Pathological fractures of long bones are one of the most annoying and painful complications that can occur in patients with an advanced stage of malignancy. There is agreement that surgical stabilization of impending or acute pathological fractures is the most important tool in order to achieve adequate local pain relief [6, 7]. Surgical fixation of unstable fractures also restores or improves upper or lower extremity function. Both aspects significantly contribute to enhance quality of life in these multimorbid patients. Surgical fracture management therefore is an important component of palliative medicine.

Since pathological fractures due to bone metastasis in long bone mostly are a sign of a progressive and systemic cancer disease, the goal of treatment is not primarily curative. Fractures are treated as they occur. However, also prophylactic fixation can avoid pain and functional disability associated with the osseous tumor progress [8]. Katzer et al. reported that patients who underwent prophylactic stabilization of impending fractures survived 5.9 months longer than those who were treated for complete pathological fractures [9].

Fidler studied the fracture risk in impending pathological fractures by correlating the incidence of fracture occurrence with the percentage of shaft destroyed [10]. The authors concluded that patients with tumors destroying >50 % of the bone diameter require prophylactic internal fixation because of a high spontaneous fracture risk (Table 31.2). Harrington’s criteria for prophylactic fracture fixation were: involvement of >50 % of the bone diameter, lesions larger than 2.5 cm in diameter, pain after radiation and fracture of the lesser trochanter [2, 11]. This study mainly focused on the proximal femur. Mirels developed a scoring system as a guideline for prophylactic osteosynthesis [12]. Parameters were: site of the lesion, subjective pain complaints, blastic or lytic character and diameter. In patients scoring 7 or higher, internal fixation was recommended (Table 31.3).

Many methods have been described to treat pathological fractures of long bones [13]. Therapeutic alternatives are: conservative management, endoprosthetic replacement, internal plate fixation with or without augmentation (ORIF) and intramedullary nailing.

Conservative management in the vast majority of cases will not lead to fracture healing. Patients will have only little pain relief and there will be no relevant functional recovery. Radiation therapy alone leads to some relief of pain but may further delay fracture healing and the return of function [11, 13, 14]. Non-operative treatment today therefore is obsolete. It is only acceptable in patients in a poor general condition that have a minimal life expectancy.

Prosthetic replacement is an effective method for achieving stability in fractures that are located in the metaphyseal and/or epiphyseal region. The technique is especially applicable in the proximal femur [15]. Extensive bone resections are possible and modern (tumor) prostheses allow bridging of large bone defects. In the majority of patients, subsequent mobilization is possible with immediate or very quick full weight-bearing. Patients experience adequate pain relief and functional recovery is good to excellent. Surgery however can be demanding and the procedure may be associated with a long operation time and severe blood loss. Infections and recurrent dislocations may pose a serious problem.

Open reduction and plate fixation is an established option in the management of non-pathological fractures of long bones. The technique is also applicable in fractures that result from metastatic disease. Unless percutaneous fixation techniques are used, plate osteosynthesis is more aggressive, requires larger incisions and is associated with a more extensive blood loss than intramedullary nailing. The approach requires opening of the tumor site, which may be necessary in cases where the metastatic lesion needs to be resected for debulking purposes in order to decrease the local tumor volume. This procedure may be useful when adjuvant treatment options like irradiation or chemotherapy are planned. Dependent upon the extent and location of the lesion but also dependent upon the general bone quality, stable fixation sometimes is difficult to achieve. There is a need for the use of long plates with multiple screws in order to achieve a strong bone-implant construct. Cement augmentation increases the stability of fixation [16]. Sometimes, additional procedures like cerclage wiring may be required. Nevertheless, full weight bearing stability cannot always be allowed and implant failure may occur. Piccioli et al. pointed out that plate fixation in pathological fractures of the humerus includes a higher potential of radial nerve palsy and that plates were unable to protect as much humeral length as compared to intramedullary nailing [17]. Damron et al. showed that the locked intramedullary nail has biomechanical advantages over plate fixation for impending fractures located in the middle-third of the humeral diaphysis in a cadaveric model [18].

Intramedullary nailing is an attractive alternative to plate fixation with obvious clinical and biomechanical advantages. The procedure provides immediate and adequate stability with good pain relief and an excellent functional recovery [2, 6, 19, 20]. The implant is inserted in the biomechanical loading axis and the bone-implant interface appropriate. The fracture site needs not always to be opened; surgical approach and technique are less invasive. The procedure mostly is well tolerated and patients regain mobility and function quickly.

Intramedullary nailing is an excellent procedure in pathological fractures of the diaphysis. Prior to take the decision of nailing a pathological shaft fracture, high quality radiographs of the whole bone including the proximal and distal joints in two planes are necessary in order to exclude additional metastases in the meta- or epiphyseal area. Osteolytic lesions of the epi- or metaphyseal area are generally not a good indication for nailing since reliable and enduring fixation of the short proximal or distal fragment is then difficult to achieve [15]. Endoprosthetic replacement and in some cases also plate fixation must be considered as alternative treatment options.

Many pathological fractures occur in the elderly population. Implants resulting from the stabilization of previous fractures may block the entry portal or the medullary canal. Implant removal or partial removal should be considered in these situations. Sometimes, alternative approaches like retrograde nailing may be an option. Nailing can be technically impossible in the presence of artificial joints. Even when the fracture itself is an excellent indication for nailing, the procedure may be impossible due to a blocked entry portal for the nail. In those situations, plate fixation with or without augmentation must be considered as the treatment of choice.

The majority of metastatic lesions are osteolytic in nature. These fractures are adequately amenable to intramedullary nail fixation. Osteoblastic metastases however may pose serious problems. Although bone is brittle, the medullary cavity often is difficult to access and sometimes occupied. Careful preoperative planning is required. As long as a guide wire can be inserted, widening of the medullary cavity by reaming might be an option. Leddy suggests reduced pressure reaming using the RIA-system when stabilizing acute or impending pathological fractures of the femur [21]. Reaming irrigation and aspiration (RIA) avoids increased intramedullary pressure during the reaming procedure and removes large parts of the metastasis while irrigating under negative pressure. We have to take into account that the intramedullary canal is not open as in acute fractures, but obliterated by the tumor mass of the metastasis. Clearing of the medullary cavity without enhancing intramedullary pressure may minimize cardiopulmonary as well as oncologic complications.

Intramedullary fixation of pathological humerus fractures requires a good quality bone stock proximal and distal to the metastatic lesion. Since the vast majority of fractures will not heal, high stability of fixation is required. This means that long nails should be used. The implant diameter should be adapted to the width of the medullary cavity in order to anticipate instability resulting from toggling. A good bone-implant interface improves rotational stability [27].

Nailing usually will be done in an antegrade manner in beach chair position. Many patients are in a reduced general condition and may have additional (skeletal) metastases elsewhere. Bringing the patient in prone position for surgery may not be tolerated or may even create spontaneous fractures in other osseous structures that are weakened by the same metastatic process. The main purpose of stabilization in those patients is achieving pain relief and restoration of function. Approaching the humerus through the rotator cuff is not a major issue as long as the tendon is reconstructed at the end of the procedure.

Routine reaming of the medullary cavity is not necessary. If reaming must be done because of a narrow medullary cavity or because of blastic obliteration of the trajectory of the nail, hand reamers are preferred. The reaming procedure should be done under image intensifier control in both planes in order to avoid accidental perforation through the weakened cortex at the fracture site or at a level more proximal or distal in case of multiple metastases.