Anract P, Biau D, Boudou-Rouquette P
Département de chirurgie orthopédique, hôpital Cochin, Assistance publique-Hôpitaux de Paris, université Paris Descartes, Sorbonne Paris cité, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France.
Département de chirurgie orthopédique, hôpital Cochin, Assistance publique-Hôpitaux de Paris, université Paris Descartes, Sorbonne Paris cité, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France.
Orthop Traumatol Surg Res. 2017 Feb;103(1S):S41-S51. doi: 10.1016/j.otsr.2016.11.001. Epub 2017 Jan 11.
The diagnosis of pathological fracture should be considered routinely in patients with long limb-bone fractures. Investigations must be performed to establish the diagnosis of pathological fracture then to determine that the bone lesion is a metastasis. In over 85% of cases, the clinical evaluation combined with a detailed analysis of the radiographs is sufficient to determine that the fracture occurred at a tumour site. Aetiological investigations establish that the tumour is a metastasis. In some patients, the diagnosis of metastatic cancer antedates the fracture. When this is not the case, a diagnostic strategy should be devised, with first- to third-line investigations. When these fail to provide the definitive diagnosis, a surgical biopsy should be performed. The primaries most often responsible for metastatic bone disease are those of the breast, lung, kidney, prostate, and thyroid gland. However, the survival gains provided by newly introduced treatments translate into an increased frequency of bone metastases from other cancers. The optimal treatment of a pathological fracture is preventive. The Mirels score is helpful for determining whether preventive measures are indicated. When selecting a treatment for a pathological fracture, important considerations are the type of tumour, availability of effective adjuvant treatments, and general health of the patient. Metastatic fractures are best managed by a multidisciplinary team. The emergent treatment should start with optimisation of the patient's general condition, in particular by identifying and treating metabolic disorders (e.g., hypercalcaemia) and haematological disorders. Treatment decisions also depend on the above-listed general factors, location of the tumour, and size of the bony defect. Prosthetic reconstruction is preferred for epiphyseal fractures and internal fixation for diaphyseal fractures.
对于长骨骨折患者，应常规考虑病理性骨折的诊断。必须进行相关检查以确立病理性骨折的诊断，进而确定骨病变为转移瘤。在超过85%的病例中，临床评估结合对X线片的详细分析足以确定骨折发生在肿瘤部位。病因学检查可确定肿瘤为转移瘤。在一些患者中，转移性癌症的诊断早于骨折。若情况并非如此，则应制定诊断策略，进行一线至三线检查。当这些检查无法提供明确诊断时，应进行手术活检。最常导致骨转移疾病的原发肿瘤是乳腺癌、肺癌、肾癌、前列腺癌和甲状腺癌。然而，新引入的治疗方法带来的生存获益导致其他癌症引起的骨转移频率增加。病理性骨折的最佳治疗是预防性的。Mirels评分有助于确定是否需要采取预防措施。在选择病理性骨折的治疗方法时，重要的考虑因素包括肿瘤类型、有效辅助治疗的可用性以及患者的一般健康状况。转移性骨折最好由多学科团队进行管理。紧急治疗应首先优化患者的一般状况，特别是通过识别和治疗代谢紊乱（如高钙血症）和血液系统紊乱。治疗决策还取决于上述一般因素、肿瘤位置和骨缺损大小。骨骺骨折首选假体重建，骨干骨折首选内固定。
