CHAPTER XXIV DIAGNOSIS OF SWELLINGS IN CON- (Part 1)

CHAPTER XXIV DIAGNOSIS OF SWELLINGS IN CON- NEXION WITH BONES How to determine whether a swelling is connected in Chan' Y^n' ^^.^^'^^^7 been discussed m Chap. Xyil., and the difficulty of so doing has been ponated o.:t. In some few caL the doubt can only be cleared up by making a careful exploratory ncision but the use of X-rays has greatly^lessened the number of such cases. In this chapter it is pro- posed to discuss how best to arrive at the dia'no^ ftnd%ot;VV/"^"^';'^-^^^^ '''' alreadjiren bone ^, .t^'/'id immoyable apart from, reckons T''""^ of particuk; regions, such as spina bifida and tumours of the £SZ^^' ^'^^ ^^-P^- - -gional 1. Ascertain the history of the swelling. First whether it is traumatic or spontaneous, then whether ,it appeared suddenly or developed more slowly and finally whether it has continuously enlarged re mamed stationary, or receded. Traumatic swellings may be dislocations fnr tures, _ h.^morrhagic, inflammatory, or neoplastic An injury may be the starting-point of J.n-owth, or a tumour may only become n """"' when some trivial' in i.,rv I, . , W^nt shell of surroSSl/ri, f i^TE' „f f/,''"; ~ of the ^Wtofa'bono/SctS,::! 314 SURGICAL DIAGNOSIS [chap. of injury is given, care must be taken to ascertain whether there were any symptoms previous to the injury, such as local pain, and whether the injury is a sufficient explanation in itself of the subsequent course of events. Spontaneous swellings are inflammatory, neo- plastic, or diathetic. The acute specific fevers, especially enteric, are liable to be followed by in- flammatory swellings of the periosteum. Swellings that appear suddenly are the direct results of in- jury— dislocation, fracture, effusion of blood. Swell- ings that develop acutely are usually inflammatory; a few are due to haemorrhage, e.g. in scurvy-rickets. Chronic swellings may be the secondary results of injury, such as the thickening round a badly- set fracture, inflammatory, neoplastic, or diathetic. Swellings that progressively enlarge may be inflam- matory or neoplastic ; very rapid steady growth is a sign of inflammation, while steady enlargement over a long period and to a great size is a fr'equent and very characteristic feature of new growths. Stationary swellings may be the result of injm-ies, of chronic inflammation, or of some forms of benign tumour. Receding swellings are always either the result of injury, e.g. callus, or inflammatory, e.g. a node. 2. Examine the tumoiu' with the hand and notice the following points : i. The part and the extent of the bone mvolved : whether the diaphysis, the epiphysis, the junction between the two, the articular sm-face, or the entire bone. ii. The number of the swellings : whether on one or on several bones. iii. Tlie outline of the tumour: wlietlier well or ill delincd, whethei; globular, lobod, pedunculated, xxivj TUMOURS OF BONE '315 enslaeatliiug, or a mere general enlargement of the bone. IV. The consistence of the swelling : hard, firm or soft, yielding under the pressure of the fingers with a cracking sensation (egg-shell crackling) ; uniform or variable at difEerent parts. V. The presence of pulsation in any part of the swe mg, or of mobility in the bone at the site of the swelling. _vi. The presence of local heat, tenderness or pain, or of oedema or redness— signs of local inflam- mation. vu. The presence of a sinus leading to the bone • with a probe a sequestrum may be struck. vm The range, the smoothness, and the pain, if any of the movement in the neighbouring joints. 6 Examine a skiagram of the part and notice tlie following points : i. The bone.-(a) Whether the hue of the bone is continuous or mterrupted, or its articular end is displaced. wl.i? tlie bone is rarefied or condensed, whether Its medullary canal is expanded, narrowed or wholly ossified. formed ^^''^ ^^^'^^'^^^^^ de- {d) AVhether the shadow of the bone is uniform or at one or more places is denser from necrosis' A metal probe in a smus will show the relation of the smus to the bone or sequestrum u. The tumour.-(«) Whether the swelling is on the outside of the bone or within it (&) Its exact relationship to the diaphysis eni- physis, and articular surface ^ ' ^ (c) Whether it is pedimculated or sessile well circumscribed or infiltratina. ' 316 SURGICAL DIAGNOSIS [chap. (d) Its opacity or transluceucy ; the distribution and arrangement of opaquer parts. 