Breast Cancer Incidence, Mortality, and Cost in Adolescent Idiopathic Scoliosis Patients and the Role of Low Dose Biplanar Radiography.

INTRODUCTION: Patients with adolescent idiopathic scoliosis (AIS) are susceptible to high doses of radiation from radiographs. The purpose of this study was to examine the future cost of radiation-induced breast cancer in patients with AIS and its potential financial and mortality impact. METHODS: A literature review identified articles relating radiation exposure in patients with AIS to increased risk for cancer. Based on population statistics and breast cancer treatment costs in the year 2020, the financial impact of radiation-induced breast cancer and the estimated number of additional deaths per year due to breast cancer for patients with AIS were calculated. RESULTS: The US female population in 1970 was 205.1 million. Based on a prevalence of 3.0%, an estimated 3.1 million patients had AIS in 1970. With an incidence of breast cancer in the general population of 128.3/100,000 and a standardized incidence ratio of 1.82-2.4 for breast cancer in patients with scoliosis, there will be a 3,282 to 5,603 patient increase in radiation-induced breast cancer in patients with scoliosis over the general population. With a projected base cost of $34,979 per patient for the first year of breast cancer diagnosis in 2020, the cost of radiation-induced breast cancer will be 114.8 to 196.0 million dollars per year. Using a standardized mortality ratio of 1.68 for scoliosis radiation-induced breast cancer, there will be an expected increase in deaths of 420 patients due to breast cancer presumably secondary to radiation exposure in the evaluation and treatment of AIS. CONCLUSION: The estimated radiation-induced breast cancer financial impact in 2020 will be between 114.8 and 196.0 million dollars per year, with an increase in deaths of 420 patients per year. Low-dose imaging systems reduce radiation exposure by up to 45 times while maintaining sufficient image quality. New low-dose radiography should be used whenever possible with patients with AIS. LEVEL OF EVIDENCE: Level 5.

SPINE: An Initiative to Reduce Pressure Sore Recurrence.

The recurrence rate after pressure sore reconstruction remains high. Primary inciting factors can be organized into efforts aimed at wound prevention: spasticity relief, pressure off-loading, infection and contamination prevention, nutrition optimization, and maximizing extremity function. This article presents our detailed protocol, SPINE, to address each inciting factor with a summary of cases at our facility and review best practices from evidence-based medicine in the literature.

Medial Epicondyle Fracture With Concomitant Flexor-Pronator Mass Avulsion From the Fracture Fragment: A Case Report.

CASE: We present a case of a pediatric patient who sustained a medial humeral epicondyle fracture with avulsion of the ulnar collateral ligament and flexor-pronator mass from the ossific nucleus fracture fragment. Treatment included excision of the medial epicondyle ossific nucleus and repair of the soft tissues. At 1-year, the patient had no pain, no elbow instability, and full and symmetric elbow range of motion. CONCLUSION: Excellent short-term pain and function outcomes can be observed in the pediatric patient after medial epicondyle fragment excision when there is concomitant avulsion of the ulnar collateral and flexor-pronator origins from the fracture fragment.

Patient demographics and risk factors in pediatric distal humeral supracondylar fractures.

The literature on distal humeral supracondylar fractures does not systematically define relationships between patient characteristics and the severity or complications of these injuries. This study evaluated age, sex, height, and body mass index (BMI) in relation to fracture severity and posttreatment complications in a pediatric population. The medical records of 382 pediatric patients treated for distal humeral supracondylar fractures over a 5-year period at 1 institution were included. Variables included age, sex, height, weight, injury mechanism, fracture severity (Gartland Classification), treatment, follow-up duration, and treatment complications. Body mass index and BMI-for-age percentile were calculated. Descriptive statistics with univariate analyses and logistic regression analysis with odds ratios and 95% confidence intervals were used. Children sustaining Gartland type 3 fractures were significantly older and taller than those sustaining Gartland type 1 and 2 fractures. No significant difference existed in fracture occurrence between boys and girls. Fracture severity did not differ significantly due to sex, BMI, or BMI-for-age percentile. Severe fractures were associated with increased posttreatment complications. Complication rates did not vary significantly by age, sex, height, BMI, or BMI-for-age. Taller children aged 5 to 6 years were at the greatest risk for Gartland type 3 distal humeral supracondylar fractures. Severe fractures are associated with an increased complication risk. Sex, BMI, and BMI-for-age percentile had no effect on fracture severity or complication rates.

