Displaced Distal Fibular Epiphysis in a Child: A Clinical and Radiological Evaluation of a Rare Injury Hidden From the Initial Radiological Examination.

Fractures of the lateral malleolus are common in children. Isolated lesions of the distal fibula physis commonly comprise nondisplaced or minimally displaced fractures. An isolated, completely displaced epiphysiolisthesis of the distal fibula is an extremely rare lesion. This study introduces the case of an 11-year-old boy presenting an extremely rare lesion of an isolated, completely displaced distal fibular epiphysis that was difficult to diagnose on X-ray. Initial radiographic examination of the injured ankle showed normal configuration of the tibia and fibula on AP projection, with soft tissue swelling of the lateral malleolus. On the lateral projection, the talus completely covered the distal fibular epiphysis, and particular attention was required to reveal the complete displacement of the distal fibular epiphysis. A CT scan confirmed the diagnosis of an isolated, completely displaced distal fibular epiphysiolisthesis. The patient was treated with a closed reduction and made an uneventful recovery. This report highlights the importance of accurate clinical and radiological assessment of an isolated, completely displaced, distal fibular epiphysiolisthesis.

Enhancing Meniscal Repair: Investigating the Impact of an Exogenous Fibrin Clot.

This study conducted a comparative analysis of meniscal rupture repair, evaluating outcomes with and without the application of an exogenous fibrin clot to enhance meniscus repair. The research incorporated a relatively large sample size (24 patients) and employed a randomized control group with similar age characteristics and morphological types of meniscal ruptures as the study group. Notably, two postoperative follow-up times, at the third and 12th postoperative months, were utilized, distinguishing this study from related research. In the third postoperative month assessment, the fibrin clot technique demonstrated a significant advantage over simple stapling, as evidenced by markedly improved Tegner Lysholm Knee Scoring Scale (TLKSS) and Modified Cincinnati Rating System Questionnaire (MCRSQ) clinical assessment scores. Subsequent MRI scans at 12 months post-treatment revealed a high rate (91.67%) of complete healing in menisci treated with a fibrin clot, with only 4.17% exhibiting incomplete healing. This study expanded on previous research by including longitudinal ruptures and bucket-handle ruptures in addition to radial ruptures. The findings highlight a notable early improvement (third postoperative month) in the clinical assessment of longitudinal and bucket-handle ruptures treated with a fibrin clot during meniscus repair. This research contributes valuable insights into the efficacy of fibrin clots in enhancing meniscus repair, suggesting positive clinical and radiological outcomes, especially in the early stages postoperatively.

Clinical Behavior of the Mucoepidermoid Carcinoma of the Larynx-A Scoping Review.

OBJECTIVE: Mucoepidermoid carcinomas (MEC) of the larynx account for less than 1% of all laryngeal tumors. The unique features and clinical behavior of these rare entities remain unknown. To fill this knowledge gap, we performed a scoping review of every reported case of laryngeal MEC to study the clinical behavior and the treatment modalities in this rare entity. REVIEW METHODS: We followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) statement. DATA SOURCES: MedLine, Google Scholar, and Science Direct databases were searched to identify eligible studies. RESULTS: We concluded with 25 studies and overall 66 cases. Our study revealed that the average age of cases was 55.7 years, and the range was from 12 to 81 years, with younger onset in females. Supraglottic (60%) is the most common subsite of laryngeal MEC s followed by glottis (27.3%). Supraglottic carcinomas frequently present with metastatic neck disease at the time of the initial diagnosis and require more extensive surgical approaches. Surgery with negative surgical margins seems to be the cornerstone in the treatment of MEC. Radiation therapy has not been tested widely as monotherapy but is considered a useful adjuvant modality. CONCLUSION: This study suggests that negative surgical margins seem to be associated to higher disease control rate and that high-grade supraglottic cases likely benefit from addressing neck disease simultaneously. LEVEL OF EVIDENCE: NA Laryngoscope, 2023.

Restoration of Limb Length Discrepancy and Alignment With the Ilizarov Device After Management of an Aneurysmal Bone Cyst Crossing the Distal Femoral Physis.