4. Investigate the general condition of the patient, looking especially for evidence of rickets, syiDhilis, tubercle, aiia3mia, and fever. In some cases a blood- count will be helpful. The evidence of a general diathetic state is only of value in the diag- nosis when the local findings point in the same direction, for a patient may suiJer from syphilis or rickets and also from sarcoma. The facts thus ascertained are of value in the diagnosis as follows : 1. Position of the lesion. — Acute and chronic inflammation and periosteal sarcoma attack dia- physes ; exostoses start at the line of junction of diaphysis and epiphysis, but as the bone grows in length an exostosis becomes farther removed from the epiphysis. Rachitic swellings are found at the imion of diaphysis and epiphysis, or of rib and cartilage. Epiphyses may be attacked by tuberculosis, coccal infection, and myeloma, and the articular end may become the seat of osteo-arthritic and gouty swell- ings. The periosteum is especially attacked by various inflammations and by sarcoma. The medulla may be the seat of acute or chronic coccal invasion, of tuberculosis, of osteitis fibrosa or cyst, of myeloma, and of carcinoma. The compact bone may be the seat of rachitic bending, of osteomalacia, of Paget's disease (osteitis deformans), or of necrosis. j 2. Changes produced in the bone. — i. Rare- faction of bone may be caused by tuberculosis, osteo- arthritis, o?teo - myelitis, osteitis fibrosa, in the | separation of a sequestrum, and by metastatic car- cinoma. ii. OondenscUion of bone may be caused by the , repair of inflammation, in osteitis deformans, and XXIV J TUMOURS OF BONE 317 aromid a tuberculous, syphilitic, or suppurative iii. Expansion of bone is caused by central sar- coma carcinoma, or myeloma, by osteitis fibrosa, by mollities ossmm (osteomalacia), by some cases of tuberculosi^, particularly of the shaft of a bone, and by hydatid disease. iy. Erosion of the surface of a bone is caused by periosteal sarcoma, and by epithelioma or other form of carcmoma extending down to a bone V. Spontaneous fracture in a bone tumour may be caused by either central or periosteal sarcomaf by TySise— ^' -^^^^^^ - due^t^ri^;^™!-^ S. Physical characters of the swellinq. i nflammatn/v '^'^^'^y ^one is characteristic of ciall^Ztr-''"'^''^'' ""^^P* i« espe- ensheatW ^T'^' ^ g'-owth s seen '^'"^'^^ ' ^ g^°bular outline osteomata -^ f ^ ^l I'^^t'^"' ^'^^ ivory osteomata , a pedunculated growth attached to a diaphysis and not in a tendon or muscle is .J exostosis, while a similar bony growthT a tenrlnn or muscle is due to myositis os^ifirans ^"^'^ u. Consistent -Bony hardness may be causerl by ossification of the sweUine or hv . i f • fluctuation. ' g^^*^ '^^ sense of iii. Pulsation of a swellinrr i.^ • 1 Cp»tfy._Bone „ recog„,zed by it, „p„it„ 318 SURGICAL DIAGNOSIS [chap. to X-rays ; tlie density of the bone, and the arrange- - ment of the bony laniellee in cancellous bone, can be identified in a good skiagram. A tumour may thus be recognized as wholly bony or partly ossified, as formed of dense bone or of cancellous bone, as- a condensation of softer bone, a thickening of bone, or an outgrowth of bone; and great aid to exact diagnosis is thus obtained. 4. Conditions o£ the overlying tissues. — Hyperifimia, local heat, oedema, and tenderness are evidences of inflammation. A glossy stretched skin with enlargement of the subcutaneous veins is a sign of actively growing and very vascular tumours. li the swelling is acute it is one of the following : Dislocation. Periostitis. Fracture. Osteo-myeUtis. Hsematoma. Deep abscess. For the diagnosis of dislocation and fractm'e, see Chapters XV., XVI. If the swelUng fluctuates and is either present at birth or foUows immediately upon an injury, it is a hsematoma. But if the swelling has developed independently of injury, or has quickly but not immediately followed it, and there are the local signs of inflam- mation, with high temperature, quick pulse, and other evidence of fever, it is acute periostitis. Of this there are two forms, circumscribed and diffuse. Circumscribed acute periostitis is generally due to. an injury, sometimes to sjqDhihs, or to enteric fever, and the history will determine tliis point. It is most common in the tibia. Examine the part care- fully for fluctuation, which will indicate a periosteal ahsoesB. XXIV] TUMOURS OF BONE 