Der Unfallchirurg
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Pathological fractures and instabilities of the spine are most often caused by primary tumors that hematogenously metastasize into the spine. In this context breast, prostate, kidney cell and bronchial carcinomas are the most relevant causative diseases. Furthermore, multiple myeloma is another frequent entity. Primary tumors of the spine are correspondingly rare and only make up a small proportion of all malignant processes in the spine. ⋯ If a curative approach is followed an individualized and interdisciplinary surgical strategy must be performed to achieve an R0 resection, usually as a spondylectomy. In the case of palliative treatment, the goal of surgical treatment must be pain reduction, stability and avoidance or restoration of neurological deficits. This requires stabilization in a percutaneous or open technique, possibly in combination with decompression and local tumor debulking.
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Pathological fractures are not only incisive events for tumor patients often with the need of surgical treatment but also often represent a relevant challenge in the overall concept of oncological treatment. ⋯ The work-up of the multifaceted oncological treatment concept represents an interdisciplinary challenge, which ideally defines the further treatment procedure, including fracture treatment, in an interdisciplinary tumor board within an overall oncological concept.
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Radiological diagnostics play a key role in the identification and assessment of pathological fractures. Conventional projection radiography is still the mainstay of imaging investigations. With knowledge of the patient history, the morphology and location of a fracture as well as concomitant findings, such as osteolysis or periosteal reactions can add valuable information on the origin of the fracture. ⋯ Computed tomography (CT) imaging provides valuable information on the morphological features of fractures and is useful for the planning of the surgical approach. Furthermore, it is the modality of choice for whole-body staging. In most cases of pathological fractures without a history of malignancy, a biopsy and histological work-up is recommended.
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Congenital pseudarthrosis of the tibia (CPT) is a rare disease that has challenged trauma and orthopedic surgeons for a long time. Clinically CPT mostly presents with progressive varus and antecurvation malformation of the tibia in infancy and childhood. In many cases CPT is associated with neurofibromatosis or fibrous dysplasia. ⋯ Histopathological investigations have revealed that a pathological alteration of the periosteum in the region of the pseudarthrosis, a hamartoma, may be essentially responsible for this disorder. Consequently, to treat the CPT a resection of the hamartoma must also be carried out. Multimodal treatment approaches combining pharmacological and surgical treatment, such as the cross-union technique of Paley, seem to have improved the prognosis of CPT.