Search

Background and Aims: Traumatic scalp defects with an exposed calvaria denuded of the pericranium are challenging to manage. In such cases, adjunctive therapies, such as milling the outer calvarial cortex and applying negative pressure wound therapy (NPWT), can promote granulation tissue. This case series describes the successful management of traumatic scalp defects after cortical craniectomy using a combination of low‐temperature plasma (LTP) and NPWT. Methods: This is a retrospective single‐surgeon case series. Three patients with traumatic scalp wound defects underwent cortical calvarial bone removal after LTP combined with NPWT. LTP was applied to the diploic space of the calvaria weekly or twice weekly using BioPlasmaJet BPJ1 (BIOPlasma System: Model‐BioPlasmaJet System). Subsequently, NPWT was applied with a continuous pressure of 110 mmHg until good granulation tissue formation was achieved for skin graft placement. Results: Two males and one female were included, and the mean follow‐up duration was 7 (range 3–12) months. In addition, the average time to achieve good granulation tissue formation was 4 (2–6) weeks; all patients achieved successful split‐thickness skin grafting within 3 weeks after placement without signs of calvarial infection. Conclusions: The combination of LTP and NPWT is a safe and effective treatment modality for scalp defects with exposed calvaria denuded of the pericranium resulting from trauma. Combining these two therapies may provide a synergistic effect that enhances granulation tissue formation and prevents local infections without complications. [ABSTRACT FROM AUTHOR]

Abstract Background and Aims Traumatic scalp defects with an exposed calvaria denuded of the pericranium are challenging to manage. In such cases, adjunctive therapies, such as milling the outer calvarial cortex and applying negative pressure wound therapy (NPWT), can promote granulation tissue. This case series describes the successful management of traumatic scalp defects after cortical craniectomy using a combination of low‐temperature plasma (LTP) and NPWT. Methods This is a retrospective single‐surgeon case series. Three patients with traumatic scalp wound defects underwent cortical calvarial bone removal after LTP combined with NPWT. LTP was applied to the diploic space of the calvaria weekly or twice weekly using BioPlasmaJet BPJ1 (BIOPlasma System: Model‐BioPlasmaJet System). Subsequently, NPWT was applied with a continuous pressure of 110 mmHg until good granulation tissue formation was achieved for skin graft placement. Results Two males and one female were included, and the mean follow‐up duration was 7 (range 3–12) months. In addition, the average time to achieve good granulation tissue formation was 4 (2–6) weeks; all patients achieved successful split‐thickness skin grafting within 3 weeks after placement without signs of calvarial infection. Conclusions The combination of LTP and NPWT is a safe and effective treatment modality for scalp defects with exposed calvaria denuded of the pericranium resulting from trauma. Combining these two therapies may provide a synergistic effect that enhances granulation tissue formation and prevents local infections without complications.

Introduction: Delayed union and nonunion development remain a major clinical problematic complication during fracture healing, with partially unclear pathophysiology. Incidences range from 5 to 40% in high-risk patients, such as patients with periosteal damage. The periosteum is essential in adequate fracture healing, especially during soft callus formation. In this study, we hypothesize that inducing periosteal damage in a murine bone healing model will result in a novel delayed union model., Materials and Methods: A mid-shaft femoral non-critically sized osteotomy was created in skeletally mature C57BL/6 mice and stabilized with a bridging plate. In half of the mice, a thin band of periosteum adjacent to the osteotomy was cauterized. Over 42 days of healing, radiographic, biomechanical, micro-computed tomography and histological analysis was performed to assess the degree of fracture healing., Results: Analysis showed complete secondary fracture healing in the control group without periosteal injury. Whereas the periosteal injury group demonstrated less than half as much maximum callus volume (p < 0.05) and bridging, recovery of stiffness and temporal expression of callus growth and remodelling was delayed by 7-15 days., Conclusion: This paper introduces a novel mouse model of delayed union without a critically sized defect and with standardized biomechanical conditions, which enables further investigation into the molecular biological, biomechanical, and biochemical processes involved in (delayed) fracture healing and nonunion development. This model provides a continuum between normal fracture healing and the development of nonunions.

