Innominate artery pseudoaneurysm from a Salter-Harris fracture of the sternoclavicular joint.

Fractures and dislocations of the sternoclavicular joint (SCJ) are uncommon, accounting for <5% of all shoulder girdle injuries. They are relatively more common in the pediatric population than in the adult population and can often present concurrently as a posteriorly displaced medial clavicular dislocation with a fracture through the unfused physis. It is especially important to recognize this injury, because its management and potential sequelae are very different from those for fractures of the clavicle shaft. This type of injury frequently requires closed or open operative management because fracture-dislocation of the SCJ can be associated with potentially serious complications such as pneumothorax, brachial plexus injury, vagus nerve injury, tracheal injury, and vascular compromise. Few case reports describe fracture-dislocation of the SCJ resulting in vascular injuries. We describe the case of a 17-year-old boy who sustained a blunt hockey injury resulting in a right physeal fracture-dislocation of the SCJ causing an innominate artery pseudoaneurysm. This was treated with excision of the pseudoaneurysm, bovine pericardial patch angioplasty repair of the innominate artery, and open reduction and internal fixation of the medial clavicular physeal fracture.

Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction?

Supracondylar humerus fractures are common pediatric injuries encountered by orthopedic surgeons. Displaced fractures are treated operatively with closed reduction and percutaneous pinning or open reduction of injuries that cannot be adequately closed reduced. The purpose of this study is to identify preoperative injury characteristics associated with open reduction. Retrospective chart review was performed on all AO type 13A (Gartland type) supracondylar humerus fractures in patients 2-13 years old treated surgically at a single level 1 trauma center over 6 years. Preoperative demographics and radiographic parameters were obtained for all patients. Primary outcomes were closed reduction or conversion to open reduction of fractures prior to k-wire fixation. Initial bivariate analysis was done using Chi-square tests. Final multivariate analysis with Bonferonni correction was performed using a backward, stepwise regression model including potential predictor variables identified in the bivariate analysis. A total of 211 patients received surgical treatment and 18 of those patients (8.5%) failed closed reduction and underwent open reduction. Final multivariate analysis demonstrated that only flexion type [relative risk (RR), 10.2] and coronal displacement more than 7 mm (RR, 4.49) were significant preoperative factors for conversion to open reduction. Patients with significant coronal displacement and flexion-type injuries are markers of challenging reduction and are at high risk for conversion to open reduction.

Upper extremity stress fractures and spondylolysis in an adolescent baseball pitcher with an associated endocrine abnormality: a case report.

Lower extremity stress fractures are relatively common among competitive athletes. Stress fractures of the upper extremity, however, are rare and most have been reported in the literature as case reports. We present a case of an adolescent baseball pitcher who had both proximal humeral and ulnar shaft stress fractures, as well as spondylolysis of the lumbar spine. This particular patient also had an underlying endocrine abnormality of secondary hyperparathyroidism with a deficiency in vitamin D. A bone mineral density panel demonstrated a high T score (+2.79 SD above the mean) and the patient's biologic bone age was noted to be 2 years ahead of his chronologic age. The patient was treated with a course of vitamin D and calcium supplementation. After treatment, both the vitamin D and parathyroid hormone returned to normal levels. The upper extremity stress fractures and spondylolysis were managed conservatively and he was able to return to full activity and baseball. For patients who present with multiple stress fractures not associated with consistent high levels of repeated stress, a bone mineral density panel should be considered. If vitamin D deficiency is present, a course of oral supplementation may be considered in the management. An endocrinology consult should also be considered in patients who present with multiple stress fractures. Conservative management of upper extremity stress fractures and spondylolysis was successful in returning this patient back to his previous activity level.

Imaging in pelvic osteomyelitis: support for early magnetic resonance imaging.

BACKGROUND: Children with pelvic osteomyelitis may present with symptoms that are nonspecific. Conventional imaging modalities including plain radiographs, ultrasound, technetium bone scan, and computed tomography rarely demonstrate pathology that is diagnostic of this condition. As a result, accurate diagnosis is often delayed, and children may undergo surgical diagnostic or therapeutic procedures that may be avoided. We report the radiographic and magnetic resonance imaging (MRI) findings in 23 children admitted with a suspected diagnosis of pelvic osteomyelitis. We are presenting imaging findings in children with suspected pelvic osteomyelitis with emphasis on MRI abnormalities and to propose an anatomical classification based on the patterns of pelvic involvement. METHODS: The medical records and imaging reports of all patients admitted to our institution with a history and physical examination suggestive of pelvic osteomyelitis between July 31, 1992, and March 10, 2003 were reviewed. Criteria were defined for the diagnosis of pelvic osteomyelitis based on criteria used by Farley et al in 1985. Specific attention was paid to the imaging strategies used and the influence of each radiographic method on the ultimate diagnosis. RESULTS: Abnormalities on the MRI included soft tissue inflammation and bone edema. These findings were bright on T2 and short inversion time Short T1 inversion recovery (STIR) images and enhanced after gadolinium administration. Five distinct patterns of pelvic involvement were observed, each corresponding to a cartilaginous epiphysis or apophysis. These were the sacroiliac joint, triradiate cartilage, pubic symphysis, ischium, and iliac apophysis. One patient had a noninfectious cause of presentation with a deep vein thrombosis, whereas another was diagnosed with Hodgkin lymphoma in addition to osteomyelitis of the ischium. CONCLUSIONS: Magnetic resonance imaging is a sensitive technique for evaluation of pyogenic infections involving the pelvis. In patients presenting with clinical findings and laboratory studies suggesting an infectious process, MRI with gadolinium enhancement should be performed as an early study. Magnetic resonance imaging is also effective in identifying other conditions that may resemble pelvic osteomyelitis.

Extraarticular synovial chondromatosis: review of epidemiology, imaging studies, microscopy and pathogenesis, with a report of an additional case in a child.

A rare benign condition of uncertain etiology and pathogenesis, Synovial Chondromatosis (SC) is most often seen intraarticularly in adults but only a handful of cases have been reported extraarticularly in children. Symptoms and physical signs consist of pain, swelling, and osteoarthritic changes related to a mass effect. Here we discuss the case of a 9-year-old boy with documented SC of the knee and critically review the Epidemiology, Clinical Presentation, Gross Anatomy and Microscopic Histopathologic Features as well as the role of Imaging Studies in Diagnosis. In addition, this paper reviews Current Pathogenetic Concepts including the infrequent but distinct possibility of malignant transformation.

Translocation (16;20)(p11.2;q13). sole cytogenetic abnormality in a unicameral bone cyst.

We report the results of cytogenetic analysis of a case of unicameral bone cyst with a t(16;20(p11.2;q13) present as the sole abnormality. To our knowledge, this is only the second report of a cytogenetically characterized tumor of this type.