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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 53-year old female presents to your community hospital with right shoulder pain of 2 weeks duration, night sweats, and loss of appetite. Her past medical history is significant for hypertension only. A radiograph is performed and is shown in Figure A. What is the most appropriate next step in management.
CT guided biopsy
Referral to an orthopaedic oncologist
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The clinical presentation is consistent with a malignant bone lesion. Referral to an orthopaedic oncologist is the most appropriate next step in management.
Biopsy of soft-tissue and bone lesions is a difficult procedure that is fraught with complications if obtained improperly. Occasionally, improperly performed biopsies may preclude limb-salvage, thus greatly altering the outcome of the disease process. Because of this, it is considered standard-of-care to refer patients with possible musculoskeletal tumors to treatment centers capable of proper diagnosis and management of the condition. While a community orthopaedic surgeon may know how to properly biopsy a lesion, it is in the patient's best interest to be referred to a treatment center prior to biopsy if that surgeon does not feel comfortable managing the patient afterwards.
Mankin et al. review 597 musculoskeletal oncology cases to determine the complications associated with biopsies. Of the 597 patients reviewed, 282 (47.2%) had the procedure at a referring institution. Out of all the biopsies, he found a 17.8% rate of diagnostic error, a 19.3% chance of an incorrectly performed biopsy causing a change in management, and a 3% incidence of an unnecessary amputation being performed.
Enneking et al. presents a surgical staging system for musculoskeletal sarcomas. They describe that their staging system, which stratifies lesions on the basis of the risk factors associated with various surgical procedures, enhances outcomes by properly weighing the risk of recurrence with the benefit of retained function.
Figure A is a radiograph that shows a ill-defined lytic lesion of the proximal humerus. The lytic appearance with cortical expansion suggests a malignant and aggressive process. The calficifications suggest a chondroid tumor and should raise the suspicion of a high grade chondrosarcoma.
Answer 1: Observation would not be appropriate as the clinical presentation is consistent for a malignant lesion.
Answer 2: The clinical presentation is not consistent with infection, so blood cultures would not be indicated.
Answer 3: A biopsy should be postponed until the patient is referred to an oncology center for the reasons described above.
Answer 4: A diagnosis must be established with proper staging prior to any treatment.
Mankin HJ, Mankin CJ, Simon MA
J Bone Joint Surg Am. 1996 May;78(5):656-63. PMID: 8642021 (Link to Abstract)
Mankin, JBJS 1996
Enneking WF, Spanier SS, Goodman MA
Clin. Orthop. Relat. Res.. 2003 Oct;(415):4-18. PMID: 14612624 (Link to Abstract)
Enneking, CORR 2003
HPI - History of trivial trauma to right thigh leading to pain and inability to bear weight.
Generalised muscular pain for last 5 years with weakness over both lower limbs for 3 years.
Cane assisted community ambulator for 3 years.
Non progressive swelling in the neck for last 7 years.
Further management of the Fracture Femur and Options for Prophylactic Fixation
Please rate question.
Average 2.0 of 37 Ratings
this is a very good review that outline anatomic sites for bone biopsy in d...
HPI - Pain started in Rt knee .gradual swelling.
no trauma. no fever.
No other body joint involvement
What would be your next step in managment?