Review Question - QID 478

The history and radiographs suggest a potentially malignant process in this patient. As such, prior to instituting any treatment, she needs complete staging. The next best step would be getting cross-sectional advanced imaging of the lower extremity

Starting treatment prior to full oncologic workup can have devastating consequences (even if the radiographs suggest a giant cell tumor. This would include chest and lower extremity imaging, laboratory work up +/- bone scan. If her pain is so severe that something needs to be done immediately, admit her for parenteral narcotics and tumor work-up would be appropriate. Pending her work-up, she may need chemo/radiotherapy, referral to a sarcoma center, and limb salvage surgery.

Biermann et al. reviewed metastatic bone disease. They emphasize that these are perpetually mechanically unstable bones with large, non-regenerating defects and that fixation constructs should be immediately stable for full weightbearing. Causes of construct failure include incomplete debulking, inadequate fixation, failure to fix the entire bone, use of degradable substances instead of cement, or use of familiar implants and techniques instead of ones appropriate for fixation of pathologic fractures.

Figure A and B show a well demarcated lytic lesion in the proximal lateral tibia.

Incorrect Answers:
Answer 1: Intra-articular cortisone injection are not recommended in this situation.
Answer 3: If her pain is so severe that something needs to be done immediately, admit her for parenteral narcotics and tumor work-up would be appropriate.
Answer 4: Physiotherapy and anti-inflammatory medications would not address the pathology noted in her tibia.
Answer 5: Hip radiograph would not be needed in the work-up of this pathologic lesion.