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MSK Systems > Bone problems > Flashcards

Bone problems Flashcards

• Recognise the salient clinical features of bone & soft-tissue tumours • Differentiate clinical features of benign vs. malignant • Appreciation of investigations Understand rationale for treatment

1
Q

Example of benign bone forming tumor (2)

A

Osteoiod osteoma

Osteoblastoma

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2
Q

Example of malignant bone forming tumor (1)

A

Osteosarcoma

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3
Q

Example of cartilage forming tumour
Benign (2)
Malignant (1)

A

Benign - enchondroma, osteochondroma

Malignant - chondrosarcoma

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4
Q

Example of fibrous tissue tumours
Benign (1)
Malignant (2)

A

Benign - fibroma

Malignant - fibrosarcoma, malignant fibrous histiocytoma (MFH)

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5
Q

Example of vascular tissue tumors
Benign (2)
Malignant (1)

A

Benign - hemangioma, aneurysmal bone cyst

Malignant - angiosarcoma

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6
Q

Example Adipose tissue tumor
Benign (1)
Malignant (1)

A

Benign - lipoma

Malignant - liposarcoma

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7
Q

Example of marrow tissue tumours
Malignant (3)
Which is most common primary malignant bone tumor in older patients?

A

Ewing’s sarcoma *
Lymphoma
Myeloma

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8
Q

Give 2 examples of benign tumor like lesions

A

Simple bone cyst

Fibrous cortical defect

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9
Q

3 clinical features of pain in bone tumour presentation

A

Activity related
Progressive pain at rest
Night pain

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10
Q

Describe radiographic features of myositis ossificans (4)

A

Extraosseus bone formation
Circumferential calcification
Lucent centre
String sign

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11
Q

Inactive radiographic features (3)

A

Clear margins
Surrounding rim of reactive bone
Cortical expansion (in aggressive benign lesions)

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12
Q

Agressive cancer radiographic features (6)

A

Codman’s triangle
Onion skinning
Sunburst pattern
Cortical destruction
Permeative growth of cancer - less well-defined border between lesion and normal bone
Periosteal reactive - new bone growth when lesion destroys cortex

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13
Q

CT x bone tumours
Function (3)
Best for…

A
  1. Assessment of ossification and calcification
  2. Assessment of cortical integrity
  3. Assessment of nidus in osteoid osteoma
    Best for staging esp lung mets
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14
Q

In an isotope bone scan what is frequently negative?

A

MM

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15
Q

Which 4 conditions is MRI specific for?

A

Lipoma
Hemangioma
Hematoma
PVNS - pigmented villonodular synovitis

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16
Q

What is MRI unhelpful in determining with regards to bone tumours

A

Differentiating benign vs malignant

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17
Q

What is PET scan useful for with regards to bone tumours

A

Assessing response to chemotherapy

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18
Q

What are the 6 components of a full blood workup needed prior to a biopsy

A 
FBC
ESR, CRP
Ca, phosphate, alkaline phosphatase
LFTs - to assess mets spread
Plasma protein electrophoresis -MM
PSA - prostate mets
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19
Q

Investigation of bone tumours

State 6 modalities

A 
X-ray - affected site and lungs
MRI
CT - chest, abdo, pelvis
Isotope bone scan
PET
Biopsy
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20
Q

What are the 5 cardinal features of malignant primary bone tumours?
3 describe the quality of the pain

A 
Increasing, unexplained pain
Night pain
Deep-seated, boring pain
Difficulty weight-bearing
Deep swelling
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21
Q

Osteosarcoma

6 Clinical features

A 
Pain, swelling and warmth
Loss of ADL functions
Pathological fracture
Joint effusion
Deformity
Systemic effects - fever, weight loss
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22
Q

Osteosarcoma

what’s the first choice of investigation and why? (5 reasons why)

A 
MRI *
Because it is very sensitive to osteosarcoma
Can visualize:
1. Intraosseous and extraosseous soft tissue extent of tumour
2. Joint involvement
3. Skip mets
4. Epiphyseal extension
5. Determine resection margin
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23
Q

What is a skip metastasis?

