Pathological Fractures in Children and Adolescents

A Registry-Based Analysis of Benign Tumors

Pathological fractures in childhood are very rare and account for around 0.2–0.5% of all fractures (1). Benign bone tumors are the commonest cause, with most fractures attributable to a bone cyst and the proximal humerus being the part of the body most frequently affected (2).

Pathological fractures should be promptly recognized as such, since adequate treatment that takes into account the causal pathology is of crucial importance for the outcome (2, 3). However, there is no standardized treatment approach as yet, meaning that the indication criteria for surgical treatment have not been precisely specified, nor is the need for histological confirmation before or after surgical treatment clearly defined (4).

Therefore, only epidemiological data with the corresponding treatment option are available at present to inform the decision-making process. Having said that, valid data on the epidemiology and incidence of pathological fractures in children are lacking, as are data on the procedure and outcomes for the standard treatment method.

To address this problem, the Pediatric Traumatology Section (Sektion Kindertraumatologie, SKT) of the German Society of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU) and the German Society of Pediatric Surgery (Deutsche Gesellschaft für Kinderchirurgie, DGKCH) launched a registry of “Pathological fractures in childhood and adolescence” (“Pathologische Frakturen im Kindes- und Jugendalter”).

In a first step, this is intended to systematically record the current treatment strategies for pathological fractures in children and adolescents in Germany and document the present reality of care in order to obtain an overview of the treatment concepts used.

Building on the existing database, a web-based RDE (remote data entry) system has been established that will also enable electronic longitudinal data collection and evaluation.

Materials and Methods

This study reports on the first epidemiological results of 250 treatment-specific experiences from cases documented in the registry in the period 2015–2022. The informed consent process was decentralized, taking place in one of the 10 cooperation hospitals. The Ethics Committee of the Albert-Ludwig University of Freiburg, Germany, granted its approval (68/14).

Inclusion criteria comprised age < 18 years and a pathological fracture due to a benign bone tumor or a non-infectious disorder of bone density. Exclusion criteria included age > 18, malignant bone tumors, or an infectious etiology as the cause of the fracture.

Index procedures were categorized into conservative and surgical procedures. Primary endpoints included time to full weight-bearing and freedom from failure. Failure was defined as revision surgery with a further open procedure following the primary surgery, more than three percutaneous procedures (for example, K-wire insertion, ESIN for fracture stabilization), as well as documented recurrence of the underlying disease and/or re-fracture.

Results

The patients included in the study were 9.2 ± 3.9 years old, and 76.8% of the pathological fractures were documented in boys. In 39% of cases, the pathological fracture was caused by inadequate trauma. The most common cause of pathological fractures (41%) was unicameral bone cysts. The proximal humerus was the predominant fracture localization (31%), followed by the humeral (14%) and femoral shaft (12%).

A total of 118 patients (48%) received conservative treatment, while 126 patients (51%) underwent surgery. In the case of conservative treatment, 55 patients (46%) were treated with an arm sling and 53 patients (44%) with a plaster cast. The duration of conservative treatment was reported to be 37.6 ± 25.4 days. The length of hospital stay in the case of inpatient treatment was reported to be 4.6 ± 3.5 days.

The leading method of treatment was intramedullary stabilization by means of ESIN (elastic stable intramedullary nailing). Thus, a total of 88 patients underwent ESIN. External fixation was performed in 16 patients (12%). Surgical management without osteosynthesis was carried out 41 times (35.5%), including, for example, curettage and defect filling with allogeneic or autogenous bone material alone. For 22 patients (17%), “further extramedullary procedures” were reported.

No complications were reported in 167 patients (66.8%), while re-fracture occurred in 11 cases (4.4%), secondary displacement in six patients (2.4%), implant complications in five patients (2%), and pseudoarthrosis in four patients (1.6%). Recurrence was documented in two cases (0.8%).

Table

Fracture localization and underlying disease

Conclusions

The recognition and treatment of pathological fractures in children and adolescents differ from that of classical fractures. They are often the result of minor trauma, and the underlying entity needs to be taken into consideration in the treatment strategy. As such, pathological fractures in childhood and adolescence represent a point of intersection between pediatrics, oncology, orthopedic oncology, pediatric surgery, pediatric orthopedics, and trauma surgery.

To date, there are no specific data in the established literature on the treatment and outcome of pathological fractures in children and adolescents in Germany. To our knowledge, the large German cancer registries also do not yet include the option to retrieve data on pathological fractures in childhood.

In one of the few literature analyses on pathological fractures in children, Canavese et al. describe solitary bone cysts, aneurysmal bone cysts, non-ossifying fibromas, and fibrous dysplasias as the typical entities of pathological fractures (5). This concurs with our data, and the therapeutic approaches described are also consistent with the approaches documented in the registry.

Due to the low number of pathological fractures in children and adolescents, further registry research is required in this field.

Nikos Karvouniaris, Jörn Zwingmann, Justus Lieber, Florian Bergmann, Björn Wilkens, Ramona Sturm, Peter Schmittenbecher, Miriam Adrian, Sebastian Reinecke, Hagen Schmal

Acknowledgments

We would like to thank our cooperation partners: the Department of Pediatric Surgery, Lübeck Campus of the University Hospital Schleswig-Holstein, the Department of Orthopedics and Trauma Surgery, Bamberg Hospital, the AKK Altonaer Children’s Hospital, and the Pediatric Traumatology Section of the German Society of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU).

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 19 June 2024, revised version accepted 26 September 2024.

Translated from the original German by Christine Rye.

Cite this as
Karvouniaris N, Zwingmann J, Lieber J, Bergmann F, Wilkens B, Sturm R, Schmittenbecher P, Adrian M, Reinecke S, Schmal H: Pathological fractures in children and adolescents—a registry-based analysis of benign tumors. Dtsch Arztebl Int 2025; 122: 135–6. DOI: 10.3238/arztebl.m2024.0203

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