Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Pathological fracture, cord compression or acute neurovascular compromise
A fracture through an unexplained destructive lesion, rapidly progressive weakness or sphincter dysfunction from vertebral disease, or threatened limb perfusion requires immediate stabilisation without contaminating future tumour planes.
Action: Immobilise and provide analgesia, document distal neurovascular status, obtain urgent radiographs and specialist cross-sectional imaging and contact the bone-sarcoma centre before biopsy, internal fixation or curettage. Manage suspected cord compression with the metastatic-spinal-cord-compression pathway and plan any operation so the biopsy tract and contaminated tissue can be removed en bloc.
Synopsis
Recognise a possible primary malignant bone tumour before fracture or unplanned surgery, complete compartment-aware imaging, obtain a sarcoma-centre-planned biopsy and coordinate histology-specific chemotherapy, wide resection, radiotherapy, reconstruction and survivorship care.
Primary malignant bone tumours are rare; osteosarcoma peaks in adolescents, Ewing sarcoma in children and young adults, and conventional chondrosarcoma in later adulthood.
Persistent night or rest pain, focal swelling and an unexplained pathological fracture are key warning features; a remembered sports injury does not exclude sarcoma.
First-line imaging is a high-quality plain radiograph in two planes including the whole involved bone and adjacent joints.
Key red flags
Persistent focal bone pain, especially pain at night or at rest, warrants imaging when it is progressive, localised or unexplained by a resolving injury.
Pathological fracture
Sudden inability to bear weight through a destructive lesion is an oncological emergency requiring immobilisation and sarcoma-centre planning before fixation.
Investigation priorities
01
First-line whole-bone radiographsFirst stepFirst line
Characterise matrix, margins, periosteal reaction, cortical integrity and fracture in two planes including both adjacent joints.
02
Preferred MRI for local stagingPreferred
Map full intramedullary length, skip lesions, soft-tissue extension, joint involvement and relationship to nerves and vessels before biopsy.
Management branches
Suspicious bone lesionImage before tissue and refer before intervention
Persistent focal bone symptoms or radiography shows an aggressive or unexplained lesion.
Obtain two-plane radiographs of the whole bone, examine swelling, joint and neurovascular function and provide safe analgesia and weight-bearing advice.
Contact the regional bone-sarcoma service and complete tumour-protocol MRI before biopsy, with CT chest and whole-body staging arranged through the specialist team.
Key medicines
MAP chemotherapy for osteosarcomaUse specialist-protocol high-dose methotrexate with folinic-acid rescue, doxorubicin and cisplatin in suitable younger patients; exact doses, cycles, hydration and rescue are determined by the national age-specific sarcoma protocol.
VDC/IE chemotherapy for Ewing sarcomaAlternate specialist cycles of vincristine, doxorubicin and cyclophosphamide with ifosfamide and etoposide at protocol-defined intervals, using mesna, hydration and growth-factor support as specified.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.