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Fractures in metastatic carcinoma
FRACTURES IN METASTATIC CARCINOMA* WILLIAM T.
FITTS, JR.
M.D., &COKE
ROBERTS, M.D. AND I~IDORE S. RAVDIN,
M.D.
Pbiladelpbia, Pennsylvania
A
LTHOUG~ cancer is wideIy considered one of our most important medica reIativeIy little attention probIems, has been given to fractures caused by cancer. The incidence of cancer is increasing in our population and those interested in the surgery of trauma should anticipate treating an increasing number of fractures due to cancer. It is our impression that the current aggressive attitude in the treatment of most forms of cancer has not been adopted for fractures due to metastatic cancer. All too often an attitude of hopelessness prevails and the patient is aIIowed to become bedfast for his remaining days, with severe pain and with rapidIy diminishing morale. AIthough the prognosis is treatment of the admittedIy poor, vigorous fracture wiII in most instances relieve pain, diminish the Iength of hospitahzation, make nursing care easier and allow the patient to be moved for supplemental forms of therapy, e.g., irradiation. In a significant number of instances bone union does occur. We have found that intrameduIIary naiIing is aImost “taiIormade” for the treatment of many of these fractures, especiahy those of the femoraI shaft. The folIowing three cases iIIustrate what can be accomplished for these patients: CASE CASE
man,
I.
REPORTS
M. S. (No. 65689), a forty-six year old
had been treated
at the HospitaI
of the
University of PennsyIvania for hypernephroma of the right kidney, found in 1944. The tumor had metastasized to severai bones. On November 28, 1949, he fractured the shaft of the right femur through an area of metastasis. An open reduction was performed the day after injury and a Kiintscher naiI inserted into the meduIIary cavity. Figure I, a roentgenogram taken two months after injury, shows abundant caIIus at the fracture site. By six months the fracture had united. (Fig. 2.) The patient was reIieved of pain by the operation, was out of bed after the first week, bore weight after the second month and worked for severa months * From the Harrison
Department
before his death, which occurred aImost a year after the fracture. CASE II. N. P. (No. 8g226), a forty-one year oId woman, fractured the neck of her femur on December 30, 1950, through an area of metastatic cancer. Four months earIier a radical mastectomy had been performed for carcinoma of the breast. The fracture was reduced and fixed with a SmithPetersen nail. (Fig. 3.) The cancer had spread far into the head of the femur and it was beiieved that the nai1 must be driven cIose to the articuIar surface to give sufhcient fixation. Because the IateraI femoraI cortex was aIso invoIved by the tumor, a McLaughIin bar was attached to the nail to give added stability. A steriIizing dose of irradiation was given over the ovaries and further irradiation was given over the site of fracture. Testosterone was given intramuscularly. The neck of the femur coIIapsed and the nai1 was dispfaced into the acetabulum. (Fig. 4.) In spite of this the fracture appears to have heaIed, the patient is bearing weight without pain and at the present time, aImost two years after fracture, has no compiaints. CASE III. C. S. (No. 79701)~ an eighty-four year oId woman, fractured the shaft of her femur on October 20, 1948, through a metastasis from carcinoma of the bladder. Both she and her husband were wiIling to risk any treatment that, if successful, would permit her to return home and be out of bed. A Kiintscher nai1 was inserted into the meduIIary cavity folIowing open reduction (Fig. 5) and she was able to return home in two weeks, out of bed and abie to bear weight. The favorabIe resuIts in these and other patients Ied us to anaIyze a11 fractures due to metastatic carcinoma seen in the HospitaI of the University of Pennsylvania during the Iast ten years. ANALYSIS
OF
DATA
ON
FIFTY
PATIENTS
During the ten-year period from July, 1942, through July, rg$z, fifty patients were treated for fractures that had occurred in areas of metastatic carcinoma. These patients were treated on the General Surgical, Orthopedic and X-Ray services. EIeven of the patients were men and thirty-nine women.
of Surgical Research, Schools of Medicine, d&phi+ Pa. 282
University
American
of Pennsyfvania,
Journal
Phita-
oJ’ Surgery
Fitts
et al.-Fractures
I
in Metastatic
Carcinoma
2
FIG. I. Fracture of femur through metastasis from hypernephroma; gram taken two months after fracture. FIG.
2.
Same bone as in Figure
283
roentgeno-
I ; roentgenogram taken six months after fracture.
4B 3 4A FIG. 3. Fracture of neck of femur through an area of metastasis from carcinoma of the breast; tixatIon with a Smith-Petersen nail. Roentgenogram taken immediately after insertion of the nail and showing involvement of the head and neck with cancer. FIG. 4. Same bone as Figure 3; roentgenograms taken one year after fracture. Collapse of neck with displaccmcnt of nail into acetabulum. A, anterior view; B, lateral view.
March,
1~53
Fitts et al.-Fractures
in Metastatic Carcinoma two groups of patients with bony metastases, one with and one without fractures. (Fig. 6.) The data are compiIed from cases reported in the Iiterature1-7 in addition to our own. Carcinoma of the breast was the primary tumor in 59 per
cent
of the
fracture
patients
and
in 47
lW5TATl
._--__--_ PRIMARY
FIG. 5. Fracture of femoral shaft through metastasis from carcinoma of the bladder; roentgenogram taken immediateIy after open reduction and fixation with an intrameduIIary nail.
Location of the Primary Tumor. The source of metastasis, as shown in TabIe I, was carcinoma of the breast in more than ha’f of the fifty patients. Carcinoma of the breast frequently metastasizes to bone and frequentIy causes fractures. This is apparent if we compare TABLE PRIMARY
TUMOR DUE
IN TO
FIFTY
I
PATIENTS
METASTATIC
WITH
Per cent
Organ
Breast, ..................... Kidney ..................... Colon and rectum ............ Lung ....................... Thyroid. .................... Prostate ....................
BIadder..................... Parotid ..................... Skin (malignant melanoma). Pancreas .................... Testicle. .................... Unknown ...................