319 An acute swelling starting in the growing end of a bone and rapidly extending along its shaft, accompanied by local signs of inflammation, is caused by an infection of the part with virulent pyogenic bacteria, and is termed acute necrosis of children, acute diffuse 'periostitis, or acute osteo-?nyelitis. (Plate IV., Fig. 1.) The skin over the bone may not be red- dened; there is oedema, and deep fluctuation can , soon be felt. The constitutional symptoms varv in severity ; as a rule the temperature is high, and all the signs of fever are marked ; rigors or con- vulsions, profuse sweatings, delirium, and even coma may be met with. If the disease has not been arrested by treatment, it may present an enormous abscess surrounding the entire diaphysis of the bone, or smuses leading down to a sequestrum, and there may be secondary abscesses and the other signs of VycBmia. As this disease starts near a joint it is liable to be at first mistaken for rheumatism' this disastrous mistake can be avoided by noticing that the pam and tenderness are in the diaphvsis, that the swelhng extends rapidly along the diaphysis, that tJie constitutional symptoms are very severe, and that only one ]omt appears to be affected. The existence of osteo-myeUtis m addition to the periostitis can be sometimes shown in a good skiagram, and can also be diagnosed when the constitutional signs are not relieved by free mcisions into, and thorough cleansing of, the periosteal abscesses, and can be demonstrated by the evacuation of pus from the medidlary cavitv Ihis disease attacks growing bones; it therefore occurs m children and adolescents. It verv ocn sionally starts at a distance from the end of the diaphysis in the completed bones of adults. It mav o. c:ur m a less intense form than that described 320 StJRGICAL DIAGNOSIS [chap. A deep abscess unconnected with bone would be indistinguishable from the above except by finding, when opened, that the bone was nowhere exposed. Chionic swellings of bone are as follows: Hypertrophy. Abscess. Rickets. Osteitis deformans. Scurvy-rickets. Necrosis and caries. SyphiUs. Tumour-. Badly-united fracture. Myositis ossificans. Periostitis. Osteitis fibrosa. Hydatid cyst. Occasionally, without any symptom of disease, the bones of one limb, or of one side of the body, are found larger than their fellows, and are spoken of as hypertrophied. The name is also given to the elongation which sometimes ensues upon inflamma- tion of a growing bone, and to the thickening result- ing from chronic inflammation. Strictly speaking, the name hypertrophy should only be applied when the increased size of the bone is due to its mcreased function, as, for example, where a fibula enlarges to take on the function of the tibia rendered useless by injury or disease. . If multiple symmetrical swellings occur m a child at the ends of the ribs, and over the junction of the epiphyses and diaphyses of the long bones, especi- ally at the lower end of the radius and tibia, and if with these there are bending of bone, due to its soft- ness and delayed ossification, the diagnosis of rickets may be made. In many cases of rickets there are other well-marked signs, such as profuse s^veatmg, especially about the head, with fallmg off of the hair, late dentition with early decay of the teeth, flabbiness of the muscles, emaciation, pigeon- XXIV] CPIRONIC SWELLINGS OF BONE 321 breast," " pot-belly," enlargement of the liver aud spleen, vomiting, diarrhosa, and general tenderness of the surface. If, in a young child, the shaft of one or more of the long bones is found to be enlarged, very tender —so tender that the child does not move the limb, and screams when it is moved- or touched— and there IS marked anaemia, the condition is scurvy-riekets. The gums will be found swollen, with petechial haemorrhages into them. This disease most often attacks the bones of the lower limb. It occurs in those brought up on artificial foods, is frequently associated, therefore, with rickets, and whilst com- moner in the first twelve months, may arise in children of a few years of age. If the swelling occurs in the humerus, or tibia of an infant or young child, is most marked over the epiphysial hne, and gradually subsides up the shaft especially if there is mobility of the epiphysis on the diaphysis, with soft or grating crepitus or sup- puration, it is syphUitic disease of the bone Othei signs of