Letter to the Editor: Reply: Osteosarcoma without Radiographic Evidence of Tumor

Abstract

Reply: We agree wholeheartedly with Dr. Marangoz's comments regarding the importance of a patient's history when evaluating fractures. As orthopaedic surgeons, we are taught the mechanism of injury should be consistent with the anatomic fracture pattern on plain radiographs. If the history does not match the fracture, then a more thorough history or closer scrutiny of the plain radiographs is warranted. Doing a biopsy before treatment is justified if there is suspicion that the lesion may be pathologic. The particular patient discussed in our article1 is interesting because there was absolutely no evidence, even in retrospect, of an underlying malignancy at the time of the initial radiographs. Given the less than accurate history that might come from a 5-year-old boy, we cannot judge our orthopaedic colleagues too harshly for not performing a biopsy. In the absence of any plain radiographic evidence of disease, we think it would be impractical, and perhaps even inappropriate, to do a biopsy of every femoral shaft fracture that did not result from an obvious high-energy injury. The patient could have just as easily presented after a fall from a swing or monkey bars and the result would have been the same. Without some conflicting evidence on the plain film, it would be difficult for an orthopaedic surgeon to approach this as anything but a fracture. Brandon A. Ramo, MD Department of Orthopaedic Surgery Washington University School of Medicine, St. Louis, MO; Michael Kyriakos, MD Division of Surgical Pathology Washington University School of Medicine, St. Louis, MO; and Douglas J. McDonald, MD Department of Orthopaedic Surgery Washington University School of Medicine, St. Louis, MO