FRACTURES
CARCINOMA
I
26
52
7
14
4 3
8 6
2 I I I I I
4 2 2 2 2 2 2
.’ ::
4
TUMOR ln 2030 ph. with mofasfatic carcmoma I* bona
Rimarzj tumor m 328 pts. with FRACTVRES due to
mptastatic carcinoma
FIG. 6. per cent of the non-fracture patients. AIthough carcinoma of the prostate aIso frequently spreads to bone, it seldom causes fracture. In our opinion the expIanation Iies in two facts: (I) metastases from carcinoma of the prostate are usuaIIy osteobIastic rather than osteolytic, and (2) prostatic metastases frequentIy invoIve
the peIvis where pathologic fractures are uncommon. AIthough carcinomas of the kidney constitute a smaI1 percentage of tumors spreading to bone, when such Iesions do metastasize to bone they are pecuIiarIy IiabIe to fracture and account for IO per cent of the fractures collected. It is Iikewise noteworthy that bone metastases are more common from both the stomach and coIon than they are from the thyroid, generaIIy considered a common source of bone metastases. Location of the Fracture. Bones of the spine and the femur are by far the most frequentIy fractured. (Fig. 7.) TabIe II shows the bones invoIved in the fifty-six fractures in our fifty patients. Data coIIected from the Iiterature1~3~5~6 and added to our own are presented in Figure 8; which compares the Iocation of fracture in
American
Journal
of Surgery
Fitts
n Metastntic
et al.-Fractures
two groups of patients with bony metastases: those with fractures and those without fracture. Bones of the spine make up a large percentage of each group. Although the femur is not commonIy the site of metastatic carcinoma, when once involved it is frequent&
28j
Carcinoma
healing of the fracture. Fractures of the spine are a common problem and cannot he treated as definitively. We are loath to put patients with pathologic compression fractures of the vertebrae in plaster hyperextension jackets. The! seem to do poorly and are uncomfortable. The -_1M)*_-_
\
‘1 , \ \\
\
‘\
‘1
\
’
\\
\
\\’ \;, \ \r \\
\\
\
’
\ \ \ \ \
\
.-e-B-_
Distribution of 56 fractures due to lnetastatic carcinoma.
FIG.
7.
fractured. The pelvis is a common site of metastases but is rarely fractured. Treatment. We have done everything possible to avoid prolonged recumbency. In fractures of the femur the use of an intramedullary nail enables the patient to become ambulatory, reduces pain and gives an excellent chance for TABLE LOCATION
OF FIFTY-SIX CARCINOMA
II
FRACTURES (FIFTY
DUE
TO METASTATIC
PATIENTS)
-r Bone
Spine ....................... Femur .................... Humerus ................... CIavicle, ................... Rib ....................... PeIvis. ..................... Ulna .......................
1933
Per cent
23
41 .o
21 6
37.5 1
3
10.7
-I::
I
,
I
I.8 I.8
I
I
March,
No. of Cases
I
1
majority of fractures of the spine do not require immobilization if they are discovered before compression has progressed very far. Pain ordinarily is encountered early In vertebral metastases. Local use of x-ray therapy is often of great benefit both in retarding the growth of the tumor and in giving symptomatic relief. In addition, endocrine therapy in suitahlc cases may also give dramatic improvement. Irradiation has a large role in the treatment of pathoIogic fractures of almost a11 types arising from metastatic carcinoma. In general we use it locally over the bony lesion both for its relief of pain and its direct effect on the lesion. The majority of carcinomas that spread to bone respond to irrbdiation, although tumors arising in the gastrointestinal tract are a notable exception. In addition to local therapy, sterilizing doses of x-ray are often used in women who have tumors that may be benetitted b\ castration. Endocrine therapy under certain circumstances may be as dramatic in its effect. as x-ray. Therapy may consist of removing the source of normal sex hormones by castration or in supplying hormones of the opposite sex. Tumors of the breast and genital tract in both male and
Fitts
286
et aI.-Fractures
in Metastatic
femaIe are particuIarIy apt to be retarded by changes in the normal baIance of sex hormones. It is now we11 known that prostatic carcinomas may be greatIy improved by castration and estrogens, and that cancers of the breast at Ieast in the period of active TABLE III DURATION OF
LIFE
AFTER
FRACTURE
TNo. of Cases Lessthan6mo.. ............ 6mo. to 12 mo ............. I2mo. to 18mo .... ........ 18 mo. to 24 mo. ............ Over24mo .................
Per cent
24 12
48 24 IO
2
4 14
7
!_ gonada function, may be improved by castration and androgens whereas in later life estrogens may be beneficia1. Huggins has presented evidence that adrenaIectomy may give further benefit after the good effects of the usual hormone therapy have worn off. Total bilateral adrenalectomy was performed in two patients of this series with great symptomatic reIief, one with carcinoma of the breast and one with carcinoma of the prostate. Radical surgery in the form of amputation seIdom is indicated for metastatic disease, but we did carry out amputation in one patient in whom a carcinoma of the coIon spread to the uIna and resuIted in a fracture. This bone did not unite and the Iesion became progressiveIy more painfu1 and the arm less usefu1. X-ray had no effect upon it and eventuaIIy amputation was performed to reIieve pain. Results. AI1 fifty patients have been foIIowed up unti1 their death or unti1 August, 1932. Twenty-two per cent of the fractures heaIed and many more were healing at the time of the patient’s death from progression of the disease. TabIe III gives the length of Iife after fracture for the fifty patients. Over half of the patients Iived for more than six months and 14 per cent Iived for more than two years. The fractures in a11 but two of the patients surviving two years or longer united soIidJy. COMMENTS
Carcinoma that has metastasized to bone has a poor prognosis, but this is hardly an indication for apathy on the part of the attending physician because many of these patients can
Carcinoma
be heIped immenseJy at a most diffrcuIt period of their lives. We believe that open reduction and interna fixation is often indicated for such fractures of the long bones, not onIy because it may give the fracture its best opportunity to hea but aJso because of its effectiveness in reIieving pain. As knowIedge of tumors and their therapy progresses, further anciJIary methods of treatment will undoubtedly be developed which wiJ1 improve the results in these fractures. At present, hormones and roentgen ray therapy are the two main adjuncts to the treatment of the fracture itseIf and are especiaIIy effective in bony metastases from cancer of the breast. The presence of an intrameduIIary nai1 does not precIude adequate irradiation therapy. PeItier and Nice8 performed experiments which showed that the areas of the bone shielded by the nai1 Iost onIy about 30 per cent of the effective irradiation. This can easily be compensated for by giving a Iarger dose of irradiation or using multipIe ports. It cannot be denied that intrameduIIary nailing spreads tumor ceIIs in the meduIIary cana1. It has been shown that red bJood ceIIs tagged with Pa2 can be wideJy spread both distally and proximaIIy in the marrow cavity of the tibia by the insertion of an intrameduIIary naiJ.g In none of our patients, however, have we noted any evidence of secondary growths along the meduIIary cavity and we believe that the advantages accruing from intrameduIIary naiIing for many of these fractures far outweigh the risk of further spread of the tumor in a patient who aIready has metastatic disease. SUMMARY
AND
CONCLUSIONS
A review of the Jiterature.on fractures due to metastatic carcinoma and an analysis of fifty patients with such fractures treated at the Hospital of the University of PennsyIvania during the last ten years Ieads us to concIude that: I. A hopeIess “do-nothing” attitude is unjustified. Vigorous treatment of the fracture reIieves pain, cuts down hospitalization, makes nursing care easier, and permits early ambuIation. 2. Carcinoma
of
the
the Jargest percentage cinoma bone
of the but
does
prostate not
breast
accounted
of these fractures. frequentIy
usuaIIy
American
cause
Journal
for Car-
spreads
to
fractures.