Objectives: To investigate the fracture pattern and periosteal entrapment in adolescent distal tibial physeal fractures., Design: Retrospective case series., Setting: Level I academic trauma center., Patients/participants: Fifty patients (10-16 years of age) with displaced Salter-Harris type II, III, or IV distal tibial physeal fractures were retrospectively reviewed., Intervention: Periosteal involvement, fracture pattern., Main Outcome Measurements: We investigated the incidence and location of periosteal entrapment in those fractures and the angle of the fracture plane of metaphyseal fragments on axial plane by using magnetic resonance imaging., Results: Of the 15 type II, 12 type III (4 malleolar and 8 Tillaux), and 23 type IV (2 malleolar and 21 triplane) fractures, 72.0% (36/50) presented with periosteal entrapment. Among all type II and triplane fractures, periosteal entrapment was observed in the anterolateral corner when there was any displacement on that corner. By contrast, only 1 of 8 Tillaux fractures presented with periosteal entrapment. In almost all supinated foot injuries of type II and triplane fractures, the metaphyseal fracture line was parallel to the intermalleolar axis on axial plane., Conclusions: Salter-Harris type II and triplane fractures have a high risk of periosteal entrapment especially in the anterolateral corner. Therefore, even without preoperative magnetic resonance imaging, surgical repositioning of entrapped periosteum should be considered after failed closed reduction. In cases of supinated foot injuries of type II or triplane fractures requiring surgical fixation, a metaphyseal fracture plane parallel to the oblique coronal plane connecting the medial and lateral malleoli may assist surgeons in achieving appropriate metaphyseal fixation., Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Bone-exposed wounds with intact or defected periosteum are difficult to heal. To provide relevant experimental evidence for guidance of clinical therapy, we established a rabbit model to compare the efficacies of negative pressure wound therapy (NPWT) and conventional guaze dressing therapy on the healing of cranial bone-exposed wounds., Methods: Full-thickness excisional circular wounds of 2.0 cm in diameter with exposed bones covered with or without periosteum were created at the parietal regions in 88 rabbits that were further randomly divided into the following treatment groups: periosteum-intact wounds treated with conventional vaseline gauze dressings (P + Control group), periosteum-intact wounds treated with NPWT (P + NPWT group), periosteum-lacking wounds treated with conventional vaseline gauze dressings (P-Control group), and periosteum-lacking wounds treated with NPWT (P-NPWT group). The wounds of NPWT groups were treated using a negative pressure therapy assembly that was set at a continuous pressure of -125 mm Hg for 7 days, then covered with vaseline gauze. The wound healing rates, wound infection rates, hydroxyproline content, and wound tissue histology were determined and evaluated., Results: The NPWT shortened the wound healing time by approximately 5 days when compared with the conventional gauze therapy. The histological characterization of wound tissues showed that NPWT decreased the inflammatory cells infiltration, accelerated reepithelialization and facilitated the organization of collagen fibers into neat layers on postoperative day (POD) 10. The NPWT enhanced bacterial clearances, reduced infection rates and increased the hydroxyproline contents in both types of wounds on PODs 10 and 15. The immunohistochemical staining of CD31 showed the NPWT treatment resulted in a significantly increased and persistent angiogenesis, and the wounds treated with NPWT showed well developed and more functional vessels at POD 7 compared with control., Conclusions: The NPWT is a more effective therapy for bone-exposed wounds than conventional guaze dressing therapy. The NPWT can promote bone-exposed wounds healing by increasing collagen contents and vessels densities while reducing inflammatory cells infiltration, reducing wound infection rates, and inducing an ordered collagen arrangement.

