Growing skull fracture with an atypical mechanism: a case report.

Growing skull fractures (GSFs) are well-known but rare causes of pediatric head trauma. They generally occur several months after a head injury, and the main lesion is located under the periosteum. We herein report a case involving a 3-month-old boy with GSF that developed by a different mechanism than previously considered. It developed 18 days after the head injury. A large mass containing cerebrospinal fluid and brain tissue was present within the periosteum. A good outcome was obtained with early strategic surgery. Injury to the inner layer of the periosteum and sudden increase in intracranial pressure might be related to GSF in this case.

Development of a novel murine delayed secondary fracture healing in vivo model using periosteal cauterization.

INTRODUCTION: Delayed union and nonunion development remain a major clinical problematic complication during fracture healing, with partially unclear pathophysiology. Incidences range from 5 to 40% in high-risk patients, such as patients with periosteal damage. The periosteum is essential in adequate fracture healing, especially during soft callus formation. In this study, we hypothesize that inducing periosteal damage in a murine bone healing model will result in a novel delayed union model. MATERIALS AND METHODS: A mid-shaft femoral non-critically sized osteotomy was created in skeletally mature C57BL/6 mice and stabilized with a bridging plate. In half of the mice, a thin band of periosteum adjacent to the osteotomy was cauterized. Over 42 days of healing, radiographic, biomechanical, micro-computed tomography and histological analysis was performed to assess the degree of fracture healing. RESULTS: Analysis showed complete secondary fracture healing in the control group without periosteal injury. Whereas the periosteal injury group demonstrated less than half as much maximum callus volume (p < 0.05) and bridging, recovery of stiffness and temporal expression of callus growth and remodelling was delayed by 7-15 days. CONCLUSION: This paper introduces a novel mouse model of delayed union without a critically sized defect and with standardized biomechanical conditions, which enables further investigation into the molecular biological, biomechanical, and biochemical processes involved in (delayed) fracture healing and nonunion development. This model provides a continuum between normal fracture healing and the development of nonunions.

Comparison of Negative Pressure Wound Therapy and Conventional Therapy for Cranial Bone-exposed Wounds in Rabbits.

BACKGROUND: Bone-exposed wounds with intact or defected periosteum are difficult to heal. To provide relevant experimental evidence for guidance of clinical therapy, we established a rabbit model to compare the efficacies of negative pressure wound therapy (NPWT) and conventional guaze dressing therapy on the healing of cranial bone-exposed wounds. METHODS: Full-thickness excisional circular wounds of 2.0 cm in diameter with exposed bones covered with or without periosteum were created at the parietal regions in 88 rabbits that were further randomly divided into the following treatment groups: periosteum-intact wounds treated with conventional vaseline gauze dressings (P + Control group), periosteum-intact wounds treated with NPWT (P + NPWT group), periosteum-lacking wounds treated with conventional vaseline gauze dressings (P-Control group), and periosteum-lacking wounds treated with NPWT (P-NPWT group). The wounds of NPWT groups were treated using a negative pressure therapy assembly that was set at a continuous pressure of -125 mm Hg for 7 days, then covered with vaseline gauze. The wound healing rates, wound infection rates, hydroxyproline content, and wound tissue histology were determined and evaluated. RESULTS: The NPWT shortened the wound healing time by approximately 5 days when compared with the conventional gauze therapy. The histological characterization of wound tissues showed that NPWT decreased the inflammatory cells infiltration, accelerated reepithelialization and facilitated the organization of collagen fibers into neat layers on postoperative day (POD) 10. The NPWT enhanced bacterial clearances, reduced infection rates and increased the hydroxyproline contents in both types of wounds on PODs 10 and 15. The immunohistochemical staining of CD31 showed the NPWT treatment resulted in a significantly increased and persistent angiogenesis, and the wounds treated with NPWT showed well developed and more functional vessels at POD 7 compared with control. CONCLUSIONS: The NPWT is a more effective therapy for bone-exposed wounds than conventional guaze dressing therapy. The NPWT can promote bone-exposed wounds healing by increasing collagen contents and vessels densities while reducing inflammatory cells infiltration, reducing wound infection rates, and inducing an ordered collagen arrangement.