of Surgery
Fitts
et al.-Fractures
Carcinoma of the kidney less commonly involves bone; but when it does, it is likely to result in fracture. 3. Thespine, femur and bones of the shoulder girdle are most frequently fractured. Fractures distal to the knee and elbow are uncommon. 4. Open reduction and fixation with an intramedullary nail is often the treatment of choice, especiaIIy in fractures of the femoral shaft. Fractures of the spine due to metastatic carcinoma are usually best handled without plaster jackets or braces. Irradiation and endocrine therapy are sufficient to give the patient comfort and to limit the local progression of the tumor. 5. Twenty-two per cent of the fractures in our series healed although almost haIf of the patients died from progression of the disease within six months of fracture. Acknowledgment: The authors wish to thank Dr. Paul Colonna and Dr. Roy Peck for allowing us to include patients treated by them in our series. Dr. Roy Greening and Dr. Richard Chamberlain were most helpful in selecting roentgenograms and in discussing the problems of irradiation in these patients. KEFERENCES I.
2.
WELCH, C. E. Pathologic fractures due to disease. Surg., cvnec. @ Obst., 62: 735, GHORMLEY, K. K., SUTHERLAND,C. G. and G. A. Pathologic fractures. J. A. M. A.,
malignant 1936. POLLOCK.
109: 21 I I.
‘937.
3. CESCHICKTEK, C. F. and MASENITZ, I. H. Skeletal metastasis
4. 5. 6. 7. 8.
9.
in canrcr. .I. Bone P? Joint Sur,~~.,2 I :
3’4. 1939. TURNER, J. W. and JAFFE, H. L. Metastatic neoplasms. Am. J. Roentgenol., 43: 479, 1940. SMEDAL, M. I. and SALZMAN, F. A. The treatment of metastatic bone tumors. Wisconsin M. J., 47: 475, 1948. GOLDING, F. C. hletastatic tumors of bone. Diagnostic aspects. J. FM. Radiologists, 1-2: 246, 1949. ABRAMS. Il. L. Skeletal metastases in carcinoma. Rudiology, 55: 534, 1950. PELTIER, L. F. and NICE, C. M., JR. Irradiation of bone lesions in the presence of metallic intramedullary fixation. Radiology, 56: 248, 195 1. PELTIER, L. F. Theoretical hazards in the treatment of pathoIogic fractures by the Kiintscher intramedullary nail. .Surger.y, 29: 466, 195 I.
DISCUSSION
OF
PAPERS
BY
DRS.
CASSEBAUM
AND HAMILTON, AND FITTS, ROBERTS AND RAVDIN HAROLD M. CHILDRESS (Jamestown, N. Y.): 1 greatIy enjoyed this most interesting and valuable paper on surgical treatment of mrtastatic bow
March,
1~53
in Metastatic
Carcinoma
287
carcinoma. By such surgery hopetess individuaIs, many with severe persistent pain, may be given a tremendous lift both mentally and physically. I wouId like to describe a simiIar case recently seen. The patient was a sixty-five year old white woman who in November, 1951, was hospitalized for pain at the left hip, Roentgenograms reveaIed a pathoIogic fracture at the proximal left femur. Traction was applied by her attending physician and she was given hormone injections but continued to experience severe localized discomfort. She was first seen by me three months after hospita1 admission. Despite the fact that her left breast had been removed twenty years previously for carcinoma of that organ, the bone lesion from its x-ray appearance could well have been a localized fibrocystic condition. Biopsy, however, proved the pathologic condition of the bone to br that of a metastatic scirrhous-type carcinoma of tht breast. The roentgenograms were reviewed by two consultants who advised deep x-ray therapy and who were not in favor of any form of surgery. Howrver, Dr. Bradley Coley of the Memorial IHospital fol agreed with me that surger,y would Cancer, probabIy be of great benefit to her. the entire ConsequentIy in March, ‘052, proxima1 femur, including the head, was excised and an Either prosthesis inserted. One comptication developed in that the stem of the prosthesis was too large for the intramedullary canal of the femoral shaft. Luckily this misfit was discovered before the appliance was driven too securely for removal. The stem was shortened I 1p inches by hacksaw and the final fitting was quite satisfactory. In two weeks she was ambulatory and was discharged from the hospital three weeks later. She now lives alone in her home and walks with a cane. She has very little discomfort and her general condition has greatly improved. The ultimate outcome is not known at present, but this patirnt is quite happy and is most grateful. JAMES J. CALI.AHAN (Chicago, Ill.): 1 would like to inject the thought here that in metastatic lesions we have been using the intramedultary nail. Our experience is practically the same; the patients live about a year. Recently in solitary metastasis, like thyroid malignancy, we have been resecting the tumor and then inserting the intramedullary nail utilizing a bone graft to compensate for any deficiency in approximation. Our results have been far superior performing this procedure than by inserting the nail through the tumor \vith the danger of spreading the tumor cells. PRESTON A. WADC (New York, N. I-.): 1 am very interested in Dr. Cassebaum’s paper because in the last few years we have been plagued at Nen York Hospital with some recurrent fractures of both hones of thr forearm in children. Dr. Ilarr!
