A 79-year old female presents with complaints of right hip pain for 2 months. She denies prior injury or precipitating event. The pain is made worse by lying on the affected side and occasionally hurts with hip motion. The pain is improved with NSAIDS and placing ice on the lateral aspect of her hip. Her primary care physician ordered x-rays which showed a bone lesion in the proximal femur. Her PCP was concerned she had bone cancer and ordered an MRI of the thigh to further evaluate. AP x-ray and a coronal MRI image are shown above. The patient denies a history of weight loss, fatigue, and history of cancer. On exam the patient has no pain with passive range of motion of the hip in all planes. She has pain with palpation over the greater trochanteric bursae. Motor and sensation are intact throughout the lower extremities. What is the most likely cause of this patient’s pain?

A 78-year old male presents with approximately 4 years of persistent right hip pain without a known injury. Initial x-rays of the hip, including an AP x-ray shown above, were taken shortly after the pain started. The x-ray showed a benign appearing lesion at the base of the femoral neck but was otherwise normal. He was advised to rest and use NSAIDS as needed. An MRI of the hip was ordered 2 years later during orthopedic follow-up for persistent pain. MRI showed trochanteric bursitis and a lobular 3 cm lesion at the base of the femoral neck. The lesion appeared benign and was diagnosed as a likely enchondroma. A steroid injection was performed for trochanteric bursitis which offered him only short term relief. The patient then saw a spine surgeon who thought the pain was related to his spinal stenosis. He received foraminal injections to the lumbar spine but they failed to relieve his hip and thigh pain. His pain is now starting to get intolerable with weight bearing and he is noticing more pain at night. Repeat AP x-ray of the hip appears to be unchanged from the AP x-ray done 4 years prior. What would be the next best step in this patient’s work-up?

A 9-year old girl presents to the office with right arm pain after falling down a few steps at home. She felt her arm twist as she grabbed the rail to catch her fall. On x-ray a pathological fracture of the proximal humerus is found. The patient denies any pain in the arm prior to the fall. What is the best treatment option?

Which choice below correctly matches the bone tumor with its most common location of occurrence?

A 16-year old male presents to your office with anterior medial knee pain after being hit during a hockey game. He denies having knee pain before this injury. On exam of the knee you notice subtle laxity with valgus stress consistent with an MCL sprain. The rest of the exam is unremarkable. When reviewing x-rays of the patient you notice a well circumscribed radiolucent lesion on the lateral side of the proximal tibia. What is the name of this bone lesion?

A 5 year old African American boy presents to the orthopedic clinic complaining of right knee pain. The mother explains that the child has been complaining about the right knee pain for about a month and he started limping a few days ago. She does not recall any trauma or injuries that may have caused this. She has tried an ace wrap and hot packs on the knee, but nothing has helped alleviate the pain. She feels that the pain is increasingly getting worse. She denies any fevers or recent illnesses. She admits that his appetite has not been great and she thinks he has lost some weight. She reports that he is otherwise healthy, on no medications and has no known drug allergies. His immunizations are up to date. On physical exam of the right knee, there is mild swelling around the proximal medial tibia, which is firm to palpation. There is increased temperature and tenderness in the area without effusion. There is full range of motion and no instability. Examination of the left knee is unremarkable. AP and lateral x rays of the right knee, tibia, and fibula are obtained and demonstrate a lucent lesion in the proximal tibia metaphysis measuring approximately 2.5 cm in length by 2.0 cm in width. There is no periosteal reaction. There is a subtle transverse lucent line extending from the lesion medially for a length of about 1.5 cm. There appears to be some soft tissue swelling posteriorly and medially. Based on these findings, which of the following is the most likely diagnosis?

Which x-ray finding below would be suggestive of a malignant bone tumor?

A 10-year old female presents to your office with a 2 day history of left ankle pain after a twisting injury during a field hockey game. She presented to an urgent care office the day of injury where x-rays showed a large bone lesion in the calcaneus. No acute fractures were seen. She was diagnosed with a lateral ankle sprain, splinted, and sent for orthopedic follow-up. The patient denies having ankle pain prior to the recent injury. On exam the patient has tenderness over the lateral anterior talofibular ligament consistent with a lateral ankle sprain. The rest of the exam is unremarkable. When reviewing the patient’s ankle x-rays you notice a large, round, well circumscribed radiolucent lesion in calcaneus. A lateral x-ray of the calcaneus and a sagittal T1 MRI image are shown above. What is the most likely diagnosis?

A 54-year old male presents with a one month history of left hip pain. He is an auto-mechanic and slipped on a patch of wet flooring. He was able to catch himself from falling but in doing so felt a sharp pain in the lateral aspect of his left hip. He continued to work after the injury despite having significant pain and limitations secondary to the injury. AP x-ray of the left hip obtained in the office reveals a fracture of the greater trochanter. He denies any history of cancer, weight loss, or fatigue. MRI shows a lytic osseous lesion within the left greater trochanter and extending to the surrounding soft tissue. What is the next best step in treating this patient?

