Bone pain - Clinical Medicine Flashcards
What is pagets disease?
A focal bone disease of remoedelling
a) Describe the predispositions of Paget’s disease
b) Describe the epidemiology
c) Descibre the genetic features of Paget’s
a)
- Genetics - 1st degree relatives of an affected person are 7x more likely
- Environment - viral infections e.g., paramyxoviralinfections, measles, RSV or canine distemper virus
b)
- More common in males
- Mostly seen in patients 40+
- 2nd most common metabolic disease
- Often asymptomatic
c)
- 10-20% have a family history
- Defects in the SQSTM1 gene - codes for a protein - affects RANK signally
- Incidence has declined rapidly in recent years
Explain the pathology of Paget’s disease
- Increases bone cell activity
- Osteoclasts are bigger than normal - they resorb bone at higher rate
- Osteoblasts lay down bone in a haphazard way to keep us with osetoclasts
- This leads to poor bone architecture leading to expansion of poor quality bone which is weak, irregular and woven
- Marrow replaced with fibrous tissue and blood vessels
a) What are the clinical features and complications of Paget’s related to?
b) How many bones can Paget’s disease affect?
a) Related to bone expansion
b) It ca be monostotic (one bone/portion) or polyostotic (2 or more bones)
Describe the clinical features of Paget’s disease
MSK
- Bone pain
- Bone deformity (bowing of legs)
- Fractures - bowing of bone secretes ares of weakness
- Acetabular protrusion
- Secondary OA (usually in pelvis)
Neurological
- Basilar invagination (top of spine pushes into base of skull)
- Cerebellar dysnfunction (inc. incoordination, imbalance and troubles with stabilizing eye movements)
- Obstructive hydrocephalus
- Cranial nerve palsies (Blood flow to cranials nerves are blocked leading to double vision or not being able to move eye a certain way)
- Spinal stenosis/cauda equina
- Deafness
- Tinnitus (ringng/other noise 1 or both ears)
- Para or quadripelgia (paralysis of lower limbs/all four limbs)
Cardiovascular
- Increased cardiac output
- Heart failure
- Aortic stenosis
- Endocardial calcification
- Atheroscelerosis
Metabolic
- Hypercalcaemia
- Hyperuricaemia
- Immobilisation hypercalciria
- Nephrolithiasis (kidney stones)
Neoplasia
- Osteosarcoma
- Chondrosarcoma
- Giant cell tumours
What are neurological symptoms of Pagets related to?
Related to bony symptoms and compression of neurological structures
a) Describe the diagnosis Paget’s disease?
b) What must you exclude?
a) Isolated alkaline phosphatase (reflects osteoblastic activity) and other markers of bone turnover are also high
b)
- Vit D deficiency
- Hyperparathyroidism
- Hyperthyroidism
- Renal osteodystrophy (constellation of MSK abnormalities that occur in patients with chronic renail failure)
- Malignany
What investigations must be undertaken to help diagnose Paget’s disease and include the findings
- Isolated alkaline phosphatase (from LFTs) - normal Ca and Phosphate
- Urine - increased hydroxyproline
- Plain radiographs - Bone expansion, cortical thickening, lysis and sclerosis, coarsened trabeculae
- Isotope bone scan - Areas of focal increased uptake, MOST SENSITIVE TEST
Desribe the radiological features of Paget’s disease
- Bones are typically expanded
- Show cortical thickening
- Coarsened trabeculae
- Mixture of lytic and sclerotic areas
Describe the treatment options for Paget’s disease
- Bisphosphonates
- Analgesia - relieve pain symptoms
- Ensure vit D levels adequate
- Physiotherapy
- Surgery- for fractures, joint replacement, spinal stenosis
List they 3 types of cancers you can get in bones and briefly describe them
- Tumour/neoplasm - cells keep dividing when new cells are not required and cause a mass of tissue or tumour
- Benign tumours - do not spread to other parts of the body - can be locally destructive
- Malignant tumour - cells are abnormal and divide out of control and can invade local and distant tissues
Bone malignancy can be primary or secondary. what is the name for a primary malignancy in:
a) Bone
b) Cartilage
c) Fibrous tissue
d) Bone marrow
e) Vascular
f) Uncertain
a) Osteosarcoma
b) Chondrosarcoma
c) Fibrosarcoma
d) Ewing’s sarcoma, myeloma
e) Angiosarcoma
f) Malignant giant cell tumour
a) Are primary bone tumours common?
b) What type of people are pirmary bone tumours seen in?
a) No
b) Young people
a) Which age group does osteosarcoma (osteoid) affect most?
