Ronald A. Bloom

Natural History of Nonoperatively Treated Symptomatic Rotator Cuff Tears in Patients 60 Years Old or Younger

Background: Rotator cuff tears are the most frequent tendon injury in the adult population. However, the natural history of nonoperatively treated full-thickness tears is poorly defined. Knowledge of the expected evolution in tear size is important when considering nonoperative versus surgical care, especially in relatively young, active patients. Purpose: To evaluate the size change of nonoperatively treated full-thickness rotator cuff tears over 2 to 3 years’ follow-up. Study Design: Case series; Level of evidence, 4. Methods: The authors prospectively followed patients 60 years old or younger who had a full-thickness rotator cuff tear equal to or larger than 5 mm, as diagnosed by bilateral shoulder ultrasound, and who were treated nonoperatively. At 2 to 3 years after the index ultrasound examination, a repeat ultrasound examination was performed by the same ultrasonographer. Results of the follow-up ultrasound examinations of both shoulders were compared with those of the index ultrasound examinations for change in rotator cuff tear size. The correlations were examined between these changes and age, sex, history of initial trauma, size of tear on the index ultrasound, and current shoulder symptoms. Results: Fifty-one patients with 61 rotator cuff tears were evaluated. At a follow-up of 25 to 39 months (mean, 29), 49% of the tears (30 tears) increased in size, 43% (26 tears) had not changed, and 8% (5 tears) decreased in size. For 25% (10 shoulders ) of initially intact shoulders (41 shoulders), a new full-thickness rotator cuff tear was diagnosed. No correlation was found between the change in tear size and age of the patient (P = .85), sex (P = .93), existence of a prior trauma (P = .63), size of tear at index ultrasound (P = .62), and bilateral tears (P = 1.00). There was a correlation between the existence of considerable pain at the time of the follow-up ultrasound and a clinically significant increase in tear size (P = .002). Conclusion: Full-thickness rotator cuff tears tend to increase in size in about half of patients aged 60 years or younger. Surgery should be initially considered in these patients to prevent a probable increase in size tear. Patients treated nonoperatively should be routinely monitored for tear size increase, especially if they remain symptomatic.

Metastatic tumours of bones of the hand and foot

Metastases in the bones of the hands and feet are rate. The literature relating to these tumours has been reviewed, and 43 new cases are reported. In the comulative total of cases, metastases to the hand outnumber those to the foot 2:1 (196 cases as against 94). Bronchial carcinoma is the most common neoplasm metastasising to the hand. Subdiaphragmatic neoplasms such as gastrointestinal, vesical, renal and uterine malignancies, metastasise more frequently to the foot. A possible explanation for this latter finding is the retrograde spead of tumour emboli from the vertebral venous plexus down incompetent leg veins.

A comparative estimation of the combined cortical thickness of various bone sites

Measurement of the cortical thickness of long bones is the best method of quantitatively diagnosing osteoporosis. Combined cortical thickness (CCT) is as good as, or better than more complicated indices. In osteoporosis studies, the problem lies in finding a physiologically consistent bone site. The CCT of the lower shaft of the humerus showed the lowest coefficient of variation in this homogeneous female population and the addition of both CCT values further reduced the variability. It is suggested that the humeral site is significantly superior to the metacarpal sites and that the variability is small enough to give clinically useful information in the diagnosis of osteoporosis.Measurement of the cortical thickness of long bones is the best method of quantitatively diagnosing osteoporosis. Combined cortical thickness (CCT) is as good as, or better than more complicated indices. In osteoporosis studies, the problem lies in finding a physiologically consistent bone site. The CCT of the lower shaft of the humerus showed the lowest coefficient of variation in this homogeneous female population and the addition of both CCT values further reduced the variability. It is suggested that the humeral site is significantly superior to the metacarpal sites and that the variability is small enough to give clinically useful information in the diagnosis of osteoporosis.

Diachronic trends in humeral cortical thickness of near Eastern populations

Humeral cortical thickness measurements (CCT) were taken from radiographs of four Near Eastern skelctal samples dated to the Epi-Paleolithic (Natufian), Middle Bronze I (MBI), Roman/Byzantine and Early Arab periods. Epi-Paleolithic CCT values in both sexes were significantly higher than those of any other group. In the males, Epi-Paleolithic CCT values were extremely high when compared with those of living populations, while CCT values in the MBI to Early Arabs were within the range considered normal for living populations. In the females Natufian and MBI CCT values fell within the range considered normal for living females, while the Roman/Byzantine and Early Arab CCT values were diagnostic of severe osteopenia. We consider that in the males, the exceptionally high Epi-Paleolithic values relfect functional demands associated with technological constraints and activity patterns of males at that time. In the same female groups, function presumably changed less drastically over time. The exceptionally low CCT values observed in the later groups were attributed to the combination of poor health status and calcium drain caused by pregnancy and lactation.

