Michael R. Ferrick

Reliability of roentgenogram evaluation of pedicle screw position.

Study Design. This was a human cadaver study of the accuracy of biplanar roentgenography in determining pedicle screw position. Objective. To determine the independent accuracy of radiologic evaluation of screw placement and to determine if there are any particular screw malpositions that are more likely to produce a false sense of acceptable screw position. Summary of Background Data. Other investigators have reported the correlation between radiologic evaluation and anatomic dissection. However, in those studies the radiologic evaluation was not independent of the surgeons placing the screws. There has been no comment in the literature regarding particular screw malpositions that would lead the surgeon into a false sense of successful screw placement. Methods. Pedicle screws were placed in cadaver spines, and biplanar roentgenograms of the specimens were evaluated by independent observers. The results of the roentgenogram evaluation then were compared to those of the anatomic dissection. Results. The accuracy of roentgenogram evaluation varied from 73% to 83%, depending on the experience of the surgeon grading the roentgenograms. Screws misplaced medially into the spinal canal are more likely to give the surgeon a false sense of successful screw placement. Conclusions. The surgeon must not rely solely on the roentgenograms, but instead continue to use tactile sensory skills, anatomic knowledge, and additional modalities such as electromyography monitoring.

Coracoid Impingement A Case Report and Review of the Literature

Subacromial impingement syndrome, or rotator cuff disease, is a common cause of shoulder pain. A less frequently recognized cause is coracoid or subcoracoid impingement. There have been only a few reports of this condition in the literature, and although there are definitely cases that go unrecognized, coracoid impingement is probably a relatively uncommon cause of shoulder pain. Patients with this disorder usually have localized pain anteriorly, especially with forward elevation, internal rotation, and cross arm adduction. Symptoms are presumed to be the result of impingement of the subscapularis tendon between the coracoid process and the lesser tuberosity. Initial treatment is nonoperative and based on activity modification and physical therapy, but operative decompression may be required if conservative measures fail. The following is a case report of coracoid impingement treated by operative decompression.

Ganglion cyst of the shoulder associated with a glenoid labral tear and symptomatic glenohumeral instability : A case report

Shoulder pain may be caused by a variety of abnormalities including glenohumeral instability, rotator cuff disease, cervical radiculopathy, nerve entrapment syndromes, neoplasm, tendinitis, adhesive capsulitis, trauma, and degenerative disease of any one of the joints about the shoulder.1, 13, 16 Patients experiencing entrapment neuropathy of the suprascapular nerve usually complain of shoulder pain.21 Symptoms involve the infraspinatus muscle if the entrapment takes place at the spinoglenoid notch, or the supraspinatus and infraspinatus muscles if the lesion is at the suprascapular notch. 3,5,22,24,30 Mass lesions such as ganglion cysts are a common cause of suprascapular nerve entrapment. 8,12,17,18,25 Glenoid labral abnormalities, including acute tears and degenerative changes, are associated with glenohumeral instability.4,9 There is evidence that periarticular abnormalities in other areas of the body may lead to the leakage of synovial fluid and the formation of so-called ganglion cystS.7,1l,15,20 We report a case of ganglion cyst of the shoulder associated with a posterior glenoid labral tear and glenohumeral instability.

Factors Predictive of Immobilization Complications in Pediatric Polytrauma

Objectives To determine in a cohort of children with polytrauma which variables are predictive of the development of complications related to immobilization. Design A retrospective study of children with polytrauma and at least one major musculoskeletal injury. A stepwise forward logistic regression analysis was used to determine variables predictive of complications related to immobilization. Participants Ninety-three children with polytrauma were studied; motor vehicle incidents accounted for 80 percent of the injuries. The average age was 8.0 ± 4.1 years. There were 152 fractures in the ninety-three children. The average Modified Injury Severity Scale (MISS) was 24.5 ± 13.6. There were thirty-five complications in twenty-two children, and four children died. Results Two variables were predictive of complications related to immobilization: age and MISS score. Complications related to immobilization were positively associated with being older than seven years of age (p = 0.027; odds ratio = 9.5; 95 percent confidence interval 1.4, 64.9) and having a MISS score greater than forty (p = 0.005; OR = 14.1; 95 percent confidence interval 2.2, 89.1). Timing of surgery showed a trend (p = 0.097) but did not reach statistical significance. Conclusions Complications of immobilization in children with polytrauma are associated with age greater than seven years and a MISS score greater than forty. Further study is needed to evaluate the effect of early fracture stabilization. Timing of osteosynthesis showed a trend but did not reach statistical significance in this study.

