Di-agnosis of metastatic humeral bone lesions and alternatives for treatment vary depending on whether the pa-tient has a large impending lesion or complete fracture, which region of the
Trang 1Frank J Frassica, MD, and Deborah A Frassica, MD
Abstract
Metastases to bone are the most
fre-quent cause of destructive lesions to
the skeleton in adults The most
com-mon primary malignancies that
me-tastasize to bone are breast, lung,
kid-ney, and prostate carcinoma The typical
distribution of metastatic lesions is to
the spine, ribs, pelvis, and proximal
limb girdles.1 However, almost any
primary malignancy may metastasize
to bone, and any bone in the body may
be involved In the upper extremity,
the most common location is the
hu-merus, usually the proximal third or
the diaphysis Lesions in the distal third
of the humerus are less common and
typically occur in patients with
my-eloma or lung or renal carcinomas
Di-agnosis of metastatic humeral bone
lesions and alternatives for treatment
vary depending on whether the
pa-tient has a large impending lesion or
complete fracture, which region of the
bone is affected, the extent of overall
disease, the histologic diagnosis, and
the nature of prior treatment
Diagnosis Presentation and Evaluation
Several distinct presentations of up-per extremity metastatic disease can occur Patients with known metastatic disease may have either an asymp-tomatic or a painful and disabling le-sion A small percentage without a known history of cancer may present with a destructive bone lesion second-ary to an occult primsecond-ary tumor Com-plete fractures secondary to metastatic lesions often occur after very minor trauma, such as rolling over the arm
in bed, a minor fall, opening a jar, or other simple activities The presence
of substantial arm or shoulder pain
in the patient with a history of can-cer indicates the possibility of bone metastases Common characteristics include pain at rest, night pain, and pain unresponsive to anti-inflam-matory medications and narcotics
During evaluation, the clinician must determine whether the pain is
secondary to bone metastases or to nononcologic sources, such as gleno-humeral arthritis or rotator cuff ten-dinosis, which also manifest as dif-fuse discomfort, night pain, difficulty with sleeping on the affected side, and limited use of the upper extremity secondary to pain Plain radiographs are the first step in evaluation An an-teroposterior view of the shoulder and humerus is done to assess the proximal half of the humerus and scapula, and a scapular axillary view
is made to evaluate the glenoid and coracoid process If the discomfort ex-hibits a radicular pattern or if the shoulder pain extends proximally into the neck, radiographs of the cer-vical spine should be obtained If plain radiographs do not show a de-structive lesion and bone metastases are suspected, technetium Tc 99m (99mTc) bone scanning or magnetic res-onance imaging (MRI) may be done
99mTc bone scanning is an excellent modality for screening the cervical spine and shoulder girdle, especially when previous scans are available for comparison MRI of the shoulder can differentiate pain secondary to
rota-Dr F Frassica is Chairman and Robert A Rob-inson Professor, Department of Orthopaedic Sur-gery, Johns Hopkins University, Baltimore, MD.
Dr D Frassica is Assistant Professor of Oncol-ogy, Department of Radiation OncolOncol-ogy, Johns Hopkins University.
Reprint requests: Dr Frank J Frassica, c/o Elaine
P Henze, Room A672, 4940 Eastern Avenue, Baltimore, MD 21224-2780.
Copyright 2003 by the American Academy of Orthopaedic Surgeons.
Metastatic bone disease is the most common cause of destructive bone lesions in
adults, and involvement of the humerus is common Patients with destructive
le-sions involving <50% of the cortex are treated nonsurgically with external beam
irradiation Patients with diaphyseal lesions involving≥50% of the cortex or those
with pain after irradiation can be treated with intramedullary nailing to achieve
rigid fixation Although closed intramedullary nailing is used most often, open
nail-ing with methylmethacrylate is appropriate for destructive lesions in which rigid
fixation cannot be achieved with closed nailing Plate fixation is acceptable when
adequate proximal and distal cortical bone is present for screw purchase, although
proximal humeral lesions usually are treated with prosthetic arthroplasty
Postop-erative external beam irradiation can help prevent disease progression and
subse-quent loss of fixation However, when disease progression persists or rigid internal
fixation is not feasible because of extensive bone destruction, wide resection and
re-construction with a custom prosthesis can be done.
