- Referrals for impending pathologic fracture due to a bony metastasis in a major long bone are typically from hospital specialties (oncology, haematology, respiratory medicine, renal medicine, breast surgery and urology) but may also be identified in primary care.
- Increasing pain, particularly on weight-bearing or loading is a red flag sign of possible impending fracture. Lytic lesions, those with cortical thinning, those affecting the lower limb (particularly the subtrochanteric area of the proximal femur) are at higher risk of fracture.
- Where a painful bony metastasis is identified in a long bone and there is a suspicion of impending pathologic fracture referral should be made to our on-call Registrar in Ninewells on pager 4561 (or to our on-call consultant on pager 3169 for primary care referrals)
- Referral should be made according to the location of the lesion (upper limb, hand, hip, knee, foot & ankle) or to paediatric orthopaedics for a child (under 16). URGENT – SUSPECTED CANCER priority.
- Advice can also be obtained by contacting the daytime on call consultant (pager 3169).
- Spinal tumours are managed by the Neurosurgery department.
Bone Tumours
Bone tumours are often detected on X-rays for the investigation of unexplained skeletal pain but may be incidental findings on X-rays performed for other reasons. Lesions may diagnosed on an X-ray report based on their appearance or a differential diagnosis may be given. A lesion may be identified as indolent or benign, locally aggressive, malignant or indeterminate. Further imaging (MRI, CT) may be required to help with the diagnosis.
- Aggressive, malignant or indeterminate bone lesions require urgent referral to one of our subspecialty clinics with URGENT – SUSPECTED CANCER priority for assessment, further investigation, staging and arrangement of biopsy where appropriate. Onward referral to a regional musculoskeletal tumour service (usually Aberdeen) for specialist management is usually required.
- Benign Bone Tumours. There are many different benign tumours of bone. Depending on their nature, size and location, some benign bone tumours may predispose to pathologic fracture and require bone grafting whilst others may benefit from surgery to help symptoms. Some may require observation and serial x-rays. Where a benign bone tumour is detected referral should be made to the appropriate subspecialty with URGENT priority.
Soft Tissue Tumours
- Any subcutaneous or deeper soft tissue lesion on a limb which is suspicious of malignancy / sarcoma (>5cm, rapid growing, ill-defined, solid or firm, irregular, suspicious features on US or MRI) should be referred as URGENT – SUSPECTED CANCER to the relevant subspecialty for assessment and staging or alternatively discussed with the on call consultant (pager 3069). Onward referral to a specialist musculoskeletal tumour unit (usually Aberdeen) is usually required