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Metastatic Bone Disease of the Humerus Frank 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, andprostatecarcinoma. Thetypical distribution of metastatic lesions is to the spine, ribs, pelvis, and proximal limb girdles. 1 However, almost any primary malignancy may metastasize to bone, andany bone in thebody 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 orrenal 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 presentationsof 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 primary 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 sleepingon 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. Ifthe discomfortex- 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 ( 99m Tc) bonescanning or magnetic res- onance imaging (MRI) may be done. 99m Tc 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 Oncology, 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;11:282-288 282 Journal of the American Academy of Orthopaedic Surgeons tor 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 indetecting 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 riskfor 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 systems 2-6 used 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 lowrisk of fracture (Fig. 1, A); bone destruction of 75% of the cortical diameter is associated with a high riskof fracture. 2-4 When bonede- 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). Mirels 4 developed 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 sub- 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. Mirels 4 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 thecourse 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, cleaning, bathing, 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 heal quickly, com- plete fractures secondaryto metastat- ic bone disease heal very slowly if it all. Flemming and Beals 13 and Doug- lass et al 14 reported 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. Frank J. Frassica, MD, and Deborah A. Frassica, MD Vol 11, No 4, July/August 2003 283 nonsurgical 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 anesthetizingor positioning the patient, andplain radiographs ora re- cent 99m Tc 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 mustbe 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 witha variety ofinternal 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 thefact that thenail can beplaced 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 diaphyseal region: intramedul- lary nailing or plate fixation. (3) Distal metadiaphyseal and metaphyseal (supra- condylar) region: either plate fixation or crossed flexible nails. Metastatic Bone Disease of the Humerus 284 Journal of the American Academy of Orthopaedic Surgeons in 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 ordistal lesions if the fixationcan 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 mustbe 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 aloneor 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 toaugment 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 fracturewas man- aged with open nailing, methylmethacrylate supplementation, and proximal interlocking. Frank J. Frassica, MD, and Deborah A. Frassica, MD Vol 11, No 4, July/August 2003 285 closed nailing, the potential for radi- al nerve injury, and inability to pro- tect as much humeral length as with intramedullary nailing. 16 When 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 ofthe hu- merus, intramedullary nailing is a better choice because aplate may not provide solid fixation. The exposure for plate fixation can be done through an anterolateral or posterior approach. A cortical win- dow iscreated 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 fixationin 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 plateis applied, the screws that span the defect are re- moved, andcement is placedby 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. Neitheranterograde 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 canbe 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. 17 In a study of 64 procedures in 60 patients, Townsend et al 17 found that the addition of ex- ternal beamirradiation 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 leftin place forapproximate- 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 surgical neck. 18 There is too little proximal bone inthis regionfor intramedullary nail fixation.The proximal hookof 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 Ahumeral 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. Metastatic Bone Disease of the Humerus 286 Journal of the American Academy of Orthopaedic Surgeons ed 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 boneneed to beresected. 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 custommodular 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 al 15 de- scribed good to excellent pain relief in 12 of 13 patients treated with in- tramedullary nail fixationfor 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°). Ofthe 13 patients, 11 recovered use of the arm for activ- ities of daily living. 15 Dijkstra et al 16 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 witheither method. The authors also reported early fixation failure secondaryto angular deformi- ty androtational instabilityin patients treated with intramedullary nails without proximal and distal lock- ing. 16 Most treatment failures are sec- ondary to disease progression or ear- ly lossof fixation. 17 Patients withrenal 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 thequality oflife for can- cer patients. Nonsurgical treatment with externalbeam irradiation is used for symptomatic lesions with <50% cortical bone destruction. With ≥50% cortical bone destruction, intramed- ullary nailing is the most common method ofboth prophylactic andfrac- 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. Frank J. Frassica, MD, and Deborah A. Frassica, MD Vol 11, No 4, July/August 2003 287 16. 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. Metastatic Bone Disease of the Humerus 288 Journal of the American Academy of Orthopaedic Surgeons . cuff ten- dinosis, which also manifest as dif- fuse discomfort, night pain, difficulty with sleepingon the affected side,and limited use of the upper extremity secondary to pain. Plain radiographs are. 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 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