orthopaedics

1. Dr. Majed Alasbali

2. Objuctive
 Pretest
 Review
 Long case
 Short cases
 Test

4. 16 y female , night pain , improved by voltaren.
treatment?

5. 30 y male foot pain
diagnosis?

6. 30 y male , ankle painful swelling
treatment ?

7. 30 y female , painless mass
treatment ?

8. 12 y female ,leg pain 3/12
treatment ?

9. 30 y/o female

10. 38 y female ,looks fine
single lab work ?

12.  Bone lesion xray

13. evaluation

14. History
Constitutional symptoms
Functional
History of Presenting Illness
Personal data : AGE
Past ,Family , Social

15. HPI
 Painless Mass (Bony or soft tissue)
 painful mass (Bony or soft tissue )
 Pathological fracture
 Incidental finding

16. EXAMENATION
Look Feel Move
Adjacent joints ROM
NV exam
Lymph nodes
General

17. Imaging
 X-Ray
 CT
 MRI
 BONE SCAN
 PET-CT

18. Imaging
 Detection (X-rays, bone scan, MRI for soft tissue tumor)
 Characterization (X-rays, CT scan)
 Local staging (MRI)
 Evaluation for regional and distant metastases (CT
chest, bone scan, PET scan)

19. What to read in X-Ray
1. Site
2. Size
3. Matrix
4. Pattern/margins incl. zone of transition
5. Effect of the lesion on bone
6. Reaction of bone to the lesion
7. Soft tissue mass

20. site
• Which bone is affected (femur, radius,…)
• Where in the bone
 Diaphysis, metaphysis, epiphysis, or combination
 Central, eccentric, intracortical, surface

21. matrix
• Fibrous
• Cartilagenous
- stippled, arcs and rings
• Osseous
- cloud-like, dense

23. LESION EFFECT ON BONE
• Cortical thinning
 Lower grade, less aggressive
• Cortical expansion
 Low or high grade, tumor mimickers
• Cortical destruction
 High grade, aggressive

24. EFFECT BONE ON LESION
Periosteal reaction
 Absent
 Mild – one layer, 1-4 mm thick, adjacent to cortex
 Major - >5mm, multilayered or lamellated
“onion-skinning”, “hair-on-end”, “sunburst”

26. SOFT TISSUE MASS
Soft Tissue Mass
• Absent
• Present

27. LABORATORY STUDIES
GENERAL : CBC, renal profile , coagulation profile
INFECTION : ESR, CRP
METABOLIC :calcium & phoshate, alkaline phosphatase , PTH
METS

28. treatment
NonOperative
 Observation
 Bisphosphonate therapy
 Radiation alone
 Chemotherapy alone

29. treatment
Operative
 Radiofrequency ablation
 Aspiration and Injection
 Curretage and Bone Grafting
 Marginal Resection
 Wide Resection Alone
 Wide Resection + Chemotherapy

32. Differential by AGE

33. Differential by LOCATION

34. Differential by ANATOMY

35.  Enneking system—Enneking and associates developed a staging
system for benign and malignant musculoskeletal tumors.
 American Joint Commission for Cancer (AJCC) classification system
STAGING

36. benign lesions
 1 latent lesion
 e.g. NOF,enchondroma
 2 active lesion
 e.g. ABC, UBC
 3 aggressive lesion
 e.g. giant cell tumor of bone

37. Staging

38. Biopsy
 Fine Needle Aspiration (FNA)
 not typically used for sarcoma
 Core biopsy (Tru-cut)
 allow for tumor structural examination
 cytologic and stromal elements of the tumor
 frequently used for sarcoma
 Incisional biopsy
 small surgical incision carefully placed to access tumor without
contamination of critical structures
 Excisional biopsy
 small, superficial soft tissue masses

39. NOT FOR BIOPSY
 An asymptomatic (latent) or symptomatic bone lesion
(active) that appears entirely benign on imaging does
not need a biopsy
 A soft tissue lesion that appears entirely benign on
MRI (lipoma, hemangioma) does not need a biopsy
 When in doubt, it is safer to do a biopsy.

40. INDICATIONS FOR BIOPSY
1) Aggressive or malignant appearing bone or soft tissue
lesions
2) For soft tissue lesions - >5cm, deep to fascia or
overlying bone or neurovascular structures
3) Unclear diagnosis in symptomatic patient
4) Special situation - solitary bone lesion in a patient
with a history of carcinoma

41. BEFORE BIOPSY
 CBC, platelets, coagulation screen
 Cross-sectional imaging – depicts local anatomy, solid
areas of tumour
 Experienced musculoskeletal pathologist available

42. PRINCIPLES OF BIOPSY
SKIN
Avoid tenuous skin , Avoid transverse incision
DEEP
Through muscle , meticulous hemostasis , Avoid NV
SAMPLE
Ensure adequate diagnostic tissue , FROZEN –SECTION
CLOSURE
Tight muscle closure , drain at corner , compression dressing
Send for C/S

43.  For tumours without soft
tissue mass, plan biopsy
through area of maximal
cortical weakening based on
CT or MRI .
 For tumours or with soft
tissue mass, biopsy soft
tissue rather than creating
hole in bone .

44. Chemotherapy
 induces apoptosis
 eliminates micrometastasis in lungs
 >98% necrosis with chemotherapy is good prognostic sign
 Multi-drug resistance (MDR) gene (poor prognosis )
 cells can pump chemotherapy out of cell
 present in 25% of primary lesions and 50% of metastatic lesions

45. Radiation therapy
 Two mechanisms of action
 production of free radicals
 direct genetic damage

46. Indications of External beam
irradiation
 Definitive control (primary malignant bone tumors)
 Ewing sarcoma , primary lymphoma of bone
 Adjuvant to surgical excision
 soft tissue sarcomas
 Palliative care and after impending fracture
fixation
 needed after fixation of impending/pathologic fractures to
reduce overall tumor burden

47. Complications of Radiation
therapy
 Radiation effects on normal tissue
 early effects
 delayed wound healing , infection
 late effects
 fibrosis , joint stiffness
 Post-radiation sarcoma
 incidence is ~13% , poor prognosis
 Post-radiation fractures

48. Impending fracture
prophylactic fixation
Harrington's criteria
 Life expectancy greater than 1 - 2 months
 Continued pain after radiotherapy
 Lesion greater than 2.5 cm diameter in metaphysis (50 - 75 %
destruction)
 Destruction of 50% or more of the diaphyseal cortex of a long bone
 Adequate bone quality
 Procedure would enhance mobilisation and independence