Discuss the presentation, initial investigation, red flags, key differential diagnosis & initial management of bone pain

Question 1

What may a plain radiograph X-ray reveal about bone pain?

Answer 1

Osteoblastic and osteoclastic activity

Question 2

True or false?

Calcium, phosphate, alkaline phosphatase, renal function, PTH and vitamin D blood tests are all elevated in primary osteoporosis?

Answer 2

False, they should all be normal in primary osteoporosis

could indicate causes of secondary osteoporosis

Question 3

A patient presents with:

• generalised bone pain
• muscle weakness

What is the most likely diagnosis?

Answer 3

Osteomalacia

Question 4

How does osteomalacia bone pain present?

Answer 4

generalised bone pain accompanied by muscle weakness

Question 5

A patient presents with:

• Low calcium levels
• Low phosphate levels
• Elevated alkaline phosphatase
• Low vitamin D levels
• Elevated PTH

What is the diagnosis?

Answer 5

Osteomalacia

Question 6

How does bone pain caused by Paget’s disease present?

Answer 6

• progressive pain
• night pain

Question 7

What are 4 red flag symptoms of bone pain?

Answer 7

1. pain is progressive
2. weight loss
3. fevers
4. night pain

Question 8

What are the similarities and differences between bone pain caused by malignancy and Paget’s disease?

Answer 8

• Similarities: progressive, night pain
• Differences: patient’s with malignancy are systemically unwell, whereas patient’s with paget’s disease are otherwise well

Question 9

A patient presents with:

• Progressive pain
• Systemic features

What are the differential diagnoses, and what investigation could help you differentiate?

Answer 9

1. Bone malignancy and osteomyelitis
2. X-ray: osteomyelitis is unlikely to cause lesion in the ilium

Question 10

When may serum calcium levels be elevated in relation to bone pain?

Answer 10

1. malignant disease
2. overprescribed vitamin D

Question 11

What blood results would you expect in a patient with osteomyelitis?

Answer 11

• elevated WCC
• elevated CRP
• elevated ESR

Question 12

Why do we not see an increase in ALP in myeloma?

Answer 12

There is no osteoblastic activity

Question 13

What blood tests should be carried out in the initial investigation for bone pain?

Answer 13

1. alkaline phosphatase
2. serum calcium

Question 14

How does osteoporosis bone pain present?

Answer 14

it doesn’t until a fracture

Question 15

How does bone pain caused by bone malignancy present?

Answer 15

• pain is progressive
• pain at night
• pain is accompanied by systemic features

Question 16

How does osteomyelitis bone pain present?

Answer 16

Progressive pain accompanied by systemic features and fever

Question 17

Which 3 bone-pain conditions will elevate ALP?

Answer 17

1. Paget’s disease
2. severe osteomalacia
3. malignancies (where there is osteoblastic activity)

Question 18

How does bone pain present (5)?

Answer 18

1. poorly localised
2. deep, aching pain
3. persistent
4. not easily relieved by analgesia
5. night pain

Question 19

What actions should be taken if a patient presents with red flag symptoms for bone pain?

Answer 19

• Either urgent assessment and treatment
• or referred to hospital on a 2 week cancer wait