Multiple concurrent insufficiency fractures possible
Delirium risk
Pain undertreatment
Opioid sensitivity
Treatment adjustments
Opioid dosing
Lower initial doses
Longer dosing intervals
NSAID cautions
CKD risk
GI bleed risk
Disposition considerations
Falls risk assessment
Home safety needs
PT and OT planning
Bone health follow up
Vitamin D supplementation plan
Osteoporosis pharmacotherapy referral
Pediatrics
Etiology differences
Benign lesions common
Unicameral bone cyst
Non ossifying fibroma
Malignancy considerations
Osteosarcoma
Ewing sarcoma
Imaging considerations
Minimize radiation
MRI preference when appropriate
CT only when necessary
Growth plate evaluation
Physeal injury assessment
Alignment and length monitoring
Pain control
Weight based dosing
Acetaminophen PO 15 mg per kg
Ibuprofen PO 10 mg per kg
Background
Epidemiology
Frequency
Metastatic disease common cause in adults
Breast prostate lung kidney thyroid typical primaries
Spine pelvis femur common sites
Myeloma associated skeletal events common
Vertebral compression fractures frequent
Long bone lesions possible
Impact
High morbidity
Loss of mobility
Pain and hospitalization
Mortality association
Reflects advanced malignancy stage in many cases
Complication driven outcomes
Pathophysiology
Structural failure concept
Bone weakened by abnormal remodeling
Lytic destruction reduces cortical strength
Medullary replacement reduces load bearing
Minimal trauma threshold
Normal physiologic loads exceed bone capacity
Progressive microfracture before complete break
Tumor biology patterns
Osteolytic lesions
Myeloma and many metastases
High fracture risk with cortical involvement
Osteoblastic lesions
Prostate metastasis typical
Mixed strength and brittleness pattern
Mixed lesions
Breast metastasis possible
Variable fracture risk
Therapeutic Considerations
Operative principles
Prophylactic fixation versus after fracture
Earlier fixation often improves function and pain
Lower complication rates compared with fixation after complete fracture in many series
Biopsy planning
Biopsy before definitive fixation when primary tumor possible
Orthopedic oncology coordination to avoid contaminating planes
Radiation therapy role
Pain control in metastasis
Palliative fractionation options
Post fixation adjuvant radiation common
Local tumor control
Reduces progression risk
Not immediate stabilization
Systemic therapy role
Antiresorptives in metastatic bone disease
Reduce skeletal related events
Osteonecrosis of jaw risk counseling
Myeloma therapy reduces lesion progression
Hematology coordination
Renal protection strategies
Patient Discharge Instructions
Copy discharge instructions
Discharge instructions
Diagnosis explanation
Fracture occurred in weakened bone
Further testing needed to find cause
Activity and immobilization
Keep splint or sling on continuously unless told otherwise
Keep limb elevated above heart when resting
No weight bearing on injured limb unless cleared
Pain control
Acetaminophen as directed on label or prescription
Avoid alcohol while taking opioid pain medicine
Wound care if present
Keep dressing clean and dry
Do not soak wound in bath or pool
Follow up
Orthopedics or orthopedic oncology appointment within time given
Oncology or family doctor appointment for further workup
Return to emergency immediately for
New numbness or weakness in the limb
Fingers or toes turning blue or cold
Severe worsening pain not controlled by medicines
Fever or chills
Increasing redness swelling or pus at wound
New back pain with leg weakness
New trouble peeing or losing bowel control
Confusion or extreme sleepiness
Chest pain or shortness of breath
References
Clinical guidelines and evidence sources
Orthopedic oncology and metastasis
Mirels scoring system for impending pathologic fracture risk stratification
Spinal Instability Neoplastic Score framework for neoplastic spine instability
Trauma and open fracture care
Early antibiotic prophylaxis for open fractures supported by trauma society guidance
Tetanus prophylaxis per national immunization guidance
Oncology emergency care
Malignant spinal cord compression pathways support urgent MRI and corticosteroids
Malignant hypercalcemia pathways support IV fluids calcitonin and antiresorptive therapy
Evidence level labels used in this reference
ACEP Level A high certainty evidence
ACEP Level B moderate certainty evidence
ACEP Level C consensus and expert opinion
Class I benefit much greater than risk
Class IIa benefit greater than risk
Class IIb benefit at least equal to risk
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.