Fitts
et al.-Fractures
Kranler of New York Hospital has Iooked up these patients and has found nine weI1. Six of our own cases recurred, and three patients treated elscwherc were treated by us for the second fracture, We found that these patients were from the ages of three to thirteen. Three had refracture after the plaster was removed in eight weeks, one a week, another a month and another four or five weeks. The other three occurred after sixteen weeks from the original fractures and after eight weeks from removal of the plaster. We have been in the habit of removing our plaster after an average of eight weeks. The cases that were three and a haIf, four, and four and a quarter months were obviousIy not onIy the resuIt of remova of the plaster. We have thought, however, that as a result of this we should keep our fractures of both bones of the forearm in chiIdren immobile for at least tweIve weeks. I toId this to Dr. Speed and he said, “The worId doesn’t know that, but I have known it for many years. But if we a11 knew that, there would be no purpose in these meetings, and that is why we are reporting our errors.” Of the three patients from other hospitals whom we treated, one was a child of two. The plaster had been removed at the end of three weeks and the fracture recurred two days Iater. One was a chiId of seven that had a pIaster immobilizing elbow and wrist for some six weeks. The plaster was then cut down, freeing the eIbow, and the second fracture occurred in the short plaster. We do not beIieve that the shorter plaster should be used, aIthough I know some textbooks stiI1 say that after six weeks or even less the elbow may be released. As Watson-Jones says, this may cause more torsion on the fractured area. 1 would like to commend Dr. Fitts on his presentation and say that we at City Hospital have also found satisfactory results in intramedullary nailing, particularly in femurs in metastatic carcinoma. I was surprised to hear him say that in 22 per cent he obtained bony union. I do not think we got as high a percentage as that. Even if bony union does not occur, these patients are much happier and much easier to take care of. THOMAS BARTLETT QUIGLEY (Boston, Mass.) : One comment on Dr. Fitts’ paper. We have been doing the same thing at the Peter Bent Brigham HospitaI and we agree with everything he said. I wouId Iike to ask him one question. In some of these patients with metastatic carcinoma of the long bones, the carcinoma is sensitive to radiation and these patients have pain. When empIoying radiation to contro1 pain, have you observed a variation in the natural history of the healing of the fracture in these cases? GEORGE WrLLrAnf BANCROFT (CoIorado Springs, Cola.): I would like to report a case of eight
in Metastatic
Carcinoma
mctastatic carcinoma fractures in one woman. Four and a half years after radical mastectomy she sustained a fracture of her rigfit femur which was treated by traction and later with cast, and healed. During the next three years, she fractured both humeri, both cIavicIes, the other femur and refractured the Hurstfemur. These were a11 treated by traction and splints, and x-ray examination showed that they were a11 united. The first femur had radiotherapy through a hoIe in the cast after it had been set. During the interim the patient did have x-ray therapy of her spine because one spina body had coIIapsed, and she aIso had osteolytic evidence in her skuI1 treated with x-ray, but actual treatment of the Iater fractures was nothing but immobiIization, fixation and traction. F. WALTER CARRUTHERS (LittIe Rock, Ark.): These papers indicate two things that I think should be emphasized. One of them is, we should make it on a comparative basis that refractures occur because of lack of proper time for complete immobilization for the fracture to reunite. Then on the other hand, we should sound a warning that other complications occur as the result of too prolonged immobilization producing what is commonly caIIed Sudeck’s syndrome or demineraIization and decaIcihcation. This latter condition is very apt to occur in prolonged immobilization of the forearm and hand and proIonged immobiIization of the foot and ankle. One of the first presentations here mentioned a separation at the head of the radius, in my opinion being reIeased far too soon and obviousIy the deformity resulted. When refractures occur, if my memory serves me correctly, they do not recur in the sense I am thinking about, namely, at the site of the old fracture, except those that have not been given an opportunity to unite in the first place. However, if union has occurred and there is socaIIed refracture, it does not occur at the site of the old fracture. They either occur above it or below it. When a patient asks, “Am I apt to break my leg or arm in this place again?” I am aIways happy to reply, “No. If a fracture shouId occur, it wiI1 occur either above it or beIow it.” That has been my experience in over thirty-five years of practice. So the question arises which should be emphasized here, of a sufficient amount of immobiIization and a sufficient amount of time to permit the fracture to unite. Obviously one cannot prevent fractures occurring if there are conditions in an individua1 that wouId produce a fracture. I therefore think we should not be misIed in our deductions with regard to refractures but rather should bear in mind that the reason why there is refracture is because it was never permitted to reunite in the first place. Obviously I have had fractures occur at the site of the old fracture but it has always been
American
Journal of Surgery
Fitts those
et d---Fractures
that have not had an opportunity originally to unite solidly. CHARLES Hucn MAGUIRE (Louisville, KY.): I was particularly interested in the latter paper on metastatic carcinoma. I think it is best to decide what we are going to do with these metastatic lesions for two reasons: First, I certainly agree with the original statcment that cancer ;a on the increase. Secondly, as one who sees a good many cancer patients, \vc arc seeing more and more bone lesions for one big reason: We are curing the primary lesions, and the patients are living long enough to develop bizarre skeletal lesions. We therefore had better decide how we arc going to treat them. H.~~n~sory. L~oun MCLAUGHLIN (New York, N. Y.): The essayists are to be commended for their stand on the subject of intramedullary fixation for metastatic fractures. It is a good and humane procedure. It may be pointed out that it is also possible to insert radon seeds or removable radium elements into the center of the diseased area by way of the intramedullary device used for fixation. This may prove to have some advantages over rxternal radiation therapy in selected radiosensitive lesions. Dr. Cassebaum’s paper has been discussed at length and there is complete agreement that the responsibility for all refractures in children occurring within three months of the origina injury rests squarely upon the surgeon. Refractures occurring after six months are different. The point of healing constitutes the only hard and brittle segment in the normally resilient child’s bone. It is onIy natural that another adequate injury will cause a fracture at this weak spot. This is conhrmed by the level of later fractures in plated long bone fractures in
&larch,
1953
in Metastatic
Carcinoma
2&)
children. That segment of the bone stabilized by the plate is relatively non-resilient. Later fractures occurring in the same bone are found consistently to occur at one or the other end of the plate. This phenomenon is sufficiently common to warrant elective removal of plates from the bones of children when the primary fracture is healed. WILLIAXI H. CASSEBAUM (closing): I would like to emphasize again that, as Dr. McLaughIin says, the doctor must share the blame when refracture occurs under three months. After that I am not so sure, and I would not advise seeking a remedy that may be worse than the condition. We have to take a calculated risk. Dr. James Ewing once told a Scotchman that bad teeth, chewing tobacco and syphilis gave him a 20 per cent chance of getting cancer of the stomach. The Scotchman thought a minute and said, “Five to one; those are good odds; I guess I’ll take them.” BROOKF. ROBERTS (cIosing): I would like to answer two questions. One is on this problem of spreading the tumor by use of the intramedullarv nail Certainly on the theoretic basis it is possible but cIinicalIy these patients have had very widrspread tumors at the time they had the fracture, and we have not seen what we believe to be a further spread due to use of the intramrdullary nail. Of course, that is a clinica impression. The other question is in regard to local treatment with x-ray, whether or not that has delayed healing of the fractures. It is always somewhat difficult to give a categorical answer to such questions. However, our radiotherapists have treated only for the reIief of pain and have not used large tumoricidal doses. For that reason we have not thought that they had much effect on the healing of the bone itseIf.
