Correspondence

Pathologic Fracture

N Engl J Med 1998; 338:394-395February 5, 1998

Article

To the Editor:

The Image in Clinical Medicine in the October 9 issue1 shows a pathologic humerus through a focus of metastatic non-Hodgkin's lymphoma. The authors state that the arm was immobilized and that after four weeks the patient “had regained a full range of motion of his left arm and had no pain in the arm.” Although these criteria are important in assessing the patient's well-being, physical examination to manipulate the bone at the fracture site and radiographs to look for signs of bony union are more important in determining when a fracture is healed.

A healthy humerus with a midshaft fracture can be successfully treated with a snug fracture brace that uses hydraulic forces to maintain fracture alignment. Pendulum shoulder exercises and range-of-motion exercises of the elbow can be initiated after the soft-tissue swelling has subsided. Union rates of up to 100 percent can be expected in healthy bone an average of eight weeks after fracture.2 Bone involved with tumor takes much longer, even with operative fixation and adjuvant radiation therapy. Gainor and Buchert3 found a union rate of 74 percent for pathologic extremity fractures caused by metastatic breast, renal-cell, or other carcinoma or multiple myeloma. However, more than six months were required for healing, and operative fixation of the fractures improved the rate of union by 23 percent.

Scott C. Wilson, M.D.
Louisiana State University Medical Center, New Orleans, LA 70112

3 References

1. 1

   Dores GM, Miller ME. Pathologic fracture. N Engl J Med 1997;337:1043-1043
   Full Text | Web of Science | Medline

2. 2

   Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am 1977;59:596-601
   Web of Science | Medline

3. 3

   Gainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop 1983;178:297-302
   Medline

To the Editor:

It is highly unlikely that the fracture shown in the Image in Clinical Medicine by Dores and Miller can solidify sufficiently to allow full arm motion in only four weeks. Such rapid restoration of function can occur when this sort of fracture is internally stabilized surgically, but this treatment was apparently not used. Also, the text describes a fracture in the left humerus, but the illustration depicts a right humerus.

Harris S. Yett, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215

Author/Editor Response

The authors reply:

To the Editor: We appreciate the comments of Drs. Wilson and Yett. As we noted, the patient had clinical improvement one month after fracture of the left arm. The arm was initially immobilized in a sling, and the patient was treated with chemotherapy. Radiation therapy was administered after six months, at the completion of chemotherapy. The patient was followed by the orthopedic service, and physical-therapy exercises were prescribed. Although the patient did well clinically, x-ray findings continued to show evidence of fracture. Four months after the fracture, x-ray films of the left humerus showed evidence of comminuted pathologic fracture of the mid-humerus with bone destruction, with some evidence of sclerosis. Fourteen months after the fracture occurred and after the completion of chemotherapy and radiation therapy to the left humerus, radiographs continued to show the fracture of the mid-humeral shaft, but with increased new bone formation around the fracture lines.

We agree that the healing of a pathologic fracture takes more than six months, as was demonstrated in the case of our patient. Our clinical observation, however, remains unchanged, in that the patient had regained a full range of motion of the left arm. The orthopedic service did not feel surgical stabilization was indicated, and the patient was treated conservatively.

The radiograph published in the Journal represents the left humerus, although the image was transposed during photography, making it appear to be the right humerus. We apologize for the confusion.

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