mherited syphilis should be sought for ihe disease may attack many bones, but in the Umbs It is generally not symmetrical. If the swelling is at the site of an old fracturo IS stationary, hard, and painless, it may be recoo" mzed as deformity due to union of tlie fracture in a bad position. The exact details will be seen in a <.oor] skiagram. In fractures where there has been muX comminution of the bone, or laceration of the soft parts the mass of callus effused is but 1 1 absorbed, and signs of it may be found for iZy months as a firm, pamless swelling round the bone There are certam very rare cases in which the caZs about a fracture steadily enlarges for some t^me ^ and very closely simulates a sarcoma ' 322 SURGICAL DIAGNOSIS [chap. A slowly formed swelling of a bone wliich gradu- ally fades ofi into healthy bone, and is tender and painful, is due to inflammation of the periosteum- periostitis. This may be limited in area— circum- scribed ; or extend along a whole diaphysis— difiuse. It is often associated with inflammatory changes m the bone beneath and in the meinlla—osteo-mijelitia. A circumscribed periostitis is called a node; when caused by plastic ossifying periostitis it is known as a hard node; when the inflammatory efiusion has softened into an abscess it is a soft node. Chronic inflammations of bone are most often due to tubercle and syphilis, but may be caused by enteric fever or by inflammation of a neighbouring soft structure. When the thickening of the bone is beneath a long-standing ulcer or the scar of one, it may be attributed to the extension of inflammation from the ulcer to the periosteum. When a limited swelling of the bone softens mto an abscess, the pus should be examined for the Bacillm tyfhosus. Enteric periostitis and osteitis may follow the acute enteric fever after a long interval, even of years ; it often attacks the ribs as well as the long bones of the extremities, and runs a slow 'course. . ,. . ^ . When the swelling of the bone is limited m area, but involves the entire circumference of a long bone, runs a slow and almost painless course, and after a time an abscess appears, it is Uihemihus. In tlie early stage the bone is rarefied, but later it is con- densed at the periphery. The patient is usually a child or youth, of delicate appearance, and he maj bear other signs of tuberculosis. If the .abscess is opened or has burst and formed a smus it is found that ll.e sinus leads into a cavity m the bone, m which a sequestrum or .soft carious bone ma) be XXIV] OSTEITIS DEFORMERS 323 felt. This disease is most often met with iu the ends of long bones, in the metacarpus, tarsus, and phalanges, but it occm-s also in the shafts of long bones. It is the common cause of caries. Multiple, painful, tender swellings of subcuta- neous bones with a tendency to recurrence are easily recognized as syphilitic owing to their association with other signs of syphilis. A slowly formed diffuse bony enlargement of the shaft of a long bone very hard and heavy, is syphilitic ; the disease affects all the parts of the bone— periosteum, compact bone and marrow— and ends in ossification. Occasionallv gummata form in bone and break down as in other parts, with or without the formation of definite sequestra ; the common bones to be thus affected are the vault of the skull, clavicle, and long bones of the limbs. Unhke other late syphilitic lesions, both these forms of syphilitic disease of bone may be accompanied by pain. If there is a slight localized swelling of a lon^ bone which IS the seat of constant and long-con- tinued aching pam, especially at night, with marked tenderness to pressure or to a smart tap just at one spot, and if further, the skiagram shows a clea area of bone with condensed bone around it, and some subperiosteal new-bone formation' there is anabscTss m the bone. (Plate iv., Fig. 2.) 'iiiaoscess A very chronic enlargement of a bone in a patient past middle life is probably osteitis deformans. TtL bone IS increased in length as well as in circumfer' once, and becomes abnormally curved, and the skiagram shows that the medullary cavit; is din^n- Kshed or absent this diagnosis is confirmed The disease known also as Paget's disease of bone afferf^ many bones (skull, spine, clavicle, huLruT' fem^' tibia, etc.), and is attended with " rheumatic^^ 324 SURGICAL DIAGNOSIS [chap. pains. The disease may remain confined to one bone for