Quantitative ultrasound measurements in premature infants at 1 year of age: the effects of antenatal administered corticosteroids.

The aim of this study was to evaluate the effects of antenatally administered glucocorticoids on bone status of preterm infants at 1 year corrected age. The study population consisted of 32 preterm infants with a gestational age of 24-34 weeks. The infants were divided into two groups according to antenatal exposure to corticosteroids. Quantitative ultrasound (QUS) assessment of bone was performed in the study infants at the corrected age of 1 year. Blood levels of carboxy-terminal propeptide of type I procollagen (PICP) and carboxy-terminal telopeptide of type I collagen (ICTP) were measured at birth and at 1 year corrected age. Levels of PICP and ICTP were significantly lower at birth in corticosteroid-exposed neonates (P < 0.05). At corrected age of 12 months ICTP levels remained significantly lower in corticosteroid-exposed infants, but we found no significant difference in levels of the bone-formation marker PICP between corticosteroid-exposed and nonexposed infants. In the majority of participant preterm infants bone speed of sound (SOS) was within age-adjusted normal values of full-term infants. There was no significant difference in bone SOS between exposed and nonexposed infants at corrected age of 12 months. There was no correlation between SOS and levels of bone markers. The results of our study indicate that, despite the suppression of fetal bone turnover at birth in corticosteroid-exposed infants, antenatal glucocorticoid treatment seems to have no long-term impact on bone status of preterm infants assessed by QUS complementary to measurement of bone-turnover markers at 1 year corrected age.

Methicillin-resistant Staphylococcus aureus osteomyelitis and septic arthritis in neonates: diagnosis and management.

Acute osteomyelitis (AO) in neonates, although rare, represents a diagnostic and therapeutic challenge. A high index of suspicion is necessary to make an early diagnosis, and the observation of clinical signs is crucial. The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) is an emerging problem in pediatrics. In neonates, MRSA infections can cause a wide spectrum of diseases including bone and joint infections. We report two cases of AO in full-term neonates, with no risk factors, due to MRSA.

Levels of bone collagen markers in preterm infants: relation to antenatal glucocorticoid treatment.

Although the beneficial effects of antenatally administered glucocorticoids are well documented, data on the potential of adverse consequences are limited. The objective of this study was to determine the effects of antenatally administered glucocorticoids on biochemical markers of bone metabolism of 55 preterm infants with a gestational age of 24-34 weeks who were enrolled in the study. Neonates were divided into two groups according to antenatal exposure to corticosteroids. There were no significant differences between the groups in clinical characteristics and anthropometric variables. We studied blood levels of osteocalcin (OC), carboxy-terminal propeptide of type I procollagen (PICP), and carboxy-terminal telopeptide of type I collagen (ICTP) at the time of delivery, on postnatal day 10, and at 2 and 4 months of life. Comparing the groups, we found statistically significant reduction in PICP levels at birth in corticosteroid-exposed neonates (P < 0.05). The levels of bone markers increased progressively on the first days of life. There were no significant differences between groups in bone markers at 10 days or at 2 and 4 months of life. We found no significant difference for bone markers between groups of infants exposed to single or repeated maternal corticosteroid treatments. In summary, antenatal glucocorticoid treatments are suggested to have a negative impact on fetal bone formation as reflected by low PICP levels at birth. However, this negative effect on bone markers seems to be a temporary effect that subsides on the first days of life and afterward.

Treatment of closed unstable metacarpal fractures using percutaneous transverse fixation with Kirschner wires.

BACKGROUND: The vast majority of metacarpal bone fractures are stable and are treated conservatively; however, when surgical intervention is to be preferred, many different operative procedures have been described. The purpose of this prospective study was to assess the anatomic and functional outcome of percutaneous transverse fixation with Kirschner wires (K-wires) of closed metacarpal neck, shaft. and intra-articular fractures of the base of the fifth metacarpal. METHODS: Twenty-four consecutive patients with 25 closed metacarpal fractures were treated with this technique between 1999 and 2001. Under fluoroscopy, closed reduction and osteosynthesis with three K-wires, one proximally and two distally, was performed on the fracture site. All patients were reviewed clinically and radiologically after 3 weeks, 6 weeks, and 3 months. RESULTS: The postoperative dorsal angulation ranged from 0 to 3 degrees. No measurable metacarpal shortening was observed. Callus formation was obvious in all fractures at 6 weeks. No complications were recorded, and all patients were cosmetically and functionally satisfied. CONCLUSION: Treatment of closed metacarpal neck, shaft, and intra-articular fractures of the base of the fifth metacarpal with percutaneous transverse pinning, using two K-wires distally and one proximally, has shown excellent functional and anatomic outcome.

