Mirels’ Classification for pathologic fractures

Mirels' classification
Nature of lesion
Nature of lesion
Nature of lesion
Nature of lesion
Venting techinique
Venting techinique
Venting techinique

 Mirels’Classification

Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 249:256–264, 1989.

Mirels’Classification : Nature of lesion

Mirels’Classification : Nature of lesion

Orthopedic Radiology: A Practical Approach, Greenspan, Adam; Lippincott, 2000

Diagnosis of Bone and Joint Disorders, Resnick, Donald, W. B. Saunders

Mirels’Classification : Nature of lesion

Score of 8 or higher  consider prophylactic internal fixation

Guideline aids in decision making, but does not serve as an absolute criterion

Each patient should be evaluated individually, keeping two generally accepted principles in mind. 

First, prophylactic internal fixation of an impending fracture is technically easier than fixation of an actual pathologic fracture.

Second, patient morbidity is decreased with prophylactic fixation compared with fixation after the fracture.


Prophylactic intramedullary fixation (↓pain and prevent subsequent complete fx)  ↑intramedullary pressure  BM extravasation into circulation  marrow embolism  cardiovascular dysfunction


Venting decreases embolic load by reducing intramedullary pressure


Venting technique

Localize the distal flare of the femur approximately 3 cortical diameters proximal to the proposed location of the end of the femoral nail

1-cm percutaneous incision along the lateral aspect of the distal thigh at the location of the beginning of the metaphyseal flare  down to the lateral femoral cortex

Drill a 4.5-mm hole



Place a triple sleeve (4-mm pin size) from the Stryker Hoffman II external fixation set in the hole

Attach standard suction tubing and connect to a low-intensity suction

Confirm depth with C-arm fluoroscopy 

Perform cephalomedullary nailing while monitoring suction output

Total output during reaming : 300 cc

Total output during nail placement : 150 cc

Once nail is seated remove cannula and close wound


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