J Am Acad Orthop Surg 2003;11:282-288
Trang 2tor cuff tendinosis from that of
met-astatic disease and can identify bone
marrow infiltration by tumor cells
and rotator cuff inflammation Short
tau inversion recovery (STIR) or a
T2-weighted fast spin-echo fat-saturated
sequence is the optimal method for
assessing tumor presence Although
computed tomography (CT) is
sensi-tive in detecting cortical bone
destruc-tion in the scapula and humerus, its
use is limited because it cannot
de-tect marrow invasion in the absence
of bone destruction However, CT is
more accurate than other diagnostic
tools in determining structural
com-promise
Criteria for Impending Fracture
Determining the risk for
patholog-ic fracture is subjective and depends
on many factors, including the
pat-tern of bone destruction, location in
the bone, response of the host bone,
and anticipated loading conditions
Most classification systems2-6used to
predict areas at risk of fracture are
based on the amount of cortical bone
destruction measured on
anteropos-terior and lateral radiographs Bone
destruction of 25% of the cortical
di-ameter has a low risk of fracture (Fig
1, A); bone destruction of 75% of the
cortical diameter is associated with a
high risk of fracture.2-4When bone
de-struction is between these extremes,
the risk of fracture is more difficult to
predict Most surgeons consider that
≥50% bone destruction indicates
im-pending fracture (Fig 1, B)
Mirels4developed a 12-point
scor-ing system based on the location,
type, and amount of bone destruction
and the presence or absence of
ac-tivity-related pain Combined scores
of 9, 8, and 7 respectively had a 33%,
15%, and 4% risk of fracture There
was a low risk of fracture in patients
with <50% cortical bone destruction
Although this is an objective scoring
method, many surgeons do not use
the Mirels system because of the
jectivity of the variables and the
sub-stantial overlap between the fracture
and nonfracture groups, which un-derscores the difficulty in predicting risk of fracture
Mirels4 showed that purely lytic bone metastases have a much higher risk of fracture than do purely blas-tic metastases (often seen in patients with metastatic breast and prostate carcinoma) However, many patients have a combination of lytic and blas-tic metastases Lesions in the proxi-mal humeral metaphysis are less prone to fracture than are those in the diaphysis or in the transition zone be-tween the metaphysis and diaphysis (in the region of the insertion of the pectoralis major muscle)
The anticipated loading of the up-per extremity is also an important consideration A patient with an iso-lated metastasis in the humerus can easily protect against overloading the upper extremity during the course of irradiation and/or chemotherapy In contrast, a patient with substantial concomitant lower-extremity disease requiring protected weight bearing
with crutches or a walker may sub-ject the upper extremity to increased loading In such a situation, internal fixation may be necessary to prevent fracture
Nonsurgical Management
Most humeral metastases that have not fractured can be managed with external beam irradiation without surgery The decision may be depen-dent on the histology of the tumor Patients are counseled to avoid pro-vocative activities that may lead to fracture while the lesion heals Pa-tients generally undergo 1 week to 2 weeks of external beam irradiation (usually 3,000 cGy in 10 fractions).7,8
If the isolated lesion occurs in a pa-tient with an excellent prognosis, a longer course of treatment may be recommended in an effort to provide more durable local control Treatment
of humeral metastases with a single dose of 800 cGy can be successful in reducing pain in patients with termi-nal disease and short life expec-tancies;9-12 this is especially useful when patient transport to the radia-tion therapy facility is difficult Al-though tumor progression generally halts after the completion of irradi-ation, activity should be modified for
2 to 3 months Patients can continue activities of daily living such as eat-ing, cleaneat-ing, batheat-ing, and changing clothes, but exertions such as tennis, changing a tire, opening tight jars, overhead throwing, and swinging an
ax are discouraged
Patients with complete fractures are poor candidates for nonsurgical treatment Fracture braces and casts are not effective in controlling dis-comfort, and patients avoid using their extremities because of pain In contrast with nonpathologic
humer-al fractures, which hehumer-al quickly, com-plete fractures secondary to
metastat-ic bone disease heal very slowly if it all Flemming and Beals13and Doug-lass et al14reported poor results with
Figure 1 A,Anteroposterior radiograph of the proximal humerus in a patient with breast cancer showing a predominantly blastic le-sion with a small amount of cortical bone de-struction This patient would be an excellent candidate for external beam irradiation.