Establishment and characterization of the Masquelet induced membrane technique in a rat femur critical-sized defect model.

The Masquelet induced membrane technique for reconstructing large diaphyseal defects has been shown to be a promising clinical treatment, yet relatively little is known about the cellular, histological and biochemical make-up of these membranes and how they produce this positive clinical outcome. We compared cellular make-up, histological changes and growth factor expression in membranes induced around femur bone defects and in subcutaneous pockets at 2, 4 and 6 weeks after induction, and to the periosteum. We found that membranes formed around bone defects were similar to those formed in subcutaneous pockets; however, both were significantly different from periosteum with regard to structural characteristics, location of blood vessels and overall thickness. Membranes induced at the femur defect (at 2 weeks) and in periosteum contain mesenchymal stem cells (MSCs; STRO-1+ ) which were not found in membranes induced subcutaneously. BMP-2, TGFß and VEGF were significantly elevated in membranes induced around femur defects in comparison to subcutaneously induced membranes, whereas SDF-1 was not detectable in membranes induced at either site. We found that osteogenic and neovascular activity had mostly subsided by 6 weeks in membranes formed at both sites. It was conclude that cellular composition and growth factor content in induced membranes depends on the location where the membrane is induced and differs from periosteum. Osteogenic and neovascular activity in the membranes is maximal between 2 and 4 weeks and subsides after 6. Based on this, better and quicker bone healing might be achieved if the PMMA cement were replaced with a bone graft earlier in the Masquelet technique. Copyright © 2013 John Wiley & Sons, Ltd.

Association of a Subperiosteal Hematoma With Minor Injury.

An intraorbitalsubperiosteal hematoma is a rare clinical entity that is usually caused by head trauma. The authors experienced a patient involving an intraorbital hemorrhage that was associated with minor injury in the forehead and that required surgical decompression. The authors describe this rare case involving an intraorbitalsubperiosteal hematoma that occurred in a conscious young boy who had no remarkable head injury and who had sudden onset of proptosis. Three-dimensional computed tomography, which was conducted with a volume-rendering method, was very useful, and the transorbital approach that was used to remove the hematoma was very effective. The patient showed good recovery. The pathogenesis of the intraorbitalsubperiosteal hemorrhage could not be fully explained, and, thus, the authors suggest that a possible pathogenesis involved the migration of the hemorrhage from the forehead into the intraorbital region.

Evaluation of oriented electrospun fibers for periosteal flap regeneration in biomimetic triphasic osteochondral implant.

Osteochondral defects represent a serious clinical problem. Although the cell-scaffold complexes have been reported to be effective for repairing osteochondral defects, a periosteal flap is frequently needed to arrest leakage of the implanted cells into the defect and to contribute to the secretion of cytokines to stimulate cartilage repair. The electrospun mesh mimicking the function of the flap assists tissue regeneration by preventing cell leakage and merits favorable outcomes in the cartilaginous region. In this study, an oriented poly(ε-caprolactone) (PCL) fibrous membrane (OEM) was fabricated by electrospinning as a periosteal scaffold and then freeze-dried with a collagen type I and hyaluronic acid cartilage scaffold (CH) and finally, freeze-dried with a tricalcium phosphate (TCP) bone substratum. Scanning electron microscopic images show obvious microstructure formation of the trilayered scaffolds, and electrospun fibrous membranes have an oriented fibrous network structure for the periosteal phase. Also shown are opened and interconnected pores with well designed three-dimensional structure, able to be bound in the CH (chondral phase) and TCP (osseous phase) scaffolds. In vitro results showed that the OEM can promote the orientation of bone marrow mesenchymal stem cell (BMSCs) and BMSCs can penetrate into the CH and TCP. After successfully combining the BMSCs, the tissue-engineered cartilage which contained the OEM and TCP complex was successfully used to regenerate the osteochondral defects in the rabbit model with greatly improved repair effects.