Objective: To describe a new sonographic feature for a traumatic lesion of the ankle in children., Materials and Methods: We present a retrospective review of superior extensor retinaculum (SER) avulsions diagnosed by ultrasound (US) as a cause of subperiosteal haematoma (SPH) and periosteal apposition of the distal fibula in seven children (3 girls and 4 boys, mean age 13.4 years; age range 10-15 years) after an inversion trauma of the ankle. Two children were subsequently examined with magnetic resonance imaging (MRI)., Results: At the acute phases (6 children), US showed a hypoechoic collection with periosteal elevation at the fibular insertion of the SER. The fibular cortex and growth plate were unremarkable. The SPH was isolated in three cases and associated with an anterior talofibular ligament sprain in four. In two cases, MRI confirmed the SER periosteal avulsion and the integrity of the distal fibula. At the later phase (one child), US showed a periosteal apposition at the fibular insertion of the SER with hypoechoic thickening of the SER and power Doppler hyperaemia., Conclusion: This is the first sonographic description of SER avulsion as cause of SPH of the distal fibula in children. SPH in children should not be considered as pathognomonic of a Salter-Harris type 1 lesion of the distal fibula. Later, it may be responsible for persistent ankle pain. Therefore, SER may be systematically explored in children during US examination of the ankle after trauma.

The Masquelet induced membrane technique for reconstructing large diaphyseal defects has been shown to be a promising clinical treatment, yet relatively little is known about the cellular, histological and biochemical make-up of these membranes and how they produce this positive clinical outcome. We compared cellular make-up, histological changes and growth factor expression in membranes induced around femur bone defects and in subcutaneous pockets at 2, 4 and 6 weeks after induction, and to the periosteum. We found that membranes formed around bone defects were similar to those formed in subcutaneous pockets; however, both were significantly different from periosteum with regard to structural characteristics, location of blood vessels and overall thickness. Membranes induced at the femur defect (at 2 weeks) and in periosteum contain mesenchymal stem cells (MSCs; STRO-1 + ) which were not found in membranes induced subcutaneously. BMP-2, TGFβ and VEGF were significantly elevated in membranes induced around femur defects in comparison to subcutaneously induced membranes, whereas SDF-1 was not detectable in membranes induced at either site. We found that osteogenic and neovascular activity had mostly subsided by 6 weeks in membranes formed at both sites. It was conclude that cellular composition and growth factor content in induced membranes depends on the location where the membrane is induced and differs from periosteum. Osteogenic and neovascular activity in the membranes is maximal between 2 and 4 weeks and subsides after 6. Based on this, better and quicker bone healing might be achieved if the PMMA cement were replaced with a bone graft earlier in the Masquelet technique. Copyright © 2013 John Wiley & Sons, Ltd., (Copyright © 2013 John Wiley & Sons, Ltd.)

Biodegradable poly([D,L]-lactide-co-glycolide) (PLGA) nanofibrous membrane embedded with two drug-to-polymer weight ratios, namely 1:3 and 1:6, which comprised PLGA 180 mg, lidocaine 20 mg, vancomycin 20 mg, and ceftazidime 20 mg, and PLGA 360 mg, lidocaine 20 mg, vancomycin 20 mg, and ceftazidime 20 mg, respectively, was produced as an artificial periosteum in the treatment of segmental femoral fractures. The nanofibrous membrane's drug release behavior was assessed in vitro using high-performance liquid chromatography and the disk-diffusion method. A femoral segmental fracture model with intramedullary Kirschner-wire fixation was established for the in vivo rabbit activity study. Twenty-four rabbits were divided into two groups. Twelve rabbits in group A underwent femoral fracture fixation only, and 12 rabbits in group B underwent femoral fracture fixation and were administered the drug-loaded nanofibers. Radiographs obtained at 2, 6, and 12 weeks postoperatively were used to assess the bone unions. The total activity counts in animal behavior cages were also examined to evaluate the clinical performance of the rabbits. After the animals were euthanized, both femoral shafts were harvested and assessed for their torque strengths and toughness. The daily in vitro release curve for lidocaine showed that the nanofibers eluted effective levels of lidocaine for longer than 3 weeks. The bioactivity studies of vancomycin and ceftazidime showed that both antibiotics had effective and sustained bactericidal capacities for over 30 days. The findings from the in vivo animal activity study suggested that the rabbits with the artificial drug-eluting periosteum exhibited statistically increased levels of activity and better clinical performance outcomes compared with the rabbits without the artificial periosteum. In conclusion, this artificial drug-eluting periosteum may eventually be used for the treatment of open fractures.

