When fracture of a long bone takes place in an adolescent or young adult from comparatively slight violence, disease of the bone should be suspected and an X-ray examination made.
In difficult cases the final appeal is to exploratory incision and microscopical examination of a portion of the tumour; this should be done when the major operation has been arranged for, the surgeon waiting until the examination is completed.
The prognosis varies widely. In general, it may be said that periosteal tumours are less favourable than central ones, because they are more liable to give rise to metastases. Permanent cures are unfortunately the exception.
Treatment.—When one of the bones of a limb is involved, the usual practice has been to perform amputation well above the growth, and this may still be recommended as a routine procedure. There are reasons, however, which may be urged against its continuance. High amputation is unnecessary in the more benign sarcomas, and in the more malignant forms is usually unavailing to prevent a fatal issue either from local recurrence or from metastases in the lungs or elsewhere. Following the lead of Mikulicz, a considerable number of permanent cures have been obtained by resecting the portion of bone which is the seat of the tumour, and substituting for it a corresponding portion from the tibia or fibula of the other limb. In a cellular sarcoma of the humerus of a boy we resected the shaft and inserted his fibula ten years ago, and he shows no sign of recurrence. When resection is impracticable, a subcapsular enucleation is performed, followed by the insertion of radium.
Pulsating Hæmatoma or Aneurysm of Bone.—A limited number of these are innocent cavernous tumours dating from a congenital angioma. The majority would appear to be the result of changes in a sarcoma, endothelioma, or myeloma. The tumour tissue largely disappears, while the vessels and vascular spaces undergo a remarkable development. The tumour may come to be represented by one large blood-containing space communicating with the arteries of the limb; the walls of the space consist of the remains of the original tumour, plus a shell of bone of varying thickness. The most common seats of the condition are the lower end of the femur, the upper end of the tibia, and the bones of the pelvis.
The clinical features are those of a pulsating tumour of slow development, and as in true aneurysm, the pulsation and bruit disappear on compression of the main artery. The origin of the tumour from bone may be revealed by the presence of egg-shell crackling, and by examination with the X-rays.
If the condition is believed to be innocent, the treatment is the same as for aneurysm—preferably by ligation of the main artery; if malignant, it is the same as for sarcoma.
Secondary Tumours of Bone.—These embrace two groups of new growth, those which give rise to secondary growths in the marrow of bones and those which spread to bone by direct continuity.
Metastatic Tumours.—Excepting certain cancers which give rise to metastases by lymphatic permeation (Handley), the common metastases arising in the bone-marrow reach their destination through the blood-stream.