Reconstruction of a functional gliding surface with extensor retinaculum in extensor tendon reconstruction in the digits.

BACKGROUND: Tendon gliding is key to optimal recovery of hand function after complex tendon injuries. Gliding is facilitated by a low-friction gliding surface that is normally provided by the periosteum of the underlying bone. However, significant injuries may damage the periosteum, which must be reconstructed to allow uninterrupted tendon excursion. The absence of the periosteum may compromise a tendon's ability to glide freely, thereby limiting the range of motion. METHODS: Six digits in 4 patients with complex, composite soft tissue defects involving tendon, periosteum, and skin of the hand underwent surgical repair. Each digit had disruption of the bony cortex underlying the tendon injury including periosteal loss. Through an incision on the dorsum of the ipsilateral wrist, an extensor retinaculum graft corresponding to the size of the periosteal defect was harvested. It was then sutured into place over the bare cortex to replace the lost periosteum. RESULTS: All the 6 digits in the 4 patients had complete return to function. Additionally, all patients had near normal strength in the repaired hand along with excellent tendon excursion in both flexion and extension. The average time of follow-up of this series of patients was 1.5 years. CONCLUSIONS: Extensor retinaculum grafting to replace lost periosteum is a technique that is easily used, uses locally available autogenous tissues, and produces excellent tendon function. Additionally, the histologic similarities between extensor retinaculum and periosteum add scientific merit to this novel approach. On the basis of our experience, we recommend the use of extensor retinaculum for periosteal reconstruction to provide an adequate gliding surface for a reconstructed tendon.

Arthroscopic findings in the recurrent anterior instability of the shoulder.

BACKGROUND: A recurrent anterior shoulder dislocation consists of a variety of lesion types. OBJECTIVES: To evaluate the pathological classification of recurrent anterior dislocation of the shoulder joint under arthroscopy. METHODS: Thirty-one patients with recurrent anterior shoulder dislocation were inspected by arthroscopy, including 23 males and 8 females, with a mean age of 35.1 (18-46) years. The patients were divided into two groups: 17 with shoulder dislocation and hyper-laxity (the hyper-laxity group) and 14 with only traumatic shoulder dislocation (the trauma group). All the patients were assessed by arthroscopy for pathological changes, and the differences in the pathological changes were compared between the two groups. RESULTS: All these 31 patients suffered from anteroinferior labrum injury. Twenty-five had Hill-Sachs injury; 27, bone or cartilage injury of anteroinferior glenoid; 16, SLAP injury; and 5, rotator cuff injury. Bankart injury occurred more in the trauma group, and anterior labroligamentous periosteal sleeve avulsion injury and glenolabral articular disruption injury were more in the hyper-laxity group. Bone or cartilage injury of anteroinferior glenoid was more noticed in the trauma group. CONCLUSIONS: Significant differences are found under arthroscopy in the pathological changes of recurrent anterior shoulder dislocation between the purely traumatic group and the hyper-laxity group. The pathological changes in the trauma group were more severe than in the hyper-laxity group.

Ossification of subperiosteal hematoma: the potential of periosteal osteogenesis in cranioplasty.

