Fracture of the odontoid process in young children.

Fracture of the odontoid process in young children is possibly not as rare as hitherto believed. In this paper, two more patients with this fracture are presented, and an important diagnostic clinical sign is described. Both patients sustained the injury by falling from heights no greater than sixty-one to ninety-one centimeters. In each instance, injury to the cervical spine was suspected but initial roentgenograms failed to reveal any fracture. The patients were quite comfortable when lying supine and when fully erect. Each child strongly resisted any attempt at extension of the neck and cried bitterly when brought to either the erect or the recumbent position unless the head was passively supported. This a valuable clinical sign when injury to the odontoid process is suspected. Subsequent roentgenograms confirmed the diagnosis in each instance.

Clinical efficacy of lumbar and lumbosacral fusion using the Boucher facet screw fixation technique.

The clinical outcome of posterolateral lumbar and lumbosacral fusions with facet screw fixation using the Boucher technique is reviewed retrospectively. The Boucher technique uses AO cortical screws that traverse the facet joint at an angle from the superior lamina, in a medial to lateral direction, to enter the respective inferior pedicle. The procedure was performed on 57 consecutive patients who had a degenerative disk disease. The pre-operative diagnosis was based on a physical examination and radiographs with myelography performed when deemed necessary. Surgery had been indicated and performed on patients with unresolved pain after 6 months of conservative therapy; radiographic signs of disk space narrowing, facet arthrosis, degenerative spondylolisthesis or instability on flexion and extension views. No prior history of spinal surgery, no involvement in any litigation or Workers Compensation process, and no detected psychiatric disturbances were also inclusion criteria for this study. Eighteen consecutive male and 39 consecutive female patients were included in the study. The average age at the time of surgery was 41.8 years. The mean active clinical follow-up (office visits) time was 5.06 months with the minimum follow-up time of 3 months. Two years after their surgery, all the patients were asked to fill out a questionnaire from which their progress was evaluated. All questionnaires were completed and returned. Postoperatively, patients were placed in either a lumbosacral corset, short rigid lumbosacral molded polypropylene brace or body cast. Overall clinical results for single level fusions showed that 91.2% of patients (31 of 34) had excellent results and 8.8% (3 of 34) had poor results. Of the multiple level fusions, 86.4% of patients (19 of 22) had excellent or good results and 9.1% (2 of 22) had poor results. Post-operative complications included only three wound infections at the iliac crest donor site. This study demonstrates that facet screw fixation using the Boucher technique has advantages. The technique not only is easy to implement by placing a small screw through a facet joint and it's respective pedicle, but produces excellent clinical results that are comparable to the other more bulky spinal instrumentation systems.

Surgical correction of congenital vertical talus under the age of 2 years.

Seven patients (10 feet) with true congenital vertical talus are described. The suggested pathomechanics of the condition correlated well with the rationale of surgical treatment. Correction of both forefoot and hindfoot deformities is necessary. Follow-up averaged 5.2 years. Cosmetic correction was excellent in seven of the 10 feet and good in the remaining three. These results indicate that there is no need for surgery to be performed in two stages and that it is not necessary for procedures to be as extensive as has been suggested in the literature.

Eosinophil granuloma of the spine.

Eosinophil granuloma of the spine is an uncommon lesion. Six patients with seven vertebral lesions were seen over the past 15 years. Clinical data and suggested pathomechanics relating to each patient are given. The latter correlates well with subsequent progress in each case. All patients were treated symptomatically with initial bed rest, with or without traction. Pain settled rapidly and patients were then allowed to ambulate wearing either a posterior spinal support or plaster jacket. The lesions healed spontaneously in all cases, and reconstitution of vertebral height occurred in all four lesions where wafer-like collapse occurred initially. An appeal is made that radiation therapy and surgical intervention not be undertaken unless specific indications such as neurological complications warrant it. Biopsy is also not necessary in typical cases but should always be considered.

Staphylococcal osteomyelitis of the carpal scaphoid.

A healthy 11-year-old boy developed staphylococcal osteomyelitis of the carpal scaphoid without any history of antecedent trauma or evidence of other sites of bony involvement. He responded well to antibiotic treatment and surgical drainage. Five months postoperatively there was partial regeneration of the scaphoid on radiographs, and no signs of recurrent infection.

Synovial hemangioma of the knee.

Synovial hemangioma is a rare, benign lesion affecting children and young adults. The lesion most commonly affects the knee joint. A recurrent history of pain and swelling is a characteristic feature. The degree of pain and tenderness can vary from mild to excruciating. Doughy consistency of the mass and quadriceps atrophy are other features. Total excision should be the object of treatment. A clinical diagnosis will be made only if the clinician is aware of the condition.

The effect of thyrocalcitonin therapy and phosphate deprivation on tumoral calcinosis.

Six siblings were screened for clinical and biochemical evidence of tumoral calcinosis. The 3 brothers showed all the characteristic manifestations of this entity. Two of them were treated for an initial period of 6 months with large doses of thyrocalcitonin, with virtually no response. After a 9-month equilibration period they were treated by phosphate depletion, and at the end of 6 months they were re-investigated. There was no appreciable objective or radiological difference in the extent of the masses. It was concluded that, in these 2 patients, surgical excision of the tumours was the only feasible form of therapy.

Solitary (unicameral) bone cyst. The fallen fragment sign revisited.

The fallen fragment sign is a prominent radiologic feature in a minority of cases of unicameral bone cyst (20% in this series). This sign is always associated with pathologic fracture. Intramedullary fracture fragments may be single or multiple and may or may not be entirely dislodged from overlying periosteum. The finding appears limited to unicameral bone cysts in patients with open physes. When present, the fallen fragment is a pathognomonic finding as it defines the interior of the cyst as nonsolid. This is particularly helpful in cases where absence of the cyst wall secondary to fracture can simulate an intramedullary malignancy with cortical erosion.

Computed tomography guidance for skeletal biopsy.

Computed tomographic (CT) guided biopsy and abscess drainage of multiple organ systems have been well described. Reports of spinal and skeletal applications have been less common. This study describes the use of CT guidance in the biopsy of various skeletal lesions in 46 patients. Forty-one patients had skinny needle aspirations (18 or 22 gauge) and 23 patients had trephine core biopsies. Sites of the lesions included: thoracic spine-15 patients, lumbosacral spine-17 patients, bony pelvis-6 patients, rib-2 patients, and long bones-6 patients. Fast scanners capable of rapid image reconstruction have overcome many constraints. With CT guidance, the physician who performs the procedure receives virtually no ionizing radiation. The exact location of the needle tip is accurately visualized in relation to the lesion being biopsied and to the vital organs.