A

Defined as a lateral lymph node metastasis without central lymph node involvement

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24
Q

Ewing’s sarcoma
Definition
Epidemiology gender and age group

A

Malignant small round blue cell tumour

Male > female and 10-20 yo

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25
Q

Ewing’s sarcoma

Sites (6)

A 
Pelvis 
Femur
Humerus
Ribs
Mandible
Clavicle
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26
Q

Ewing’s sarcoma
Clinical features
- Systemic symptoms
- Focal symptoms

A 
Systemic symptoms 
- Intermittent fevers
- Anemia
- Leukocytosis
- Increased ESR
Focal symptoms
- Localised pain
- Swelling
- Sporadic bone pain
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27
Q

Ewing’s sarcoma
Aetiology
Surgical indications (2)

A

Translocation between Ch11 and Ch22
Surgery indicated in:
- Pathological fractures
- Poorly performed biopsy

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28
Q

7 causes of bone metastatic disease

A 
Lung
Breast
Prostate
Kidney
Thyroid
GIT
Melanoma
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29
Q

3 red flags of soft tissue tumours

A
  1. Deep tumors of any size
  2. Subcutaneous tumours > 5cm
  3. Rapid growth, hard, craggy, non-tender
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30
Q

Pathogenesis of metastasis

A
  1. Tumor invasion of normal stroll cells
  2. Increased local pressure
  3. Lymphovascular invasion resulting in dislodge emboli
  4. NK cells, vascular turbulence destroy tumor emboli but some survive
  5. Tumour emboli adhere to capillary bed of organ and tumor angiogenesis occurs
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31
Q

Most primary bone malignancies are radio-resistant except for 4

A

Multiple myeloma
Lymphoma
Ewing sarcoma
Metastatic carcinoma

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32
Q

What are 4 states/conditions that are associated with acute osteomyelitis

A

RA
DM
Sickle cell
Immunocompromised

33
Q

Acute osteomyelitis

5 sources of infection

A 
Hematogenous spread
Local spread from site of infection
Open fracture
Bone surgery - ORIF
Secondary to vascular insufficiency
34
Q 
Acute osteomyelitis
Infants < 1 yo
3 pathogens
Presentation (3)
Commonest site
A 
Staph aureus
Group B streptococci
E. Coli
Presentation
- Infected umbilical cord
- Failure to thrive
- Decreased ROM
Commonest around knee
35
Q

Acute osteomyelitis
Children
3 pathogens
Presentation (2)

A 
Staph aureus
Strep pyogenes
Hemophilis influenza
Presentation
- Systemic symptoms: malaise, swinging pyrexia, nausea vomiting
- Severe pain 
- So NWB and reluctant to move
36
Q

Acute osteomyelitis
Children
Etiology (3)

A

Boils
Tonsilitis
Skin abrasions/lacerations

37
Q

Acute osteomyelitis
Adults
Pathogens 4

A

Coagulase negative staphylococci
Propionibacterium spp
Mycobacterium tuberculosis
Pseudomonas aeroginosa

38
Q

Acute osteomyelitis
Adults
Etiology 2

A

UTI

Catheters

39
Q

If its acute osteomyelitis secondary to penetrating foot injuries e.g. nail penetrating feet into bone OR in IVDA - what is the most likely pathogen?

A

Pseudomonas aeroginosa

40
Q

Acute osteomyelitis
Adults
PC?
Name 4 risk factors

A 
PC: Acute backache
History of UTI
Elderly
Diabetic
Immunocompromised
41
Q

Pathogen causing osteomyelitis in sickle cell disease

A

Salmonella spp

42
Q

Pathogen causing osteomyelitis in fishermen, filleters

A

Mycobacterium marinum

43
Q

What instances can candida cause osteomyelitis

A

HIV/AIDS

44
Q

Acute OM
Pathogenesis
Where does it start?
Describe 5 steps in pathogenesis

A

Starts at metaphysis

  1. Vascular stasis
  2. Acute inflammation
  3. Suppuration
  4. Bone necrosis
  5. Involucrum - new bone formation
45
Q

Acute OM

2 Outcomes

A

Resolution

Chronic OM

46
Q

Acute OM

Dx 10 modalities

A 
History and clinical exam
Lab work
Bone biopsy
Tissue swabs 
Imaging
USS
Aspiration
Isotope bone scan
Labelled WBC scan
MRI
47
Q

Acute OM

What are the 4 lab tests needed in investigations

A 
FBC
WBC
ESR, CRP
Blood cultures
U&amp;Es
48
Q

Justify U&Es for acute OM (2)

A

Dehydration

Renal function may deteriorate

49
Q

When must blood cultures be done in acute OM? (1)
Why? (1)
How many must be done? (1)

A

Blood cultures should be done at pyrexial peak as the most bugs are released into circulation at this point
3 must be done

50
Q

In prosthetic infections, how many tissue swabs must be done around implant at debridement?

A

Max 5 sites

51
Q

Early radiographs of acute OM will show minimal changes. What range of dates is this?