BACKGROUND: Subperiosteal hematoma is the accumulation of blood between the periosteum and the skull, which commonly occurs in the neonatal period but rarely in other ages. Subperiosteal hematoma can be self-absorbed in most cases and occasionally may cause ossification. MATERIALS AND METHODS: This study reports a case of subperiosteal hematoma formed in a 16-year-old adolescent boy after a minor trauma. Because the hematoma did not disappear for more than a month after the trauma, the patient was treated with multiple hematoma punctures. However, the hematoma recurred and led to ossification. Finally, the patient underwent surgical treatment. RESULTS: Finally, the ossification associated with the hematoma was treated through surgery. The head contour recovered normally. CONCLUSIONS: The occurrence of hematoma ossification in the 16-year-old patient suggests that the periosteum has great potential for osteogenesis. This is likely caused by the joint action of some active factors in the blood and a certain tension of the hematoma on the local periosteum. This case provides the following thoughts. (1) A subperiosteal hematoma that has not been absorbed after 1 month should be treated promptly to avoid ossification. Once ossification has occurred, the hematoma should be treated surgically. (2) The potential for periosteal osteogenesis is great, which may provide a new thought for cranioplasty.

The effects of low-level laser therapy on palatal mucoperiosteal wound healing and oxidative stress status in experimental diabetic rats.

OBJECTIVE: The biostimulation effects of low-level laser therapy (LLLT) have recently been demonstrated. In this study, we aimed to investigate the effects of LLLT on palatal mucoperiostal wound healing and oxidative stress status in experimental diabetic rats. MATERIALS AND METHODS: Forty-two male Wistar rats that weighed 250-300 g were used in this study. Experimental diabetes was induced in all of the rats using streptozotocin. A standardized full thickness wound was made in the mucoperiosteum of the hard palates of the rats using a 3 mm biopsy punch. The rats were divided into groups: 1 (control group, non- irradiated), and 2 (experimental group, irradiated). Treatment using a GaAlAs laser at a wavelength of 940 nm and at dose of 10 J/cm(2) began after surgery, and was repeated on the 2nd, 4th, and 6th days post-surgery. Seven animals from each group were killed on the 7th, 14th, and 21st day after surgery. Biopsies were performed for the histological analysis and blood samples were collected by cardiac puncture for biochemical analysis. RESULTS: The histopathological findings revealed reduced numbers of inflammatory cells, and increased mitotic activity of fibroblasts, collagen synthesis, and vascularization in rats in group 2. The total oxidative status was significantly decreased in the laser-treated group on the 21st day. CONCLUSIONS: LLLT elicits a positive healing effect on palatal mucoperiostal wounds, and modulates the oxidative status in experimental diabetic rats.

Validation of MRI classification system for tibial stress injuries.

OBJECTIVE: The purpose of our study was to compare an MRI classification system for tibial stress injuries with semiquantitative MR features of injury severity and clinical outcome. MATERIALS AND METHODS: Two musculoskeletal radiologists retrospectively reviewed in consensus the MR findings of 142 tibial stress injuries to quantify the degree of periosteal and bone marrow edema and grade the injuries using the Fredericson classification system (grade 1 = periosteal edema only, grade 2 = bone marrow edema visible on T2-weighted images, grade 3 = bone marrow edema visible on T1-weighted and T2-weighted images, grade 4a = multiple focal areas of intracortical signal abnormality, and grade 4b = linear areas of intracortical signal abnormality). Kruskal-Wallis tests were used to determine the relationship between the grade of stress injury and the degree of periosteal and bone marrow edema and the time to return to sports activity. RESULTS: Grade 4b injuries had significantly (p < 0.002) more severe and grade 1 injuries less severe periosteal and bone marrow edema than grades 2, 3, and 4a injuries. Grade 4b injuries had significantly (p < 0.002) longer time and grade 1 injuries shorter time to return to sports activity than grades 2, 3, and 4a injuries. There was no significant difference (p = 0.06-0.79) among grades 2, 3, and 4a injuries in the degree of periosteal and bone marrow edema and the time to return to sports activity. CONCLUSION: Grades 2, 3, and 4a stress injuries had similar degrees of periosteal and bone marrow edema and similar time to return to sports activity, which suggests that these three grades can be combined into a single category in an abbreviated Fredericson classification system.

Preferential recruitment of bone marrow-derived cells to rat palatal wounds but not to skin wounds.

