For those children identified as having a fracture, the pattern of bone destruction was classified according to the modified Lodwick Classification system. 9 For those children who did not have histological confirmation of the diagnosis, final diagnosis was based on classical radiological appearances and follow-up for lesions which were indeterminate in nature. All histological specimens had been reported by Consultant Histopathologists with a specialist interest in bone and soft tissue tumours and the diagnoses based on the 20 World Health Organisation Classification of Soft Tissue and Bone Tumours. For patients who went on to biopsy and/or curettage, histology results were reviewed. All radiographs had been reviewed for the study by one of two consultant musculoskeletal radiologists with 26- and 9-years experience of bone tumour imaging. Data collected included patient age and gender, bone involved and the presence of a pathological fracture. Therefore, all patients had a new lesion at presentation for which radiographs were available. However, nine cases were excluded since there was no radiograph available at presentation, and one further case was excluded since it represented a recurrent fracture in a child with a known humeral SBC. By the termination of data collection, 241 cases had been collected. Patients were added to an excel spreadsheet following each weekly new patient multidisciplinary team meeting. The study was approved by the local Research and Innovation Centre of The Institute of Orthopaedics under the Integrated Research Application System number 262826, with no requirement for informed patient consent.Ī retrospective review was undertaken of all children up to the age of 18 years presenting to a specialist musculoskeletal oncology service with a suspected bone tumour from September 2019 to August 2020. Therefore, the aim of the current study was to determine the incidence of pathological fracture in children with primary bone tumours and tumour-like lesions, and to determine whether they are predictive of benign lesions as previously suggested. However, we are unaware of any study that has documented the incidence and underlying cause of pathological fractures in a large consecutive group of children presenting to a specialist musculoskeletal oncology service. Therefore, only 16 of 111 combined cases (14.4%) occurred with malignant lesions, suggesting that a pathological fracture through a bone tumour in a child may be a marker of a benign lesion. Similarly, Jackson et al 8 reviewed 23 children under 16 years of age who presented with a fracture as the first indication of a bone tumour over a 7-year period, the underlying diagnoses being a SBC in 9, fibrous dysplasia in 5, giant cell tumour (GCT) in 2, ABC in 3, chondroblastoma in 1, and Ewing sarcoma in 3. Eighty-eight cases were included, 35 SBCs, nine aneurysmal bone cysts (ABC), 14 FD, 17 NOFs and 13 osteosarcomas. 2,3,5,6 Ortiz et al 7 performed a retrospective review of children under the age of 14 years presenting with a pathological fracture between 19 at three different hospitals, with the aim of determining the optimal treatment approach. 4 Review articles have stated that most bone tumours associated with pathological fracture in children are benign, the commonest underlying causes being simple bone cyst (SBC), non-ossifying fibroma (NOF) and fibrous dysplasia (FD), while fractures associated with bone sarcomas are considered to be rare. 1 Metabolic bone diseases, osteogenesis imperfecta, infection and tumours are cited as the common causes, 2,3 although fractures in the setting of metabolic bone diseases may also be referred to as insufficiency/fragility fractures with the term pathological fracture used in the setting of bone tumours and tumour-like lesions. Pathological fractures occur in the setting of abnormal bone and can be due to a wide variety of conditions in children.
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