An intraorbitalsubperiosteal hematoma is a rare clinical entity that is usually caused by head trauma. The authors experienced a patient involving an intraorbital hemorrhage that was associated with minor injury in the forehead and that required surgical decompression. The authors describe this rare case involving an intraorbitalsubperiosteal hematoma that occurred in a conscious young boy who had no remarkable head injury and who had sudden onset of proptosis. Three-dimensional computed tomography, which was conducted with a volume-rendering method, was very useful, and the transorbital approach that was used to remove the hematoma was very effective. The patient showed good recovery. The pathogenesis of the intraorbitalsubperiosteal hemorrhage could not be fully explained, and, thus, the authors suggest that a possible pathogenesis involved the migration of the hemorrhage from the forehead into the intraorbital region.

Osteochondral defects represent a serious clinical problem. Although the cell-scaffold complexes have been reported to be effective for repairing osteochondral defects, a periosteal flap is frequently needed to arrest leakage of the implanted cells into the defect and to contribute to the secretion of cytokines to stimulate cartilage repair. The electrospun mesh mimicking the function of the flap assists tissue regeneration by preventing cell leakage and merits favorable outcomes in the cartilaginous region. In this study, an oriented poly(ε-caprolactone) (PCL) fibrous membrane (OEM) was fabricated by electrospinning as a periosteal scaffold and then freeze-dried with a collagen type I and hyaluronic acid cartilage scaffold (CH) and finally, freeze-dried with a tricalcium phosphate (TCP) bone substratum. Scanning electron microscopic images show obvious microstructure formation of the trilayered scaffolds, and electrospun fibrous membranes have an oriented fibrous network structure for the periosteal phase. Also shown are opened and interconnected pores with well designed three-dimensional structure, able to be bound in the CH (chondral phase) and TCP (osseous phase) scaffolds. In vitro results showed that the OEM can promote the orientation of bone marrow mesenchymal stem cell (BMSCs) and BMSCs can penetrate into the CH and TCP. After successfully combining the BMSCs, the tissue-engineered cartilage which contained the OEM and TCP complex was successfully used to regenerate the osteochondral defects in the rabbit model with greatly improved repair effects., (© 2014 Wiley Periodicals, Inc.)

Background: A recurrent anterior shoulder dislocation consists of a variety of lesion types., Objectives: To evaluate the pathological classification of recurrent anterior dislocation of the shoulder joint under arthroscopy., Methods: Thirty-one patients with recurrent anterior shoulder dislocation were inspected by arthroscopy, including 23 males and 8 females, with a mean age of 35.1 (18-46) years. The patients were divided into two groups: 17 with shoulder dislocation and hyper-laxity (the hyper-laxity group) and 14 with only traumatic shoulder dislocation (the trauma group). All the patients were assessed by arthroscopy for pathological changes, and the differences in the pathological changes were compared between the two groups., Results: All these 31 patients suffered from anteroinferior labrum injury. Twenty-five had Hill-Sachs injury; 27, bone or cartilage injury of anteroinferior glenoid; 16, SLAP injury; and 5, rotator cuff injury. Bankart injury occurred more in the trauma group, and anterior labroligamentous periosteal sleeve avulsion injury and glenolabral articular disruption injury were more in the hyper-laxity group. Bone or cartilage injury of anteroinferior glenoid was more noticed in the trauma group., Conclusions: Significant differences are found under arthroscopy in the pathological changes of recurrent anterior shoulder dislocation between the purely traumatic group and the hyper-laxity group. The pathological changes in the trauma group were more severe than in the hyper-laxity group.

