Images in Clinical Medicine

Pathologic Fracture

Graça M. Dores, M.D., and Marilyn E. Miller, M.D.

N Engl J Med 1997; 337:1043October 9, 1997

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Figure 1 A 65-year-old man had T-cell, large-cell non-Hodgkin's lymphoma of the right temporalis muscle with localized bone destruction. Computed tomography of the chest, abdomen, and pelvis showed no evidence of lymphoma. Bone marrow biopsy and analysis of cerebrospinal fluid were also negative for lymphoma. The serum alkaline phosphatase concentration was normal, and the patient had had no skeletal symptoms. While undergoing evaluation, he experienced severe pain in his left arm when he picked up a small bag of paper towels. A radiograph of the left upper arm showed an osteolytic lesion in the middle of the humeral diaphysis (arrow), with a spiral comminuted fracture. The soft-tissue mass proximal to the fracture represents swelling that developed at the time of fracture. A bone scan revealed increased uptake in the middle of the left humerus and right temporal bone. The results of serum immunoelectrophoresis and tests for prostate-specific antigen were both normal. The patient's left arm was immobilized, and he was subsequently treated with chemotherapy. After four weeks, he had regained a full range of motion of his left arm and had no pain in the arm.

Graça M. Dores, M.D.
Marilyn E. Miller, M.D.
Memorial Hospital of Rhode Island, Pawtucket, RI 02860

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