The use of bone scanning for the diagnosis and management of musculoskeletal trauma.

Bone scanning provides a unique way of monitoring early metabolic changes in bone and its adjacent soft tissues after trauma. An abnormal scan may often precede radiographic changes by days or weeks. This accounts for its usefulness in the early diagnosis of occult fractures and in fractures not clinically suspected or seen on initial x-ray films in the patient with multiple trauma. Dynamic imaging along with static imaging can be used to evaluate fracture healing and predict delayed union and nonunion. The combined technique is useful in assessing many of the complications arising after trauma and provides a reliable method of observing their treatment. It is also a useful noninvasive technique in the evaluation of pathologic fractures. Bone scanning is becoming an increasingly useful adjunctive procedure in the diagnosis and management of musculoskeletal trauma. However, as with any diagnostic technique, it provides only part of the overall picture and must always be carefully correlated with the history, physical findings, radiographic changes, and other laboratory data.

Quantitative regional blood-flow analysis and its clinical application during routine bone-scanning.

A method of combined dynamic and static bone-imaging using technetium 99-labeled phosphonate is described. During the dynamic part of the study, immediately after intravenous injection of the radionuclide, counts per second were recorded over a period of time for analogous regions of normal and diseased bones. The counts per second then were plotted against time to give time-activity curves for each of these regions. The time-activity curves were divided into arterial, venous, and blood-pool phases. Each phase was integrated and then divided by the time-span of the phase to give average total counts per unit of time. The values of these normalized integrals were directly proportional to the blood flow to the regions of bone from which they were calculated. Ratios of normalized integrals from the analogous regions of the diseased bone to the normal bone were calculated to determine whether the blood flow to the diseased bone was decreased or increased. Static images of the bone structures analyzed during the dynamic portion of the study were obtained two hours after the initial injection of the radionuclide and the total number of counts for analogous regions on the static images of the normal and diseased bones were static images of the normal and diseased bones were recorded. The total number of counts for each region was divided by the area of that region to give average total counts. Ratios of the normalized counts were calculated for analogous regions of the diseased to the normal bone to determine whether there was an increase or decrease in concentration of the radionuclide. The method first was used to evaluate hip pain in children and adults. In order to recognize an abnormal result, mean values and two standard deviations were calculated for the dynamic and static ratios in a group of fifty patients who had no clinical complaints about the hips or lower extremities. Any ratios outside of the range of two standard deviations were considered abnormal. The method later was used to evaluate other bones, such as the tibia and humerus. Any value for the ratios beyond 1 +/- 0.20 was considered abnormal for these studies.

A fixed-ankle, below-the-knee orthosis for the management of genu recurvation in spastic cerebral palsy.

A fixed-ankle, below-the-knee molded plastic splint designed to maintain the ankle in 5 degrees of dorsiflexion and correct any foot deformity was used on eighteen extremities of twelve children with spastic cerebral palsy and genu recurvatum. After an average follow-up of twenty-six months, the genu recurvatum was well controlled and gait was improved.

Genu recurvatum in spastic cerebral palsy. Report on findings by gait analysis.

Using high-speed motion pictures, electromyography, a dynamic piezoelectric force plate, and computer analysis of the data, the gait patterns of fifteen children, four to sixteen years old, with spastic cerebral palsy and genu recurvatum were analyzed to determine the mechanisms producing genu recurvatum and the effect of fixed-ankle below-the-knee orthoses. In all children the recurvatum during stance phase began when the tibia stopped moving forward and disappeared when tibial movement resumed. In six patients (Group I), excessive activity of the calf muscles in response to the increasing dorsiflexion moment about the ankle produced by the foot-floor reaction force arrested the forward motion of the tibia. In six others (Group II), the contraction of the calf muscles was not sufficiently strong to resist the dorsiflexion moment and the tibia moved forward until maximum dorsiflexion had occurred and then stopped. In both instances recurvatum was produced when the femur continued to move forward over the stationary tibia and an extension moment was produced at the knee. In no patient did activity of the knee flexors prevent recurvatum, which was eliminated only by resumption of forward movement of the tibia. This movement of the tibia was produced either by heel-off (Group I) or by sudden unweighting of the limb due to opposite heel-strike (Group II). In Group I, when tibial motion stopped in the first half of stance phase the position of the hip rapidly changed from flexion to extension and there was forward leaning of the trunk, while in Group II the change from hip flexion to extension occurred with backward leaning of the trunk. The fixed-ankle below-the-knee orthosis, by preventing excessive dorsiflexion and plantar flexion, produced more normal moments about all joints, especially the knee. In the three children (Group III) whose recurvatum was permanently corrected by the brace, no explanation for the improvement was evident in these studies.

