Bone disease Flashcards by Nader Raafat

Most common types of bone tumour

Metastatic: Breast, bronchus, Thyroid, Kidney, prostate

Haematopoietic: Lymphoma, leukaemia, myeloma

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Presenting complaints for bone tumours

Incidental finding

Pathological fracture

Bony pain (Esp night pain)

Soft tissue swelling

Painless bony mass

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Characteristic location of chondrosarcoma

Pelvis

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Characteristic location of osteoblastoma

Posterior spine

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Characteristic location of simple bone cyst

Proximal humerus

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Characteristic location of adamantinoma

Tibia diaphysis

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Tumours in patients <20

Osteosarcoma

Osteoid osteoma

Ewing’s

Simple cyst

Chondroblastoma

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Tumours in patients >60

Mets, myeloma, Chondrosarcoma, malignant fibrous histiocytoma

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Tumours in middle-aged patients (20-60)

Giant cell

Malignant fibrous histiocytoma

Lymphoma

Chondrosarcoma

Mets

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Features of bone tumours to look for on X-ray

Periosteal reaction

Zone of transition

Cortical breach

Bone loss

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Types of periosteal reaction to tumour

None

Solid

Lamellated

Spiculated/sunburst

Codman’s triangle

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Radiology of zone of transition

Most reliable indicator of benign vs malignant

Can be narrow or wide

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Patterns of bone destruction

Geographic

Moth-eaten

Permeative

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Presentation of osteoid osteoma

Small solitary nodule

Cortical

Central nidus, lytic surroundings + sclerotic rim

Painful (night pain) but responds to NSAIDs

5-25y, M:F 3:1

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Management of osteoid osteoma

Radioablation

Surgical excision

NSAIDs

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Presentation of osteochondroma

90% isolated lesion due to abnormal growth of growth plate

Growth ceases with growth plate fusion

Painless lumps or pain from soft tissue impingement

Points away from affected joint w/ continuous cortex

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Management of osteochondroma

Excise if large/suspicious

Small risk of malignant transformation (higher in hereditary multiple exostoses)

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What is an enchondroma?

Intramedullary cartilage-forming lesion

Cortical thinning

no periosteal reaction

lytic/mottled appearance

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Management of enchondroma

None necessary unless painful/enlarging

Small risk of malignant change (higher in Ollier’s or Marfucci’s)

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Aggressive vs non-aggressive lesions

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Presentation of chondroblastoma

Benign tumour

Epiphyseal, lower limb/prox humerus

Young patients (10-25)

Round, lytic, well-defined X-RAY lesion

Presentation of fibrous cortical defect/non-ossifying fibroma

Young children

Arises from cortex –> thing sclerotic rim + oval-shaped lucent lesion

Distal femur/tibia

Benign, asymptomatic

Fibrous dysplasia

Developmental abnormality, becomes evident in adolescence

Ribs, femur, prox tibia esp affected (shepherd’s crook appearance)

Multiple fractures, heal but remain deformed

Treat by strengthening + straightening bone

Intramedullary bulged cortex

Simple bone cyst

Well-defined circular lucent lesion in centre (c.f. aneurysmal expansile + blood-filled)

Mainly in children (c.f. aneurysmal in teenagers)

Giant cell tumours

Late teens, 3rd and 4th decades, F\>M Lytic lesions, mainly around knees Metaphyseal Sharp zone of transition Benign

Ewing's sarcoma presentation

Young child Most commonly in femur/tibia diaphysis Pain/swelling of weeks-months + systemic upset Periosteal reaction + lytic + destructive (radiolucent) lesion

Endocrine causes of osteoporosis

Post-menopausal oestrogen deficiency (late menarche/early menopause) Hyperparathyroidism, hyperthyroidism Cushing's, hypogonadism Corticosteroid excess

Investigations for osteoporosis

DEXA scan (\<-2.5 is bad, \<-1 osteopaenia) TFTs, U&Es, LFTs Bone profile (Ca, PTH) Consider cortisol, testosterone, oestradiol, VitD Multiple myeloma screen (ESR, serum IG + electrophoresis, urinary bence-jones)

Treatment for osteoporosis

Ca and VitD Bisphosphonate Synthetic PTH (teriparatide) Denozumab (RANK-L biologic) HRT Exercise, weight loss Stop smoking

Clinical features of osteomalacia

VitD deficiency Bone pain/waddling gait Polyarthralgia Pathological fractures Subperiosteal erosions/cortical compression fractures in Looser's zone Proximal myopathy w/ normal CK

Clinical features of Paget's

Bone tenderness cortical thickening, sclerosis Deafness from nerve compression Headache Pathological fractures Osteoarthritis Rarely: osteosarcoma, vascular steal Often asymptomatic raised ALP \>50-80

Sites commonly affected in Paget's disease

Pelvis, spine, skull

Genetics of Ewing sarcoma

Mutations chromosome 11 and 22 Neuro-ectodermal cell origin

Syndromic associations of enchondromas

Ollier Marfucci

Locations of primaries in bone mets

Paired midline organs Lung Kidney Thyroid *Prostate* Breast

Radiographic features of malignant tumours

Codman's triangle Fuzzy zone of transition Onion peel appearance Sunburst

What is an involucrum?

Complication of osteomyelitis Thick periosteal sheath (new, ossified bone) surrounding sequestrum

What is a sequestrum?

Necrosed bone separated from surrounding bone Complication of osteomyelitis

What are bisphosphonates?

E.g. alendronate Bone protection with steroids, and in post-menopausal osteoporotic women

MRI finding osteomyelitis

Loss of high T1 signal in bone marrow

Management of osteomyelitis

Wound swab Blood cultures Bone biopsy IV abx Surgical debridement

Complications of osteomyelitis

Bone destruction Pathological fracture Septic arthritis Deformity/growth disturbance Sepsis

Most common XR abnormality in myeloma

Vertebral osteoporosis/osteopaenia Punched-out Lytic bone lesions may be present

Demographics of osteosarcoma

Most common bone sarcoma Affects adolescents, mainly males Paget's disease in elderly

Clinical features of osteosarcoma

Long bone metaphyses (dital femur \> proximal tibia \> distal humerus) Mixed sclerotic/lytic lesion Codman's triangle

Presentation of chondrosarcoma

Adults in 5th decade 10% arise from previous enchondroma

Retinoblastoma tumour association

Osteosarcoma

Hereditary multiple exostosis tumours

Osteochondroma Chondrosarcoma chromosome 8 and 11 muts

Nutritional causes of osteoporosis

Anorexia nervosa Malabsorption VitD deficiency --\> hyperPTH Ca deficiency Smoking/alcohol/caffeine

Medical (non-endocrine) causes of osteoporosis

RA Osteogenesis imperfecta Multiple myeloma