Impending fracture risk and prophylactic fixation

Ask exactly which movement hurts. Mechanical risk is signalled by pain on first standing, single-leg loading, turning in bed, rising from a chair or rotating the limb, not merely a high background pain score. Establish trajectory, radiotherapy timing, systemic response and any crack or sudden loss of confidence. Record walking aids, falls, pre-morbid function and the activity that the patient hopes surgery will restore. Define prognosis collaboratively rather than using one oncological estimate in isolation.

Observe transfers rather than asking the patient to perform a dangerous stress test. Inspect alignment, swelling, skin and previous incisions and palpate gently along the whole bone. Assess adjacent joints and distal motor, sensory and vascular function. Do not apply torsional examination to a large peritrochanteric lytic lesion. Give a frame, crutches or bed-to-chair restriction immediately when ordinary loading reproduces focal pain and communicate that instruction to every team.

Obtain full-length orthogonal radiographs and compare previous studies for progression or recalcification. Describe lytic, mixed or blastic character, location, longitudinal size, cortical breach and whether the lesion reaches a joint or implant. CT provides cross-sectional measurement of remaining cortex and three-dimensional geometry. MRI identifies marrow length, soft-tissue extension and a stress reaction or occult fracture, while bone scan or PET shows distribution rather than local strength.

Mirels adds one to three points for upper versus lower versus peritrochanteric site, mild versus moderate versus functional pain, blastic versus mixed versus lytic pattern and less than one-third, one-third to two-thirds or more than two-thirds diameter involvement. A score of nine or above was proposed for fixation, eight is a difficult intermediate zone and seven or below often supports observation. Sensitivity and specificity are imperfect, especially around size estimation and subjective pain.

Specialist assessment therefore overlays the score with CT cortical involvement, lesion length, axial location, primary histology, expected treatment response, current systemic control and likely survival. Quantitative CT rigidity analysis and finite-element methods can improve prediction where available, but they are not universal first-line services. Functional pain in a lytic peritrochanteric lesion may justify surgery below a rigid threshold, while a stable blastic lesion in a rapidly deteriorating patient may not benefit despite a score.

Confirm diagnosis before instrumentation. Widespread radiographically concordant disease with established cancer histology may proceed without new tissue. A solitary lesion, no known primary or atypical imaging needs systemic staging and specialist-planned core biopsy. Never assume a sarcoma is a metastasis and pass a nail through the entire medullary canal. Biopsy and definitive reconstruction are planned by the team that would perform oncological resection if pathology proves unexpected.

Select reconstruction from anatomy. Cephalomedullary nailing can protect a peritrochanteric and subtrochanteric segment when sufficient proximal and distal bone remains. Cement fills defects and shares immediate load but does not control tumour. Plate fixation can address selected metaphyseal or periarticular lesions but requires durable purchase. Extensive femoral-head, neck or proximal-femoral destruction often favours arthroplasty or modular endoprosthesis, which bypasses diseased bone and permits immediate loading.

Coordinate timing with oncology and anaesthesia. Embolise selected hypervascular renal or thyroid lesions before surgery. Prepare blood, VTE prophylaxis and postoperative loading and arrange radiotherapy after wound review when indicated. If surgery is disproportionate, use explicit load restriction, aids, analgesia and radiotherapy with close reassessment. The decision is revisited if pain becomes functional, cortex worsens or systemic therapy extends survival.