Rural Orthopaedic Surgeon Offers Perspective on Musculoskeletal Oncology

Editor’s note: The Final Cut is a recurring editorial series written by a member of the AAOS Now Editorial Board.

I saw a patient within the past year who was aged around 60 years and in generally good health, though he was a heavy smoker. He had been having shoulder pain for several months and had seen his primary care physician twice for this. He was diagnosed with a muscular strain and given medication and referral to physical therapy, but no imaging was done. After a few months of continued pain, he returned to that physician, and an MRI was ordered, which was denied by insurance due to lack of physical therapy. Not long after that, he presented to the emergency department for shortness of breath, during which time he reported his ongoing shoulder pain. Radiographs showed a very large metastatic lesion in the proximal humerus with a pathologic fracture. The tumor was invading the local soft tissues, and a very large lung mass was discovered, along with a pleural effusion. I stabilized the fracture, mostly for palliative reasons, and it allowed easy sampling of the tumor for diagnosis; it was confirmed to be squamous cell lung cancer. Had the initial physician performed a radiograph and seen the mass earlier, would it have changed his outcome? Likely not, but it may have allowed earlier intervention and spared some pain and surgery for the pathologic fracture. The physician was not an orthopaedic surgeon, but it’s safe to assume that a busy surgeon could easily overlook this.

Why am I telling this story? Because having to look that patient in the eyes and counsel him about his fracture, all the while knowing he would not survive long enough to see it heal, if it ever did, was emotional for me. It reinforced the importance to me of knowing the basics of musculoskeletal oncology. At the very least, I believe it’s important to recognize when something is not a normal or expected finding and when to refer to a higher level of care. Having a working relationship with an orthopaedic oncologist in your area is invaluable. Your area of practice may be hand surgery, joint reconstruction, or general orthopaedics (like me), but every so often you will be the first one to see a patient with cancer, and recognizing this may help save their life, impact their treatment options, or provide them with better quality of life for their remaining time.

I suspect I was not alone in my lack of enjoyment taking pathology courses as an orthopaedic surgery resident. Diagnosing, staging, and treating musculoskeletal tumors are not easy. The surgeries are complex, are often very long, and require meticulous surgical technique. One of the perks of orthopaedics, in my opinion, is not having to manage terminal illnesses or life-threatening situations on a daily basis. There’s an emotional toll in caring for critically ill patients, and, as vital as that care is, I knew I didn’t want that to be my day-to-day work. I enjoy helping patients heal fractures and restore function or improve existing function from arthritic joints or sports injuries. Orthopaedic oncology was always something I was happy to learn and then promptly forget. But these things have a way of following you. I’ve become a general orthopaedic surgeon in a rural area, and I see patients with tumors more than I expected. I’ve been the first to diagnose and treat a new cancer in at least two patients this year and treated pathologic fractures or prophylactically stabilized lytic lesions in several others. I believe it’s imperative that all orthopaedic surgeons maintain at least a basic knowledge of common musculoskeletal tumors and their presentation. You will encounter these patients no matter what subspecialty you’re in. Knowing how to approach these patients is important and can make the difference in early versus late diagnosis. It can also help with pain control and palliation in a terminally ill patient.

The concept of maintaining basic competency in areas you may not necessarily have an interest in treating or subspecializing in, such as oncology, can be extended to other areas—for example, infection, pediatric injuries, and urgent conditions such as compartment syndrome or open fractures. If you take call at a hospital, you will see all of those problems at some point. There will always be calls to rule out a septic joint, finger infection, compartment syndrome, etc. If you live in an isolated area like I do, transferring these patients isn’t always an option either, so being able to treat these patients is important as well. Knowing what to treat, what is emergent/urgent, what should be referred to a specialist, and when something just doesn’t look right and needs a second opinion are all important skills to have.

A good example is a patient I treated for an open tibia fracture. She was a young, healthy woman involved in a high-speed motor vehicle accident. I work at a large regional hospital, but it is not a trauma center. We handle many orthopaedic injuries, but we do not have general surgery trauma surgeons. Any high-energy trauma is taken to the nearest level 1 trauma center an hour and a half away. On this particular night, however, severe weather kept the medevac helicopters grounded, and there were no ambulances available to transport her; they were all in service already. This poor lady was stuck with me, and although I am not a trauma surgeon, I treated her open fracture; she ultimately did very well. There’s a reason we learn so many things in residency! I may not treat complex trauma every day, but being able to handle an emergency like that helped me provide the care she needed to make a full recovery.

I believe it’s important for all orthopaedic surgeons to remain up to date on a breadth of issues, no matter what our subspecialty is. A particular topic may not be everyone’s cup of tea, but staying current with the basics will make you a better physician, and that’s something I believe we should all strive for.

Leslie Schwindel, MD, FAAOS, is a general orthopaedic surgeon at Lake Cumberland Regional Hospital in Somerset, Kentucky, and a member of the AAOS Now Editorial Board.