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Figure 1. Anteroposterior view of the right forearm showing fracture.
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Figure 2. Lateral view of the right forearm.
An 83-year-old woman presents with right forearm pain that has been bothering her for a few weeks. The patient has baseline dementia and presents with a nurse from the assisted living facility where she resides. The patient and nurse are unaware of any recent falls or known injury. On physical examination, the patient has pain to palpation over the proximal forearm without bruising or deformity. Radiographs of the right forearm are taken (Figures 1 and 2).
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The patient presents with a pathologic fracture to the proximal radius. After calling the nursing facility where she resides, it was determined that she has a history of breast cancer diagnosis 10 years ago, which has been in remission. Bone is the most common site of a first distant relapse of breast cancer.1,2
Most pathologic fractures are caused by metastatic disease and not primary disease. The most common primary sources of cancer are lung, breast, thyroid, renal, and prostate.1 In patients older than 40 years, metastatic disease is 500 times more likely than primary bone sarcoma.1 Aggressive features on this patient’s bone lesion that indicate a pathologic fracture include cortical disruption and periosteal reaction (see Figures).
Radiography is the best modality for characterizing a pathologic fracture.1 Pathologic fractures have altered healing biology because of destructive cancer cells and may be slow to heal or may never heal depending on the life expectancy of the patient. External beam radiation therapy may be used to prevent the fractures from spreading and help relieve pain. Most impending or pathologic fractures of the upper extremity can be treated in a sling for comfort.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. Rizzo SE, Kenan S. Pathologic Fractures. In: StatPearls [Internet]. Updated May 22, 2023. StatPearls Publishing; 2023.
2. Hamaoka T, Madewell JE, Podoloff DA, Hortobagyi GN, Ueno NT. Bone imaging in metastatic breast cancer. J Clin Oncol. 2004;22(14):2942-2953. doi:10.1200/JCO.2004.08.181
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