FITTS, JR.
M.D., &COKE
ROBERTS, M.D. AND I~IDORE S. RAVDIN,
M.D.
Pbiladelpbia, Pennsylvania
A
LTHOUG~ cancer is wideIy considered one of our most important medica reIativeIy little attention probIems, has been given to fractures caused by cancer. The incidence of cancer is increasing in our population and those interested in the surgery of trauma should anticipate treating an increasing number of fractures due to cancer. It is our impression that the current aggressive attitude in the treatment of most forms of cancer has not been adopted for fractures due to metastatic cancer. All too often an attitude of hopelessness prevails and the patient is aIIowed to become bedfast for his remaining days, with severe pain and with rapidIy diminishing morale. AIthough the prognosis is treatment of the admittedIy poor, vigorous fracture wiII in most instances relieve pain, diminish the Iength of hospitahzation, make nursing care easier and allow the patient to be moved for supplemental forms of therapy, e.g., irradiation. In a significant number of instances bone union does occur. We have found that intrameduIIary naiIing is aImost “taiIormade” for the treatment of many of these fractures, especiahy those of the femoraI shaft. The folIowing three cases iIIustrate what can be accomplished for these patients: CASE CASE
man,
I.
REPORTS
M. S. (No. 65689), a forty-six year old
had been treated
at the HospitaI
of the
University of PennsyIvania for hypernephroma of the right kidney, found in 1944. The tumor had metastasized to severai bones. On November 28, 1949, he fractured the shaft of the right femur through an area of metastasis. An open reduction was performed the day after injury and a Kiintscher naiI inserted into the meduIIary cavity. Figure I, a roentgenogram taken two months after injury, shows abundant caIIus at the fracture site. By six months the fracture had united. (Fig. 2.) The patient was reIieved of pain by the operation, was out of bed after the first week, bore weight after the second month and worked for severa months * From the Harrison
Department
before his death, which occurred aImost a year after the fracture. CASE II. N. P. (No. 8g226), a forty-one year oId woman, fractured the neck of her femur on December 30, 1950, through an area of metastatic cancer. Four months earIier a radical mastectomy had been performed for carcinoma of the breast. The fracture was reduced and fixed with a SmithPetersen nail. (Fig. 3.) The cancer had spread far into the head of the femur and it was beiieved that the nai1 must be driven cIose to the articuIar surface to give sufhcient fixation. Because the IateraI femoraI cortex was aIso invoIved by the tumor, a McLaughIin bar was attached to the nail to give added stability. A steriIizing dose of irradiation was given over the ovaries and further irradiation was given over the site of fracture. Testosterone was given intramuscularly. The neck of the femur coIIapsed and the nai1 was dispfaced into the acetabulum. (Fig. 4.) In spite of this the fracture appears to have heaIed, the patient is bearing weight without pain and at the present time, aImost two years after fracture, has no compiaints. CASE III. C. S. (No. 79701)~ an eighty-four year oId woman, fractured the shaft of her femur on October 20, 1948, through a metastasis from carcinoma of the bladder. Both she and her husband were wiIling to risk any treatment that, if successful, would permit her to return home and be out of bed. A Kiintscher nai1 was inserted into the meduIIary cavity folIowing open reduction (Fig. 5) and she was able to return home in two weeks, out of bed and abie to bear weight. The favorabIe resuIts in these and other patients Ied us to anaIyze a11 fractures due to metastatic carcinoma seen in the HospitaI of the University of Pennsylvania during the Iast ten years. ANALYSIS
OF
DATA
ON
FIFTY
PATIENTS
During the ten-year period from July, 1942, through July, rg$z, fifty patients were treated for fractures that had occurred in areas of metastatic carcinoma. These patients were treated on the General Surgical, Orthopedic and X-Ray services. EIeven of the patients were men and thirty-nine women.
of Surgical Research, Schools of Medicine, d&phi+ Pa. 282
University
American
of Pennsyfvania,
Journal
Phita-
oJ’ Surgery
Fitts
et al.-Fractures
I
in Metastatic
Carcinoma
2
FIG. I. Fracture of femur through metastasis from hypernephroma; gram taken two months after fracture. FIG.
2.
Same bone as in Figure
283
roentgeno-
I ; roentgenogram taken six months after fracture.
4B 3 4A FIG. 3. Fracture of neck of femur through an area of metastasis from carcinoma of the breast; tixatIon with a Smith-Petersen nail. Roentgenogram taken immediately after insertion of the nail and showing involvement of the head and neck with cancer. FIG. 4. Same bone as Figure 3; roentgenograms taken one year after fracture. Collapse of neck with displaccmcnt of nail into acetabulum. A, anterior view; B, lateral view.
March,
1~53
Fitts et al.-Fractures
in Metastatic Carcinoma two groups of patients with bony metastases, one with and one without fractures. (Fig. 6.) The data are compiIed from cases reported in the Iiterature1-7 in addition to our own. Carcinoma of the breast was the primary tumor in 59 per
cent
of the
fracture
patients
and
in 47
lW5TATl
._--__--_ PRIMARY
FIG. 5. Fracture of femoral shaft through metastasis from carcinoma of the bladder; roentgenogram taken immediateIy after open reduction and fixation with an intrameduIIary nail.
Location of the Primary Tumor. The source of metastasis, as shown in TabIe I, was carcinoma of the breast in more than ha’f of the fifty patients. Carcinoma of the breast frequently metastasizes to bone and frequentIy causes fractures. This is apparent if we compare TABLE PRIMARY
TUMOR DUE
IN TO
FIFTY
I
PATIENTS
METASTATIC
WITH
Per cent
Organ
Breast, ..................... Kidney ..................... Colon and rectum ............ Lung ....................... Thyroid. .................... Prostate ....................
BIadder..................... Parotid ..................... Skin (malignant melanoma). Pancreas .................... Testicle. .................... Unknown ...................
