| Ch 16 | Page 6 / 16 | |
| Cancer emergencies |
Fractures | |
Pathological fractures result from the loss of mechanical bone sustaining functions in relation to their metastatic involvement.
Thus, two simultaneous events occur: an osteolytic bone lesion and a traumatism which can be minimal.
There is no clear correlation between the radiological importance of bone metastases and the occurrence of fractures.
The commonest fracture sites are the vertebrae (pathological collapse with risk of neurological complications), femur (neck but also diaphysis), humerus, ribs, iliac bone and particularly the cotyloid cavity.
Quite frequently, fractures are preceded by bone pain which may occur at rest but is most severe when the bone structure responds to a load (like walking, sitting, wearing an object). This is called the pre-fracture syndrome.
When such effort pains occur in cancer patients, x-rays should be quickly performed to verify bone structure (especially the thickness of the cortical bone) in order to possibly propose preventive surgery.
Preventive surgery will be proposed when the cortical bone is profoundly and largely destroyed (2 to 3 cm), when the bone shaft is destroyed over 50% of its width or when radiotherapy does not improve pain (radiotherapy cannot relieve mechanical pain).
Orthopaedic surgery should be proposed when the life expectancy is longer than one or two months and when no absolute contra-indications exist (such as major respiratory insufficiency, terminal cardiac insufficiency) although some acts could be performed under local anaesthesia.
Leaving an immobilised patient to suffer in bed and die from confinement complications constitutes a great failure in our capacity to mobilise carers for the patient’s benefit. It is a genuine ethical error.
Orthopaedic action offers very quick relieve of the mechanical aspect of bone pain, and often also of its inflammatory aspect (hyper-pressure is one of the causes of metastatic bone pain and may be relieved by the local bleeding induced by surgery). Secondarily, the surgical procedure can be followed by palliative analgesic radiotherapy.
The psychological impression is of great importance for the patient and his/her family: the idea that carers do not abandon their patients, so ’something can still be done’.
The patient recovers, for a given period of time, a ‘normal’ life and concentrates his/her whole energy on walking or using the restored limb.
After the adversity of fracture and the doubt before a surgical decision, comes a new psychological surge of will and hope.
Among the most frequently proposed procedures: total hip replacement prosthesis, centromedullar or interlocking nails, replacement of a vertebral body with cement, resection of a vertebral lamina with liberation of nerve root, decompression of spinal cord).
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