Functional evaluation after primary flexor tendon repair in zone II.

The purpose of this prospective study was to evaluate the results of primary treatment of flexor tendon laceration in zone II according to Verdan's zone system. Special emphasis was given to the postoperative rehabilitation program. Nineteen patients (23 fingers) with laceration of the flexor tendons in zone II were treated operatively. Twelve males and seven females were included in the study. Their mean age was 28 years (range, 16 to 50 years). In 12 cases a concomitant laceration of the digital nerve was present. In all cases primary repair of all injured tendons and nerves was performed and a dorsal splint was applied. On the third to fifth postoperative day an exercise program commenced involving passive flexion-active extension of the injured fingers. Eighteen (22 fingers) of 19 patients completed the follow-up. The results were evaluated according to Strickland's original classification system. The result was excellent in 15 cases, good in five and fair in two. After primary repair of injured flexor tendons, a program of close follow-up, early protected motion and unrestricted motion of the interphalangeal joints offers the best chance of restoring optimal function to the hand.

Complications and problems related to pedicle screw fixation of the spine.

This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. One hundred twelve patients were treated using the Cotrel-Dubousset pedicle screw fixation system for degenerative disease (57 patients), trauma (42 patients), infection (eight patients), and tumor (five patients) of the lumbar or thoracolumbar spine. The average age of the patients was 47 years and the average followup was 35 months. Forty-seven general complications were seen in 41 patients (36.5%). In addition, hardware failures were observed in 12 patients (10.7%), junctional problems were seen in five patients (4.5%), problems in the instrumented segments were seen in 39 patients (34.7%), and problems of balance occurred in five patients (4.5%). Although the rate of the reported complications was high, the final outcome of the patients was not affected significantly. Placement of the pedicle screws in the thoracolumbar and lumbar spine is a technically demanding procedure. It should be used by experienced and qualified surgeons who are aware of the pitfalls associated with its use.

Gertzbein and load sharing classifications for unstable thoracolumbar fractures.

From 1996 to 1998, 30 consecutive patients with Level 1 thoracolumbar spinal injury were classified and treated according to the Gertzbein classification and the load sharing classification. A posterior short segment pedicle screw implant was used in 21 patients; anterior decompression with strut grafting and application of the Kaneda device was used in three patients; and six patients were treated with short posterior instrumentation and an anterior strut graft. The average followup was 32 months (range, 24-50 months). The clinical outcome was satisfactory in 22 of 30 patients. Five of nine patients had neurologic improvement. Radiographic imaging findings showed a slight loss of reduction, but the clinical outcome of the patients was not affected. No pseudarthrosis and no implant failures were recorded. The Gertzbein classification correlates the type of fracture with the degree of mechanical instability and neurologic lesion. The load sharing classification correlates fracture comminution and displacement with mechanical stability and implant failure. Patient selection is a fundamental component for a successful outcome. The best candidates for surgery are cooperative patients who require spinal mobility, patients who are able to tolerate a two-stage reconstruction, and patients in good general health.

Peroneal nerve palsy: a complication of umbilical artery catheterization in the full-term newborn of a mother with diabetes.