FRACTURES
CARCINOMA
I
26
52
7
14
4 3
8 6
2 I I I I I
4 2 2 2 2 2 2
.’ ::
4
TUMOR ln 2030 ph. with mofasfatic carcmoma I* bona
Rimarzj tumor m 328 pts. with FRACTVRES due to
mptastatic carcinoma
FIG. 6. per cent of the non-fracture patients. AIthough carcinoma of the prostate aIso frequently spreads to bone, it seldom causes fracture. In our opinion the expIanation Iies in two facts: (I) metastases from carcinoma of the prostate are usuaIIy osteobIastic rather than osteolytic, and (2) prostatic metastases frequentIy invoIve
the peIvis where pathologic fractures are uncommon. AIthough carcinomas of the kidney constitute a smaI1 percentage of tumors spreading to bone, when such Iesions do metastasize to bone they are pecuIiarIy IiabIe to fracture and account for IO per cent of the fractures collected. It is Iikewise noteworthy that bone metastases are more common from both the stomach and coIon than they are from the thyroid, generaIIy considered a common source of bone metastases. Location of the Fracture. Bones of the spine and the femur are by far the most frequentIy fractured. (Fig. 7.) TabIe II shows the bones invoIved in the fifty-six fractures in our fifty patients. Data coIIected from the Iiterature1~3~5~6 and added to our own are presented in Figure 8; which compares the Iocation of fracture in
American
Journal
of Surgery
Fitts
n Metastntic
et al.-Fractures
two groups of patients with bony metastases: those with fractures and those without fracture. Bones of the spine make up a large percentage of each group. Although the femur is not commonIy the site of metastatic carcinoma, when once involved it is frequent&
28j
Carcinoma
healing of the fracture. Fractures of the spine are a common problem and cannot he treated as definitively. We are loath to put patients with pathologic compression fractures of the vertebrae in plaster hyperextension jackets. The! seem to do poorly and are uncomfortable. The -_1M)*_-_
\
‘1 , \ \\
\
‘\
‘1
\
’
\\
\
\\’ \;, \ \r \\
\\
\
’
\ \ \ \ \
\
.-e-B-_
Distribution of 56 fractures due to lnetastatic carcinoma.
FIG.
7.
fractured. The pelvis is a common site of metastases but is rarely fractured. Treatment. We have done everything possible to avoid prolonged recumbency. In fractures of the femur the use of an intramedullary nail enables the patient to become ambulatory, reduces pain and gives an excellent chance for TABLE LOCATION
OF FIFTY-SIX CARCINOMA
II
FRACTURES (FIFTY
DUE
TO METASTATIC
PATIENTS)
-r Bone
Spine ....................... Femur .................... Humerus ................... CIavicle, ................... Rib ....................... PeIvis. ..................... Ulna .......................
1933
Per cent
23
41 .o
21 6
37.5 1
3
10.7
-I::
I
,
I
I.8 I.8
I
I
March,
No. of Cases
I
1
majority of fractures of the spine do not require immobilization if they are discovered before compression has progressed very far. Pain ordinarily is encountered early In vertebral metastases. Local use of x-ray therapy is often of great benefit both in retarding the growth of the tumor and in giving symptomatic relief. In addition, endocrine therapy in suitahlc cases may also give dramatic improvement. Irradiation has a large role in the treatment of pathoIogic fractures of almost a11 types arising from metastatic carcinoma. In general we use it locally over the bony lesion both for its relief of pain and its direct effect on the lesion. The majority of carcinomas that spread to bone respond to irrbdiation, although tumors arising in the gastrointestinal tract are a notable exception. In addition to local therapy, sterilizing doses of x-ray are often used in women who have tumors that may be benetitted b\ castration. Endocrine therapy under certain circumstances may be as dramatic in its effect. as x-ray. Therapy may consist of removing the source of normal sex hormones by castration or in supplying hormones of the opposite sex. Tumors of the breast and genital tract in both male and
Fitts
286
et aI.-Fractures
in Metastatic
femaIe are particuIarIy apt to be retarded by changes in the normal baIance of sex hormones. It is now we11 known that prostatic carcinomas may be greatIy improved by castration and estrogens, and that cancers of the breast at Ieast in the period of active TABLE III DURATION OF
LIFE
AFTER
FRACTURE
TNo. of Cases Lessthan6mo.. ............ 6mo. to 12 mo ............. I2mo. to 18mo .... ........ 18 mo. to 24 mo. ............ Over24mo .................
Per cent
24 12
48 24 IO
2
4 14
7
!_ gonada function, may be improved by castration and androgens whereas in later life estrogens may be beneficia1. Huggins has presented evidence that adrenaIectomy may give further benefit after the good effects of the usual hormone therapy have worn off. Total bilateral adrenalectomy was performed in two patients of this series with great symptomatic reIief, one with carcinoma of the breast and one with carcinoma of the prostate. Radical surgery in the form of amputation seIdom is indicated for metastatic disease, but we did carry out amputation in one patient in whom a carcinoma of the coIon spread to the uIna and resuIted in a fracture. This bone did not unite and the Iesion became progressiveIy more painfu1 and the arm less usefu1. X-ray had no effect upon it and eventuaIIy amputation was performed to reIieve pain. Results. AI1 fifty patients have been foIIowed up unti1 their death or unti1 August, 1932. Twenty-two per cent of the fractures heaIed and many more were healing at the time of the patient’s death from progression of the disease. TabIe III gives the length of Iife after fracture for the fifty patients. Over half of the patients Iived for more than six months and 14 per cent Iived for more than two years. The fractures in a11 but two of the patients surviving two years or longer united soIidJy. COMMENTS
Carcinoma that has metastasized to bone has a poor prognosis, but this is hardly an indication for apathy on the part of the attending physician because many of these patients can
Carcinoma
be heIped immenseJy at a most diffrcuIt period of their lives. We believe that open reduction and interna fixation is often indicated for such fractures of the long bones, not onIy because it may give the fracture its best opportunity to hea but aJso because of its effectiveness in reIieving pain. As knowIedge of tumors and their therapy progresses, further anciJIary methods of treatment will undoubtedly be developed which wiJ1 improve the results in these fractures. At present, hormones and roentgen ray therapy are the two main adjuncts to the treatment of the fracture itseIf and are especiaIIy effective in bony metastases from cancer of the breast. The presence of an intrameduIIary nai1 does not precIude adequate irradiation therapy. PeItier and Nice8 performed experiments which showed that the areas of the bone shielded by the nai1 Iost onIy about 30 per cent of the effective irradiation. This can easily be compensated for by giving a Iarger dose of irradiation or using multipIe ports. It cannot be denied that intrameduIIary nailing spreads tumor ceIIs in the meduIIary cana1. It has been shown that red bJood ceIIs tagged with Pa2 can be wideJy spread both distally and proximaIIy in the marrow cavity of the tibia by the insertion of an intrameduIIary naiJ.g In none of our patients, however, have we noted any evidence of secondary growths along the meduIIary cavity and we believe that the advantages accruing from intrameduIIary naiIing for many of these fractures far outweigh the risk of further spread of the tumor in a patient who aIready has metastatic disease. SUMMARY
AND
CONCLUSIONS
A review of the Jiterature.on fractures due to metastatic carcinoma and an analysis of fifty patients with such fractures treated at the Hospital of the University of PennsyIvania during the last ten years Ieads us to concIude that: I. A hopeIess “do-nothing” attitude is unjustified. Vigorous treatment of the fracture reIieves pain, cuts down hospitalization, makes nursing care easier, and permits early ambuIation. 2. Carcinoma
of
the
the Jargest percentage cinoma bone
of the but
does
prostate not
breast
accounted
of these fractures. frequentIy
usuaIIy
American
cause
Journal
for Car-
spreads
to
fractures.
