Clinical assessment

The following factors should be elicited in the history:

• family history of bone diseases;

• genetic predisposition to conditions that may be associated with bone tumours (e.g. diaphyseal aclasis (Fig. 22.42));

• previous medical history (e.g. Paget's disease (Fig. 22.43));

• previous history of cancer;

• industrial exposure to carcinogens (i.e. employment history/occupation);

Figure 22.41. Echondroma of the proximal phalanx of the little finger.
Figure 22.42. Diaphyseal aclasis.

• environmental factors;

• geographical factors (e.g. UV light exposure);

• other predisposing factors such as previous DXRT for benign/malignant conditions or HIV infection.

Clinical features to be described are:

• Pain: site, characteristics, nocturnal component, aggravating/relieving factors, distribution, intensity/severity, duration, associated swellings/lumps/nodes.

• Swelling: site, size, shape, tenderness, etc. (Fig. 22.44), regional/distant nodal involvement, associated vis-ceromegaly (liver, spleen).

• Loss of function of affected part.

Figure 22.43. Malignant change in Paget's disease of the upper femur.

• Neural/vascular impairment.

• Associated systemic symptoms: loss of weight, anorexia, apathy, loss of interest, disturbed mental function, cachexia, night sweats, icterus.

• Associated features: pathological fracture (Fig. 22.46).

• Impairment of surrounding structures: nerves, vessels, tendons, joints, ligaments, for example solitary exostosis impairing function of hamstring tendons (Fig. 22.47).

• Spinal involvement either primarily or secondarily: cord/cauda equina/radicular involvement from extradural compression (Fig. 22.48).

• Cerebral involvement (from metastases): disturbed mental capacity/function.

• Biochemical upset: hypercalcaemia, hyponatraemia, hypoalbuminaemia.

In the case of metastases to the bony skeleton, consideration must be given to the site of the primary. This may not always be clinically obvious. The commonest organ tumours to

Figure 22.44. Giant cell tumour of the proximal phalanx of the third toe.
Figure 22.45. Aneurysmal bone cyst of the proximal ulna.

metastasize to bone are breast (Fig. 22.48), lung (Fig. 22.49), thyroid, kidney and prostate. Therefore, it is essential to identify a general examination of a patient presenting with malignant disease involving the skeleton to locate a primary tumour at a remote site. Assess for:

• neck lumps/swelling;

• respiratory symptoms (chest pain, productive cough, haemoptysis);

• breast lumps, previous mastectomy/lumpectomy scars;

• urinary symptoms/haematuria;

• rectal examination for rectal masses and assess the prostate.

Figure 22.46. Carcinoma of the prostate with pelvic metastases: pathological fracture of the left acetabulum.
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