B,Anteroposterior radiograph of a humeral lesion in a patient with metastatic prostate cancer showing ≥ 50% cortical bone destruc-tion This lesion meets the criteria of impend-ing fracture.
Trang 3nonsurgical management of
patho-logic humeral fractures and later
characterized the results of closed
management as “unsatisfactory,
pro-ducing limited use, incomplete pain
relief, and unpredictable healing.”13
Surgical Management
Preoperative Planning
The general medical condition of
the patient must be assessed before
surgery Terminally ill patients
(antic-ipated survival, <2 to 3 weeks) are
poor candidates, unlikely to benefit
from the surgery Although there are
no absolute criteria to predict
surviv-al of the patient with metastatic bone
disease, poor prognostic factors
in-clude hypercalcemia, substantial
cy-topenia from bone marrow failure,
cachexia, and poor performance
sta-tus
Careful preoperative planning is
essential The cervical spine should
be carefully assessed for destructive
lesions so that injury can be avoided
while anesthetizing or positioning the
patient, and plain radiographs or a
re-cent 99mTc bone scan should be
re-viewed The entire humerus should
be viewed with plain radiography in
two orthogonal planes to determine
if there are multiple lesions
Position-ing the end of the fixation device at
a site of diseased bone must be
avoid-ed so that fracture does not occur in
this transition zone when the patient
begins using the extremity CT and
MRI scans generally are not needed
for preoperative planning However,
if plain radiographs are equivocal as
to the presence of cortical destruction
in regions designated to receive the
fixation device, MRI can be used to
confirm the presence of disease
Because patients with metastatic
bone disease may survive only 3 to
12 months, the goal of surgery is to
attain rigid and durable internal
fix-ation and, accordingly, immediate
postoperative use of the upper
ex-tremity Rigid fixation can be
achieved with a variety of internal fix-ation or prosthetic devices These de-vices can be used with or without methylmethacrylate Fracture healing should not be necessary to achieve functional stability
Device Selection
The selection of the reconstruction device, such as an intramedullary nail, plate, or prosthesis, depends on the area of humeral involvement and the degree of bone destruction When selecting a fixation method, it is con-venient to divide the humerus into three regions: (1) proximal metaphy-seal, (2) metadiaphyseal and diaphy-seal, and (3) distal metadiaphyseal and metaphyseal (supracondylar) (Fig 2)
Proximal Metaphyseal Region
Complete or impending fractures
of the proximal humerus usually are managed with a humeral endopros-thesis Intramedullary nails are diffi-cult to use in the proximal metaphy-sis because rigid proximal fixation cannot be achieved Plate fixation is likewise ineffective for solid fixation because of the thin and compromised cortical bone
The surgical procedure is similar
to that for a nonpathologic fracture,
in which a deltopectoral approach is used to osteotomize the humeral head For a pathologic fracture, the proximal fragments are excised The proximal humeral metaphysis is carefully curetted to remove all of the gross tumor but not the cortical shell or periosteal tissues The hu-merus is prepared through the en-tire diaphysis to receive a long-stem prosthesis The prosthesis is care-fully cemented in place so that the cement does not enter the soft tis-sues; extravasation through hu-meral defects might result in neuro-logic or vascular injury A long-stem prosthesis spanning the diaphysis to the supracondylar region is gener-ally used to maximize protection of the entire humeral shaft
Metadiaphyseal and Diaphyseal Region
Metadiaphyseal and diaphyseal lesions can be managed with either intramedullary nail or plate fixation Both methods are effective, and the choice of implant rests with the indi-vidual surgeon Each technique has specific advantages and disadvan-tages
Intramedullary Nail Fixation
In-tramedullary nailing, the most pop-ular method used for humeral shaft lesions, can be done either closed or open through an anterograde or ret-rograde approach The major advan-tage of intramedullary nail fixation is that it can protect a long segment of the humerus When augmented with methylmethacrylate, it also can pro-vide rigid fixation of a long segment
