Bone Pain profoma

Question 1

What is bone pain?

Answer 1

Extreme tenderness, aching, or discomfort in 1 or more bones.

differs frommuscle&joint painbecause it’s present whether you’re moving or not.

pain is commonly linked to diseases that affect the normal function or structure of the bone.

Question 2

What diagnoses should you consider in bone pain and joint pain?

Answer 2

Bone pain:
- Vascular – haemangioma, Sickle cell anaemia, vascular necrosis.
- Infection- osteomyelitis
- Trauma
- Auto-immune - e.g. SLE, RA, SpA
- Metabolic- Osteoporosis, Paget’s disease, osteomalacia, hypercalcaemia (↑ Ca).
- Idiopathic or iatrogenic e.g. steroids
- Neoplastic - e.g. multiple myeloma, tumours, osteosarcoma, metastasis, leukaemia.
- Congenital
- Degenerative e.g. OA

Joint pain:
- OA
- RA
- Psoriatic Arthritis
- Polymyalgia Rheumatica
- Bursitis
- Cysts
- Fracture or Dislocation
- Rupture of tendon or ligament
- Ankylosing spondylitis
- Entropathic arthritis
- Reactive arthritis
- Lyme arthritis

Question 3

Presentation of bone pain

Answer 3

• Often poorly localised e.g. in the hip region but nowhere specific.
• Deep, aching pain.
• Persistent
• Tender
• Not easily relieved by analgesia e.g. paracetamol, NSAIDs
• Night pain
• Pain at rest
• NOTE: Experienced in the periosteum because it becomes stretched and that is where nerve endings are in bone.

Osteoporosis- painless until fracture

Osteomalacia- generalised bone pain & muscle weakness- Proxima; myopathy

Bone malignancy- progressive & often night pain w/ systemic features

Paget’s- progressive & often night pain but patient’s systemically well

Osteomyelitis- malaise, fever, unwell, bone pain, red, swollen

Question 4

Red flag symptoms in bone pain?

Answer 4

• Progressive weight loss
• Anorexia- loss of appetite.
• Fevers - could suggest infection.
• Malaise - generally feeling unwell.
• Functional impairment e.g. difficulty weight bearing
• Night sweats
• Previous history of malignancy or TB
• Night pain

Question 5

Initial investigation for bone pain: blood tests

Answer 5

Alkaline phosphatase (ALP)
- Reflects osteoblast activity so elevated in some bone diseases.
- High in Paget’s disease- if elevated on its own, without Ca²⁺ elevation, more likely to be Paget’s.
- High in malignancies that involve osteoblastic activity (but not multiple myeloma).
- High in severe osteomalacia (PTH will also be raised)
- High in hyperparathyroidism- more likely if Ca, & PTH also high

Serum calcium
- May be elevated in malignant disease - if elevated with alkaline phosphatase, could suggest malignancy.
- Maybe elevated if prescribed too much vitamin D.
- Low in Osteomalacia.

FBC, U&Es, ESR/CRP, LFT

25-hydroxyvitamin D
- Low in osteoporosis & osteomalacia
- Normal or low in hyperparathyroidism & Paget’s

Thyroid tests

Myeloma screen

Phosphate:
- High in chronic kidney disease- CKD likely if ALP & PTH also high
- Low in osteomalacia & hyperparathyroidism
- Normal in Paget’s disease & osteoporosis

PTH
- Normal in osteoporosis & Paget’s
- High in osteomalacia & hyperparathyroidism & CKD

Prostate specific antigen test

NOTE: VIEW TABLE ON NOTES! VERY IMPORTANT!

https://www.notion.so/Bone-pain-5ef52bb325594d218ce653a9455b70da

Question 6

Initial investigation for bone pain: imaging

Answer 6

X-rays - shows bone structure - look for lytic areas & sclerosis - always do this first.

CT - looks at structure of bone.

Isotope bone scans - highlights areas w/ metabolic activity - rarely used. Used for looking at high bone turnover e.g. Paget’s disease of bone.

PET CT

MRI - looks for soft tissue involvement & can help with diagnosis of primary bone tumours.

DEXA scan for OP - not good for imaging bones - used to look at bone density.

Question 7

Key differential diagnosis for bone pain

Answer 7

• Osteomyelitis
• Osteoporosis (e.g. spinal compression fracture)
• Osteomalacia or Rickets
• Osteogenesis Imperfecta
• Paget’s disease of bone
• Primary bone cancer
• Secondary (metastatic) cancer
• Fracture
• Hypercalcaemia - may be due to secondary hyperparathyroidism.
• Frailty - can lead to generalised aches and pains.
• Growing pains
• Hyperparathyroidism
• OA or inflammatory arthritis
• Psychosomatic - e.g. fibromyalgia.
• Myeloma

Question 8

Initial management for bone pain

Answer 8

Further investigation e.g. DEXA scan

Dietary changes - protein, calcium, vit D, micronutrients.

Hot or cold packs - for symptomatic relief

Physiotherapy

Analgesia- use WHO ladder in line w/ pain intensity increase
1. Non-opioids- NSAID & paracetamol
2. Weak opiates- Codeine
3. Strong opiates- morphine, fentanyl, diamorphine. Bisphosphonates - alendronic acid

Consider psychological adjuvantsL
- tricyclic antidepressants, benzodiazepines

Question 9

Presentation of myeloma

Answer 9

Back pain w/ no history of trauma

Longer than 6 weeks

No fever

Pancytopenia - anaemic, leukopenia, thrombocytopenia.

High ESR

NOTE- view history example on notes!