Multifocal variant of heterotopic ossification.

In this case report, we present a 25 year follow-up of a single patient with a previously undescribed multifocal variant of heterotopic ossification. The patient presented with multiple occurrences of lesions similar to myositis ossificans atraumatica as well as some lesions resembling exostoses/osteochondromas. Several images and histological sections show the range of appearances and locations of her somewhat disparate lesions, including an exostosis with intraspinal extension. Until additional similar cases are brought forward, we consider this a unique variant of heterotopic ossification. The precise aetiology of this patient's condition is unknown.

A bullet-sired bone cyst.

Random gunfire deposited a bullet in the proximal tibial metaphysis of a 9-year-old girl. The wound was not incapacitating and was treated conservatively. Within 17 months, soreness developed in the proximal leg, and radiography revealed a large unicameral cyst within which the bullet freely tumbled. Eventually, fear of impending fracture prompted further radiography, computed tomography, surgical intervention and pathological examination of the cyst wall. We believe this is only the second description in the English-language literature of this rare sequence of events.

Acute compartment syndrome after rupture of the medial head of the gastrocnemius muscle.

Rupture of the gastrocnemius muscle is an uncommon injury, with most cases occurring in athletically active individuals. The presentation of a gastrocnemius rupture is the acute onset of calf pain and subsequent ecchymosis. Most of these injuries can be treated symptomatically with good results. We present an unusual case of gastrocnemius muscle tear complicated by acute compartment syndrome. Physicians need to be aware of this potentially devastating complication of gastrocnemius rupture.

An irreducible knee dislocation: a case report.

An 8-year-old man presented after sustaining an injury during a fall. A closed reduction attempt failed, and after several tests, an open reduction was performed. With posterolateral dislocation of the knee, there can be anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament disruption. At the 6-month (final) follow-up, the patient had no subjective pain or instability. With this type of injury, the approach can be conservative monitoring or repair of all of the ligaments. Because of the age and activity level of our patient, we opted for repair of the medial collateral ligament initially with the possibility of late anterior cruciate ligament and/or posterior cruciate ligament reconstruction.

Tumoral calcinosis in an infant.

We report tumoral calcinosis, an uncommon disease of uncertain origin, in an infant-only the sixth instance of the disease reported in this age group. The radiologic features are typical as illustrated by three modalities. The clinical, radiologic and pathologic features are discussed along with comments concerning possible etiologies and management.

Ultrasonography in the management of painful hips in children.

The decision to aspirate a painful hip joint is often based on history, physical, and laboratory findings. The purpose of this study is to determine whether ultrasound is helpful in making decisions to aspirate a painful hip joint in children. The anterior capsular distance was determined in 10 children with painful or irritable hips. This anterior capsular distance is 2 to 4 mm in most hips. A side difference of 2 mm or more is considered a significant capsular distension. Based on these criteria and clinical parameters, 3 hips were aspirated, and 7 were observed without aspiration. None of the 7 hips subsequently required further diagnostic workup or treatment and all have had a satisfactory outcome. Ultrasound is a reliable method to detect capsular distension or joint effusion. It helps significantly in making the decision as to "when to aspirate" a painful or irritable hip joint.

Ultrasonography in the management of developmental dysplasia of the hip (DDH).

Real time ultrasonography, according to the method of Graf, was performed on 113 infant hips because of abnormal physical findings (ranging from hip clicks to frank dislocation). Three parameters were measured on the standard coronal images: alpha and beta angles of Graf and the d/D ratio of Morin. Results indicated that the presence of hip clicks (88 hips) in general is a benign condition and not associated with abnormal anatomy. Hips that were reduced at birth but dislocatable (Barlow hip) showed no significantly abnormal acetabular anatomy. Hips that were dislocated at rest but were reducible (Ortolani hip) showed definite abnormal acetabular anatomy and femoral head coverage. Ultrasonography is beneficial in the management of developmental dysplasia of the hip (DDH); it confirms the clinical findings and eliminates radiation exposure to the infant's pelvis, especially in the first 4-6 months of life when standard radiography is not always reliable in diagnosing DDH.

Intramedullary screw fixation of lateral malleolus fractures.

A biomechanical evaluation of intramedullary versus buttress plate and lag screw fixation of lateral malleolus fractures is combined with a clinical evaluation of 44 patients with lateral malleolus fractures who underwent intramedullary screw fixation. The biomechanical study was performed in experimentally produced, Weber B, supination-eversion ankle fractures. The fractures were fixed with one of the two above fixation methods and then placed under a torsional load to failure. Sixteen cadaver ankles were tested as compared with native bone. The intramedullary screw provided 66.5% the resistance of torsion, and the buttress plate and lag screw provided 61.5% the resistance to torsion. There was no statistical difference between these two groups. The 44 fractures treated with an intramedullary screw were reviewed retrospectively. There was one failure of fixation, and one prominent hardware problem. Time to full weightbearing averaged 7.2 weeks. These results suggest that intramedullary screw fixation of noncomminuted lateral malleolus fractures provides stable fixation with good clinical results. This technique has the advantages of providing dynamic intramedullary fixation with limited surgical dissection and no subcutaneous hardware.

Percutaneous intramedullary fixation of lateral malleolus fractures: technique and report of early results.