Posterior arm compartment syndrome after a combined supracondylar humeral and capitellar fractures in an adolescent: a case report.

BACKGROUND: Supracondylar humeral fractures in children are common, with associated bony injuries typically being fractures of the forearm or distal radius. To our knowledge, a combined supracondylar humeral fracture associated with a Hahn-Steinthal capitellar fracture has not been reported earlier. Similarly, posterior arm compartment syndrome is extremely rare, with most instances having occurred after chronic compression and bleeding into the compartments from anticoagulation, direct trauma including crush, or tendon ruptures. Only 2 cases have been reported after a fracture of the humerus. One of these described fractures was localized to a distal shaft and the other involved the surgical neck. No cases have been reported in children, nor have any been reported after a supracondylar humeral fracture. METHODS: In this case report, we describe a patient who presented with an ipsilateral Wilkins type-3A supracondylar humeral fracture, Hahn-Steinthal capitellar fracture, Salter-Harris II distal radius fracture, and posterior arm compartment syndrome. RESULTS: The patient was taken to the operative room for closed reduction and percutaneous pinning of the radius fracture with open reduction, internal fixation of the distal humeral fractures. Elevated compartment pressure measurements were anticipated because of the nature of the injuries. After fixation of the fractures, the mobile wad, volar, and dorsal compartments measured 9, 9, and 8 mm Hg, respectively. The absolute pressure in the posterior arm compartment was measured multiple times in different locations ranging from 34 to 39 mm Hg. The patient's blood pressure throughout the case averaged 115/65 mm Hg. A diagnosis of posterior arm compartment syndrome was confirmed and the fascia was released. CONCLUSIONS: Our patient ultimately suffered 2 uncommon injuries involving the arm. She sustained a complex fracture of the distal humerus with an extension type supracondylar fracture, a separate Hahn-Steinthal capitellar fracture, and isolated posterior arm compartment syndrome. This is an unusual case that required specialized care and follow-up. LEVEL OF EVIDENCE: Level IV.

Evaluation of low back pain in athletes.

CONTEXT: Low back pain is a common complaint in athletes. Athletes differ from the general population physiologically, making it unclear if the evaluation of low back pain should differ between these 2 groups. EVIDENCE ACQUISITION: A literature search (PubMed, Ovid) was performed for the years 1995 through 2010. Keywords used were lumbar back pain, athletes, and adolescence. RESULTS: Athletes with low back pain represent a very diverse group. The evaluation depends on the athlete's age and the presence of "red flags." The most common causes of low back pain in the preadolescent population are infection, tumor, and trauma. In the adolescent population, trauma spondylolysis/spondylolisthesis and hyperlordosis are commonly seen. Leading causes in the adult population are mechanics and osteoarthritis. The elderly frequently present with osteoarthritis, spinal stenosis, and internal medical etiologies. CONCLUSION: Athletes with back pain should have a diagnostic workup guided by their age, history, and physical examination. Although this work up is similar in nonathletes, the demands of the athlete must be taken into account in a treatment plan.

Determination of bone age in children with cartilaginous dysplasia (multiple hereditary osteochondromatosis and Ollier's enchondromatosis).

Cartilaginous dysplasias (multiple hereditary osteochondromatosis [MHO] and Ollier's enchondromatosis [OE]) are common pediatric orthopaedic conditions. Long bone growth deformities commonly develop in children with MHO and OE. The timing of procedures frequently used to treat these deformities is often dependent upon the bone age. It was the purpose of this study to investigate bone ages in a series of 40 children with MHO and OE. There were 6 girls and 9 boys with OE, and 9 girls and 16 boys with MHO. Each child's age, gender, race, and diagnosis were recorded. Hand-wrist radiographs obtained during routine evaluation of hand-wrist deformities or scanograms were identified, randomly numbered, and blinded regarding the identity and age of the child. Each radiograph was reviewed by five different observers at two different times separated by a minimum of 3 weeks. Statistical analyses were performed, looking at differences between bone and chronological age; inter- and intraobserver variability in bone age assessment; and differences by observer. The average chronological age (n = 40) was 7.8 +/- 3.6 years, average bone age (n = 400) was 7.2 +/- 3.7 years, and average difference between chronological and bone age (n = 400) was 0.6 +/- 1.3 years (P < 10-6). Intra- and interobserver variability was +/-1.5 and +/-1.6 years. There were no differences between observers in the average chronological/bone age difference (P = 0.63). Clinicians should be aware of this average 0.6-year delay in bone age when planning an epiphysiodesis for limb length equalization in children with cartilaginous dysplasias.