Humeral cortical thickness in female Bantu — Its relationship to the incidence of femoral neck fracture

Measurements of the humeral cortical thickness demonstrate that generalised osteoporosis in female Bantu commences in the fifth decade and gradually increases until, in the ninth decade, all subjects are osteoporotic. The combined cortical thickness (CCT) of the humerus in young adults is very similar to that found previously in a white London population and the loss of cortex with age is very similar. It is concluded that the known low incidence of femoral neck fracture in Bantu is not due to a lower incidence of generalised osteoporosis but to environmental factors. The chief environmental factor postulated is the greater amount of physical work performed by the Bantu. A more careful mode of walking is suggested as a subsidiary cause.Measurements of the humeral cortical thickness demonstrate that generalised osteoporosis in female Bantu commences in the fifth decade and gradually increases until, in the ninth decade, all subjects are osteoporotic. The combined cortical thickness (CCT) of the humerus in young adults is very similar to that found previously in a white London population and the loss of cortex with age is very similar. It is concluded that the known low incidence of femoral neck fracture in Bantu is not due to a lower incidence of generalised osteoporosis but to environmental factors. The chief environmental factor postulated is the greater amount of physical work performed by the Bantu. A more careful mode of walking is suggested as a subsidiary cause.

The periosteal sunburst reaction to bone metastases

The periosteal sunburst reaction is an unusual response to metastatic bone tumours. Fifty such cases are reported in the literature, and 20 additional cases are reported in this study. The most common primary tumour showing this response is prostatic carcinoma, and the majority of cases are associated with osteoblastic metastases. Twenty percent of sunburst metastases occur in bones distal to the elbow and knee, a much higher prevalence than is found overall in bone metastases.

Mediastinal lymph node metastases from gastrointestinal carcinoma

Mediastinal and hilar lymphadenopathy secondary to gastrointestinal metastases rarely have been reported and have been considered to occur only in conjunction with lymphangitic lung spread. The current report is of 15 cases of hilar and mediastinal metastases secondary to pancreatic, gastric, and colonic primary tumors. In only three of these cases was lymphangitic lung involvement noted. Possible pathways of spread of these tumors to the mediastinal lymph nodes are discussed.

Posttraumatic Painful Hip Sonography as a Screening Test for Occult Hip Fractures

Objective. Nondisplaced hip fractures may be radiographically occult and require magnetic resonance imaging (MRI) or bone scintigraphy for diagnosis. Both examinations are expensive and are not readily available in many hospitals. Our objective was to evaluate sonography as a screening tool for occult hip fractures in posttraumatic painful hips in elderly patients. Methods. We prospectively evaluated 30 patients (mean age, 73 years), who were admitted for painful hips after having low‐energy trauma with nondiagnostic hip radiographs. After inclusion, patients underwent sonography of both hips for signs of injury. After completion of the sonographic examination and analysis of the results, patients underwent MRI of both hips. The sonographic findings were compared with the MRI findings, which served as the reference standard for accurate detection of a hip fracture. Results. Ten hip fractures were diagnosed by MRI. Sonography showed trauma‐related changes in all of those patients and in 7 additional patients, 3 of whom had pubic fractures. Sonography correctly identified 13 patients without hip fractures. The sensitivity of sonography was found to be 100%, whereas the specificity for hip fractures was 65%. Conclusions. Sonography for posttraumatic hip pain with negative radiographic findings did not result in a single missed hip fracture. Therefore, sonography may serve as an effective screening tool, mandating MRI only for cases with positive findings, whereas patients with negative sonographic findings need no further investigation. Sonography may therefore be very useful in hospitals around the world, where MRI may not be readily affordable or available.

Granulocytic sarcoma (chloroma) of bone: The CT appearance

Granulocytic sarcoma (chloroma) is an unusual tumour usually seen in cases of myelogenous leukemia. The tumour is most commonly located in the skull, orbits and sinuses. Extracranial tumours occur mainly in the soft tissues of the body and bone involvement is uncommonly seen and is almost invariably lytic in nature. We describe the first case of CT demonstration of bone involvement by such a tumour. A mixed sclerotic and lytic pattern was seen.

Radiogrammetry of the metacarpal: a critical reappraisal.

The precise estimation of osteoporosis is hampered by the lack of a generally accepted method of evaluation. Measurement of the combined cortical thickness (CCT) of the centre point of the second metacarpal has been widely used for this purpose, but the wide normal variation found in population studies has reduced its value in the diagnosis of this condition in the individual.The factors leading to this normal variability are discussed and the three centre metacarpals are compared with each other. It is concluded that simple CCT measurement is preferable to any of the indices so far devised, but that a single measurement of a given metacarpal is too imprecise to be of real value. If a single metacarpal is to be chosen, three measurements of the third metacarpal gives a coefficient of variation lower than those of the second or fourth, and an average of nine measurements of the three centre metacarpals produces a further useful reduction in variability.