Simple Presentations of Sinister Pathology to an Upper Limb Orthopaedic Clinic

Abstract

Background: Bone and soft tissue sarcomas present to orthopaedic and rheumatology clinics in district general hospitals with a diverse array of symptoms and signs. Delays in diagnosis adversely effect prognosis and referral pathways have been set up in order to centralise care of these complex and rare tumours to improve outcomes. Methods: We present a series of 7 interesting cases that presented with bone and soft tissue tumours to an elective upper limb clinic over a period of 3 years and managed using the appropriate referral pathways. Results: In this series 1 patient presented with a metastatic bone deposit from a renal primary and had treatment locally after investigations suggested it was metastatic. Six patients were seen with soft tissue swellings, had magnetic resonance imaging and were subsequently referred to the sarcoma unit for further assessment. Two patients underwent biopsy and were found to have uncommon benign pathology – nodular fasciitis and tumoural calcinosis. The remaining 4 patients were found to have sarcomas with different histological features – spindle cell, epithelioid, alveolar soft part and follicular dendritic (recurrent). Each of these patients was referred expeditiously from the orthopaedic clinic but despite this later developed metastasis from their primary sarcoma. Discussion: Recognition of bone and soft tissue tumours is not always straightforward and it is not unusual to see delays in diagnosis and consequent referral. Late referral to specialist orthopaedic services has a significant impact on prognosis and guidelines have been developed to facilitate this. Awareness of the red flag symptoms and signs to arrange prompt referral leads to better outcomes.