Signaling by carcinogenic metals and metal-induced reactive oxygen species.

Epidemiological data indicate that exposure to metal and metalloid species, including arsenic(III), chromium(VI), and nickel(II), increases the risk of cancer, particularly of the lung and skin. Alterations in normal signal transduction as a result of exposure to carcinogenic metals, and to metal-catalyzed reactive oxygen species (ROS) formation, appear to play an important role in the etiology of metal-induced carcinogenesis. Signaling components affected by metals include growth factor receptors, G-proteins, MAP kinases, and nuclear transcription factors. This article reviews current literature on the effects of carcinogenic metals and metal-induced ROS on cancer-related signaling pathways. In addition, the mechanisms by which those changes occur, and the role of those changes in carcinogenesis are discussed.

Scoliotic curve patterns in patients with Chiari I malformation and/or syringomyelia.

STUDY DESIGN: A retrospective radiographic review was performed on 41 patients with scoliosis associated with a Chiari I malformation and/or syringomyelia. OBJECTIVES: To characterize curve patterns and curve features in this population and possibly refine the radiographic indications for magnetic resonance imaging in patients with a normal history and physical examination. SUMMARY OF BACKGROUND DATA: A subset of patients with "idiopathic" scoliosis may have an underlying neurologic abnormality. The radiographic indications for magnetic resonance imaging in asymptomatic patients with a normal clinical examination are not well defined. METHODS: Data were collected from standing posteroanterior and lateral radiographs. The curve pattern and specific curve features were recorded and compared with historic controls. Thoracic kyphosis and total lumbar lordosis were also measured. RESULTS: Fifty-one percent of patients were male. Ten curve patterns were identified, and, based on our criteria, approximately 50% of patients had an "atypical" pattern (left thoracic, double thoracic, triple, long right thoracic). A subset of those with "typical" patterns (right thoracic, right thoracic/left lumbar) had atypical features including a superior or inferior shift of the apex and/or the upper or lower end vertebrae. The mean kyphosis (T3-T12) was 41.8 degrees. CONCLUSIONS: Although the decision to obtain magnetic resonance imaging in a patient with scoliosis should be based on both clinical and radiographic criteria, we suggest that a heightened index of suspicion is warranted with certain curve patterns (left thoracic, double thoracic, triple, and a long right thoracic curve with end vertebra caudal to T12), and with a high or low apex and/or end vertebra, especially in males and patients with a normal to hyperkyphotic thoracic spine.

Neonatal kyphectomy in the patient with myelomeningocele.

STUDY DESIGN: A retrospective cohort study was used to investigate a group of neonates with myelomeningocele who had a kyphectomy performed in conjunction with dural sac closure during the first few days of life. OBJECTIVES: To assess the effectiveness of operative intervention in the neonatal period to correct the kyphotic deformity in the patient with myelomeningocele and to monitor its long-term results. SUMMARY OF BACKGROUND DATA: Orthopedic management originally focused on the immediate treatment of the kyphotic deformity in the infant with myelomeningocele. However, there has been a movement toward postponing surgical treatment of the kyphos until a later age. This study included the longest follow-up of the largest group of neonates that a single surgeon has managed surgically since the treatment of this condition was originally described. METHODS: The radiographic and clinical results for all neonates treated with a kyphectomy at the time of myelomeningocele closure between 1980 and 2000 were analyzed. RESULTS: Neonatal kyphectomy was performed on nine males and two females. The average preoperative kyphotic angle measured 67 degrees. The average initial correction was 77 degrees, and the average loss of correction at follow-up assessment was 55 degrees. There were no serious complications, and wound closure was successful in all patients. One patient required a repeat kyphectomy and posterior spinal fusion at the age of 9 years and 2 months. The average follow-up period was 7 years and 4 months (range 44-174 months). CONCLUSIONS: Kyphectomy performed at the time of dural sac closure in the neonate is a safe procedure with excellent initial correction. Eventual recurrence is expected despite the procedure. However, it occurs in the form of a longer, more rounded deformity that is less technically demanding.