OBJECTIVE: To investigate the contribution of bone marrow-derived cells to oral mucosa wounds and skin wounds. BACKGROUND: Bone marrow-derived cells are known to contribute to wound healing, and are able to differentiate in many different tissue-specific cell types. As wound healing in oral mucosa generally proceeds faster and with less scarring than in skin, we compared the bone marrow contribution in these two tissues. DESIGN: Bone marrow cells from GFP-transgenic rats were transplanted to irradiated wild-type rats. After recovery, 4-mm wounds were made in the mucoperiosteum or the skin. Two weeks later, wound tissue with adjacent normal tissue was stained for GFP-positive cells, myofibroblasts (a-smooth muscle actin), activated fibroblasts (HSP47), and myeloid cells (CD68). RESULTS: The fraction of GFP-positive cells in unwounded skin (19%) was larger than in unwounded mucoperiosteum (0.7%). Upon wounding, the fraction of GFP-positive cells in mucoperiosteum increased (8.1%), whilst it was unchanged in skin. About 7% of the myofibroblasts in both wounds were GFP-positive, 10% of the activated fibroblasts, and 25% of the myeloid cells. CONCLUSIONS: The results indicate that bone marrow-derived cells are preferentially recruited to wounded oral mucosa but not to wounded skin. This might be related to the larger healing potential of oral mucosa.

Evaluation of a biodegradable novel periosteal distractor.

UNLABELLED: We developed a new device composed of a thin biodegradable mesh (poly-L-lactide/hydroxyapatite composite) for distracting periosteum. The purpose of this study is to evaluate the effect of using this device as a periosteal distractor. MATERIALS AND METHODS: Eight Japanese male rabbits were divided into two groups according to time of sacrifice. The calvarial periosteum was elevated and one side of a biodegradable mesh was fixed to the bone surface with two titanium screws. Seven days after the surgery, an elevating screw was inserted into the other side of the mesh. Then, the calvarial periosteum was elevated at maximum 0.5 mm every 12 h for 5 days. The device was designed to distract the periosteum at different rates along its entire surface. At 4 and 6 weeks of the consolidation, the animals were sacrificed and newly formed bone was histologically and radiographically evaluated. RESULTS: The new device simplified periosteal distraction and reduced its invasiveness. Moreover, it successfully induced new bone formation from two sources; the periosteum and the underlying basal bone. Histomorphometric analysis of the distracted space showed that there is a relation between the rate of distraction and the amount of newly formed bone. We suggest that the optimal speed range for periosteal distraction in rabbit calvarial model could be less than 0.33 mm/day. CONCLUSIONS: The new device is slim, biodegradable and the procedure is simple. Thus, periosteal distraction with this device is potential for vertical and horizontal ridge augmentation in oral cavity.

Adolescent slipped capital femoral epiphysis treated by a modified Dunn osteotomy with surgical hip dislocation.

Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire. Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips. Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure.

Bone marrow-derived cells in palatal wound healing.

OBJECTIVE: Myofibroblasts are responsible for contraction and scarring after cleft palate repair. This leads to growth disturbances in the upper jaw. We hypothesized that cells from the bone marrow are recruited to palatal wounds and differentiate into myofibroblasts. METHODS: We transplanted bone marrow from green fluorescent protein (GFP)-transgenic rats into lethally irradiated wild-type rats. After recovery, experimental wounds were made in the palatal mucoperiosteum, and harvested 2 weeks later. GFP-expressing cells were identified using immunostaining. Myofibroblasts, activated fibroblasts, endothelial cells, and myeloid cells were quantified with specific markers. RESULTS: After transplantation, 89 ± 8.9% of mononuclear cells in the blood expressed the GFP and about 50% of adherent cells in the bone marrow. Tissue obtained during initial wounding contained only minor numbers of GFP-positive cells, like adjacent control tissue. Following wound healing, 8.1 ± 5.1% of all cells in the wound area were positive, and 5.0 ± 4.0% of the myofibroblasts, which was significantly higher than in adjacent tissue. Similar percentages were found for activated fibroblasts and endothelial cells, but for myeloid cells it was considerably higher (22 ± 9%). CONCLUSIONS: Bone marrow-derived cells contribute to palatal wound healing, but are not the main source of myofibroblasts. In small wounds, the local precursor cells are probably sufficient to replenish the defect.