of Surgery
Fitts
et al.-Fractures
Carcinoma of the kidney less commonly involves bone; but when it does, it is likely to result in fracture. 3. Thespine, femur and bones of the shoulder girdle are most frequently fractured. Fractures distal to the knee and elbow are uncommon. 4. Open reduction and fixation with an intramedullary nail is often the treatment of choice, especiaIIy in fractures of the femoral shaft. Fractures of the spine due to metastatic carcinoma are usually best handled without plaster jackets or braces. Irradiation and endocrine therapy are sufficient to give the patient comfort and to limit the local progression of the tumor. 5. Twenty-two per cent of the fractures in our series healed although almost haIf of the patients died from progression of the disease within six months of fracture. Acknowledgment: The authors wish to thank Dr. Paul Colonna and Dr. Roy Peck for allowing us to include patients treated by them in our series. Dr. Roy Greening and Dr. Richard Chamberlain were most helpful in selecting roentgenograms and in discussing the problems of irradiation in these patients. KEFERENCES I.
2.
WELCH, C. E. Pathologic fractures due to disease. Surg., cvnec. @ Obst., 62: 735, GHORMLEY, K. K., SUTHERLAND,C. G. and G. A. Pathologic fractures. J. A. M. A.,
malignant 1936. POLLOCK.
109: 21 I I.
‘937.
3. CESCHICKTEK, C. F. and MASENITZ, I. H. Skeletal metastasis
4. 5. 6. 7. 8.
9.
in canrcr. .I. Bone P? Joint Sur,~~.,2 I :
3’4. 1939. TURNER, J. W. and JAFFE, H. L. Metastatic neoplasms. Am. J. Roentgenol., 43: 479, 1940. SMEDAL, M. I. and SALZMAN, F. A. The treatment of metastatic bone tumors. Wisconsin M. J., 47: 475, 1948. GOLDING, F. C. hletastatic tumors of bone. Diagnostic aspects. J. FM. Radiologists, 1-2: 246, 1949. ABRAMS. Il. L. Skeletal metastases in carcinoma. Rudiology, 55: 534, 1950. PELTIER, L. F. and NICE, C. M., JR. Irradiation of bone lesions in the presence of metallic intramedullary fixation. Radiology, 56: 248, 195 1. PELTIER, L. F. Theoretical hazards in the treatment of pathoIogic fractures by the Kiintscher intramedullary nail. .Surger.y, 29: 466, 195 I.
DISCUSSION
OF
PAPERS
BY
DRS.
CASSEBAUM
AND HAMILTON, AND FITTS, ROBERTS AND RAVDIN HAROLD M. CHILDRESS (Jamestown, N. Y.): 1 greatIy enjoyed this most interesting and valuable paper on surgical treatment of mrtastatic bow
March,
1~53
in Metastatic
Carcinoma
287
carcinoma. By such surgery hopetess individuaIs, many with severe persistent pain, may be given a tremendous lift both mentally and physically. I wouId like to describe a simiIar case recently seen. The patient was a sixty-five year old white woman who in November, 1951, was hospitalized for pain at the left hip, Roentgenograms reveaIed a pathoIogic fracture at the proximal left femur. Traction was applied by her attending physician and she was given hormone injections but continued to experience severe localized discomfort. She was first seen by me three months after hospita1 admission. Despite the fact that her left breast had been removed twenty years previously for carcinoma of that organ, the bone lesion from its x-ray appearance could well have been a localized fibrocystic condition. Biopsy, however, proved the pathologic condition of the bone to br that of a metastatic scirrhous-type carcinoma of tht breast. The roentgenograms were reviewed by two consultants who advised deep x-ray therapy and who were not in favor of any form of surgery. Howrver, Dr. Bradley Coley of the Memorial IHospital fol agreed with me that surger,y would Cancer, probabIy be of great benefit to her. the entire ConsequentIy in March, ‘052, proxima1 femur, including the head, was excised and an Either prosthesis inserted. One comptication developed in that the stem of the prosthesis was too large for the intramedullary canal of the femoral shaft. Luckily this misfit was discovered before the appliance was driven too securely for removal. The stem was shortened I 1p inches by hacksaw and the final fitting was quite satisfactory. In two weeks she was ambulatory and was discharged from the hospital three weeks later. She now lives alone in her home and walks with a cane. She has very little discomfort and her general condition has greatly improved. The ultimate outcome is not known at present, but this patirnt is quite happy and is most grateful. JAMES J. CALI.AHAN (Chicago, Ill.): 1 would like to inject the thought here that in metastatic lesions we have been using the intramedultary nail. Our experience is practically the same; the patients live about a year. Recently in solitary metastasis, like thyroid malignancy, we have been resecting the tumor and then inserting the intramedullary nail utilizing a bone graft to compensate for any deficiency in approximation. Our results have been far superior performing this procedure than by inserting the nail through the tumor \vith the danger of spreading the tumor cells. PRESTON A. WADC (New York, N. I-.): 1 am very interested in Dr. Cassebaum’s paper because in the last few years we have been plagued at Nen York Hospital with some recurrent fractures of both hones of thr forearm in children. Dr. Ilarr!