Twenty-four patients with Weber B and low Weber C displaced lateral malleolus fractures who underwent closed reduction and percutaneous internal fixation with an intramedullary, fully threaded, self-tapping screw were retrospectively reviewed. Nineteen of these patients were followed for an average of 63.4 weeks. A good radiographic reduction was obtained in 87.5% of patients, a fair reduction in 8.3%, and a poor reduction in 4.2%. The reduction that was obtained was maintained in all patients. Fracture union was achieved in 95.5% of patients, with an average time to union of 8.2 weeks. In all patients the average time to full weight bearing was 6.8 weeks, whereas that in patients with isolated lateral malleolus fractures was 4.5 weeks. There were no deep wound infections or complaints of painful hardware. At latest follow-up, functional results were excellent in 42.1%, good in 42.1%, fair in 5.3%, and poor in 10.5% of patients. If reduction of the lateral malleolus fracture can be obtained in a closed fashion (with the aid of an image intensifier), we believe that fixation may be performed with an axial screw percutaneously. This technique requires minimal soft-tissue dissection, thereby decreasing wound complications and painful hardware sites that are occasionally observed after open techniques. This closed technique also eliminates screw penetration of the ankle joint and damage to the peroneal tendons, which can be risks when a plate or lag screws are employed as internal fixation. Surgical time is also reduced and tourniquet use is optional. If an acceptable reduction cannot be obtained using this technique, open reduction and internal fixation should be performed.

Chondromyxoid fibroma.

Chondromyxoid fibroma (CMF) is the least common cartilage-producing tumor. In Dahlin and Unni's series of 8,542 bone tumors, 39 of which were CMF, none were found in the femoral shaft. In this case, a CMF in the femoral shaft presented initially as a pathologic fracture. Attempts at curettage and autogenous bone graft failed, and en bloc resection and segmented allograft reconstruction were eventually required.

Superficial temporal artery laceration. A complication of skull tong traction.

Complications associated with the use of skull tongs are not uncommon. We report a case of superficial temporal artery injury as a complication of Gardner-Wells tong application. Chronic recurrent episodes of pulsatile bleeding from the pin site necessitated arterial ligation to control the bleeding.

Hereditary spastic paraplegia.

Hereditary spastic paraplegia (HSP) is a genetically determined condition that is often confused with, and misdiagnosed as, spastic diplegic cerebral palsy. Both autosomal dominant and recessive forms have been reported. We present three index patients in a single family with this disease. The pedigree of three generations strongly supports the genetic basis of an autosomal dominant condition. Awareness of this entity may help in genetic counseling and possibly avoiding some medical litigation related to cerebral palsy patients.

Surgical treatment of clubfoot: a comparison of two techniques.

Between 1977 and 1989, 28 clubfeet were operated on, with follow-up ranging from 2 to 13 1/2 years and averaging 79 months. Group I (16 feet; average follow-up 104 months) underwent a modified Turco's posteromedial release. The functional result in this group was satisfactory in general, but approximately one third of this group required a secondary procedure for persistent intoeing or residual metatarsus adductus. Group II (12 feet; average follow-up 45 months) underwent a modified, complete subtalar release of McKay and Simons utilizing the Cincinnati incision. No patient in this second group required a secondary procedure. In our experience, the more complete subtalar release procedure of McKay and Simons resulted in better correction than the Turco posteromedial release. Although follow-up in group II was much shorter than that in group I, we felt that 2 years of minimum follow-up in group II was meaningful, since most of the recurrence or residual deformities were noticed within 18 months after surgery. The Cincinnati incision allowed better exposure and a more complete release. Skin flap necrosis was not a problem in this series.

Cat-scratch disease: orthopaedic presentation.

Although cat-scratch disease is not uncommonly treated by pediatricians, it is rarely seen by orthopaedists. In this review of cat-scratch disease, two cases with orthopaedic manifestations are high-lighted. One patient had a positive bone scan in the distal humerus that simulated osteomyelitis on presentation. The second patient presented with a rapidly enlarging soft-tissue mass in the arm that resembled a soft-tissue sarcoma. The diagnosis of cat-scratch disease eventually was made late in the course of management in both cases. Both patients underwent surgical drainage and evacuation of the suppurated lymph node and recovered without sequelae.

Plastic deformation of the forearm: a review and case reports.

Plastic deformation of long bones can occur in any age group but it is more common in children. Based on our experience with this condition and the suggested guidelines for treatment in the literature, we believe that significant deformity (15 degrees or more) in children over 10 years of age should be manipulated and corrected. In children 6 to 10 years of age, attempts should be made to correct a severe deformity (20 degrees or more). Children under 5 years of age probably require no treatment, since remodelling most likely will restore the correct anatomy and function.

Septic hip in pelvic fracture with urologic trauma: case report.

Urologic injuries occur in 10% of pelvic fractures and hip sepsis is a rare complication. The symptoms of a septic hip are often not as dramatic when found in the setting of an acute pelvic fracture and may be overlooked. A case is presented with a review of the literature. Early recognition and aggressive surgical debridement are important to prevent the long-term sequelae of septic arthritis.

Avulsion fracture of the tibial tuberosity in late adolescence.

Between January 1982 and May 1985, eight patients with avulsion fractures of tibial tuberosity were seen at the University of South Alabama Medical Center. All were boys, average age, 15 years 8 months. Six of eight had a positive history of Osgood-Schlatter disease. Seven patients underwent open reduction and internal fixation, one had closed reduction and cast. Followup ranged from 5 months to 3.5 years, averaging 19.5 months. All, except one who had lateral meniscectomy, regained practically full ROM and reported no pain or limitation of activities. No patient developed genu recurvatum deformity or leg length discrepancy due to the injury. Open reduction and internal fixation is the treatment of choice in displaced intra-articular fractures. Lateral parapatellar incision is a more direct approach to this fracture and is less likely to injure the infrapatellar branch of the saphenous nerve.