1
Q
Name four primary bone tumours
A
Osteosarcomas, fibrosarcoma, chondromas, Ewing’s tumour
2
Q
What are the most common primary sites for secondary bone tumours?
A
Bronchus, breast and prostate
3
Q
What is the presentation of bone tumours?
A
- Related to anatomical position of the tumour with local bone pain:
- Systemic symptoms e.g. malaise and pyrexia
- Aches and pains are occasionally related to hypercalcaemia
4
Q
How are bone tumours diagnosed?
A
- Skeletal isotope scan show bony metastases
- X-rays show metastases as osteolytic areas
- MRI used for vertebral lesions
- Serum alk phos raised
- Hypercalcaemia
- PSA is raised if prostatic metastases
5
Q
How are bone tumours managed?
A
- Analgesics and anti-inflammatory drugs
- Local radiotherapy to bone metastases
- Some tumours response to chemotherapy
- Some tumours are hormone-dependent and respond to hormonal therapy
- Bisphosphonate e.g. alendronate can help symptomatically
6
Q
What are the most common osteosarcoma sites?
A
Knee and proximal humerus (long bones)
7
Q
What is the presentation of osteosarcoma?
A
- Often presents as a painless tumour
- Rapidly metastasised to the lung
8
Q
How is osteosarcoma diagnosed?
A
- XR: bone destruction and formation, soft tissue calcification produces a sunburst appearance
9
Q
How was osteosarcoma managed?
A
- Cut the tumour and some of the healthy tissue around it from the affected bone (doesn’t always require amputation)
10
Q
What is a Ewing’s sarcoma?
A
- Rare cancer that affects bones/ soft tissues around bones
- Much more common in children and young people
- Thought to arise from mesenchymal stem cells
11
Q
What is the presentation of a Ewing’s sarcoma?
A
- Presents with a mass/swelling, most commonly in the long bones of the arms, legs, pelvis and chest
- Can present in the skill and flat bones of the trunk
- Painful swelling
- Redness around the tumour site
- Malaise
- Anorexia
- Weight loss
- Fever
- Paralysis and/or incontinence (only if affecting the spine)
- Numbness in affected limb
12
Q
What is a chondrosarcoma?
A
- Cancer of the cartilage
- Most common adult sarcoma
- Commonly affects the pelvis, femur, humerus, scapula and ribs
13
Q
What is the presentation of chondrosarcoma?
A
- Dull, deep pain
- Affected area is swollen and tender
14
Q
How are you chondrosarcomas diagnosed?
A
- XR
- MRI
- CT
- Biopsies
15
Q
How will chondrosarcomas managed?
A
- Chemotherapy/ stem cell transplant
- Localised therapy with radiotherapy or surgery
16
Q
What is the aetiology of fibromyalgia?
A
- Associated with depression, chronic headache, IBS, chronic fatigue and myofascial pain syndrome
17
Q
What is the definition of fibromyalgia?
A
- Widespread MSK pain after other diseases have been excluded
- Symptoms present for >3m
- Pain at 11 of 18 tender point sites on palpation
18
Q
What are the risk factors of fibromyalgia?
A
- Female
- Middle age
- Low household income
- Divorced
- Low educational status
19
Q
What is the presentation of fibromyalgia?
A
- Widespread chronic pain lasting >3m
- Aggravated by stress, cold and activity
- Associated with generalised morning stiffness
- Tingling hands and feet
- Pain usually focuses on: lower neck in front, base of skull, upper edge of breast, neck and shoulder, below side bone at elbow, upper outer buttock, hip bone, inside just above knee
- Fatigue is often extreme and occurs after minimal exertion
- Non-restorative sleep: frequent waking in the night, waking unrefreshed, poor concentration and forgetfulness, low mood, irritable, weepy, function pain from lack of non-REM sleep
20
Q
What are the differential diagnosis of fibromyalgia?
