Etiology and Diagnostic Challenges of Ulnar Wrist Pain in Pediatric and Adolescent Patients.

PURPOSE: Diagnosing the cause of ulnar-sided wrist pain can be difficult in the pediatric and adolescent age group. While frequently used, the diagnostic accuracy of magnetic resonance image (MRI), as compared with intraoperative arthroscopic findings, is not well-described in this population. This study aimed to determine concordance rates between magnetic resonance and arthroscopic findings depending on the specific ulnar wrist pathology. METHODS: A retrospective review was performed to identify pediatric and adolescent patients who underwent operative treatment of ulnar wrist pain between 2004 and 2021. Patients were included in the analysis if they were <18 years of age, complained of ulnar-sided wrist pain, underwent MRI of the affected wrist with an available report interpreted by a consultant radiologist, and had a diagnostic arthroscopy procedure within one year of imaging. Ulnar pathologies analyzed included triangular fibrocartilage (TFCC) tears, ulnotriquetral (UT) ligament tears, lunotriquetral ligament abnormalities, and ulnocarpal impaction. RESULTS: A total of 40 patients with a mean age of 15-years-old (range 11 to 17) were included in the analysis. Twenty-four were female, and approximately half had their dominant extremity affected. Most had a history of antecedent trauma (n = 34, 85%), but only 15/40 (38%) had a history of fracture. The mean duration of symptoms prior to presentation was six months (standard deviation, 7). The most common etiologies were Palmer 1B TFCC tears (n = 27, 68%) followed by UT split tears (n = 11, 28%). MRI overall demonstrated high specificity (82% to 94%), but low sensitivity (14% to 71%) for ulnar-sided wrist conditions. Accuracy varied between 70% and 83% depending on the specific injury. CONCLUSION: While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. Surgeons should have a high degree of suspicion for TFCC-related pathology in the setting of positive provocative clinical examination despite negative MRI findings in young patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IIb.

Staged Intracranial Free Tissue Transfer and Cranioplasty for a Refractory Nasal-cranial Base Fistula.

After a transnasal endoscopic resection of a high-grade adenoid cystic carcinoma that underwent adjuvant chemoradiation, there was delayed recurrence managed by en bloc resection through an open craniofacial approach. Subsequently, the patient developed a chronic nasocranial fistula with secondary infection and bone flap resorption. This resulted in infectious episodes with secondary scalp incisional dehiscence and hardware exposure which required multiple bone debridement procedures, hardware removal, prolonged IV antibiotics, and hyperbaric oxygen treatment. The nasocranial fistula and chronic frontal bone osteomyelitis persisted despite the previous interventions. The patient underwent a frontal bone removal and obliteration of the anterior cranial base fistula with a free vastus lateralis muscle flap. At 4 weeks postoperatively, the intranasal portion of the muscle flap had completely mucosalized. After a 6-week course of IV antibiotics, a secondary cranioplasty using a custom-made poly-ether-ether-ketone implant was performed. The patient remained disease- and infection-free for the duration of follow-up (17 months).