Nonoperative management of pediatric grade 1 open fractures with less than a 24-hour admission.

Background: The purpose of this study was to evaluate the results of nonoperative management of pediatric grade 1 open fractures treated either in the emergency room only or with a less than 24-hour admission. Methods: A retrospective chart review was done on all patients with this type of injury who were treated by nonoperative modalities in the emergency room and who were admitted for no more than 24 hours for administration of intravenously administered antibiotics. Our population included 25 patients who were followed up until healing was confirmed clinically and radiographically. Results: One patient with persistent serosanguineous drainage from the wound site and fever was admitted for 48 hours of intravenously administered antibiotics for presumed infection. That patient went on to heal both clinically and radiographically without further complication. Therefore, our infection rate was 4.0%. Conclusions: This study demonstrates the safe nonoperative treatment of grade 1 open fractures in our pediatric population. This management eliminates any possible anesthetic risk as well as significantly decreases the cost of caring for these patients in the health care system. Level of Evidence: This study was a retrospective case series and thus is classified as level IV evidence.

Correction of non-Blount's angular knee deformity by permanent hemiepiphyseodesis.

This retrospective study evaluated the results of permanent hemiepiphyseodesis for the correction of non-Blount’s coronal plane angular knee deformity. The medical records and radiographs of 75 patients with 125 angular knee deformities were analyzed for overall rate of success and factors predicting successful correction of deformity. There were 38 patients with idiopathic genu valgum and 37 with various other skeletal disorders. Sixty-nine out of 75 patients had reached skeletal maturity at latest follow-up. One hundred six knees out of 125 were successfully treated by the procedure. Of the 19 remaining knees, 15 were operated on too close to skeletal maturity to expect correction and 4 were technically unsuccessful in achieving closure of the targeted physis. There were no complications other than overcorrection, which occurred in 15 knees (11 patients). This study indicates that permanent hemiepiphyseodesis is a very useful procedure if performed in a timely and technically successful manner.

Developmental expression of S-antigen in fetal human and rat eye

Development expression of S-antigen and its mRNA in human and rat fetal retina was studied by immunocytochemical and in situ hybridization techniques. Immunocytochemistry indicated that S-antigen was present after 4 months gestation in the fetal human retina. In the rat, S-antigen was detected in the retina only after birth. In situ hybridization studies indicated that the S-antigen mRNA was present at 13 weeks gestational age in the human and at 15 days in the rat embryo. S-antigen mRNA was expressed not only in the retina but also in ocular tissues of neural crest origin in the fetus.

Brace Treatment Resulting in Overcorrection of Adolescent Idiopathic Scoliosis

Brace treatment for idiopathic scoliosis in skeletally immature children is the only effective nonoperative modality for the control of curve progression. The Charleston bending brace is a custom-molded spinal orthosis that holds the patient in a completely corrected or overcorrected position while worn at night. A 9-year-old girl presented with 10° right upper thoracic and 7° left lower thoracic curves and was Risser sign 0. Nighttime treatment with a Charleston bending brace was initiated when the left lower thoracic curve progressed to 19°. After 27 months of nighttime brace wear, the lower thoracic curve was 21° to the right. Further investigation, including magnetic resonance imaging of the spine, failed to diagnose an identifiable explanation for this atypical occurrence. Conservative treatment may improve radiographic and cosmetic appearance. Overcorrection of the curve, although not likely, is possible when part-time or nighttime bracing is implemented as a means of conservative management.

Transphyseal Femoral Neck Fracture in a Twenty-Month Old Male Child

Transphyseal femoral neck fractures are an extremely rare event, mainly occurring in children subjected to an significant traumatic force. The diagnosis is usually suggested by clinical examination with radiographic confirmation. Management varies; however, no consensus exists as to proper treatment. Intervention is primarily focused on the prevention of avascular necrosis (AVN) of the femoral epiphysis. We present the case of a 20-month-old male with a delayed diagnosis of transphyseal femoral neck fracture. X-ray (XR) and computed tomography (CT) scan images were used for diagnosis, to track healing, and monitor the possible emergence of avascular necrosis. Final imaging demonstrated full healing without AVN at two years. This study demonstrates the successful treatment of a rare pediatric fracture type with possible life-changing complications. Reduction, surgical fixation with K-wires, and spica casting are demonstrated as being acceptable treatment in the very young transphyseal fracture patient.