History and Physical Examination

Although pain is an important symptom of musculoskeletal metastases, it is nonspecific. The pain pattern can be helpful if, in addition to being activity-related, it is present at rest and at night, especially in patients older than 50 years. However, this pain pattern can be present in patients with osteomyelitis and Paget disease, and in these instances, it is also nonspecific.

There are two main scenarios in which an orthopedic surgeon will be consulted to help evaluate a patient with a suspicious bony defect, as follows:

In the first instance, the surgeon is asked to help evaluate a patient who has experienced a pathologic fracture or who has a known primary carcinoma as well as a bony defect
In the second, more worrisome instance, the surgeon is consulted in the evaluation of a patient whose bony defect was serendipitously found during the radiologic evaluation of another condition

In the above instances, the orthopedist must perform the following three functions:

Determine the cause of the bony defect
Predict the probability of fracture ^[23]
Prophylactically fix a pathologic or impending fracture

These functions are discussed further in Workup.

Differential Diagnoses

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Media Gallery

Lateral view of the femur of a 70-year-old man with metastatic prostate carcinoma, the most common cause of osteoblastic metastases in men.
Radiograph of a patient with severe rest- and activity-related pain at the time of presentation.
Pathologic fracture. Radiograph shows a displaced fracture through an osteolytic lesion in the distal femur of a 53-year-old woman with lung carcinoma.
Radiograph shows osteolytic metastasis in the distal femur of a 51-year-old woman with breast carcinoma.
Lateral radiograph shows sclerotic metastasis of the L2 vertebra in a 54-year-old man with prostatic carcinoma.
Axial computed tomography scan shows 2 rounded, mixed osteolytic-sclerotic lesions in the thoracic vertebral body of a 44-year-old woman with lung carcinoma.
Axial computed tomography scan shows a destructive osteolytic lesion in the left acetabulum of a woman with vulval carcinoma. Soft-tissue extension into the pelvic cavity is present.
Sagittal spin-echo T2-weighted magnetic resonance image shows hypointense lesions in the T10 and L3 vertebrae in a 66-year-old man with lung carcinoma. The tumor involves the T10 pedicle. See also the next image.
Sagittal short-tau inversion recovery magnetic resonance (MRI) from a 66-year-old man with lung carcinoma. This MRI shows hyperintense lesions in the T10 and L3 vertebrae, with T10 pedicular involvement.
Sagittal short-tau inversion recovery (STIR) magnetic resonance image (MRI) in a 68-year-old man with thyroid carcinoma. This MRI shows severe compression of the L1 vertebra with retropulsion. Affected T11-L2 vertebrae show signal hyperintensity, posterior vertebral body marginal bulging, and spinal canal narrowing. See also the next image.
Sagittal gadolinium-enhanced spin-echo T1-weighted magnetic resonance image from a 68-year-old man with thyroid carcinoma. This image shows heterogeneous enhancement of the T11-L2 vertebrae, with prominent epidural component enhancement and spinal canal compromise. See also the next image.
Axial spin-echo T1-weighted magnetic resonance image (MRI) in a 68-year-old man with thyroid carcinoma. This MRI shows tumor extension from the L1 vertebral body and left pedicle into the left psoas muscle and epidural space, with resultant spinal cord compression. See also the next image.
Axial gadolinium-enhanced spin-echo T1-weighted magnetic resonance image from a 68-year-old man with thyroid carcinoma. This image shows heterogeneous enhancement of the soft tissue component of the L1 vertebral metastatic tumor.
Typical scintigraphic pattern of bone metastases in a 60-year-old man with nasopharyngeal carcinoma. This posterior technetium-99m bone scintiscan shows multiple randomly distributed focal lesions scattered throughout the skeleton, particularly the spine, ribs, and pelvis.

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Metastatic Bone Disease Clinical Presentation

History and Physical Examination

References

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