Orthopaedic department

Model answer quiz 1 RT4

Objectives
1. Understand the important history, physical exam, and radiographic findings consistent
with a diagnosis of osteosarcoma.
2. Know the essential components of the workup for a musculoskeletal lesion, specifically
an osteosarcoma.
3. Appreciate the need for a multidisciplinary approach to treatment

Summary:
This is a 12-year-old otherwise healthy boy who presents with a 2-month history of dull left
thigh pain that was initially activity dependent but has progressed and is now most severe at
rest, especially at night. he denies any fevers, chills, night sweats, or recent weight loss. A
mass in his distal thigh is palpated on examination.

Model answers

- X-ray findings:
(a) Anterior-posterior and (b) lateral radiographs of the left knee demonstrate bone
formation (black asterisk) and bone destruction at distal end of femur ,There is an
associated large soft tissue component. The lesion results in periosteal reaction and
elevation of the periosteum (Codman triangle) (white arrow). Note that the physes are
open.

• Most likely diagnosis: Pathologic bone tumor, specifically osteosarcoma.

• Next steps in workup: Magnetic resonance imaging (MRI) y, tissue biopsy, computed
tomography (CT) scan of the chest, and a bone scan.
Orthopaedic department
Model answer quiz 1 RT4

• Treatment approach:
Two to three cycles of neoadjuvant chemotherapy are commonly given before wide-margin
surgical resection is performed, which involves achieving the largest possible margin
without unnecessary functional sacrifice, The excised segment of bone may be replaced
with a prosthesis and/or allograft. Postoperative chemotherapy is also typically used.
Fortunately, approximately 90% of patients with osteosarcoma are able to undergo limb
salvage procedures and do not require amputation. Radiation is not used in the treatment
of osteosarcoma

Considerations
There are many important clinical, radiographic, and pathologic findings that will aid the
orthopaedic surgeon in establishing the proper diagnosis in the setting of a likely
musculoskeletal tumor, as in this case.
Diagnosis begins with the history and physical exam. Concerning findings in this patient
include his progression of pain symptoms, to the point where it awakens him from sleep,
and the presence of a palpable mass.
Age is another important consideration, especially for establishing an appropriate
differential diagnosis. Furthermore, some tumors have a sex predilection; osteosarcoma is
more common in males.
Laboratory tests are not typically diagnostic for bone tumors, but may be helpful once a
diagnosis is made. Imaging must begin with at least 2 plain radiographic views of the lesion.
An MRI is typically obtained after and has become the imaging modality of choice for most
musculoskeletal tumors. Nuclear imaging and CT are also performed for evaluation of
metastases, staging, and surveillance
. Biopsy of the lesion allows for histologic analysis, which determines tumor grade and
significantly impacts treatment options and ultimate prognosis.
After this workup, a multidisciplinary treatment orthopaedic surgeon and oncologist