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Pathological fracture is a bone fracture that occurs in a region weakened by an underlying disease. Unlike typical fractures from trauma to normal bone, these occur with minimal or no trauma, and the underlying pathology compromises the structural integrity of the bone.

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📌 Causes of Pathological Fractures:

Category Examples
‣ Osteoporosis, Osteomalacia, Rickets, Renal osteodystrophy
Neoplastic Primary bone tumors (e.g., osteosarcoma, multiple myeloma), Bone metastases (e.g., breast, prostate, lung)
Congenital/Genetic Osteogenesis imperfecta, Osteopetrosis
Infectious Osteomyelitis, Chronic bone infections
Endocrine Hyperparathyroidism (brown tumors)
Miscellaneous Paget disease, Fibrous dysplasia, Radiation-induced bone weakening

Radiology

Modality Imaging features
XR • Fracture through abnormal bone (e.g., lytic or sclerotic lesions).
• Minimal periosteal reaction unless healing has begun.
• Margins of fracture may appear smooth (not sharp as in acute traumatic fractures).

• Associated bone lesions: ◦ Lytic lesions (e.g., metastasis, myeloma). ◦ Sclerotic areas (e.g., osteopetrosis, sclerotic metastasis). | | MR/CT | extent of marrow involvement or soft tissue mass can be better assessed. | | Bone scan/PET | shows metabolic activity (to detect additional lesions). |

Common Radiologic Patterns in Specific Conditions:

Condition Radiologic Clue Typical Site
‣ Compression fractures, particularly vertebrae; thin cortices Vertebrae, femoral neck, distal radius
‣ “Punched-out” lytic lesions, no periosteal reaction Spine, ribs, pelvis, skull
‣ Lytic (lung, thyroid) or sclerotic (prostate) Spine, pelvis, femur
‣ Generalized osteopenia, multiple healed fractures, bowing Long bones
‣ Diffuse sclerosis, bone-in-bone, brittle bones Long bones, spine
‣ Coarsened trabeculae, cortical thickening, bone enlargement Pelvis, femur, skull

🧪 Workup of a Pathological Fracture:

  1. Clinical history – trauma level, age, systemic symptoms (fever, weight loss, bone pain).
  2. X-rays – evaluate fracture and background bone architecture.
  3. CT/MRI – better delineation of underlying lesion.
  4. Bone scan/PET – detect multifocal lesions.
  5. Blood work – calcium, phosphate, PTH, ALP, vitamin D, ESR, CRP, tumor markers.
  6. Biopsy – definitive for neoplastic/infectious causes.

Management

Step Approach
Stabilization Orthopedic fixation often needed with intramedullary nail, plates, or prosthesis
Treatment of underlying cause Antiresorptive therapy, chemotherapy, surgery, antibiotics, hormone correction
Bone support Bisphosphonates, calcium, vitamin D, physical therapy
Prophylactic fixation In cases with impending fractures based on Mirels’ criteria (for metastasis)