William L. Oppenheim

Operative treatment versus steroid injection in the management of unicameral bone cysts

The operative treatment of 37 patients with unicameral bone cysts was compared with the newer method of steroid injection in 20 patients whose cysts were similarly predisposed with respect to mode of presentation, location, age, and sex. In the surgical group the average operative time was 100 min. with a mean estimated blood loss of 300 ml. The recurrence rate was 409?, rising to 88% in patients under the age of 10 years with active cysts (less than 1 cm from the physis). Major complications occurred in 15% and included infection, refracture, coxa vara. extremity shortening, and physeal damage. A minimum follow-up of 2 years was necessary to rule out recurrence. In contrast, the steroid-injected group had a recurrence rate of 5%, although 50% required more than one injection for maximum obliteration. The average operative time was 30 min, with negligible blood loss and a minimum hospital stay and rehabilitation. The only complications were a mild steroid Hush in one patient and extremity shortening due to preexisting fracture in another. The end point of healing was reconstitution of cortical thickness, rather than total obliteration at the cyst. No secondary fractures were encountered. Both operative treatment and percutaneous steroid injection exhibited a high rate of recurrence or persistence. The greater simplicity and lesser morbidity associated with the steroid technique favored it as the method of choice.

Both-bone midshaft forearm fractures in children.

Summary: To determine whether closed treatment of both-bone midshaft forearm fractures routinely results in acceptable clinical outcome for children <16 years of age, we retrospectively studied all such patients treated at our two hospitals between 1970 and 1982. All children <10 years of age at the time of fracture had excellent results. Of 14 patients between the ages of 10 and 16 years, closed treatment failed in nine. We conclude that the incidence of poor results from closed treatment of the fractures in children >10 years of age is seriously underestimated.

Osteoid osteoma diagnosis and management with low morbidity.

Wide excision, a recommended treatment for osteoid osteoma, creates needless resection of surrounding bone and causes difficult intraoperative nidus identification. Less bone resection is required by successively burring through the reactive bone to identify the nidus, which is then removed with curettes and burrs. This burr-down technique requires precise preoperative anatomic localization by thin section (1-1.5 mm) computed tomography (CT) scans. In a consecutive series of 19 osteoid osteomas, 18 were accurately diagnosed before operation, using a combination of clinical findings, plain roentgenograms, and CT scans. The burr-down technique was successfully used in 15 cases, and four were treated with wide excision. There have been no local recurrences. The follow-up period for all 19 patients was at least six months. No bone grafts were required in the burr-down group in nonspinal locations; there have been no fractures despite early return to unrestricted activity. The burr-down technique was associated with less postoperative immobilization, a shorter duration of protected weight bearing, and an earlier return to activity. The burr-down technique is recommended for accessible osteoid osteoma lesions.

Supracondylar Humeral Osteotomy for Traumatic Childhood Cubitus Varus Deformity

Between 1958 and 1983, 45 corrective supracondylar osteotomies of the humerus were performed for post-traumatic cubitus varus deformity in 43 children. The average follow-up period was two and one-half years. Excellent or good results were obtained in 33 patients. Unsatisfactory results were seen in 12. The operation, though deceptively simple, had a significant complication rate (24%), including neuropraxia, sepsis, and cosmetically unacceptable scarring. After these problems were analyzed, the important points of technique that were noted were a comprehensive preoperative plan and a simple lateral closing wedge osteotomy, leaving the medial cortex intact and ignoring rotational deformity.

Selective Control Assessment of the Lower Extremity (SCALE): development, validation, and interrater reliability of a clinical tool for patients with cerebral palsy

Normal selective voluntary motor control (SVMC) can be defined as the ability to perform isolated joint movement without using mass flexor/extensor patterns or undesired movement at other joints, such as mirroring. SVMC is an important determinant of function, yet a valid, reliable assessment tool is lacking. The Selective Control Assessment of the Lower Extremity (SCALE) is a clinical tool developed to quantify SVMC in patients with cerebral palsy (CP). This paper describes the development, utility, validation, and interrater reliability of SCALE. Content validity was based on review by 14 experienced clinicians. Mean agreement was 91.9% (range 71.4–100%) for statements about content, administration, and grading. SCALE scores were compared with Gross Motor Function Classification System Expanded and Revised (GMFCS‐ER) levels for 51 participants with spastic diplegic, hemiplegic, and quadriplegic CP (GMFCS levels I – IV, 21 males, 30 females; mean age 11y 11mo [SD 4y 9mo]; range 5–23y). Construct validity was supported by significant inverse correlation (Spearmans r=‐0.83, p<0.001) between SCALE scores and GMFCS levels. Six clinicians rated 20 participants with spastic CP (seven males, 13 females, mean age 12y 3mo [SD 5y 5mo], range 7–23y) using SCALE. A high level of interrater reliability was demonstrated by intraclass correlation coefficients ranging from 0.88 to 0.91 (p<0.001).