An aneurysmal bone cyst (ABC), when located juxta-physeal, may rarely penetrate the growth plate and extend into the epiphysis. The recurrence rate is considered higher when ABC is in contact with the active growth plate. Treatment methods usually focus on cyst healing and the rate of cyst recurrence. We present the method of treatment used for addressing the lesion of the growth plate following the surgical management and healing of a juxta-physeal ABC. A seven-year-old girl had an aggressive ABC in the juxta-physeal area of the distal femur, penetrating the growth plate and extending in the epiphysis. Surgical treatment was performed, including curettage and autologous bone grafting, avoiding the growth plate. The cyst healed; however, physis presented an obliteration. The affected limb developed valgus deformity and severe leg length discrepancy (LLD). To address this issue, once our patient completed her growth, we proceeded with distraction osteogenesis, using the Ilizarov device, with asymmetrical lengthening of the rods. We achieved the correction of the limb alignment and resolved the LLD. ABCs in the juxta-physeal area of a growing child are benign metaphyseal tumors that exceptionally may penetrate the physis and extend into the epiphysis. Our report highlights that the growth plate's lesion, despite the cyst's healing, may compromise the final result. The use of the Ilizarov device is an effective method for correcting the malalignment and the LLD that may emerge.

Neonatal Transphyseal Separation of the Distal Humeral Epiphysis: Early Diagnosis and Immediate Treatment with Radiographic Evaluation.

Introduction: Epiphyseal separation of the distal humeral epiphysis is an extremely rare injury. Both clinical and radiological examinations are unclear and delayed diagnosis is reported. The absence of the ossification center of the capitellum complicates the radiological diagnosis and often it is reported as elbow dislocation. Case Report: We are reporting a case of a distal humeral epiphysis separation, diagnosed in the maternity hospital. The neonate had severe discomfort and reduced mobility of the affected arm. We confirmed the diagnosis with the conventional radiological examination, with the medial displacement of the olecranon and the articulation of the radius with the medial humeral condyle. We performed immediate reduction of the lesion and evaluated the restoration of the normal elbow anatomy with the correct articulation of the radius with the lateral humeral condyle. The neonate was followed for a year and there is normal development of the affected elbow. Conclusion: Knowledge of this rare neonatal fracture is essential to diagnose properly the lesion. Plain radiographic evaluation enabled us to diagnose the epiphysiolesthesis. We have treated our neonate with no invasive procedures and the final result was the normal development of the elbow joint.

The Presence of a Zygomatic Nerve Plexus in a Cadaveric Specimen Without a Zygomatic Branch of the Facial Nerve.

The extratemporal course of the facial nerve distributes in facial mimic muscles in a complex pattern. The traditional depictions of five main branches without anastomoses are not common. Davis classification remains the gold standard in the classification of facial nerve branching patterns. During a routine dissection of an 74-year-old male cadaveric specimen, we detected a very rare anatomical variation. The zygomatic branch of the facial nerve was totally absent. The temporofacial division of the main trunk was bifurcated to a temporal and a buccal branch. The anterior temporal and posterior buccal branches formed a plexus to supply the orbicularis oculi muscle. This unique variability highlights the complexity of the extratemporal facial nerve course. Retrograde facial nerve dissection requires deep knowledge of every anatomical variation of the facial nerve course to avoid an iatrogenic injury. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03601-y.

A Cadaveric Case of an Accessory Cleido-Occipital Muscle Over the Common Trunk of the Supraclavicular Nerves.

The current study describes a case of an aberrant cleido-occipital muscle. In particular, this muscle was arising from the middle part of the clavicle, inserted into the medial part of the upper trapezius muscle, and crossed over the supraclavicular nerves with possible compression of them, especially during shoulder abduction. Knowledge of the muscular variability of the posterior cervical triangle is crucial for supraclavicular nerve entrapment syndrome diagnosis and treatment. The appearance of aberrant muscular fascicles may lead to misinterpretation of neck imaging, as well as difficulties during surgical procedures undertaken in the region.