of diseased bone Other advantages include a low risk of implant failure and the fact that the nail can be placed
Figure 2 Different regions of the humerus are amenable to fixation with various
devic-es (1) Proximal metaphyseal region—head and anatomic neck region: prosthetic arthro-plasty with a Neer-type endoprosthesis; sur-gical neck: either prosthetic arthroplasty with aNeer-typeprosthesisorRushrodwithmeth-ylmethacrylate supplementation (2) Metadi-aphyseal and diMetadi-aphyseal region: intramedul-lary nailing or plate fixation (3) Distal metadiaphyseal and metaphyseal (supra-condylar) region: either plate fixation or crossed flexible nails.
Trang 4in a closed manner The major
disad-vantage of anterograde
intramedul-lary nailing is the mandatory incision
and repair of the rotator cuff Many
patients experience residual rotator
cuff tendinitis and weakness
Prom-inent hardware (proximal
interlock-ing screws or the tip of the nail) can
cause persistent symptoms.
Intramedullary nail fixation can be
used for destructive bony lesions
from 2 to 3 cm below the level of the
greater tuberosity (proximal one sixth
of the humerus) to approximately 5
cm above the olecranon fossa.15
An-terograde or retrograde nailing may
be used; care must be taken to
pro-tect areas of bone destruction.16 To
achieve rigid fixation, there must be
at least 4 to 5 cm of intramedullary
nail on either side of the lesion with
intact cortices surrounding its
prox-imal and distal ends An intramedul-lary nail can be used for more prox-imal or distal lesions if the fixation can
be made rigid with an interlocking screw or methylmethacrylate If the bone destruction occurs in the supra-condylar region of the distal
humer-us, plate fixation or crossed flexible nails can be used
The amount and location of the bone destruction must be carefully as-sessed Closed nailing is an excellent technique for both impending and complete fractures Proximal and dis-tal locking is recommended to ensure rigid fixation for complete fractures
Patients with intact cortices after nail-ing may be treated with proximal in-terlocking alone or with proximal and distal interlocking (Fig 3) With the closed technique, augmentation with methylmethacrylate generally is not necessary However, for severe bone destruction with no remaining corti-ces over a length of 3 to 6 cm, open nailing with curettage of the tumor and methylmethacrylate can be con-sidered to supplement the fixation
Open nailing is done with a tech-nique similar to closed nailing The fracture site can be approached through an anterolateral or posterior incision or, if the entire humerus needs to be exposed, through a del-topectoral approach proximally and the anterolateral approach distally A portion of the deltoid insertion is el-evated off the humerus, and the bra-chialis muscle is split to expose the humeral shaft After either exposure,
a cortical window is made through the area of bone destruction, and all
of the gross tumor is removed with curettes The humerus is prepared to receive the nail, as in the closed tech-nique The open fixation can be sup-plemented with methylmethacrylate (Fig 4)
After the nail is inserted over a guide wire, the entire humerus is im-aged to verify satisfactory length and fracture reduction The nail is then withdrawn into the proximal frag-ment to a level just above the point
where the cement augmentation is to end The cement is mixed, placed in the cement gun, and injected through
a small insertion tube first into the distal fragment, then the proximal fragment The guide wire is
general-ly left in the proximal and distal frag-ments The fracture is reduced and the nail advanced into the distal frag-ment Interlocking screws then can be placed if necessary If sufficient ce-ment has been injected into the dis-tal fragment to secure the nail, an interlocking screw can be placed proximally to augment stability in the proximal fragment
Plate Fixation Plate fixation is also
an acceptable technique for impend-ing and complete fractures of the proximal metadiaphyseal and di-aphyseal region (Fig 5) A major ad-vantage of plate fixation is that the ro-tator cuff is not disturbed as it is with anterograde intramedullary nailing Disadvantages of plate fixation in-clude more blood loss than with
Figure 3 A, Anteroposterior radiograph
showing a destructive humeral diaphyseal
le-sion with ≥ 50% cortical bone destruction.
