- Case report
- Open Access
Hypertrophic non-union of a pathological forearm fracture secondary to multiple myeloma: a case report
© Okoro and Ashford; licensee BioMed Central Ltd. 2010
Received: 13 November 2009
Accepted: 21 April 2010
Published: 21 April 2010
Skeletal lesions in multiple myeloma are predominantly lytic and when non-union of pathological fractures occur it is typically atrophic. We report a lady of 61 years of age with myeloma who presented with a pathological fracture through an ulnar myeloma deposit. The fracture was immobilised initially then irradiated. Nine months later she re-presented with marked forearm pain particularly on rotation. Radiographs demonstrated a hypertrophic non-union of a pathological fracture with a typical elephant's hoof appearance. The fracture was immobilised using an ulnar nail. Whilst non-unions in metastatic malignancy are typically atrophic, just occasionally hypertrophic non-unions can occur. Management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate.
Multiple myeloma (MM) is an incurable disease that is characterised by the accumulation of clonal plasmocytes in the bone marrow . It accounts for 10-15% of all haematological malignancies and 1-2% of all cancers . MM occurs in Europe in approximately 4 out of every 100,000 individuals  Approximately 10-40% of patients are asymptomatic at diagnosis  whilst 50-70% of MM patients have bone pain due to lytic lesions and pathological vertebral fractures .
The characteristic bone lesion seen in myeloma is a sharply defined small lytic area with no reactive bone formation arising in the medulla; the absence of bone sclerosis is due to an inhibition of osteoblastic activity . Involvement of the cortex causes characteristic endosteal scalloping with invasion of the periosteum and occasionally extraosseous extension 
Radiotherapy often forms an important part of management and can lead to resolution of bone lesions . We report a case where an undisplaced pathological fracture, treated by a short period in a below elbow cast and subsequently by external beam radiotherapy, went on to form a hypertrophic non-union.
Radiographic review of the ulna fracture at 7 weeks showed that there was an attempt at bony union along with an improvement in her symptoms, therefore no further orthopaedic intervention was planned at the time. External beam radiotherapy to this lesion was subsequently arranged by the oncologists.
She was re-referred to the Orthopaedic Oncology service after 9 months with increasing pain in her right forearm whilst performing specific tasks such as cleaning her teeth.
Forearm lesions and pathological fractures are relatively rare in multiple myeloma. The commonest sited of fracture are the spine (55%-70% of patients) especially in the lower thoracic or lumbar vertebral bodies . Other common sites of fracture include the femur, pelvis, ribs, and humerus . Fractures result from direct myelomatous involvement of the bone and also can result from the generalized bone loss that is a hallmark of myeloma .
Radiation therapy for the treatment of bone tumours and soft-tissue sarcomas may deliver damaging doses of radiation to skeletal bone . It is known that ionizing radiation has a detrimental effect on cortical bone  and that it may inhibit and delay fracture union .
Failure of bone healing or non-union results from an arrest of the healing process. A non-union that occurs despite the formation of a large volume of callus around the fracture site is commonly referred to as a hypertrophic non-union whilst in an atrophic non-union, little or no callus forms and bone resorption occurs at the fracture site . Fractures through bone involved with malignancy such as myeloma in this instance often will not heal unless the neoplasm is treated . Subperiosteal new bone and fracture callus may form, but the mass of malignant cells impairs or prevents fracture healing, particularly if the malignant cells continue to destroy bone. The radiotherapy administered in this case has once again led to radiographic resolution of the bone lesion . However, this radiotherapy has likely also interrupted the initial attempt at bone union. We postulate that there was an inherent lack of stability in the ulna fracture as upper extremity pathologic fractures are often subjected to distractive forces inherent in lifting and pulling . Although radiotherapy has been shown to help relieve pain in myeloma bone disease with success rates of 50-80% , a lack of stability and the radiotherapy would potentially explain the increased hyper vascular response of the callus and the hypertrophic non-union. The use of a reamed nail was in an attempt to achieve union. Most recent radiographs demonstrate satisfactory progression of the lesion towards union (figures 3 and 4). A 9 month interval from radiotherapy to re-presentation indicates that there was an initial satisfactory response to bone pain alleviation but the fracture became the important issue not the tumour. This was the indication for surgical fixation using the intramedullary device.
Whilst non-unions in metastatic malignancy are typically atrophic, just occasionally hypertrophic non-unions can occur. This is a rare occurrence and the management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate.
Written informed consent was obtained from the patient for publication of this case and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Dmoszynska A: Diagnosis and the current trends in multiple myeloma therapy. Pol Arch Med Wewn. 2008, 118 (10): 563-566.PubMedGoogle Scholar
- Gibson J, Joshua D: Epidemiology of plasma cell disorders. Edited by: Myeloma. 2002, Dunitz Ltd., London, 139-150.Google Scholar
- Angtuaco EJC, Fassas AB, Walker R, Sethi R, Barlogie B: Multiple myeloma: clinical review and diagnostic imaging. Radiology. 2004, 231: 11-23. 10.1148/radiol.2311020452.View ArticlePubMedGoogle Scholar
- Winterbottom AP, Shaw AS: Imaging patients with myeloma. Clinical Radiology. 2009, 64: 1-11. 10.1016/j.crad.2008.07.006.View ArticlePubMedGoogle Scholar
- Lecouvet FE, Berg Vande BC, Maldague BE, Michaux L, Laterre E, Michaux JL, Ferrant A, Malghem J: Vertebral compression fractures in multiple myeloma. Part 1. Distribution and appearance at MR imaging. Radiology. 1997, 204: 195-9.View ArticlePubMedGoogle Scholar
- Angtuaco EJ, Justus M, Sethi R: Analysis of compression fractures in patients with newly diagnosed multiple myeloma on comprehensive therapy (abstract). Radiology. 2001, 221 (P): 13-Google Scholar
- Duffy GP, Wood MB, Rock MG, Sim FH: Vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy. J Bone Joint Surg Am. 2000, 82 (4): 544-54.PubMedGoogle Scholar
- Maeda M, Bryant MH, Yamagata M, Li G, Earle JD, Chao EY: Effects of irradiation on cortical bone and their time related changes. A biomechanical and histomorphological study. J Bone and Joint Surg. 1988, 70-A: 392-399.Google Scholar
- Markbreiter LA, Pelker RR, Friedlaender GE, Peschel R, Panjabi MM: The effect of radiation on the fracture repair process. A biomechanical evaluation of a closed fracture in a rat model. J Orthop Res. 1989, 7: 178-183. 10.1002/jor.1100070204.View ArticlePubMedGoogle Scholar
- Buckwalter JA, Einhorn TA, Marsh JL: Bone and Joint Healing. Rockwood and Green's Fractures in Adults. Edited by: Bucholz RW, Heckman JD, et al. 2006, Lippincott Williams and Wilkins USA, 297-312. 6Google Scholar
- Harrington KD: Orthopedic surgical management of skeletal complications of malignancy. Cancer. 1997, 80 (8 Suppl): 1614-27. 10.1002/(SICI)1097-0142(19971015)80:8+<1614::AID-CNCR12>3.0.CO;2-2.View ArticlePubMedGoogle Scholar
- Yaneva MP, Goranova-Marinova V, Goranov S: Palliative radiotherapy in patients with multiple myeloma. J BUON. 2006, 11 (1): 43-8.PubMedGoogle Scholar
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