Pathological fractures in pediatric extremities: a comparative analysis of patient characteristics, trauma mechanisms, and lesion types

Pathological fractures in children are uncommon manifestations of underlying bone lesions. Differences in biomechanical loading and lesion distribution between the upper and lower extremities may result in distinct fracture characteristics and clinical presentations. The aim of this study was to characterize pathological fractures in the growing skeleton and to identify location-specific differences between upper- and lower-extremity fractures regarding patient demographics, trauma mechanisms, fracture characteristics, and underlying lesion types. This retrospective single-center study included 235 pediatric patients (0-17 years) with radiologically confirmed pathological fractures treated between 1999 and 2021. Demographic, clinical, and radiographic data were extracted from institutional records. Fractures were classified according to trauma mechanism, accident setting, anatomical location and underlying pathology. Statistical comparisons between upper- and lower-extremity fractures were performed using standard statistical tests, with statistical significance defined as p < 0.05. A total of 235 pathological fractures were analyzed, including 120 fractures of the upper extremity (51.1%) and 115 fractures of the lower extremity (48.9%). Age distribution was comparable between groups (median age 11 years; p = 0.887). Female patients were significantly more likely to sustain a pathological fracture of the lower extremity than of the upper extremity (38.3% vs. 25.0%; OR 1.86, 95% CI 1.06-3.25; p = 0.041). Significant differences were observed regarding accident setting and trauma mechanism (p = 0.011 and p = 0.0015, respectively). Lower-extremity fractures occurred more frequently in the absence of trauma or following low-energy trauma, whereas upper-extremity fractures were predominantly associated with falls on level surfaces. Malignant lesions were more common among lower-extremity fractures than upper-extremity fractures (9.6% vs. 3.3, p = 0.063). CONCLUSION: Pathological fractures of the upper and lower extremities in children demonstrate distinct clinical characteristics. Lower-extremity fractures were more frequently associated with absent or low-energy trauma and showed a trend toward a higher proportion of malignant underlying lesions, whereas upper-extremity fractures predominantly resulted from falls on level surfaces. These location-specific differences suggest that fracture location may provide valuable diagnostic information and should be considered during the evaluation of children presenting with pathological fractures. WHAT IS KNOWN: • Pathological fractures in children may be the first manifestation of underlying skeletal pathology. • Fractures after minimal trauma warrant careful diagnostic evaluation. WHAT IS NEW: • Lower-extremity pathological fractures were more frequently associated with absent or low-energy trauma and a higher burden of systemic or multifocal bone disorders. • Lower-extremity fractures showed a trend toward a higher prevalence of malignant underlying lesions, supporting their value as a diagnostic red flag.