B,The lesion was managed with closed
in-tramedullary nailing with proximal
interlock-ing Distal interlocking was not used because
the medial cortex was intact after nail
place-ment.
Figure 4 A, Anteroposterior radiograph showing a pathologic fracture with >90%
cor-tical bone destruction B, The fracture was
man-aged with open nailing, methylmethacrylate supplementation, and proximal interlocking.
Trang 5closed nailing, the potential for
radi-al nerve injury, and inability to
pro-tect as much humeral length as with
intramedullary nailing.16When
con-sidering plate fixation, the
radio-graphs must be studied carefully to
determine that at least three screws
can be placed in normal cortical bone
on either side of the fracture When
there is diffuse involvement of the
hu-merus, intramedullary nailing is a
better choice because a plate may not
provide solid fixation
The exposure for plate fixation can
be done through an anterolateral or
posterior approach A cortical
win-dow is created large enough to curette
the gross tumor Care must be taken
not to remove an excessive amount
of normal bone; otherwise, it will be
difficult to achieve rigid fixation in the
remaining cortical bone The cement
can be applied before or after the in-ternal fixation, but it is easier to re-duce the fracture and place the inter-nal fixation device first To obtain good apposition of bone ends, irreg-ular fracture ends can be shortened
if necessary Once the plate is applied, the screws that span the defect are re-moved, and cement is placed by hand into the defect The screws can be re-placed while the cement is curing or
by drilling and tapping once the ce-ment hardens
Distal Metadiaphyseal and Metaphyseal Region
Lesions within 2 to 4 cm of the olecranon fossa are best managed with plate fixation Neither anterograde nor retrograde nails can provide rigid fix-ation in these distal lesions Plating through a posterior triceps muscle–
splitting approach is very effective when the distal fragment is large enough to receive three 4.5-mm screws Distal lesions that involve the supracondylar area are difficult to manage Fixation can be achieved with medial and lateral plates, flexible nails inserted from the epicondyles, or pros-thetic arthroplasty
Postoperative Management
After prophylactic fixation or sur-gical treatment of a pathologic frac-ture, radiation therapy to the site of the lesion and the implanted device
is recommended to decrease the risk
of continued bone destruction (which could lead to increased pain), loosen-ing of the fixation, and the need for additional surgery.17In a study of 64 procedures in 60 patients, Townsend
et al17found that the addition of ex-ternal beam irradiation to surgery
sig-nificantly (P = 0.02) improved
func-tional outcome There was also a
significantly (P = 0.035) higher risk of
the need for a second surgical proce-dure in patients who did not receive postoperative radiation The dose of radiation is similar to that used when treating patients nonsurgically (3,000 cGy in 10 fractions over 1 week to 2
weeks) Treatment is generally de-layed to 10 days after surgery so that the skin incision can heal
Patients may begin range of mo-tion movement of the elbow and shoulder during the first postopera-tive week If the patient has not pre-viously undergone radiation therapy, the sutures or staples are removed 2 weeks after surgery If the patient has previously received radiation, the su-tures are left in place for
approximate-ly 4 weeks
Alternative Surgical Techniques
Rush rods can be used for very proximal (within 3 cm of the
humer-al head) fractures at the surgichumer-al neck.18 There is too little proximal bone in this region for intramedullary nail fixation The proximal hook of the Rush rod is anchored in the rotator cuff, and the fixation is
supplement-Figure 5 A,Anteroposterior radiograph of
a patient with prostate cancer showing a
met-astatic diaphyseal lesion with >90% cortical
bone destruction B, The lesion was managed
with plate fixation and methylmethacrylate
augmentation.