Background: Tendon gliding is key to optimal recovery of hand function after complex tendon injuries. Gliding is facilitated by a low-friction gliding surface that is normally provided by the periosteum of the underlying bone. However, significant injuries may damage the periosteum, which must be reconstructed to allow uninterrupted tendon excursion. The absence of the periosteum may compromise a tendon's ability to glide freely, thereby limiting the range of motion., Methods: Six digits in 4 patients with complex, composite soft tissue defects involving tendon, periosteum, and skin of the hand underwent surgical repair. Each digit had disruption of the bony cortex underlying the tendon injury including periosteal loss. Through an incision on the dorsum of the ipsilateral wrist, an extensor retinaculum graft corresponding to the size of the periosteal defect was harvested. It was then sutured into place over the bare cortex to replace the lost periosteum., Results: All the 6 digits in the 4 patients had complete return to function. Additionally, all patients had near normal strength in the repaired hand along with excellent tendon excursion in both flexion and extension. The average time of follow-up of this series of patients was 1.5 years., Conclusions: Extensor retinaculum grafting to replace lost periosteum is a technique that is easily used, uses locally available autogenous tissues, and produces excellent tendon function. Additionally, the histologic similarities between extensor retinaculum and periosteum add scientific merit to this novel approach. On the basis of our experience, we recommend the use of extensor retinaculum for periosteal reconstruction to provide an adequate gliding surface for a reconstructed tendon.

Background: Subperiosteal hematoma is the accumulation of blood between the periosteum and the skull, which commonly occurs in the neonatal period but rarely in other ages. Subperiosteal hematoma can be self-absorbed in most cases and occasionally may cause ossification., Materials and Methods: This study reports a case of subperiosteal hematoma formed in a 16-year-old adolescent boy after a minor trauma. Because the hematoma did not disappear for more than a month after the trauma, the patient was treated with multiple hematoma punctures. However, the hematoma recurred and led to ossification. Finally, the patient underwent surgical treatment., Results: Finally, the ossification associated with the hematoma was treated through surgery. The head contour recovered normally., Conclusions: The occurrence of hematoma ossification in the 16-year-old patient suggests that the periosteum has great potential for osteogenesis. This is likely caused by the joint action of some active factors in the blood and a certain tension of the hematoma on the local periosteum. This case provides the following thoughts. (1) A subperiosteal hematoma that has not been absorbed after 1 month should be treated promptly to avoid ossification. Once ossification has occurred, the hematoma should be treated surgically. (2) The potential for periosteal osteogenesis is great, which may provide a new thought for cranioplasty.

Objective: The biostimulation effects of low-level laser therapy (LLLT) have recently been demonstrated. In this study, we aimed to investigate the effects of LLLT on palatal mucoperiostal wound healing and oxidative stress status in experimental diabetic rats., Materials and Methods: Forty-two male Wistar rats that weighed 250-300 g were used in this study. Experimental diabetes was induced in all of the rats using streptozotocin. A standardized full thickness wound was made in the mucoperiosteum of the hard palates of the rats using a 3 mm biopsy punch. The rats were divided into groups: 1 (control group, non- irradiated), and 2 (experimental group, irradiated). Treatment using a GaAlAs laser at a wavelength of 940 nm and at dose of 10 J/cm(2) began after surgery, and was repeated on the 2nd, 4th, and 6th days post-surgery. Seven animals from each group were killed on the 7th, 14th, and 21st day after surgery. Biopsies were performed for the histological analysis and blood samples were collected by cardiac puncture for biochemical analysis., Results: The histopathological findings revealed reduced numbers of inflammatory cells, and increased mitotic activity of fibroblasts, collagen synthesis, and vascularization in rats in group 2. The total oxidative status was significantly decreased in the laser-treated group on the 21st day., Conclusions: LLLT elicits a positive healing effect on palatal mucoperiostal wounds, and modulates the oxidative status in experimental diabetic rats.

