The fate of femora with pathologic fractures due to malignant tumors, stabilized by intramedullary nails, as shown by serial roentgenograms.

Abstract

The treatment of fractures of long bones by intramedullary-nail fixation has become a well accepted procedure (1–4). Since 1948 there have appeared several reports of femoral stabilization with intramedullary nails following pathologic fractures (5–7), and it has become apparent that this procedure offers a valuable adjunct in the management of these difficult cases. How adequate such intramedullary support really is, and what changes take place in the presence of the intramedullary nails in bones involved by malignant lesions, are questions of great interest. In the following cases serial roentgenograms obtained over a period of months showed the changes in femora involved by metastatic carcinoma and osteogenic sarcoma, with pathologic fractures and stabilization of the affected bone by means of intramedullary rods. It is hoped that this report will stimulate further interest in this important subject. Case Reports Case I: R. G., a white female aged sixty-three years, was admitted to the Henry Ford Hospital on March 4, 1951, with the history of radical mastectomy three years previously, for carcinoma of the breast with axillary metastases. On the day of admission the patient fell, while walking at home, experiencing severe pain in the left upper leg. Admission roentgenograms revealed changes in the lower third of the left femur characteristic of a pathologic fracture from malignant metastases. Roentgenograms of the chest showed metastases throughout the lungs. Amputation was refused, and it was therefore elected to stabilize the involved femur with an intramedullary rod. Five days after admission this procedure was carried out by open reduction of the fracture and retrograde insertion of a Street rod. At operation the femur in the region of the fracture was seen to be invaded by tissue with the gross appearance of metastatic carcinoma, and this impression was confirmed by microscopic examination. Postoperatively the patient was mobile in bed, with little pain in the involved leg; after one week she was mobilized in a wheelchair. She was discharged following deep x-ray therapy and treatment with radioactive phosphorus. At home she remained mobile in a wheelchair, since axillary scars from the earlier breast amputation precluded crutches. Pain in the involved leg was a minimal factor. The involved femur remained clinically stable until death, which ensued eight months after the occurrence of the fracture. The progress of the femoral lesion during this period is shown by serial roentgenograms (Figs. 1–6). Case II: F. B., a white female aged fifty-nine years, was admitted to the Henry Ford Hospital on March 30, 1951, having fallen at home a few hours previously, experiencing severe pain in the left leg above the knee. Roentgenograms revealed in the lower third of the left femur changes characteristic of osteogenic sarcoma with a pathologic fracture through the tumor area. This diagnosis was confirmed by biopsy.