External Jugular Vein Perforation by the Transverse Cutaneous Nerve of The Neck: A Case Report and Review of The Literature.

A very rare anatomical variation of external jugular vein's penetration by the transverse cutaneous nerve of the neck is displayed in the current study. The phenomenon of veins' fenestration or penetration by other structures, such as nerves along with its likely embryologic development are discussed. Moreover, the potential clinical significance of that variation's awareness on behalf the physician is discussed in detail.

Solitary Extraskeletal Giant Osteochondroma of the Ankle in a Four-Year-Old Boy.

Solitary extraskeletal osteochondromas are rare benign lesions usually located close to a joint and are characterized by the absence of continuity with the adjacent bone. They are usually found in the hand and feet and are extremely rarely reported in the growing skeleton. In this paper, we describe a four-year-old boy who presented with a solitary calcified tumor in the posterior part of his ankle. We performed a detailed evaluation using plain X-rays, a CT scan, and an MRI, which revealed a well-demarcated calcified tumor that had the characteristics of an osteochondroma but without any continuity with the bones of the ankle joint. The lesion was treated surgically with the excision of a giant osteochondral lesion. Pathological examination revealed mature cartilage at the periphery with cancellous bone in the central part. Thus, we present the clinical and laboratory investigation of a solitary extraskeletal osteochondroma in the ankle of a four-year-old boy, which is an extremely rare case.

Early Trifurcation of the Mandibular Branch of the Facial Nerve in a Cadaveric Specimen.

Rare facial nerve branching patterns, pose dangers due to their unexpected course. Cases with multiple branches may reduce the intraoperative risk, due to the compensation of adjacent branches. We present a case of a cadaveric specimen where an early trifurcation of the mandibular branch of the facial nerve was noted. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03352-2.

Foot Oligodactyly as the Main Dysplasia in Children.

Introduction Foot oligodactyly is usually associated with fibular insufficiency or cleft foot syndrome. A foot with a reduced number of rays may occasionally have an isolated dysplasia. Methods We reviewed the clinical notes and X-rays of six children with oligodactyly, having a normal development of the tibia and fibula. Clinical evaluation recorded the plantigrade or deviated foot, appropriate shoe wear, and aesthetic presentation of barefoot children. Radiological examination revealed missing or hypoplastic bones in the foot, the presence of other deformities, and leg length discrepancy (LLD) of the affected limb. Results On clinical evaluation, all children except one had a plantigrade foot with normal shoe wear; the lesion was not spotted in three of them unless informed of the presence of the dysplasia. Radiological examination in four of them revealed the absence or hypoplasia of the navicular, with a normal shape of the first metatarsal. Calcaneocuboid joints were normal in five of them; LLD was the main problem in three children. The girl with bilateral oligodactyly presented as a normal child. Conclusion Oligodactyly may present as an isolated dysplasia. LLD in these patients, which is less severe than in children with fibular or tibial insufficiency, is the main issue that requires surgical management in later life. Prenatal diagnosis of oligodactyly as an isolated dysplasia is an important feature for appropriate counseling of parents.

Concentric Circles: A New Ultrasonographic Sign for the Diagnosis of Normal Infantile Hip Development.

Ultrasound (US) of the infant hip is used to diagnose developmental dysplasia of the hip (DDH). We present a new sonographic sign that describes the periphery of the femoral head and the acetabulum as two concentric circles.During 2008−2019, 3650 infants were referred for diagnosis of DDH. All underwent a clinical and US examination. We recorded the femoral head as the inner circle, within a fixed external circle, which was identified as the acetabulum. We analysed the clinical signs and risk factors. The US sign of two concentric circles was normal in 3522 infants and was classified as normal hip development. The alpha angle was >60° in 3449 (95%) infants. For the remaining 73 (5%) infants, the alpha angle was 50−60° and underwent further follow-up examination until the alpha angle was normalised. In 128 babies (3.5%), we detected the disruption of the concentric circle sign; the femoral head was found outside the acetabulum, which appeared with an upward sloping roof and the alpha angle was <50°. These infants had DDH and received appropriate treatment. Infants with a concentric circle sign and normal alpha angle are normal, whereas those with a disrupted sign are considered as having DDH.