A
- Hypothyroidism
- SLE
- Polymyalgia rheumatica (PMR)
- High calcium
- Low vitamin D
- Inflammatory arthritis
21
Q
How is fibromyalgia diagnosed?
A
- Pain at 11 of 18 tender points on digital palpation
No diagnostic test, so can only exclude things:
- Thyroid function test (to exclude hypothyroidism)
- ANA and DsDNA (to exclude SLE)
- ESR and CRP (to exclude polymyalgia rheumatica)
- Ca2+ and electrolytes (to exclude high calcium)
- Vit D (to exclude low vit D)
- Examine patient and CRP (to exclude inflammatory arthritis)
22
Q
How is fibromyalgia managed?
A
- Educate patient and family
- Avoid unnecessary investigations
- Reset pain thermostat: correct non-restorative sleep, improve aerobic fitness (tires them so they sleep better)
- Low dose antidepressants and anticonvulsants
- NSAIDs and steroids rarely work
23
Q
What is the aetiology of mechanical lower back pain?
A
- Often trauma or work related
- Main causes: lumbar disc prolapse, osteoarthritis, fractures, spondylolisthesis, heavy manual handling, stooping and twisting whilst lifting, exposure to whole body vibration
- Need to be aware of more sinister causes: malignancy, infection, inflammatory causes
24
Q
What are the red flags for serious spinal pathology?
A
- Age of onset <20y or >55y
- Violent trauma (e.g. fall from height or road traffic accident)
- Constant, progressive, non-mechanical pain
- Thoracic pain
- Systemic steroids, drug use or HIV
- Systemically unwell, weight loss
- Persisting severe restriction of lumbar flexion
- Widespread neurology
- Structural deformity
25
What are the risk factors of mechanical low back pain?
- Psychosocial distress
- Smoking and dissatisfaction with work
- Risk factors for recurrent back pain: female, increasing age, pre-existing chronic widespread pain (fibromyalgia), psychosocial factors
26
What is the presentation of mechanical low back pain?
- Stiff back that may present with scoliosis when standing
- Visible muscular spasm, palpable and causes local pain/tenderness (relieved by sitting or lying)
- Pain is often unilateral
- Episodes are generally short-lived and self-limiting
- Sudden onset
- Pain worse in evening
- No morning stiffness
- Aggravated by exercise
27
What is the differential diagnoses of mechanical low back pain in elderly patients?
- Polymyalgia rheumatica
28
How is mechanical low back pain diagnosed?
- Spinal XR if red flags present
- MRI > CT
- Bone scans
29
How is mechanical low back pain managed?
- Urgent neurosurgical referral if any neuro deficit
- Analgesia to allow normal mobility
- Combined with physiotherapy, back muscle training regimens and manipulation
- Acupuncture can help
- Avoid excessive rest
- Re-education in lifting and exercises to prevent further attacks of pain
- Comfortable sleeping position using a medium firm mattress
30
What is the aetiology of osteomalacia?
- Most common cause is hypophosphataemia due to hypoparathyroidism
- Vitamin D deficiency
- Renal disease
- Drug induced
- Liver disease
31
What is the pathophysiology of osteomalacia?
- Normal amount of bone, but mineral content is low (excess uncalcified osteoid and cartilage)
- Defective mineralisation after fusion of epiphyses (i.e. in adults)
32
What is the presentation of osteomalacia?
- Muscle weakness leading to waddling gait and difficulty climbing stairs/ getting out of a chair
- Widespread bone pain (dull ache worse on weight-bearing and walking)
- Bone pain and tenderness
- Fractures especially of the femoral head
33
How is osteomalacia diagnosed?
Bloods:
- Low Ca2+ and phosphate
- Raised serum alk phos
- Elevated PTH
- Low 25-hydroxy vit D
Biopsy:
- Shows incomplete mineralisation
- Gold standard, but not practical
XR:
- Shows defective mineralisation
34
How is osteomalacia managed?
- Vit D replacement
2a mid tier
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