Der Unfallchirurg
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Pathological tumor-associated fractures are overall rare. They can occur in every age group and every bone. ⋯ False treatment is frequently associated with far-reaching negative consequences with respect to the course of the disease. The great challenge is not the expeditious surgical treatment but much more the adequate diagnostics and the incorporation of local fracture treatment into an interdisciplinary overall oncological concept.
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Pathological fractures of the extremities frequently lead to uncertainty with respect to the treatment strategy and timing. The origin of metastases is typically breast, bronchial, renal and prostate cancer and myelomas. Primary bone tumors play a subordinate role. ⋯ Based on all these aspects the surgical approach can be chosen. Treatment options range from osteosynthetic stabilization and augmentation osteosynthesis up to endoprosthesis replacement. The treatment is carried out in an interdisciplinary procedure as additional measures need to be addressed in addition to the surgical treatment.
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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.