A

10-14days

52
Q

Radiographic features of acute OM 4

A

Periosteal changes
Medullary changes with lytic areas
Late osteonecrosis
Periosteal new bone - involucrum

53
Q

What can be seen on ultrasound in acute OM

A

Pus collection in periosteum

54
Q

DDX Acute OM X5

A 
Soft tissue infections 
Acute septic arthritis
Acute inflammatory arthritis
Trauma
Transient synovitis
55
Q

Rare DDX for acute OM x4

A

Sickle cell crisis
Gaucher’s disease
Rheumatic fever
Hemophilia

56
Q

Treatment modalities for OM

4

A

Supportive measures
Rest and splintage
Antibiotics
Surgery

57
Q

Describe 2 aspects of supportive care in OM treatment

A
  1. Pain relief

2. Manage dehydration if vomiting - put a drip in

58
Q

Antibiotic treatment in OM
ROA
Dosage and duration
What is the ab of choice while waiting for cultures?

A

ROA: IV or oral and switch every 7-10 days
For 4-6 weeks
Fluclox + Benzylpen

59
Q

7 reasons for failure of ab

A 
Drug resistance
Bacterial persistence
Poor host defenses
Poor drug absorption
Drug inactivation by host flora
Poor bone penetration
MRSA
60
Q

Indications for surgery in OM

A

Refractive to non-operative management for 24-48 hours

61
Q

OM complications (5)

A 
Septicemia
Metastatic infection
Pathological fracture
Septic arthritis
Altered bone growth
Chronic osteomyelitis
62
Q

Chronic OM

4 pathogens

A

Staph aureus
E coli
Strep pyogenes
Proteus

63
Q

Chronic OM

4 treatment modalities

A

Chronic long term antibiotics for suppression - local and systemic
Surgical - removal of infected bone
Amputation
Treatment of soft tissue problems

64
Q

Tuberculosis
3 categories of classification
Which is the commonest site in UK

A

Extra-articular
Intra-articular
Vertebral body

65
Q

Name 3 symptoms of bone tuberculosis

3 systemic symptoms

A 
Systemic symptoms (3)
-Malaise
-Weight loss
-Low grade pyrexia
Night pain 
Ill defined swelling
Decreased ROM
66
Q

2 presentation of spinal tuberculosis

A

Abscess

Collapse of vertebral bodies

67
Q

Bone TB

5 diagnostic features

A 
Hx - long hx of TB
Single joint involvement
Synovial hypertrophy
Marked muscle wasting
Periarticular osteoporosis
68
Q

Bone TB

Ix

A 
Bloods: FBC, ESR
Mantoux 
Sputum, urine culture
CXR, affected area x-ray
Joint aspiration and biopsy
69
Q

5 DDX of Bone TB

A 
Transient synovitis
MonoarticularRA
Hemorrhagic arthritis in hemophiliacs
Pyogenic arthritis
Tumor
70
Q

Bone TB
3 treatment modalities
Total length of treatment
2 stage treatment

A 
Treatment modalities:
1. Chemotherapy
2. Rest and splint age
3. Operative drainage 
1 year chemotherapy
8 weeks of rifampicin, isoniazid, ethambutol
6-12 months - rifampicin and isoniazid
71
Q

Indications of operative drainage (rarely necessary)

A

Indicated in spine when causes compression to prevent continuous collapse

72
Q

Acute septic arthritis
Route of infection 2
+ 2 ways of direct invasion

A

Hematogenous spread
Eruption of bone abscess
Direct invasion via penetrating wound and intra-articular injury

73
Q

Acute septic arthritis
4 causative pathogens
Which is most common in infants <1m and adults with UTI/cath

A

Staph aureus
Hemophilis influenzae
Strep pyogenes
E. Coli

74
Q

Acute septic arthritis
Neonates will present with a picture of septicemia
What are 3 signs

A
  1. Irritability
  2. Failure to thrive
  3. Resistant to movement
75
Q

Acute septic arthritis
Children and adult
Common sites
Common presentation

A

Common sites: superficial joints e.g. knee, ankle, wrist

Acute pain in single large joint

76
Q

Acute septic arthritis

Ix - 5 blood tests to do

A 
FBC
WBC
ESR
CRP
Blood cultures
77
Q

Acute septic arthritis

Ix - 3 modalities excluding bloods

A

USS
Aspiration
X-ray

78
Q

Acute septic arthritis

Treatment

A

Pain relief, dehydration
Antibiotics
Surgical drainage and lavage

79
Q

Acute septic arthritis
Why does SA require shorter course than chronic OM
3-4 weeks vs 4-6 weeks?

A

Joint responds better than bone to antibiotics

MSK Systems (7 decks)

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