Pathological fractures in the paediatric orthopaedic patient population: a current concepts overview of assessment and management.

Paediatric pathological fractures occur due to an underlying abnormality of the material properties of bone, which fails during normal activity or minimal trauma. Intrinsic factors which can cause pathological fractures include benign and malignant tumours, infections, skeletal disorders, and generalised metabolic abnormalities. Extrinsic factors include irradiation, chemotherapy, steroids and fracture malunion. Patients often present without a previous diagnosis and it is important to recognise clinical and radiological features that suggest an underlying abnormality. Systematic evaluation is necessary to effectively manage both the fracture and the underlying cause. This initially involves a detailed history, examination, and plain orthogonal radiographs, with or without CT and MRI scans, laboratory investigations, and biopsy if there is diagnostic doubt. Early referral to a multidisciplinary team is often appropriate to manage underlying disease, optimise bone health and therefore reduce risk of further fractures. Management is determined by the underlying disease and may involve systemic pharmacological treatment, intralesional injection and surgery including curettage, intercalary excision, bone grafting, and operative stabilisation, while considering potential impact on the epiphysis, with subsequent potential deformity due to growth disturbance. There is a paucity of currently available literature and good quality evidence is required to predict impending fracture and guide prophylactic surgical intervention. This review aims to provide an overview of the assessment and principles of orthopaedic management in paediatric patients presenting with pathological fractures.