Combined asymptomatic congenital anterior and posterior deficiency of the atlas.

Atlas anomalies in terms of clefts and aplasia are rare. They can sometimes simulate fractures and need further evaluation. Imaging in terms of CT and MR can help resolve diagnostic confusion and also outline associated neurological involvement. A rare anomaly of anterior and posterior atlas arch, previously unclassified, is presented.

Prevalence of positive preoperative pregnancy testing in teenagers scheduled for orthopedic surgery.

The pregnancy status of female teenagers presenting for orthopaedic surgery is often unknown. Anesthetics may have teratogenic or abortive effects. The authors report the results of a screening program for unrecognized pregnancy in 532 female teenagers presenting for orthopaedic surgery. Five patients with a positive urine human chorionic gonadotropin test were identified, for a prevalence of 1 positive result in 106 patients tested (0.9%). Surgery was cancelled in each case.

Comparison of morphine patient-controlled analgesia with and without ketorolac for postoperative analgesia in pediatric orthopedic surgery.

The purpose of this prospective, randomized, double-blind, placebo-controlled clinical study was to determine whether the administration of intravenous ketorolac, coadministered with morphine patient-controlled analgesia (PCA), demonstrates an opioid-sparing effect, provides improved analgesia, and reduces the incidence of opioid-induced side effects in children after orthopedic surgery. The findings of enhanced analgesia with decreased opioid use suggest that coadministration of ketorolac with morphine PCA is beneficial for the treatment of pain in children after orthopedic surgery.

Musculoskeletal coccidioidomycosis. A review of 25 cases.

Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Musculoskeletal involvement is rare, and there are few reports with clear recommendations regarding treatment. The purpose of this study was to review a series of 25 patients with musculoskeletal coccidioidomycosis and to assess their outcomes with respect to presentation and treatment. There were 36 lesions among the 25 patients, 8 located in the spine, with the remainder distributed throughout the body. Seventeen patients had a delay in diagnosis of more than 1 month. Eight patients had an elevated white blood cell count, and 10 had an elevated sedimentation rate. Only 7 of the patients had an overt pneumonia before the musculoskeletal presentation. Twenty-four patients underwent formal irrigation and debridement and 22 patients had at least 1 course of Amphotericin B. The average followup after the initiation of treatment was 3.5 years, ranging from 2 to 10 years. Seven patients had recurrent lesions that required further surgical intervention, 4 of whom had a delay in diagnosis of more than 1 month. There were 3 deaths. All surviving patients were free of disease at final followup.

The safety of continuous epidural infusion for postoperative analgesia in pediatric spine surgery.

Epidural analgesia and anesthesia are standard regional techniques in orthopaedic surgery of the lower extremities. Benefits of epidural anesthetic infusions include excellent analgesia, minimal respiratory depression, no somnolence, and decreased need for blood transfusion. Adverse effects include pruritus, nausea, and urinary retention, but standard methods have evolved to counter each adverse effect. A continuous epidural infusion of opioid and bupivacaine was used as the principal postoperative analgesic for 71 young patients undergoing surgery for the correction of spinal deformity. The infusion was titrated to a point at which each patient denied having any pain and was maintained for an average of 2.9 days. Sixty-four patients experienced satisfactory analgesia with minimal adverse effects. The technique worked despite multiple laminotomies for segmental fixation and did not compromise neurologic assessment. We conclude that epidural analgesia is as safe and effective after spinal-deformity surgery as it is after other types of surgery.

Pediatric update #10. Treatment of displaced supracondylar fractures of the humerus in children by closed reduction and percutaneous pinning.

In a retrospective study of 25 displaced supracondylar fractures of the humerus in children, treatment by closed reduction and percutaneous pin fixation was reviewed. Follow-up averaged 16 months. Loss of elbow motion and carrying angle were graded according to Flynn's criteria. Twenty-two patients' results were rated excellent, two were good, none was fair, and one was poor. There were no complications reported. Comparison of the values of Baumann's angle obtained from intraoperative, postreduction roentgenograms with those of the opposite, normal elbows predicted the final carrying angles within two degrees in 14 of 17 cases and within five degrees in all 17 cases where such comparison was possible. We conclude that this technique is safe and effective and recommend the use of Baumann's angle as a standard to judge the quality of reduction.

Acute carpal tunnel syndrome secondary to septic arthritis of the wrist.

A case of acute carpal tunnel syndrome secondary to septic arthritis of the wrist is reported. Treatment consisted of carpal tunnel release, incision and drainage of the wrist joint, intravenous injection of antibiotics, and delayed primary closure. The infection resolved and median nerve function promptly returned to normal. We believe this is the first report of septic arthritis of the wrist as a cause of acute carpal tunnel syndrome.

Four cases of injury involving soda vending machines.

Injuries resulting from rocking soda vending machines are severe and potentially fatal. Four cases of significant trauma stemming from soda vending machine accidents are reported: One patient died, one is disabled, and two healed uneventfully. As a result, we recommend securing heavy soda vending machines to prevent further injuries. To our knowledge, this is the first report on a mechanism of injury resulting from soda machines.