Fitts
et al.-Fractures
Kranler of New York Hospital has Iooked up these patients and has found nine weI1. Six of our own cases recurred, and three patients treated elscwherc were treated by us for the second fracture, We found that these patients were from the ages of three to thirteen. Three had refracture after the plaster was removed in eight weeks, one a week, another a month and another four or five weeks. The other three occurred after sixteen weeks from the original fractures and after eight weeks from removal of the plaster. We have been in the habit of removing our plaster after an average of eight weeks. The cases that were three and a haIf, four, and four and a quarter months were obviousIy not onIy the resuIt of remova of the plaster. We have thought, however, that as a result of this we should keep our fractures of both bones of the forearm in chiIdren immobile for at least tweIve weeks. I toId this to Dr. Speed and he said, “The worId doesn’t know that, but I have known it for many years. But if we a11 knew that, there would be no purpose in these meetings, and that is why we are reporting our errors.” Of the three patients from other hospitals whom we treated, one was a child of two. The plaster had been removed at the end of three weeks and the fracture recurred two days Iater. One was a chiId of seven that had a pIaster immobilizing elbow and wrist for some six weeks. The plaster was then cut down, freeing the eIbow, and the second fracture occurred in the short plaster. We do not beIieve that the shorter plaster should be used, aIthough I know some textbooks stiI1 say that after six weeks or even less the elbow may be released. As Watson-Jones says, this may cause more torsion on the fractured area. 1 would like to commend Dr. Fitts on his presentation and say that we at City Hospital have also found satisfactory results in intramedullary nailing, particularly in femurs in metastatic carcinoma. I was surprised to hear him say that in 22 per cent he obtained bony union. I do not think we got as high a percentage as that. Even if bony union does not occur, these patients are much happier and much easier to take care of. THOMAS BARTLETT QUIGLEY (Boston, Mass.) : One comment on Dr. Fitts’ paper. We have been doing the same thing at the Peter Bent Brigham HospitaI and we agree with everything he said. I wouId Iike to ask him one question. In some of these patients with metastatic carcinoma of the long bones, the carcinoma is sensitive to radiation and these patients have pain. When empIoying radiation to contro1 pain, have you observed a variation in the natural history of the healing of the fracture in these cases? GEORGE WrLLrAnf BANCROFT (CoIorado Springs, Cola.): I would like to report a case of eight
in Metastatic
Carcinoma
mctastatic carcinoma fractures in one woman. Four and a half years after radical mastectomy she sustained a fracture of her rigfit femur which was treated by traction and later with cast, and healed. During the next three years, she fractured both humeri, both cIavicIes, the other femur and refractured the Hurstfemur. These were a11 treated by traction and splints, and x-ray examination showed that they were a11 united. The first femur had radiotherapy through a hoIe in the cast after it had been set. During the interim the patient did have x-ray therapy of her spine because one spina body had coIIapsed, and she aIso had osteolytic evidence in her skuI1 treated with x-ray, but actual treatment of the Iater fractures was nothing but immobiIization, fixation and traction. F. WALTER CARRUTHERS (LittIe Rock, Ark.): These papers indicate two things that I think should be emphasized. One of them is, we should make it on a comparative basis that refractures occur because of lack of proper time for complete immobilization for the fracture to reunite. Then on the other hand, we should sound a warning that other complications occur as the result of too prolonged immobilization producing what is commonly caIIed Sudeck’s syndrome or demineraIization and decaIcihcation. This latter condition is very apt to occur in prolonged immobilization of the forearm and hand and proIonged immobiIization of the foot and ankle. One of the first presentations here mentioned a separation at the head of the radius, in my opinion being reIeased far too soon and obviousIy the deformity resulted. When refractures occur, if my memory serves me correctly, they do not recur in the sense I am thinking about, namely, at the site of the old fracture, except those that have not been given an opportunity to unite in the first place. However, if union has occurred and there is socaIIed refracture, it does not occur at the site of the old fracture. They either occur above it or below it. When a patient asks, “Am I apt to break my leg or arm in this place again?” I am aIways happy to reply, “No. If a fracture shouId occur, it wiI1 occur either above it or beIow it.” That has been my experience in over thirty-five years of practice. So the question arises which should be emphasized here, of a sufficient amount of immobiIization and a sufficient amount of time to permit the fracture to unite. Obviously one cannot prevent fractures occurring if there are conditions in an individua1 that wouId produce a fracture. I therefore think we should not be misIed in our deductions with regard to refractures but rather should bear in mind that the reason why there is refracture is because it was never permitted to reunite in the first place. Obviously I have had fractures occur at the site of the old fracture but it has always been
American
Journal of Surgery
Fitts those
et d---Fractures
that have not had an opportunity originally to unite solidly. CHARLES Hucn MAGUIRE (Louisville, KY.): I was particularly interested in the latter paper on metastatic carcinoma. I think it is best to decide what we are going to do with these metastatic lesions for two reasons: First, I certainly agree with the original statcment that cancer ;a on the increase. Secondly, as one who sees a good many cancer patients, \vc arc seeing more and more bone lesions for one big reason: We are curing the primary lesions, and the patients are living long enough to develop bizarre skeletal lesions. We therefore had better decide how we arc going to treat them. H.~~n~sory. L~oun MCLAUGHLIN (New York, N. Y.): The essayists are to be commended for their stand on the subject of intramedullary fixation for metastatic fractures. It is a good and humane procedure. It may be pointed out that it is also possible to insert radon seeds or removable radium elements into the center of the diseased area by way of the intramedullary device used for fixation. This may prove to have some advantages over rxternal radiation therapy in selected radiosensitive lesions. Dr. Cassebaum’s paper has been discussed at length and there is complete agreement that the responsibility for all refractures in children occurring within three months of the origina injury rests squarely upon the surgeon. Refractures occurring after six months are different. The point of healing constitutes the only hard and brittle segment in the normally resilient child’s bone. It is onIy natural that another adequate injury will cause a fracture at this weak spot. This is conhrmed by the level of later fractures in plated long bone fractures in
&larch,
1953
in Metastatic
Carcinoma
2&)
children. That segment of the bone stabilized by the plate is relatively non-resilient. Later fractures occurring in the same bone are found consistently to occur at one or the other end of the plate. This phenomenon is sufficiently common to warrant elective removal of plates from the bones of children when the primary fracture is healed. WILLIAXI H. CASSEBAUM (closing): I would like to emphasize again that, as Dr. McLaughIin says, the doctor must share the blame when refracture occurs under three months. After that I am not so sure, and I would not advise seeking a remedy that may be worse than the condition. We have to take a calculated risk. Dr. James Ewing once told a Scotchman that bad teeth, chewing tobacco and syphilis gave him a 20 per cent chance of getting cancer of the stomach. The Scotchman thought a minute and said, “Five to one; those are good odds; I guess I’ll take them.” BROOKF. ROBERTS (cIosing): I would like to answer two questions. One is on this problem of spreading the tumor by use of the intramedullarv nail Certainly on the theoretic basis it is possible but cIinicalIy these patients have had very widrspread tumors at the time they had the fracture, and we have not seen what we believe to be a further spread due to use of the intramrdullary nail. Of course, that is a clinica impression. The other question is in regard to local treatment with x-ray, whether or not that has delayed healing of the fractures. It is always somewhat difficult to give a categorical answer to such questions. However, our radiotherapists have treated only for the reIief of pain and have not used large tumoricidal doses. For that reason we have not thought that they had much effect on the healing of the bone itseIf.