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Case 30

Paget's disease of the humerus & pathological fracture

A 76 year old man with a painful arm

This elderly gentleman presented with a painful upper arm following a minor fall a few weeks earlier.

Findings

There is a coarse sclerotic pattern to the upper humerus and humeral head. The cortex of the upper shaft is markedly thickened. There is a clearly visible advancing front of bone resorption in the lower humeral shaft. There is a fracture of the mid shaft with callus formation.

Diagnosis

Paget's disease of the humerus & pathological fracture

Discussion

This film demonstrates both phases of Paget's disease. The initial lytic phase consists of an advancing front of resorption, sometimes described as flame shaped, referring to the V-shaped leading edge of lysis. This starts at one end of a long bone and advances to the other, and is characteristic.

The sclerotic phase follows, and may coexist, as here. This is due to new bone formation and remodelling. This new bone is however not as structurally sound as normal bone, and predisposes to fracture, as here.

The other major complication occuring in long bones is that of sarcomatous change into chondrosarcoma or osteochondroma. This is said to occur in 1-5% of cases, and may present with worsening pain or a pathological fracture, but there is no evidence of this in this case.

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