Working Rules for Lesions of the Bone

Abstract

As experience accumulates in the larger clinics where the diagnosis of bone lesions is a daily problem, it becomes increasingly evident that certain working rules can be formulated, which will simplify greatly the problem of diagnosis and facilitate accuracy in the procedures recommended at consultation. Too often when an important decision is to be made by the consultant, the initial steps taken in the case have been inadequate or ill advised and much valuable time is lost. For this reason an attempt has been made to set up the following working rules which are subject to revision in the light of subsequent experience. The Rules of Procedure 1. Take X-ray films after every severe injury followed by pain on motion of the part, or when there is increasing tenderness, swelling, and pain over the bone. The films should be retaken if not clear, and views should be obtained in two different directions. 2. Take an X-ray film of the opposite side for comparison; early changes are otherwise indiscernible. 3. Multiple foci of pathology or diffuse lesions in bone or about a joint in the first film taken demand a film of the entire pelvis (lumbar spine and upper femurs included) and chest (with upper arms included) to rule out multiple bone or joint involvement, which usually contra-indicates surgery, and narrows the possibilities for diagnosis. An examination of the urine for Bence-Jones bodies is also essential. 4. Take a complete history and do a thorough physical examination, with special emphasis on palpation and search for a primary focus of infection or cancer outside of bone. Strive to rule out acute osteomyelitis by history and examination, for in no other lesion of bone is a moderate degree of delay costly. 5. If acute osteomyelitis is ruled out, use the X-ray film for consultation when in doubt, before surgery. Surgery is rarely indicated in the multiple lesions and in the minority of single lesions. There is no harm in waiting for a confirming opinion. 6. While waiting, put the part at rest and give deep X-ray or radium therapy to determine radiosensitivity. Four out of eight types of solitary bone tumors are radiosensitive—this provides a therapeutic test. 7. Regardless of the diagnosis, do not operate without a Wassermann reaction report. 8. Before operating for a malignant lesion of bone take an X-ray of the chest to rule out metastases. 9. Pulmonary metastases in a film of the chest are not proved unless there is fluid in the chest, cachexia, or a recurrent tumor or metastatic gland elsewhere in the body. A chest film does not contra-indicate surgery, if signs of metastases are doubtful. 10. Do not explore a doubtful tumor unless adequate provision has been made for the interpretation of the biopsy material and for a radical operation if indicated. 11. If a previous operation has been done make every attempt to secure sections or tissue for examination.