Objective: The purpose of our study was to compare an MRI classification system for tibial stress injuries with semiquantitative MR features of injury severity and clinical outcome., Materials and Methods: Two musculoskeletal radiologists retrospectively reviewed in consensus the MR findings of 142 tibial stress injuries to quantify the degree of periosteal and bone marrow edema and grade the injuries using the Fredericson classification system (grade 1 = periosteal edema only, grade 2 = bone marrow edema visible on T2-weighted images, grade 3 = bone marrow edema visible on T1-weighted and T2-weighted images, grade 4a = multiple focal areas of intracortical signal abnormality, and grade 4b = linear areas of intracortical signal abnormality). Kruskal-Wallis tests were used to determine the relationship between the grade of stress injury and the degree of periosteal and bone marrow edema and the time to return to sports activity., Results: Grade 4b injuries had significantly (p < 0.002) more severe and grade 1 injuries less severe periosteal and bone marrow edema than grades 2, 3, and 4a injuries. Grade 4b injuries had significantly (p < 0.002) longer time and grade 1 injuries shorter time to return to sports activity than grades 2, 3, and 4a injuries. There was no significant difference (p = 0.06-0.79) among grades 2, 3, and 4a injuries in the degree of periosteal and bone marrow edema and the time to return to sports activity., Conclusion: Grades 2, 3, and 4a stress injuries had similar degrees of periosteal and bone marrow edema and similar time to return to sports activity, which suggests that these three grades can be combined into a single category in an abbreviated Fredericson classification system.

Unlabelled: We developed a new device composed of a thin biodegradable mesh (poly-L-lactide/hydroxyapatite composite) for distracting periosteum. The purpose of this study is to evaluate the effect of using this device as a periosteal distractor., Materials and Methods: Eight Japanese male rabbits were divided into two groups according to time of sacrifice. The calvarial periosteum was elevated and one side of a biodegradable mesh was fixed to the bone surface with two titanium screws. Seven days after the surgery, an elevating screw was inserted into the other side of the mesh. Then, the calvarial periosteum was elevated at maximum 0.5 mm every 12 h for 5 days. The device was designed to distract the periosteum at different rates along its entire surface. At 4 and 6 weeks of the consolidation, the animals were sacrificed and newly formed bone was histologically and radiographically evaluated., Results: The new device simplified periosteal distraction and reduced its invasiveness. Moreover, it successfully induced new bone formation from two sources; the periosteum and the underlying basal bone. Histomorphometric analysis of the distracted space showed that there is a relation between the rate of distraction and the amount of newly formed bone. We suggest that the optimal speed range for periosteal distraction in rabbit calvarial model could be less than 0.33 mm/day., Conclusions: The new device is slim, biodegradable and the procedure is simple. Thus, periosteal distraction with this device is potential for vertical and horizontal ridge augmentation in oral cavity., (Copyright © 2011 Wiley Periodicals, Inc.)