Umbilical artery catheters are an essential aid in the treatment of newborn infants who have cardiopulmonary disease. However, it is well-known that umbilical artery catheterization is associated with complications. The most frequent visible problem in an umbilical line is blanching or cyanosis of part or all of a distal extremity or the buttock area resulting from either vasospasm or a thrombotic or embolic incidence. Ischemic necrosis of the gluteal region is a rare complication of umbilical artery catheterization. We report the case of a full-term infant of an insulin-dependent diabetic mother with poor blood glucose control who developed a left peroneal nerve palsy after ischemic necrosis of the gluteal region after umbilical artery catheterization. The infant was born weighing 5050 g. The mother of the infant had preexisting diabetes mellitus that was treated with insulin from the age of 14 years. The metabolic control of the mother had been unstable both before and during the pregnancy. The neonate developed respiratory distress syndrome soon after birth and was immediately transferred to the neonatal intensive care unit. Mechanical ventilation via endotracheal tube was quickly considered necessary after rapid pulmonary deterioration. Her blood glucose levels were 13 mg/dL. A 3.5-gauge umbilical catheter was inserted into the left umbilical artery for blood sampling without difficulty when the infant required 100% oxygen to maintain satisfactory arterial oxygen pressure. Femoral pulses and circulation in the lower limbs were normal immediately before and after catheterization. A radiograph, which was taken immediately, showed the tip of the catheter to be at a level between the fourth and fifth sacral vertebrae. The catheter was removed immediately. Circulation and femoral pulses were normal and no blanching of the skin was observed. Another catheter was repositioned and the tip was confirmed radiologically to be in the thoracic aorta between the sixth and seventh thoracic vertebrae. The catheter was continuously flushed with heparinized solution. Three days after umbilical arterial catheterization, bruising was observed over the left gluteal region. The catheter was immediately removed despite its correct position. Over the next few days, the bruised skin and underlying tissues became necrotic. The area affected was 3 x 4 cm in diameter, with central necrosis surrounded by a rim of dark, red skin, which, in turn, was sharply demarcated from normal skin by a narrow, pale zone. Surgical excision of the gluteal necrosis was performed, but a deep ulcer 3 cm in diameter was left. The gluteal ulcer required 1 month to heal completely with extensive scar tissue formation. Throughout this period, the infant showed active movements in all of her limbs. At 4 weeks of age deterioration of all movement below the left knee with a dropping foot was observed. Severe peroneal nerve palsy was confirmed through nerve conduction studies, and there was electromyographic evidence of degeneration of the muscles supplied by the peroneal branch of the sciatic nerve. A Doppler study, which was also conducted, revealed no vascular damage. Treatment with physiotherapy and night-splinting of the left ankle was instituted. Repeated examination and nerve conduction tests at 3 months showed slow improvement with the left peroneal nerve remaining nonexcitable. At the time of this writing, the infant is 6 months old, and muscular strength below the left knee is still weak and atrophic changes in the form of muscle-wasting are already present. The rest of her motor development is normal. In our case, gangrene of the buttocks and sciatic nerve palsy followed displacement of the tip of the catheter into the inferior gluteal artery, a main branch of the internal iliac artery supplying the gluteus maximus, the overlying skin, and the sciatic nerve. The gangrenous changes were probably caused by vascular occlusion resulting from catheter-induced vasospasm of the inferior gluteal artery. Sciatic nerve palsy associated with umbilical artery catheterization has been postulated to be caused by vascular occlusion of the inferior gluteal artery. Infants of diabetic mothers may exhibit changes in coagulation factors and be at increased risk of thrombotic complications in utero and postnatally. In addition, maternal diabetes mellitus is associated with an increased incidence of congenital abnormalities, the incidence of which is 3 to 5 times higher than that among nondiabetic mothers. Although no particular or specific abnormalities have been associated with maternal disabilities, abnormalities of the cardiovascular system, including the development of umbilical vessels, frequently occur. This complication of umbilical artery catheterization has not been widely reported. We describe the first case that refers to gluteal gangrene and peroneal nerve palsy after umbilical artery catheterization of a newborn infant of a diabetic mother with poor blood glucose control. It should be noted that there were no contributing factors except that of the displacement of the catheter into the inferior gluteal artery. We speculate that the displacement of the tip of the catheter, with no difficulty in the present case, was associated with the maldevelopment of normal branching patterns of arteries after exposure of the fetus to hyperglycemia. In conclusion, umbilical artery catheterization is possibly associated with vascular occlusion, particularly in infants of diabetic mothers. Frequent inspection after the procedure has been performed is of the utmost importance especially in these neonates who often suffer from cardiopulmonary disease and require catheterization of their umbilical artery.