A 55-year-old woman with breast cancer presents with mid-shaft femoral metastasis causing impending pathological fracture (Mirels score 9). The best management is:

• A Radiotherapy alone to the lesion
• B Long-leg cast immobilization and zoledronate infusion
• C Above-knee amputation
• D Prophylactic intramedullary nailing followed by radiotherapy ✓

Explanation

A Mirels score ≥9 indicates >33% risk of pathological fracture and mandates prophylactic fixation. For femoral diaphyseal metastases, intramedullary nailing (IMN) is the preferred method as it provides immediate weightbearing, protects the entire femur, and allows adjuvant radiotherapy for local disease control. Radiotherapy alone does not provide immediate structural stability and takes weeks to reduce fracture risk. Mirels scoring: site, pain, type of lesion, and size each scored 1-3; total score ≥9 = surgical stabilization indicated.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.