Miscellaneous MSK Conditions and Malignancy

Question 1

Describe the classical symptoms associated with a patient presenting with bone pain due to metastasis or myeloma?

Answer 1

Pain is often described as a deep seated pain within the bone. It is persistent/progressive and is usually worse at night.

Red flag symptoms:

• History of malignancy
• B symptoms: Weight loss, night sweats, reduction in appetite
• Night pain/ persistent pain
• Can cause spinal cord compression (rare)
• Myeloma: bone marrow impairment (anaemia, infections)

Question 2

Outline the management of malignant bone cancer?

Answer 2

• Analgesia often with NSAIDs
• Bisphosphonates can be used to reduce bone resorption + fracture risk
• Radiotherapy of the affected area can help control the pain
• May need surgical stabilisation to prevent pathological fractures

Question 3

What are the different primary tumours of the bone?

Name some other differentials for bone cancer?

Answer 3

Sarcoma’s:

• Osteosarcoma (mostly in children)
• Ewing’s sarcoma (in children and young adults)
• Chondrosarcoma (in adults)

DDx: multiple myeloma, mets, lymphoma, chronic osteomyelitis

Question 4

How do primary bone tumours tend to present?

Answer 4

Dull pain (also at night), swelling (of an area), local tenderness.

Mass

Rapid growth (suggestive of malignancy)

Pathological fractures

Question 5

Describe the x-ray appearance of bone metastasis?

Answer 5

• Usually radiolucent patches (lytic)
• Prostate metastases form sclerotic patches.
  +/- Pathological fractures

Question 6

What are the causes of a neuropathic joint?

Answer 6

Also known as charcot joint.

Most common cause is diabetes.
If in the upper limb classically caused by syringomyelia.
Can also be caused by tertiary syphilis.

Question 7

Describe the pathophysiology of a neuropathic joint?

Answer 7

Dysfunction of sympathetic nerves cause the arterioles to dilate.

Causes there to be excess oxygen resulting in oxidative free radical formation which causes joint damage.

Question 8

Describe the clinical features of a neuropathic joint?

Answer 8

Joint damage tends to occur sub acutely over weeks.

May be initially painful but often pain does not match the degree of deformity.

Becomes deformed.

Question 9

Describe the radiological appearance of a neuropathic joint?

Answer 9

Dense bones (subchondral sclerosis)
Degeneration
Destruction of articular cartilage
Loose bony debris

Question 10

What is complex regional pain syndrome (algodystrophy)?

Answer 10

Complex regional pain syndrome (CRPS) is a chronic pain condition most often affecting one of the limbs usually after an injury or trauma to that limb.

It is characterized by prolonged or excessive pain and mild or dramatic changes in skin color, temperature, and/or swelling in the affected area.

Aetiology is thought to be related to nerve damage.

Question 11

How is complex regional pain syndrome managed?

Answer 11

Exercise programme: to keep the painful limb or body part moving can improve blood flow and lessen the circulatory symptoms.

Psychological therapy: to help deal with the pain and prevent mental health conditions

Pharmacological:
NSAIDs
Steroids to help reduce swelling.
Neuropathic analgesics

Interventional:
Nerve blocks

Question 12

How are malignant bone tumours investigated?

Answer 12

• Whole body radioisotope scan
• MRI / CT of tumour
• Biopsy of tumour (CT guided)
• General bloods and markers

Question 13

Describe the x ray findings of benign and malignant tumours?

Answer 13

Benign = well demarcated, no soft tissue involvement

Malignant = boundaries not clear, soft tissue involvement, extends into cortex (outer bit)

Question 14

Name the types of benign bone tumours + briefly describe their appearance.

Answer 14

Enchondroma: lytic and well defined, mostly hands or feet, amorphous new cartilage

Osteoma: new bone growing on bone

Osteochondroma: cartilage with bone inside (cant see cartilidge on xray), sticks out like stalk

Osteoid ostoma: small lytic lesion called nidus dot in bone

Extosis: developmental separation of metaphyseal from growth plate, grows new blob near joint

Question 15

Name the types of malignant bone tumours + briefly describe their appearance.

Answer 15

Osteosarcoma: sclerotic lesion that grows out of bone, looks bright white on X-ray.

Chondrosarcoma: Lytic lesion in bone, not well defined, amorphous new bone suggest cartilage

Multiple myeloma: Lytic lesions e.g. pepper pot skull

Question 16

Which malignant bone tumour is the most common?

Which has the worst prognosis?

Answer 16

1. Osteosarcoma (aggressive and mets early)

2. Osteosarcoma 5-10% 10 year survival