Humerus shaft fractures in young children: accident or abuse?

We performed a retrospective review of 34 humerus shaft fractures (HSFs) in children younger than 3 years to determine the frequency of child abuse in young children with this injury. Data were obtained from hospital records (including previous and subsequent emergency, clinic, and inpatient notes), radiographs, and county childprotective services. Cases were reviewed independently by four physicians and were classified as probable abuse, probable not abuse, and indeterminate. Only 18% were classified as probable abuse. The history and findings other than the fracture itself were critical in establishing cause. Neither age nor fracture pattern is pathognomonic of abuse, but suspicion should remain high. A detailed history, complete physical examination, and appropriate radiographic investigation are required in every case either to make the diagnosis of abuse or to avoid the trauma of a false accusation.

Clavicle fractures in the newborn

A retrospective review of 21,632 live births from January 1982 to July 1987 was performed to determine the incidence and risk factors associated with fractures of the clavicle in the newborn. Fifty-eight fractures (57 patients) were identified, for an incidence of 2.7 clavicle fractures per 1000 live births. Fractures of the clavicle were associated with heavy neonates and shoulder dystocia. Three patients had concurrent clavicular fractures and Erbs palsy. These findings suggest that the incidence of clavicle fractures in the newborn may be reduced by identifying the macrosomic fetus and by minimizing shoulder dystocia. When clavicle fractures occur, a brachial plexus injury should be ruled out.

Delayed reduction of traumatic knee dislocation. A case report and literature review.

Knee dislocation after high energy trauma poses a major challenge to patients and treating physicians. The case presented documents the history and treatment of an unreduced posterior knee dislocation discovered 24 weeks after injury. Delayed surgical reduction was achieved, and satisfactory results were obtained with 22 months of followup of the patient. A detailed review of the literature found no comparable examples of longstanding traumatic dislocations of the knee but shed light on the probable cause for this unusual case. Close clinical followup, even after appropriate initial treatment of knee dislocations, is needed to eliminate similar occurrences.

Musculoskeletal Coccidioidomycosis: A Review of 25 Cases

Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Musculoskeletal involvement is rare, and there are few reports with clear recommendations regarding treatment. The purpose of this study was to review a series of 25 patients with musculoskeletal coccidioidomycosis and to assess their outcomes with respect to presentation and treatment. There were 36 lesions among the 25 patients, 8 located in the spine, with the remainder distributed throughout the body. Seventeen patients had a delay in diagnosis of more than 1 month. Eight patients had an elevated white blood cell count, and 10 had an elevated sedimentation rate. Only 7 of the patients had an overt pneumonia before the musculoskeletal presentation. Twenty-four patients underwent formal irrigation and debridement and 22 patients had at least 1 course of Amphotericin B. The average followup after the initiation of treatment was 3.5 years, ranging from 2 to 10 years. Seven patients had recurrent lesions that required further surgical intervention, 4 of whom had a delay in diagnosis of more than 1 month. There were 3 deaths. All surviving patients were free of disease at final followup.

Fractures of the hip in children: a review of forty cases

In a series of childrens hip fracture seen over a 27-year-period, there were 39 patients (40 fractures) with a mean age of 8.9 years followed for an average 7 years. After an initial period of traction, 50% of the fractures were treated in a spica cast, 40% by internal fixation, and 10% by bed rest. Overall, there were 65% good results, 25% fair and 10% poor. All nondisplaced fractures were found to have a good result, while only one-half of displaced fractures were considered a good result. The complications were premature epiphyseal closure 23%, avascular necrosis 17%, coxa vara 12.5%, and nonunion 7.5%. Intertrochanteric fractures should be treated in traction followed by a spica cast. All other displaced fractures should be reduced and internally fixed. The hip joint capsule is opened in those transepiphyseal and transcervical fractures for which closed reduction has been unsuccessful. Spica casts are used to protect the fixation until roentgenograms show healing. Nondisplaced fractures may be treated non-operatively but must be watched closely for varus angulation. Threaded pins or lag screws are the devices of choice except in transepiphyseal fractures where smooth pins can be used to cross the physis. Nail-plates should be avoided.