Synopsis
Recognise mechanically unstable metastatic bone disease, establish diagnosis before contaminating surgery and construct a coordinated stabilisation, radiotherapy and systemic-treatment plan that restores useful function.
- Deep progressive pain is common, but functional pain with standing, transfers or limb rotation is the high-yield sign of mechanical instability.
- First-line imaging of a symptomatic peripheral bone is radiography in two planes including the whole lesion and adjacent joint; a normal film does not exclude marrow disease.
- CT defines cortical destruction and fixation anatomy, while MRI is the reference study for marrow, occult fracture, soft tissue and neural involvement.
Key red flags
Functional pain on standing or transfers through a proximal femoral lesion indicates mechanical failure risk even before a visible fracture line.
Investigation priorities
Define fracture, lesion phenotype, cortical loss, joint involvement and other deposits along the proposed construct.
Management branches
Functional pain, cortical destruction or a complete fracture threatens safe limb use.
- Stop unprotected loading, splint a completed fracture and document skin, pulses and neurological function.
- Provide multimodal analgesia and assess bleeding, calcium, renal function, VTE and pressure-area risk.
The lesion is painful but structurally stable or surgery offers no proportionate benefit.
Key medicines
Zoledronic acid for eligible bone metastasesUse 4 mg by intravenous infusion over at least 15 minutes every three to four weeks for licensed skeletal-event prevention, modifying dose for baseline renal function according to the product information.
Denosumab for eligible solid-tumour bone diseaseAdminister 120 mg subcutaneously once every four weeks with calcium and vitamin-D supplementation unless hypercalcaemia prevents it, following NICE eligibility and product guidance.