A 47-year old female presents to the emergency department with severe right hip pain after a standing height fall at home. She took a few steps off her front porch and her right leg collapsed from underneath her. She was unable to bear weight and was brought to the ED by EMS. X-rays of the right femur reveal a pathological subtrochanteric femur fracture. The patient was diagnosed with small cell lung cancer in the right upper lobe 6 months ago and is currently undergoing chemotherapy treatments. PET/CT scan one month ago revealed invasion into the mediastinum and right paravertebral area. You are called to evaluate the patient in the ED. Which choice is the next best step in treating this patient?

A 77-year old male presents to your office with a one month history of atraumatic left thigh pain. The patient is followed by a local oncologist who diagnosed him with multiple myeloma 2 years ago. He has known metastatic lesions throughout his spine. Recent x-rays and MRI confirm the source of the patient’s thigh pain is an impending fracture from a metastatic lesion. The patient’s life expectancy is greater than 6 months. What is the best next step in treatment of this patient’s impending fracture?

A 17-year old male presents to the office with a mass on the lateral aspect of his right knee. He noticed the mass approximately 6 months ago and doesn’t believe it has grown since. He denies pain at rest but he is starting to have pain over the mass when running. On exam the patient has a firm, nontender 2 cm mass over the lateral supracondylar femur. A positive Ober’s test is noted. AP and lateral x-rays are shown above. What is the most likely diagnosis?

A 42-year old male presents with a 2-month history of right sided groin pain. He denies injury or any known precipitating event. The pain is constant at rest and seems to be worse at night. He denies any history of known cancer. An AP pelvis x-ray, coronal MRI image, and an axial CT image are shown above. Results from a needle biopsy are consistent with a low grade chondrosarcoma. What is the next best step in treatment?

A 20-year old male presents with a 10 month history of progressive right knee pain and soft tissue swelling. AP x-ray and coronal MRI images are shown above. What is the most appropriate treatment plan?

A 15-year old male presents to the primary care office with complaints of right arm pain. He states that he has been experiencing the pain for a few months and really didn’t think about it until he started baseball practice recently. Upon further questioning, you find that he also admits to recent weight loss of 10lbs and a low grade fever. What is the most likely diagnosis?

A 17-year old male presents with progressive pain in his left shin for 3 months. Swelling is noted in the left calf and he has difficultly bearing weight on the leg. AP x-ray of the left leg, axial MRI, and axial CT images are shown above. What is the most likely diagnosis?

A 41-year old female presents with progressive right knee pain for the past 4 months. X-ray, MRI, and CT images are shown above. What is the most likely diagnosis?

A 13-year old male presents with left ankle pain after a fall 5 days ago. X-rays done at an outside urgent care facility show no evidence of a fracture (Figures 1 and 2 above). His exam reveals pain to palpation over the distal fibula physis consistent with a Salter-Harris type 1 fracture. An incidental bone cyst is noted in the distal tibia and the patient’s parents would like to know if the lesion requires further treatment. Which choice is the most appropriate recommendation?

A 63-year old female with a history of stage 4 non-small cell lung cancer presents to the emergency department with increasing pain in the right femur. The pain started 3 months ago and she denies any known injury or precipitating event. The pain is present with activities and at rest. A recent CT scan showed metastatic disease to her liver, adrenal glands, and pelvis. A bone scan showed increase uptake in bilateral femurs. X-rays (shown above) and CT of the right femur show cortical erosion along the diaphysis of the midshaft femur with periosteal reaction consistent with metastatic disease. The lesion involves approximately 20% of the medial femoral cortex. What is the best treatment choice for this patient?

A 65-year-old female presents to the orthopedic clinic with a 6-month history of right low back, gluteal, and thigh pain. The patient works as a nurse and has gradually noticed increasing pain in the right leg. She describes no history of injury or fall. She presented to the emergency room 2 months after the onset of pain for radiographs, which were read as negative. She was referred to a physiatrist, who repeated the AP x-ray shown above, which was also read as negative. The pain significantly affected the patient’s daily activities as well as work. The pain is worse with standing and walking activities, and is getting progressively worse throughout the day. She also complains of night time symptoms that regularly wake her from sleep. The physiatrist gave the patient a prescription for NSAIDs, which she states did improve her symptoms slightly, although the pain has returned. CT scan of the femur is shown above. What is the most likely diagnosis?

A 21 year-old male presents to the office with 4-5 months of right upper arm pain. He works in a warehouse and lifting objects is becoming increasingly painful. The pain became severe at work which prompted him to visit an urgent care. AP and lateral x-rays of the right humerus show a well circumscribed cystic lesion in the proximal humerus. MRI shows a 4 cm intramedullary lesion within the right proximal humeral diaphysis consistent with a unicameral bone cyst. There is endosteal erosion consistent with an impending or early fracture. What is the best treatment option for this patient?