The Risk of Injury in Wrist Arthroscopy Portals: A Cadaveric Study.

During wrist arthroscopy, the wrist joint can be visualized from almost every perspective through a combination of standard dorsal and volar arthroscopic portals. This cadaveric study aims to compare all wrist portals described in terms of their safety in order to rank them according to the distance from the nearest structure at risk for arthroscopic wrist procedures. Twenty-nine cadaveric formalin-embellished upper limbs were examined. Needles were inserted at dorsal and volar portal sites to perform the measurements. During the subsequent dissection, distances were measured as the shortest possible distance from the nearest structure at risk for each portal. Safe zones were determined for all portals, and the safety classification of arthroscopic wrist portals was proposed, ranking them from the safest to the most perilous. Applying the proposed safety classification to arthroscopic practice, wrist arthroscopy can be performed with a lower risk of iatrogenic complications arising from the implementation of the wrist portals.

Uncommon Anatomical Variation of the Facial Artery: A Cadaveric Case Report.

The facial artery is a branch of the external carotid artery, one of the major arteries supplying blood to the head and neck. The normal route of the facial artery follows a well-defined path. It typically arises from the external carotid artery, above the superior border of the hyoid bone. During its route, the facial artery gives off branches in the neck, mandible, buccal region, and face. This case report explores a rare anatomical variation of the facial artery characterized by an unusual termination point above the upper lip as the superior labial artery, found during a routine cadaveric dissection. While variations in the course of the facial artery are documented, this particular deviation, with its termination anterior to the typical endpoint, presents a unique anatomical variation.

Does the orientation of the styloid process cause Eagle Syndrome? An anatomical study of the styloid process in 72 Greek skulls.

<b>Introduction:</b> Patients often suffer from an elongated styloid process. This clinical entity is well known and is described as Eagle syndrome. The presence of this anatomical variation is not always associated with symptoms. However, there is a strong correlation between the elongated styloid process and Eagle syndrome </br></br> <b>Aim:</b> This study aims to calculate the incidence of elongated styloid processes in the Greek population, to analyze the morphometric characteristics of styloid processes, and to compare these among sexes. </br></br> <b>Material and methods:</b> This is a single-center retrospective study. All skulls were donated to the Department of Anatomy, the Ari-stotle University of Thessaloniki from January 2013 to May 2019 for research purposes. A styloid process longer than 30 mm was considered elongated. We used Welch's t-test for the statistical analysis of the data. </br></br> <b>Results:</b> The prevalence of elongated styloid processes was 35%. The average diameter was 3.32 mm and the average total length was 25.02 mm. There was no statistically significant difference between male and female skulls, though the female styloid processes were slightly longer and the male ones were slightly wider. Symmetry was recorded in 31% of skulls. Average axial angle was 650 but in 4% of cases it was less than 20⁰. </br></br> <b>Conclusions:</b> The elongated styloid process is not a rare entity. Eagle syndrome should always be considered in the differential diagnosis when patients report chronic sore throat. Our anatomical findings add a new dimension to the etiopathogenesis of Eagle syndrome.

Osteochondritis Lesions of the Ischiopubic Area in Young Adolescents.

Osteochondritis of the ischiopubic area is a rare disease of children that presents with hip pain and limping. Careful examination and appropriate investigations are essential to establish a definite diagnosis. We report a case series of four children, ages 10-14-year-old, with osteochondritis of the ischiopubic area. Plain X-ray examination showed an area of diffuse irregular calcification of the ischium in two of the children, while in the other two there was an asymmetrical enlargement of the ischiopubic synchondrosis. MRI investigation was the most helpful examination. Bone edema was found in all four children. A calcified mass separated from the host ischium was found in the first two children. The cortex was normal, without irregular destruction. Bone edema of both the ischium and pubic alongside the synchondrosis was found in the following two children, with intact cortices and asymmetrical enlargement. Osteochondritis lesions of the ischium and the ischiopubic area have radiological findings similar to several severe diseases. Bone edema on MRI investigation in children must be properly evaluated. Appropriate radiological examination enabled us to confirm the diagnosis of the osteochondritis and to avoid unnecessary procedures. We want to draw attention to the rare diagnosis of osteochondritis of the ischiopubic area, and the clinical significance, as a cause of hip pain and limping in children.