b) Which type of bones does it affect?
c) Describe the radiological features
a) Usually under 20s
b) Affects long bones and growth plates
c) Sunburst appearance due to lifting of periosteum and Codman’s triangle
a) Which age groups does Chondrosarcoma usually affect
b) What are 2 clinical features?
c) What my it arise from?
a) Usually in 40s
b) Painful and progressive
c) May arise in underlying benign lesions
a) When is Ewing’s tumour most likely to occur
b) What part of the bone does it affect
c) Describe the radiological features
d) What may it present with?
a) Childhood (2nd most commnest in childhood)
b) From medullary (long bones) cavity
c) Onions on x-ray
d) Metastases
Bone cancer can be secondary. List the 5 most common types of cances that bone metastases originate from?
- Breast
- Prostate
- Lung
- Kidneys
- Thyroid
a) Which bones in the body can be affected by Paget’s?
b) What will you see and feel on examination of someone suspicious of Paget’s?
a) Any bone in the body
a) Warm, tender and deformities
What must you look for when examining for bone cancers
- Consitency with history and expected findings
- Beware of co-existing pathologies
- Scarring and skin changes
- Neurology and vascularity
- May not be any abnormalities - high index of suspicion
What investigations can be undertaken for bone cancers and describe their uses
Serum biohemistry
Plain X-rays
- Essential to shown bone structure
- Lysis/scelerosis
Isotope bone scan - highlights areas of metabolic activity
- No value is assessing structure
- Limited use in myeloma
- Beware sacral lesions (may not show up)
CT
- Good for structure
- Good for pelvic and acetabular mets (3D)
- Screening of chest/abdomen and pelvis
MRI
- Defines soft tissue involvement
- Essential in spinal disease
- “Skip lesions” in long bones
- Evaluation of suspected primary bone tumours
Bone biopsy
How should you initally treat bone tumours as?
Treat as primary bone tumour until proven otherwise
Describe the managment of metastases
- Pain - Analgesia
- Bisphosphonates
- Radiotherapy/Chemotherapy
- Surgery
What are the clinical features of osteoporosis?
There are no clinical features until fracture (usually from low energy injury)
a) List the risk factors to osteoporosis including modifiable and non-modifiable risk factors
b) List 5 secondary causes
- Age (> 50 for women and >65 for men)
- Female sex
SHATTERED FAMILY
- Steroid use
- Hyperthroidism, hyperparathyroidism
- Alcohol and smoking
- Thin (BMI < 22)
- Testesterone deficiency
- Early menopause
- Renal/liver failure
- Erosive/inflammatory bone disease
- Diabetes
- Family history
b)
- Drugs: corticosterioids/heparin
- Rheumatoid arthritis
- Coeliac disease
- Multiple myeloma
- Cushing syndrome
a) Describe the 3 types of verterbral fractures
b) Which is the most common?
a)
- Wedge fracture - several of these causes the person to become bent over
- Biconcave fracture - both sides of the vertebra collapse
- Crush fracture - whole vertebral body collapses in on itself
b) Wedge fracture
a) There are 3 types of vertebral compression fracture appearence. Fill out the box.
b) What are the signs of vertebral fractures
b)
- Thoracic pain after minor fall (sometimes no pain)
- If no pain, complain they’re ‘shrinking’, ‘kyphotic’ or ‘round shouldered’
Descibe how age related changes in bone mass varies between men and women
Men
- Peak bone mass peaks at late 20s
- Bone mass consolidated until mid/late 40s
- After mid/late 40s bone mass deteriorates gradually over time
Women
- Peak bone mass peaks at late 20s but less than men
- Bone mass cosolidated until mid/late 40s
- After mid/late 40s bone mass decreases rapidly due to menopause which mean less oestrogen around the bone health. This brings them much closer to the fracture threshold
a) What are features in the history that suggests bone pain
b) Red flag symptoms
c) How would you manage this?
d) Is he at risk of low viamin D? Explain your answer
e) What is your diagnosis?
a)
- Often poorly localised
- Deep, aching pain
- Persistent
- Not easily relieved by analgesia
- Often complain of night pain
b)
- Progressive
- Weight loss
- Aorexia
- Fevers
- Malaise etc
c)
- Red flag symptoms indicate a need to intervene quickly.
- Patients either need to be assessed and treated urgently or referred to secondary on a 2 week cancer wait
d) Yes, dietary intake decreases as you age, likelihood increases as he lives alone. May be possibly covered up when he goes on walks. Could be going out less due to the pain. He could be darker skinned
e) Metastatic bone malignany that spreadad to his pelvis
