Step 4: Imaging

Objective :

Recognize features of an abnormal X-ray

Tip 1

A fracture line can be appreciated at the base of the femoral neck, which is also significantly shortened. You can also see that the femur on the right has moved proximally and rotated due to the action of the psoas muscle.

Tip 2

Multiple lytic and blastic lesions involve both femurs and the pelvis. The bones appears 'moth-eaten', which is a term used to describe this appearance, which is characteristic of metastatic disease.

Tip 3

Here you can see another lesion in the bone that looks suspicious. The fact there is more than one lesion suggests metastatic disease rather than a primary bone cancer.


What are the most likely diagnoses?

Metastatic Disease

Tip 6

This X-ray has many hallmarks of metastatic carcinoma. The cancers that most commonly spread to bone include breast, prostate, lung, renal cell carcinoma, and thyroid – all the 'paired' organs.



Tip 7

Yes. There is a fracture at the base of the right femoral neck.


Primary Bone Tumour

Tip 8

Very unlikely, but possible. The multiplicity of lesions, the findings of a breast mass and the X-ray appearance are much more like metastatic disease.



Tip 9

No. There does not appear to be severe osteoarthritis of her hip joints.

More Info Next Step

This lady has sudden onset of hip pain with inability to weight bear after minor trauma. Initial work-up should include an X-ray, which will detect the presence of fracture and/or bone tumours. Other investigations would include bloodwork, a chest X-ray and a biopsy of her breast mass.