (using plates, rods, or screws), prosthetic replacement, and the use of bone cement are common techniques 8 10 11 12. For metastatic fractures, surgery aims to restore function, relieve pain, and allow early mobilization. The choice of implant (nail, prosthesis, plate) depends on the lesion's size, location, and expected patient survival 11 12.

• Endoprosthetic replacement (megaprosthesis) is increasingly preferred for lesions in the proximal femur, offering durable fixation, good pain relief, and improved quality of life 11.
• Cement augmentation is often used for large lesions to enhance stability 12.

Adjuvant and Lesion-Specific Therapies

For malignant or metastatic disease, adjuvant therapies such as chemotherapy and radiotherapy are crucial. These are often combined with surgery to control local and systemic disease 11 12. In select benign lesions, percutaneous sclerotherapy, curettage, or bone grafting may be the treatment of choice 3 6.

Multidisciplinary and Individualized Approach

Optimal care requires coordination between orthopaedic surgeons, oncologists, radiologists, and rehabilitation specialists. Decisions are tailored based on:

• Patient age and overall health
• Type and location of lesion
• Functional status and life expectancy
• Risk of recurrence or complications

For children, limb salvage is prioritized over amputation whenever possible, and most lesions can be managed successfully without radical surgery 6.

Conclusion

Pathologic fractures represent a unique challenge in bone and joint medicine due to their complex causes and management needs. Recognizing their symptoms, understanding their types and causes, and applying individualized, evidence-based treatment strategies are essential for optimal outcomes.

Key Points Covered:

• Pathologic fractures often present with persistent pain, swelling, and occur after minimal trauma.
• They are classified by cause—especially neoplastic, metabolic, infectious, and insufficiency types.
• Tumors (benign or malignant) are the leading cause, but metabolic, infectious, and genetic diseases also contribute.
• Treatments range from nonoperative management for benign, stable lesions, to complex surgical interventions and adjuvant therapies for malignant cases.
• Multidisciplinary care and individualized treatment planning are critical for best outcomes.

Early recognition and appropriate intervention can dramatically improve quality of life and functional outcomes for those affected by pathologic fractures.