Radiofrequency energy on cortical bone and soft tissue: a pilot study.

BACKGROUND: Radiofrequency-generating energy devices have been used clinically in musculoskeletal procedures to provide hemostasis and capsular shrinkage (thermal capsulorrhaphy). However, the dose-effects are not well known. QUESTIONS/PURPOSES: We therefore determined dosage effects of radiofrequency energy on bone, skin incisions, and joint capsule in sheep. METHODS: Five mature sheep had six 2.5-cm(2) tibial periosteal defects and six 1.0-cm skin incisions assigned to six treatments varying by watts and fluence (f = watts . seconds/cm(2)): (1) untreated control, (2) 50 W for 9.5 seconds (190f; n = 5), (3) 110 W for 4.3 seconds (190f; n = 5), (4) 170 W for 2.8 seconds (190f; n = 5), (5) 170 W for 5.6 seconds (380f; n = 5), or (6) 170 W for 8.4 seconds (570f; n = 5). Outcomes included hemostasis, contraction, healing, and histomorphometry for inflammation and necrosis at 2 weeks. RESULTS: Radiofrequency energy application on skin at 190f or greater had more than 80% hemostasis and dose-dependent contraction, inflammation, and necrosis. Radiofrequency energy application on bone had good (70%) hemostasis at 190f and complete (> 95%) hemostasis at 380f and 570f, without histologic or clinically detectable necrosis. CONCLUSIONS: Hemostasis can be achieved with radiofrequency energy at 190f in skin and bone. Bone necrosis was not detected at up to 570f. Using fluence greater than 190f in skin achieved dose-dependent necrosis and incisional contraction. CLINICAL RELEVANCE: Radiofrequency energy can be used on bone and skin for hemostasis, but potential incisional complications, such as necrosis and an atypical firm and desiccated surface, should be expected.

Céfalo-hematoma subperiosteal gigante ossificado na infância / Ossified giant subperiosteal cephalhematoma in childhood

Hematoma subperiosteal ou céfalo-hematoma, apesar de condição conhecida em neonatos, é rara em adultos e mesmo em crianças maiores, o que levanta a suspeita de uma diferente patogênese entre as duas situações. A cronificação e a ossificação do céfalo-hematoma são condições extremamente infrequentes, com escasso material bibliográfico, e sua presença no adulto é fato inusitado na literatura. Reportamos o caso de um hematoma subperiosteal crônico de grandes proporções, ossificado, com um ano de evolução, tratado cirurgicamente, em um menino de 12 anos de idade com síndrome epiléptica e déficit cognitivo prévios. A revisão e a discussão de sua patogênese e seu tratamento foram realizadas para exposição da condição.

Subperiosteal hematoma or cephalhematoma is a well known condition on newborns, but rare in adults and older children, what may lead to a different pathogenic origin. Chronic or ossificated cephalhematoma are infrequent, with few reports in medical literature. There are no cases reported in adults. It is presented a case of a 12 year-old boy, with previous epileptic syndrome and cognitive deficit, who was admitted because of a large chronic ossified subperiosteal hematoma. It was removed surgically. Revision and discussion of its pathogenesis were prepared for the case presentation.

The effects of early or late treatment of osteochondral defects on joint homoeostasis: an experimental study in rabbits.