Anatomical Structures Responsible for CTEV Relapse after Ponseti Treatment.

Relapse of deformity after a successful Ponseti treatment remains a problem for the management of clubfoot. An untreated varus heel position and restricted dorsal flexion of the ankle are the main features of recurrences. We analyze the anatomical structures responsible for these recurrences. Materials and methods: During 5 years, 52 children with CTEV (Congenital Talipes Equino Varus) were treated with casts according to the Ponseti method, with a mean number of 7 casts. Closed percutaneous tenotomy was performed in 28 infants. Children were followed monthly and treated with the continuous use of a molded cast. We had 9 children with relapsed clubfeet. During the standing and walking phase, they had a fixed deformity with a varus position of the heel and dorsal flexion of the ankle <10 d. They were surgically treated with the posterolateral approach. Results: In all patients, we found a severe thickening of the paratenon of the Achilles in the medial side, with adhesions with the subcutaneous tissue. The achilles after the previous tenotomy was completely regenerated. The achilles was medially displaced. Conclusions: A severe thickening of the paratenon of the achilles and adhesions with the subcutaneous tissue are anatomical structures in fixed relapsed cases of clubfoot. We treated our patients with an appropriate surgical release.

Impressive Remodeling of the Fractured Femur with Transposition of the Fractured Parts, Treated Conservatively with skin Traction, in a 3-Year-Old Boy.

Introduction: Conservative management of femoral fractures in children in the preschool age is considered as the standard care. In the past years, there is an increase in the number of surgically treated children with IM nails, even in these young ages. Several papers report on the results comparing the final alignment of the fractures but there are no reports on the conservative treatment of a fracture with transposition of the fragments. Case Report: A 3-year-old boy was referred in our hospital with a spiral fracture of his right femur. There was transposition of the fragments, with the proximal part shifted medially and the distal part laterally. We informed the parents for the methods of treatment available for his fracture. After 1 week of hospitalization, the child was transferred home, with skin traction, with supervision of an orthopedic surgeon. The child was regularly evaluated with radiological examination, every 10 days. There was an uneventful healing of the fracture, with normal alignment of the leg and acceptable initial leg length discrepancy (LLD). One year after the fracture, there is an impressive remodeling of the fracture with restoration of the medullary canal and absent LLD. Conclusion: Conservative treatment of spiral fracture in a child younger than 3 years is an effective method. Remodeling in this young age can restore not only deviations on the frontal and sagittal plane but also correct the transposition of the fragments with restoration of the medullary canal.

A Seven Toes Foot: Case Series as an Isolated Dysplasia With Variety of Appearance.

A seven toes foot is an extremely rare foot disorder. It may appear as part of a complex limb dysplasia or as an isolated deformity. We present five children with a seven toes foot. Supernumerary bones of the foot were found either as isolated duplicated great and little toe either affecting proximal bones, including the metatarsals or midtarsal bones, characterized as mirror foot. Radiological examination with X-rays was adequate for the evaluation of the affected foot. All patients had dysplasia isolated to the foot. Spine dysplasia was found in one child, and a hypoplastic unilateral little finger in another. The affected foot had a plantigrade shape without leg length discrepancy (LLD). The aesthetic of the enlarged foot with the problems of shoe wear was the main concern of the dysplasia. Surgical treatment was provided after the walking age. Surgery was demanded to provide a cosmetically acceptable foot. Removal of the supernumerary rays, either the medial or the central rays, was performed after the radiological evaluation. Our results were satisfactory, and none of our patients required additional interventions, although a mild varus position of the great toe was still observed in one patient.