Synopsis
Recognise fracture through diseased bone and lesions at imminent risk, protect the limb and neurovascular structures, image and biopsy in the correct sequence and coordinate fixation, radiotherapy, bone-targeted treatment, rehabilitation or comfort-focused care.
- A pathological fracture occurs through bone weakened by metastasis, myeloma, primary tumour, osteoporosis or another metabolic lesion, sometimes after minimal or no trauma.
- New focal weight-bearing pain, night pain, functional decline or pain despite analgesia can signal an impending fracture before displacement occurs.
- Sudden pain, deformity, inability to use the limb, shortening or crepitus requires immediate immobilisation, neurovascular assessment, analgesia and orthopaedic review.
- First-line imaging is two-view plain radiography including the entire affected bone and adjacent joints; image before forcing movement or weight bearing.
- CT defines cortical destruction and fixation anatomy, while MRI best shows marrow and soft-tissue extension; staging imaging establishes whether disease is solitary or widespread.
- A solitary destructive lesion without secure cancer diagnosis needs orthopaedic-oncology planning before biopsy, because an incorrectly placed tract can compromise definitive surgery.
- Mirels scoring supports assessment of impending long-bone fracture, but progressive functional pain and specialist judgement matter more than a threshold used in isolation.
- Prophylactic stabilisation of a high-risk lesion is generally safer and restores function more predictably than operating after a displaced fracture.
- Fixation or endoprosthetic replacement is followed by oncology review and often radiotherapy; bisphosphonate or denosumab reduces future skeletal events but does not repair an acute break.
- When surgery is unlikely to benefit, provide stable positioning, pressure care, rapid analgesic access, practical transfer planning and an honest discussion of expected mobility.
Key red flags
A pulseless, pale or cold limb or progressive motor and sensory loss indicates neurovascular compromise.
Pain out of proportion, tense swelling or pain on passive stretch suggests compartment syndrome.
An open wound over a fracture risks contamination and tumour or bone exposure and needs emergency care.
Pelvic fracture with hypotension, abdominal distension or falling haemoglobin may conceal life-threatening haemorrhage.
Back pain with weakness, sensory change or sphincter dysfunction moves immediately to the MSCC pathway.
A solitary aggressive lesion must not undergo unplanned biopsy or fixation before bone-tumour specialist review.
New weight-bearing pain in known metastasis can be an impending fracture even when the initial radiograph shows no complete break.
Absent pulse, increasing tense swelling, pain on passive stretch, pallor or progressive sensory and motor loss requires immediate orthopaedic and vascular action.
Investigation priorities
Obtain orthogonal views of the entire affected bone including both adjacent joints without unsafe loading or manipulation.
Management branches
Sudden pain, deformity or functional loss indicates a pathological fracture.
- Immobilise in a comfortable position, provide rapid analgesia, document neurovascular findings, assess blood loss and obtain whole-bone radiographs.
- Contact orthopaedics promptly and define cancer diagnosis, prognosis, comorbidity, previous radiotherapy and the functional outcome important to the patient.
- Use fixation or replacement designed for immediate function and expected lifetime, followed by oncology, radiotherapy and rehabilitation planning.