Figure 6 A humeral lesion in a patient with metastatic renal cell cancer was treated with intramedullary nailing and external beam
ir-radiation A, Anteroposterior radiograph
show-ing disease progression and fracture (arrow) around the nail just below the locking screw.
B,The patient was treated with resection and custom proximal humeral arthroplasty.
Trang 6ed with methylmethacrylate If the
hook protrudes, it can cause
symp-toms with overhead activity; if it is
driven through the proximal cortical
bone, there will be less purchase in
the proximal fragment Flexible nails
also have been used for diaphyseal
and proximal metadiaphyseal
le-sions.19
Custom proximal humeral
prosthe-ses can be used selectively when large
segments of bone need to be resected.20
Resection is usually reserved for
pa-tients with progressive disease after
external beam irradiation or in patients
with failed internal fixation and poor
bone stock Some custom modular
de-vices allow the restoration of length
of the humerus with immediate rigid
fixation after resection of variable
lengths of the proximal humerus (Fig
6) Other devices have been designed
to permit resection and reconstruction
of the diaphysis in the presence of an
intact proximal humeral segment.21
These designs, with medullary stems
cemented into the proximal and
dis-tal intramedullary canals, are still in
development and are associated with
complication rates as high as 25%.22
Results
Pain relief can be reliably obtained in
>90% of patients treated with rigid fixation.21-23 Redmond et al15 de-scribed good to excellent pain relief
in 12 of 13 patients treated with in-tramedullary nail fixation for
humer-al pathologic fractures In 10 patients with documented postoperative range of motion, there was a mean of 101° of abduction (range, 55° to 180°) and a mean of 98° of forward flexion (range, 45° to 170°) Of the 13 patients,
11 recovered use of the arm for activ-ities of daily living.15Dijkstra et al16
retrospectively compared nail and plate fixation in 37 patients with 38 pathologic humeral fractures There was good to excellent subjective pain relief in approximately 90% of the pa-tients treated with either method The authors also reported early fixation failure secondary to angular
deformi-ty and rotational instabilideformi-ty in patients treated with intramedullary nails without proximal and distal lock-ing.16Most treatment failures are sec-ondary to disease progression or
ear-ly loss of fixation.17Patients with renal
cell carcinoma are especially prone to disease progression and often are treated with higher initial doses of ra-diation (4,500 cGy) to reduce the risk
of early failure
Summary
Metastatic disease of the humerus is common, and effective management can improve the quality of life for can-cer patients Nonsurgical treatment with external beam irradiation is used for symptomatic lesions with <50% cortical bone destruction With≥50% cortical bone destruction, intramed-ullary nailing is the most common method of both prophylactic and frac-ture fixation Locked intramedullary nails can provide rigid fixation with early pain relief Methylmethacrylate can be used to aid in the reconstruc-tion of defects caused by the surgi-cal treatment of large lesions and to improve fixation Plate fixation also can be used for diaphyseal and dis-tal lesions Immediate rigid fixation
is necessary to achieve consistently good pain relief
References
1 Frassica FJ, Gitelis S, Sim FH:
Metastat-ic bone disease: General principles,
pathophysiology, evaluation, and
biop-sy Instr Course Lect 1992;41:293-300.
2 Fidler M: Prophylactic internal fixation
of secondary neoplastic deposits in
long bones BMJ 1973;1:341-343.
3 Fidler M: Incidence of fracture through
metastases in long bones Acta Orthop
Scand 1981;52:623-627.
4 Mirels H: Metastatic disease in long
bones: A proposed scoring system for
diagnosing impending pathologic
frac-tures Clin Orthop 1989;249:256-264.
5 Beals RK, Lawton GD, Snell WE:
Pro-phylactic internal fixation of the femur
in metastatic breast cancer Cancer 1971;
28:1350-1354.
