John A. Ogden

Congenital anomalies of the coronary arteries.

Abstract The coronary arteries, like other organ arterial patterns in the body, are subject to congenital variations of both minor and major consequence. This paper presents a review of these variations based upon a series of 224 cases. There are three basic categories. First, minor anomalies in which there is a variation of the origin of the vessels from the aorta and the distal circulation is normal. Second, major anomalies in which there is an abnormal communication (arteriovenous) between an artery and a cardiac chamber or an abnormal origin of a major coronary artery from the pulmonary artery. Third, secondary anomalies in which the coronary arterial variation probably represents a circulatory response to the primary intracardiac pathologic defect. Each category is discussed in detail with reference to the specific anomalies and illustrated with examples from our study.

Radiology of postnatal skeletal development

Thirty-six manubriosternal composites from skeletally immature cadavers were examined morphologically and radiographically. Sternebral ossification followed certain patterns. The manubrium (first sternebra) usually had one primary ossification center and one or two smaller centers. These usually were caudad to the major center (longitudinally bifid). The second sternebra invariably had only one ossification center. The third and fourth sternebrae had latitudinal (right-left) bifid ossification centers, undoubtedly a result of the original formation of the sternum from two longitudinal mesenchymal anlagen. Occasionly the fourth sternebra exhibited longitudinally bifid ossification. The usual pattern was ossification of four sternebrae, although a fifth was intermittently present. The xiphisternum (not a true sternebra) was infrequently ossified.

Changing patterns of proximal femoral vascularity.

Thirty-six hip joints from cadavera ranging in age from seven fetal months to three years were studied. During the first year of life there is a diffuse, canalicular vascular network, primarily end-arterial, within the chondroepiphysis, with several arteriosinusoidal vessels crossing the growth plate. Initially the proximal femoral chondroepiphysis and growth plate are supplied approximately equally by lateral circumflex (anterior half) and medial circumflex (posterior half) arterial branches. Subsequent vascular development is characterized by regression of the lateral circumflex system and concomitant development of the medial circumflex system. A few large intra-articular vessels coursing along the posterior portion of the femoral neck enter the capital femoral epiphysis. The transition from lateral circumflex to medial circumflex arterial supply renders the anterior and lateral segments of the capital femoral epiphysis and growth plate more susceptible to vascular compromise, because the initial course of the medial circumflex artery is between the iliopsoas and adductor longus muscles, and then between the iliopsoas and pubic ramus, and positional extremes may partially or completely occlude the medial circumflex artery between these structures.

Subluxation and dislocation of the proximal tibiofibular joint.

Four types of instability or disruption of the proximal tibiofibular joint were found in a compilation of forty-three cases. These were classified as subluxation, anterolateral dislocation, posteromedial dislocation, and superior dislocation. Idiopathic subluxation of the proximal end of the fibula appeared to be a self-limited condition of youth, with decreasing symptoms as the patient approached skeletal maturity. Anterolateral dislocation was the most common injury encountered. Unfortunately, the diagnosis was initially missed in about one-third of the cases. Most cases responded satisfactorily to closed reduction. Several of the dislocations developed into either a chronic subluxation or arthritis of the proximal tibiofibular joint. Two surgical approaches were used to alleviate these complications, arthrodesis of the joint and resection of the proximal end of the fibula. Arthrodesis of the proximal tibiofibular joint was complicated by a prolonged period for fusion, as well as by eventual development of pain and instability in the ankle. In contrast, resection of the proximal end of the fibula was associated with significantly more satisfactory results in long-term follow-up. Posteromedial dislocations proved more unstable after initial reduction.

Injury to the growth mechanisms of the immature skeleton

A new classification scheme of physeal and epiphyseal injuries is proposed. This is based partially on the Salter-Harris system, but additionally details subclassifications that relate to specific injury patterns. Furthermore, four other growth mechanism injury patterns not included in the previous systems are presented. It is hoped that this new, more detailed scheme will further our understanding of physeal/epiphyseal fractures, will aid in radiologic recognition, and will allow better estimation of prognosis for normal or abnormal growth.

Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis.

