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.
Key red flags
A pulseless, pale or cold limb or progressive motor and sensory loss indicates neurovascular compromise.
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.
Key medicines
Pre-emptive opioid for fracture movementGive an immediate-release opioid dose before imaging, turns or transfers, selected from current opioid exposure and renal function; titrate the regular regimen from documented rescue use and prescribe bowel care.
Denosumab for future skeletal-event reductionFor an eligible solid tumour with bone metastases, use the commissioned oncology regimen, commonly 120 mg subcutaneously every four weeks, with calcium and vitamin D management tailored to renal and calcium status.