Synopsis
Detect a metastatic long bone approaching mechanical failure, integrate symptoms and cross-sectional cortical assessment with decision tools and stabilise electively before fracture when benefit outweighs operative burden.
- Functional pain during weight bearing or transfer is the most important bedside warning of impending long-bone failure and should trigger immediate load protection.
- First-line imaging is full-length radiography in two planes; CT is the preferred structural adjunct for circumferential cortical loss and operative geometry.
- Mirels scores site, pain, lytic character and lesion size from one to three each; a total of nine or more historically supports fixation consideration.
Key red flags
Pain produced by standing, rising from a chair or rotating the limb is a mechanical warning even when resting pain is controlled.
Investigation priorities
Establish lesion phenotype, longitudinal extent, cortical destruction, fracture and relation to joints or existing implants.
Management branches
Functional pain or imaging indicates a high-load cortex may fail during ordinary activity.
- Prescribe explicit protected or non-weight bearing and provide a safe aid before further transfers.
- Obtain full-length radiographs and urgent CT, adding MRI for occult fracture or uncertain extent.
Key medicines
Paracetamol during protected mobilisationUse 500 to 1,000 mg orally when required with at least four hours between doses, limiting total intake to 4 g daily and reducing the ceiling in low weight, malnutrition or liver disease.
Low-molecular-weight heparin when VTE assessment supports itUse the locally approved prophylactic regimen according to body weight, renal function, platelet history, bleeding risk and planned neuraxial or operative timing.