6 Hipp JA, Springfield DS, Hayes WC:
Predicting pathologic fracture risk in
the management of metastatic bone
de-fects Clin Orthop 1995;312:120-135.
7 Arcangeli G, Giovinazzo G, Saracino B,
et al: Radiation therapy in the manage-ment of symptomatic bone metastases:
The effect of total dose and histology on
pain relief and response duration Int J
Radiat Oncol Biol Phys
1998;42:1119-1126.
8 Tong D, Gillick L, Hendrickson FR: The palliation of symptomatic osseous me-tastases: Final results of the Study by the Radiation Therapy Oncology
Group Cancer 1982;50:893-899.
9 Cole DJ: A randomized trial of a single treatment versus conventional fraction-ation in the palliative radiotherapy of
painful bone metastases Clin Oncol
1989;2:59-62.
10 Hoskin PJ, Price P, Easton D, et al: A prospective randomised trial of 4 Gy or
8 Gy single doses in the treatment of
metastatic bone pain Radiother Oncol
1992;23:74-78.
11 Nielsen OS, Bentzen SM, Sandberg E, Gadeberg CC, Timothy AR:
Random-ized trial of single dose versus fraction-ated palliative radiotherapy of bone
metastases Radiother Oncol
1998;47:233-240.
12 Price P, Hoskin PJ, Easton D, Austin D, Palmer SG, Yarnold JR: Prospective randomised trial of single and multi-fraction radiotherapy schedules in the treatment of painful bony metastases.
Radiother Oncol 1986;6:247-255.
13 Flemming JE, Beals RK: Pathologic
frac-ture of the humerus Clin Orthop 1986;
203:258-260.
14 Douglass HO Jr, Shukla SK, Mindell E: Treatment of pathological fractures of long bones excluding those due to
breast cancer J Bone Joint Surg Am 1976;
58:1055-1061.
15 Redmond BJ, Biermann JS, Blasier RB: Interlocking intramedullary nailing of pathological fractures of the shaft of the
humerus J Bone Joint Surg Am 1996;78:
891-896.
Trang 716 Dijkstra S, Stapert J, Boxma H, Wiggers
T: Treatment of pathological fractures
of the humeral shaft due to bone
me-tastases: A comparison of
intramedul-lary locking nail and plate
osteosynthe-sis with adjunctive bone cement Eur J
Surg Oncol 1996;22:621-626.
17 Townsend PW, Rosenthal HG, Smalley
SR, Cozad SC, Hassanein RE: Impact of
postoperative radiation therapy and
other perioperative factors on outcome
after orthopedic stabilization of
im-pending or pathologic fractures due to
metastatic disease J Clin Oncol 1994;12:
2345-2350.
18 Lewallen RP, Pritchard DJ, Sim FH:
Treatment of pathologic fractures or impending fractures of the humerus with Rush rods and methylmethacry-late: Experience with 55 cases in 54
pa-tients, 1968-1977 Clin Orthop 1982;166:
193-198.
19 Lin J, Hou SM, Hang YS, Chao EY:
Treatment of humeral shaft fractures by
retrograde locked nailing Clin Orthop
1997;342:147-155.
20 Sim FH, Frassica FJ, Chao EY: Ortho-paedic management using new devices
and prostheses Clin Orthop 1995;312:
160-172.
21 Chin HC, Frassica FJ, Hein TJ, et al: Metastatic diaphyseal fractures of the shaft of the humerus: The structural strength evaluation of a new method of treatment with a segmental defect
pros-thesis Clin Orthop 1989;248:231-239.
22 Damron TA, Sim FH, Shives TC, An
KN, Rock MG, Pritchard DJ: Intercalary spacers in the treatment of segmentally destructive diaphyseal humeral lesions
in disseminated malignancies Clin
Orthop 1996;324:233-243.
23 Sim FH, Pritchard DJ: Metastatic
dis-ease in the upper extremity Clin Orthop
1982;169:83-94.