A 3.5 x 4 mm tubular osteochondral defect was created on the right medial femoral condyles of 51 adult rabbits. In the control group (CG), defects were left untreated. In the early-(ETG) and late-(LTG) treatment groups, defects were treated by an osteoperiosteal graft 1 and 12 weeks, respectively, after the index procedure. Synovial fluid (SF) samples were collected regularly and proteoglycan fragments (PF), total collagen (TC) and collagenase (MMP-1) levels were measured. Rabbits were killed at 4 (early period), 12 (intermediate period), or 24 (late period) weeks postoperatively. Histological examination indicated a more successful healing in both grafting groups than in the CG, but without any difference at any time period between the grafting groups. In the CG, PF, and TC levels in SF increased continuously until the late period, indicating an ongoing degenerative activity in the joints. In contrast, SF marker levels in both grafting groups indicated that normalization in joint metabolism could be achieved-at least partially-after treatment. However, PF levels in the SF showed that the treatment of defects in earlier stages might result in better outcomes since the negative effects were more prominent in chronic stages, presumably due to the more prolonged period of disturbed homeostasis. Thus, histological values and SF marker levels indicated that treatment of osteochondral defects at any time of the disease had a positive effect on healing when compared to no treatment. Early treatment might better assist the recovery of joint homeostasis than late treatment.

Subperiosteal hematoma and orbital compression syndrome following minor frontal trauma in sickle cell anemia: case report / Hematoma subperiósteo e compressão orbitária após trauma frontal leve na anemia falciforme: relato de caso

We report the case of an 11-year-old girl with sickle cell disease who presented to the emergency room after being hit by a mud pie in the left frontal region. Examination evidenced left eye proptosis, eyelid swelling, reduced visual acuity and afferent pupillary defect, without any inflammatory signs such as fever, hyperemia or tenderness. Computed tomography of the orbits showed a large superomedial subperiosteal hematoma in the left orbit. The patient was treated with canthotomy, cantholysis and surgical draining of the hematoma. Two days after drainage she persisted with a subperiosteal hematoma and low visual acuity. A wide exploration of the orbital roof through a lid crease approach disclosed a thickened superior orbital rim with multiple bone defects along the roof and with continuous bleeding. Hemostasis was accomplished with bone wax. Orbital compression was resolved and the patient recovered her previous normal visual acuity.

Relatamos o caso de uma menina de 11 anos com doença falciforme, trazida à sala de emergência após ser atingida por um bloco de barro na região frontal esquerda. Apresentava ao exame proptose do olho esquerdo, edema palpebral, diminuição da acuidade visual e defeito pupilar aferente, sem quaisquer sinais inflamatórios como febre, hiperemia ou aumento de sensibilidade. A tomografia computadorizada de órbitas demonstrou um extenso hematoma subperiósteo superomedial na órbita esquerda. A paciente foi tratada com cantotomia, cantólise e drenagem cirúrgica do hematoma. Dois dias após a drenagem, ela permaneceu com um hematoma subperiósteo e a acuidade visual diminuída. Uma ampla exploração através de incisão no sulco palpebral superior revelou um rebordo orbitário superior espessado, e múltiplos defeitos ósseos ao longo do teto da órbita com sangramento persistente. Foi realizada hemostasia com cera óssea. A compressão orbitária foi resolvida, e a paciente recuperou a acuidade visual normal prévia.

Giant occipital intradiploic epidermoid cyst associated with iatrogenic puncture.

The origin of cranial epidermoid cysts (EC) remains controversial, and although generally considered to be congenital, acquired origin has been reported. EC represent 0.2 to 1.8% of all brain tumours, and only one fourth are intradiploic in location. We report of a 44-year-old woman with a giant intradiploic EC of the occipital bone with intracranial extension confirmed on brain MRI. Three years previously, in the same location, she underwent resection of an intradermal melanocytic naevus of the skin under local anaesthesia with lidocaine infiltration of skin and periosteum. Brain CT scan performed at the time of naevus surgery because of associated headache did not show a lesion of the cranial vault. Iatrogenic epidermoid tumours are extremely rare, and although seeding of epidermal cells has been classically described only after lumbar puncture, the same mechanism may be involved after head injury, cranial surgery or cranial periosteal iatrogenic puncture.