This 74-year-old woman had a long history of migraine, which had been fairly stable for years, but started to cause more problems. Her doctor tried several treatment options, including triptans, none of which worked. She was referred to a neurologist, who arranged an MRI scan. This revealed a large benign meningioma. The patient was referred for surgery. Following her craniotomy, her migraines disappeared, but she was left with some residual mobility problems.
Malignant myxoid chondrosarcoma
This 51-year-old man presented with a fracture of his right shoulder. He was referred urgently and this MRI scan shows a large tumour in the proximal humerus. A biopsy confirmed the malignancy. Treatment is usually surgical and the patient underwent a proximal humeral replacement. There was no evidence of metastatic spread, so no further treatment was required in the early stages. His prosthesis worked loose after a couple of years and required revision surgery.
This elderly woman with severe osteoarthritis had undergone bilateral hip replacements. Bearing in mind recent concerns over the long-term risks of metal on metal operations, the procedure has significantly improved quality of life for many. It does not last forever, though, and this patient was experiencing increasing pain in her right hip. This X-ray reveals some bone resorption of the acetabular component and possible loosening. She was too frail for surgery and had to be managed conservatively.
This man presented with a persistent cough. Every winter, the surgery is full of patients with coughs following viral respiratory tract infections, and many will have symptoms for several weeks. This patient fitted that profile. He was a 72-year-old who had stopped smoking 20 years earlier. There was no weight loss, breathlessness or haemoptysis, but he had signs on the right side. A chest X-ray revealed changes in the right lung and in spite of treatment, he died four months later.
This elderly woman had bunions on both feet. They had been present for decades, causing her problems with finding footwear. She was very upset - she could not understand why she had bunions as she had never worn stilettos, she said. The X-ray shows the damage and distortion at both MTPJs of her big toes, and the secondary changes affecting other toes. She had surgery which included osteotomy and pinning to straighten the toes, which was followed by several weeks in plaster.
FRACTURED TIBIA AND FIBULA
This 60-year-old woman had a total hip replacement. She did well postoperatively and decided to have a holiday in Italy to help recover from the operation. Unfortunately, she fell down the stairs on her arrival at her hotel, fracturing her tibia and fibula. The new hip joint was undamaged. She had further surgery to fix the fractures and recovered very well.
Osteoarthritis is a very common condition in primary care, but the elbow joint is less often affected than the hip, knee, spine or hands. This 72-year-old man presented with severe destruction of the joint. The normal architecture is almost invisible on this X-ray. There was no obvious cause. Investigations, including an autoimmune profile and joint aspiration for TB, were negative and a diagnosis of seronegative arthritis was made. Other joints were subsequently affected. The patient was started on leflunomide and sulfasalazine and his joints improved significantly, although clearly with this degree of joint destruction, he is not pain free.
Another very common problem in primary care is low back pain. As in many situations, we have to try to identify which patients have more serious problems, rather than a simple strain or sprain. This 40-year-old patient had severe pain which did not resolve over a period of weeks. A plain X-ray was unremarkable, but he was referred to the orthopaedic surgeons, who arranged this scan, which revealed a large disc prolapse. The patient had an epidural to relieve some of his pain, then underwent microdiscectomy, which solved the problem.
- Dr Marazzi is a GP in East Horsley, Surrey