Objective: To investigate the contribution of bone marrow-derived cells to oral mucosa wounds and skin wounds., Background: Bone marrow-derived cells are known to contribute to wound healing, and are able to differentiate in many different tissue-specific cell types. As wound healing in oral mucosa generally proceeds faster and with less scarring than in skin, we compared the bone marrow contribution in these two tissues., Design: Bone marrow cells from GFP-transgenic rats were transplanted to irradiated wild-type rats. After recovery, 4-mm wounds were made in the mucoperiosteum or the skin. Two weeks later, wound tissue with adjacent normal tissue was stained for GFP-positive cells, myofibroblasts (a-smooth muscle actin), activated fibroblasts (HSP47), and myeloid cells (CD68)., Results: The fraction of GFP-positive cells in unwounded skin (19%) was larger than in unwounded mucoperiosteum (0.7%). Upon wounding, the fraction of GFP-positive cells in mucoperiosteum increased (8.1%), whilst it was unchanged in skin. About 7% of the myofibroblasts in both wounds were GFP-positive, 10% of the activated fibroblasts, and 25% of the myeloid cells., Conclusions: The results indicate that bone marrow-derived cells are preferentially recruited to wounded oral mucosa but not to wounded skin. This might be related to the larger healing potential of oral mucosa., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Irreducible fracture of the distal tibial physis due to interposed soft tissue including periosteum is well documented in the orthopedic literature but is uncommon. This condition has been associated with subsequent growth disturbance and requires open reduction. There are very few prior reports of MRI depiction of soft tissue interposition and none of periosteal interposition in the distal tibial physis. This is a relatively common location of physeal injury and related growth disturbance. We present a case of periosteum trapped in the distal tibial physis, diagnosed on MRI, in a Salter-Harris II fracture and its management implications.

Understanding how bone behaves when subjected to ballistic impact is of critical importance for forensic questions, such as the reconstruction of shooting events. Yet the literature addressing microscopic anatomical features of gunshot wounds to different types of bone is sparse. Moreover, a biomechanical framework for describing how the complex architecture of bone affects its failure during such impact is lacking. The aim of this study was to examine the morphological features associated with experimental gunshot wounds in slaughtered pig ribs. We shot the 4th rib of 12 adult pigs with .22 mm subsonic bullets at close range (5 cm) and examined resultant wounds under the light microscope, scanning electron microscope SEM and micro tomograph μCT. In all cases there was a narrow shot channel followed by spall region, with evidence of plastic deformation with burnishing of the surface bone in the former, and brittle fracture around and through individual Haversian systems in the latter. In all but one case, the entrance wounds were characterized by superficially fractured cortical bone in the form of a well-defined collar, while the exit wounds showed delamination of the periosteum. Inorganic residue was evident in all cases, with electron energy dispersive spectroscopy EDS confirming the presence of carbon, phosphate, lead and calcium. This material appeared to be especially concentrated within the fractured bony collar at the entrance. We conclude that gunshot wounds in flat bones may be morphologically divided into a thin burnished zone at the entry site, and a fracture zone at the exit.

The aim of this study was to retrospectively identify the role of plaster in redisplacement of dorsal distal radius fracture in children. A total of 60 children with displaced dorsal distal radius fractures were included in this study. All these fractures were reduced under general anesthesia. A total of 22 redisplacements were observed. Statistical analysis was performed to search for risk factors of redisplacement. Poor modeling immobilization of the wrist in the cast, studied by the three-point index was the only significant risk factors for redisplacement. The three-point index is an excellent index to predict redisplacement and assess the quality of the cast treatment of these fractures. The type of study or level of evidence is therapeutic IV.

We report on two patients who sustained Salter-Harris II fractures of the distal femur with physeal widening after being tackled in football games. Preoperative MRI indicated entrapped periosteum at the physeal fracture site for both patients. Both patients underwent open reduction of the physeal fracture with removal of the entrapped periosteum and achieving an anatomic reduction. Follow-up MRI's revealed premature physeal arrest. Subsequent procedures were performed to address sequelae of premature physeal arrest. The presence of physeal widening and entrapped periosteum may reflect high-energy trauma to the physis. This can result in injury to both the epiphyseal blood supply and to the physeal cartilage (germinal zone) resulting in physeal arrest despite anatomic reduction after removal of the entrapped periosteum. Upon literature review, pre-operative MRI demonstrating entrapped periosteum has not been previously reported. We hypothesize that the presence of entrapped periosteum following distal femoral physeal fractures may be associated with an increased risk for premature physeal arrest.