Differentiation of Charcot joint from osteomyelitis through dynamic bone imaging.

The bone scans of 25 patients with a clinical diagnosis of diabetic osteoarthropathy (Charcot joint) of the ankle and foot were analysed using the technique of dynamic bone imaging. The analysis of time-activity curves generated over the Charcot joint, the contralateral joint and the bone above the Charcot joint, produces characteristic patterns that are distinguishable from the ones observed for osteomyelitis. Recently it has been shown that the significance of dynamic bone imaging resides in its correlation to physiological and morphological components of bone. The difference in the blood supply to the long bones has been suggested as an explanation for the difference in time-activity curve patterns.

Atlas of computerized blood flow analysis in bone disease.

The role of computerized blood flow analysis in routine bone scanning is reviewed. Cases illustrating the technique include proven diagnoses of toxic synovitis, Legg-Perthes disease, arthritis, avascular necrosis of the hip, fractures, benign and malignant tumors, Paget's disease, cellulitis, osteomyelitis, and shin splints. Several examples also show the use of the technique in monitoring treatment. The use of quantitative data from the blood flow, bone uptake phase, and static images suggests specific diagnostic patterns for each of the diseases presented in this atlas. Thus, this technique enables increased accuracy in the interpretation of the radionuclide bone scan.

Computerized blood-flow analysis in osteochondritis dissecans.

A retrospective review of static images and computerized blood flow studies (CBFS) in patients with osteochondritis dissecans (OCD) suggests that CBFS maybe useful in following the clinical course of this disease.

Evans repair of lateral instability of the ankle.

The Evans operation for lateral instability of the ankle is a simple procedure technically. The peroneus brevis tendon is passed through a drill hole in the distal fibula and fastened under tension, producing a strong autogenous lateral ligament of the ankle. In a series of five patients followed an average of 21A years postoperatively, the Evans operation has resulted in a stable ankle in each instance, with the patients able to carry out athletic activities as desired. A loss of inversion of the ankle ranging from 10° to 30° was noted in each patient.

Traumatic subarachnoid-pleural fistula in a child. A case report.

A seven-year-old girl sustained a gunshot wound to the chest and spine. Evaluation of a persistent pleural effusion demonstrated a subarachnoid-pleural fistula. Surgical closure of the dural defect resulted in resolution of the fistula. Traumatic subarachnoid-pleural fistulae are rare. The diagnosis is reached by an awareness of fistula formation from penetrating or blunt trauma to the chest.

Electrical stimulation for idiopathic scoliosis.

To evaluate the effectiveness of lateral electrical spinal stimulation for idiopathic scoliosis, 87 patients treated with this modality were reviewed retrospectively. All patients had no prior treatment, had a documented progression of more than 5 degrees, and were skeletally immature. Forty-seven patients were compliant and followed until skeletal maturity or institution of other treatment. Fifty percent of patients with a high probability of progression required surgery. For compliant patients, 51% progressed 5 degrees or more and 36% progressed 10 degrees or more or required a change to another treatment modality. Statistical analysis demonstrated no significant difference in the probability of progression between this group of treated patients and previously published groups of untreated patients.