TREATMENT GOALS

Pain relief and bone stabilization are the methods by which the medical goals of patient comfort and independence are achieved. Symptomatic relief is usually satisfactory from radiation therapy and chemotherapy. Most patients without a fracture do not require surgery for the bone metastasis. Fractures are best treated by operative internal fixation. Even when fractures can heal by nonoperative therapy, the protracted treatment time is inappropriate. The duration of any treatment must be carefully considered in a patient with a limited life expectancy. For example, in a patient with a 4-month life expectancy, 2 weeks of treatment for bone metastases may be appropriate, whereas 2 months of treatment would be excessive. Finally, the goal of surgical intervention is to allow immediate weight bearing. If this cannot be achieved, then surgery should be avoided. Prosthetic replacement and stabilization with polymethylmethacrylate are frequently selected, whereas such techniques would be avoided in the treatment of nonneoplastic fractures.

Generally, pathologic fractures through weight-bearing bones (e.g., femur) should be treated if the patient has more than 1 month to live, whereas non-weight-bearing bones should be treated if life expectancy is more than 3 months. Indications for treating impending fractures are discussed later. Impending fractures are worth fixing if it will help eliminate the need for narcotic analgesics or will reduce the patient’s overall pain by approximately 50%, and equally effective nonoperative treatments are lacking.