Introduction
The tool is based on the 'A guideline to assist healthcare professionals in the assessment of children and young people who may have a bone tumour'. The guideline has been developed following careful consideration of the available evidence through a systematic review and has incorporated professional expertise via a Delphi consensus process. You can also access the full guideline, and a summary version will be produced shortly.
Click on the symptoms below to navigate individual sections of the guideline and our recommendation to either Refer/Review/Reassure.
Key symptoms
The following symptoms and signs are all associated with childhood bone tumours. Their presence should alert the clinician to this possibility.
Core symptoms
- Bone pain
- Swelling
- Bone mass/lump
- Limp/Restricted movement
Associated symptoms
- Persistent back pain especially with associated bladder/bowel/erectile dysfunction
- Fever
- Weight loss
Symptoms and signs in childhood bone tumours may occur singularly or in combination.
1. Bone pain
- Consider a bone tumour in any child with persistent* bone pain
- Ask about the presence of the other symptoms of a bone tumour (swelling, palpable lump, restricted movement/limp, fever, weight loss, back pain and bowel/bladder/erectile dysfunction) in a CYP presenting with persistent bone pain.
- Bone pain from a bone tumour can occur at any time of the day or night
- Injuries can be a red herring. Take a detailed history of the events including the onset of the symptoms after the alleged injury. Pain secondary to an injury will get better day by day.
*Persistent = continuous or recurrent bone pain present on most days for 2 weeks or more
Reassure
Symptom:
- Pain for less than 2 weeks
- Convincing history of injury that fits with the localised pain and is improving
- Reducing need for pain relief
- Not associated with other worrying features
Action(s):
- Reassure
Review/refer
Symptom:
- Pain present for less than 2 weeks
- Vague or presumed history of injury
- Any other worrying features
Action(s):
- Observe and review at two weeks
- Repeat history and examination
Scan
Symptom:
- Persistent worsening bone pain lasting more than 2 weeks
- Localised bone pain that is waking a child or teenager at night
- Unexplained bone pain without any preceding injury
- Bone pain that is out of proportion to the injury sustained or that does not improve 2 weeks from injury
- Bone pain with associated neurological symptoms
- Persistent back pain or pelvic pain
(discuss with paediatric radiologist as X-ray may not exclude a tumour)
Action(s):
- Urgent X-ray
- In primary care, request for imaging should not delay referral
- Attributing symptoms to an injury incorrectly – when there is a vague or only suspected history
- Assuming that a normal X-ray findings exclude a bone tumour, especially for back or pelvic pain and when symptoms are still persisting
- Joint/limb examination: look, feel, move, assess
- Neurological examination
- pGALS examination
- Pain in spine or pelvis
- Affecting activities of daily living
- Associated neurological deficit
2. Swelling
- Swelling from a bone tumour can be discrete or diffuse
- It can occur along the long bone or around a joint
- Swelling due to a bone tumour can present with overlying erythema
- Ask about the presence of the other symptoms of a bone tumour (bone pain, palpable lump, restricted movement/limp, fever, weight loss, back pain and bowel/bladder/erectile dysfunction)
Reassure
Symptoms:
- Swelling for less than 2 weeks
- Clear evidence of infective cause eg bite/sting
- Clear evidence of injury
- Responding to antibiotic therapy
- No worrying features
- No high-risk conditions
Action(s):
- Reassure
Review/refer
Symptoms:
- Swelling for less than 2 weeks
- No corroborating infective cause
- Not responding to antibiotic therapy
- Vague or unclear injury reported
- Injury not improving as expected
- Any other worrying features
Action(s):
- Observe and review two weeks
- Repeat history and examination
Scan
Symptoms:
- Persistent* swelling rapidly increasing in size
- Persistent* swelling not resolving despite treatment with regular anti-inflammatories or antibiotics
*Persistent swelling present for more than 2 weeks
Action(s):
- Refer for assessment and imaging
- Attributing a red warm swelling to infection despite no improvement with antibiotics
- Determine the exact duration of the swelling and characteristics of the swelling
- Determine any preceding mechanism of injury or bite/scratch
- Ask specifically for associated symptoms and risk factors: personal history of Li Fraumeni syndrome or hereditary retinoblastoma
- Joint/limb examination: look, feel, move, assess
- Neurological examination
- pGALS examination
- Swelling that is rapidly increasing in size
3. Bone mass/lump
- A bony mass/lump which is increasing in size can be a sign of a bone tumour
- Ask and examine for the other signs and symptoms suggestive of a bone tumour (bone pain, swelling, limp/restricted movement, fever, weight loss, back pain and bladder/bowel/erectile dysfunction) in CYP with a lump/mass
Reassure
Action(s):
- All bony masses will need a review to monitor any growth
Review/refer
Symptom:
- Bony mass present for less than 2 weeks
- With or without corroborating injury history
- No associated symptoms
- No high-risk conditions
- Any other worrying features
Action(s):
- Urgent X-ray
- In primary care, refer for assessment imaging
Scan
Symptom:
- A rapidly increasing lump
- A lump/mass with one or more other symptom
Action(s):
- Urgent X-ray
- In primary care, refer for assessment imaging
- Attributing a bony lump/mass to infection despite no response to antibiotics
- Assuming that bony lump has been present since birth and unnoticed by parents/carers prior to presentation
- Determine the exact duration and size of the lump/mass
- Determine any preceding mechanism of injury
- Ask specifically for associated symptoms and risk factors: personal history of Li Fraumeni syndrome or hereditary retinoblastoma
- Joint/limb examination: look, feel, move, assess
- Neurological examination
- pGALS examination
- With associated neurological deficit
4. Restricted movement/limp
- A bone tumour in the pelvis or lower limb can present as a limp
- A bone tumour in the upper limb can manifest as restricted movement
- Ask about the presence of the other symptoms of a bone tumour (bone pain, palpable lump, restricted movement/limp, fever, weight loss, back pain and bowel/bladder/erectile dysfunction)
- Have a high level of concern for a CYP who is normally highly active or sporty but is no longer able to play sport due to the presenting symptom
- Follow your local limping child pathway
Reassure
- Very short history of limp consistent with history of transient synovitis
- Short-lived restricted movement with clear cause without any other symptoms or high-risk conditions
- No associated with other worrying features
Action(s):
- Follow your local limping child pathway
Review/refer
- Limp/restricted movement for less than 2 weeks
- Improving at a slower rate than expected
- Any other worrying features
Action(s):
- Observe and review at two weeks/ follow your local limping child pathway
- Repeat history and examination
Scan
- A child or young person who is non-weight bearing
- Persistent* restricted movement despite adequate analgesia
*Persistent = present for more than 2 weeks
Action(s):
- Urgent X-ray
- (Refer for imaging in conjunction with following limping child pathway)
- Failure to enquire about activities of daily living
- Determine the exact duration of the limp/ restricted movement
- Determine any preceding mechanism of injury
- Ask specifically for associated symptoms and risk factors: personal history of Li Fraumeni syndrome or hereditary retinoblastoma
- Joint/limb examination: look, feel, move, assess
- Neurological examination
- pGALS examination
- Associated neurological deficit
- Previously high-level athlete, unable to continue
Summary poster