BACKGROUND Plantar fasciitis is a common foot disorder that may be resistant to nonoperative treatment. This study evaluated the use of electrohydraulic high-energy shock waves in patients who failed to respond to a minimum of six months of antecedent nonoperative treatment. METHODS A randomized, placebo-controlled, multiply blinded, crossover study was conducted. Phase 1 consisted of twenty patients who were nonrandomized to treatment with extracorporeal shock waves to assess the phase-2 study protocol. In phase 2, 293 patients were randomized and an additional seventy-one patients were nonrandomized. Following ankle-block anesthesia, each patient received 100 graded shocks starting at 0.12 to 0.22 mJ/mm(2), followed by 1400 shocks at 0.22 mJ/mm(2) with use of a high-energy electrohydraulic shock-wave device. Patients in the placebo group received minimal subcutaneous anesthetic injections and nontransmitted shock waves by the same protocol. Three months later, patients were given the opportunity to continue without further treatment or have an additional treatment. This allowed a patient in the active treatment arm to receive a second treatment and a patient who received the placebo to cross over to the active treatment arm. Patients were followed at least one year after the final treatment. RESULTS Treatment was successful in seventeen of the twenty phase-1 patients at three months. This improved to nineteen (95%) of twenty patients at one year and was maintained at five years. In phase 2, three months after treatment, sixty-seven (47%) of the 144 actively treated patients had a completely successful result compared with forty-two (30%) of the 141 placebo-treated patients (p = 0.008). At one year, sixty-five of the sixty-seven actively treated, randomized patients maintained a successful result. Thirty-six (71%) of the remaining fifty-one nonrandomized patients had a successful result at three months. For all 289 patients who had one or more actual treatments, 222 (76.8%) had a good or excellent result. No patient was made worse by the procedure. CONCLUSIONS The application of electrohydraulic high-energy shock waves to the heel is a safe and effective noninvasive method to treat chronic plantar fasciitis, lasting up to and beyond one year.

The painful accessory navicular

The accessory navicular is usually considered a normal anatomic and roentgenographic variant. The term may refer to two distinct patterns. First, a sesamoid bone may be present within the posterior tibial tendon (Type 1); this is anatomically separate from the navicular. Second, an accessory ossification center may be medial to the navicular (Type 2). During postnatal development this is within a cartilaginous mass that is continuous with the cartilage of the navicular. At skeletal maturity the accessory center usually fuses with the navicular to form a curvilinear bone The Type 2 pattern may be associated with a painful foot, particularly in the athletic adolescent, and should not be arbitrarily dismissed as a roentgenologic variant in the symptomatic patient.The clinical, radiologic, pathologic, and surgical findings in ten cases are reviewed. Roentgenographically the ossicle is triangular or heartshaped. 99mTc MDP imaging may be of value when the significance of the ossicle is uncertain. Even when the roentgenographic variant is bilateral, increased radionuclide activity occurs only on the symptomatic side. Histologic examination of surgically excised specimens reveals inflammatory chondro-osseous changes in the navicular-accessory nacicular synchondrosis compatible with chronic trauma and stress fracture. Nonsurgical treatment with orthotics or cast immobilization produces variable results and resection of the accessory navicular may be the treatment of choice.

Radiology of Postnatal Skeletal development: The proximal humerus

Twenty-three pairs of proximal humeri obtained from human cadavers ranging in age from fullterm stillborn to fourteen years were studied morphologically and radiographically. Roentgenograms of the specimens demonstrated the osseous and cartilaginous portions of the epiphyses, using air/cartilage interfacing. Comparable clinical simulations were obtained by using water immersion of the specimens. The metaphyseal cortex remained thin and trabecular near the physis. Histologically this area had multiple fenestrations, which provide a potential pathway for childhood osteomyelitis into the subperiosteal space, and may also affect the biomechanics of this region (i.e., susceptibility to Salter epiphyseal fractures). As skeletal maturity was reached, thicker cortical (osteonal) bone extended toward the physis. The epiphyseal secondary ossification centers form an osseous connection shortly after the appearance of greater tuberosity ossification center, although this may not be radiologically evident until the child is older. The major intent of this roentgenographic survey is to provide a reference index of proximal humeral development for the adequate interpretation of shoulder radiography in children who have not yet attained skeletal maturity.

Roentgenographic indicators of skeletal maturity in marine mammals (Cetacea)

A new roentgenographic classification (grading) scheme is presented for utilization in studies of skeletal development and maturation in marine mammals, particularly cetaceans. This is based on adequate description of the extent of development and maturation of the various secondary ossification centers, their eventual patterns of fusion, and subsequent remodeling with the metaphysis. The six stages are illustrated schematically and roentgenographically. This scheme may be applied to any cetacean longitudinal bone developing proximal and distal epiphyseal ossification centers.

An Unusual Branch of the Median Nerve

An unusual branch of the median nerve that probably separated from the median nerve high in the forearm, coursed entirely within (rather than beneath) the flexor retinaculum, and rejoined both the motor recurrent and sensory median nerve branches in the hand, is described.