Isolated injuries of the posterolateral corner of the knee are uncommon injuries in adults and are relatively unheard of in the pediatric population. This article reports a case of a 13-year-old boy who sustained an external rotation injury to his proximal tibia on a slightly flexed knee while playing football. Radiographs showed an avulsed fragment from the lateral femoral condyle. A magnetic resonance image was read as an avulsion of the femoral insertion of the lateral collateral ligament with associated bone bruise of the lateral femoral condyle. At operation, the fragment consisted of the femoral insertion of the popliteus tendon and the lateral collateral ligament, which was anatomically reduced and internally fixed with a screw and soft tissue washer. Six weeks postoperatively, the patient had full range of motion. To our knowledge, this injury has not been reported in the pediatric population., (Copyright 2011, SLACK Incorporated.)

Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire. Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips. Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure.

The aim of this article is to review data concerning paediatric orbital fractures. These fractures exhibit strong specificities because they occur in a growing face. Due to the craniofacial growing pattern and the peumatization of paranasal sinuses, there are differences in the anatomical location of orbital fracture with the age: before the age of seven they are mostly orbital roof and after seven they involve the orbital floor. The clinical diagnosis is confirmed with a computed tomography scan (CT scan), gold standard for the imaging in the orbital fractures. The magnetic resonance imaging (MRI) offers a better soft-tissue depiction and is useful when clinical data are not consistent with CT scan findings. The orbital fractures in children are rarely operated. In emergency the main surgical indications are the trap-door fracture involving the ocular muscles and the compressive haematomas. We hypothesize that the periosteum more likely than the bony structure is involved in the responsible trap-door fractures: the thickness and the elasticity of the periosteum leads to reposition the floor or the medial wall of the orbit to its initial position., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: Myofibroblasts are responsible for contraction and scarring after cleft palate repair. This leads to growth disturbances in the upper jaw. We hypothesized that cells from the bone marrow are recruited to palatal wounds and differentiate into myofibroblasts., Methods: We transplanted bone marrow from green fluorescent protein (GFP)-transgenic rats into lethally irradiated wild-type rats. After recovery, experimental wounds were made in the palatal mucoperiosteum, and harvested 2 weeks later. GFP-expressing cells were identified using immunostaining. Myofibroblasts, activated fibroblasts, endothelial cells, and myeloid cells were quantified with specific markers., Results: After transplantation, 89 ± 8.9% of mononuclear cells in the blood expressed the GFP and about 50% of adherent cells in the bone marrow. Tissue obtained during initial wounding contained only minor numbers of GFP-positive cells, like adjacent control tissue. Following wound healing, 8.1 ± 5.1% of all cells in the wound area were positive, and 5.0 ± 4.0% of the myofibroblasts, which was significantly higher than in adjacent tissue. Similar percentages were found for activated fibroblasts and endothelial cells, but for myeloid cells it was considerably higher (22 ± 9%)., Conclusions: Bone marrow-derived cells contribute to palatal wound healing, but are not the main source of myofibroblasts. In small wounds, the local precursor cells are probably sufficient to replenish the defect., (© 2010 John Wiley & Sons A/S.)

Background: Radiofrequency-generating energy devices have been used clinically in musculoskeletal procedures to provide hemostasis and capsular shrinkage (thermal capsulorrhaphy). However, the dose-effects are not well known., Questions/purposes: We therefore determined dosage effects of radiofrequency energy on bone, skin incisions, and joint capsule in sheep., Methods: Five mature sheep had six 2.5-cm(2) tibial periosteal defects and six 1.0-cm skin incisions assigned to six treatments varying by watts and fluence (f = watts . seconds/cm(2)): (1) untreated control, (2) 50 W for 9.5 seconds (190f; n = 5), (3) 110 W for 4.3 seconds (190f; n = 5), (4) 170 W for 2.8 seconds (190f; n = 5), (5) 170 W for 5.6 seconds (380f; n = 5), or (6) 170 W for 8.4 seconds (570f; n = 5). Outcomes included hemostasis, contraction, healing, and histomorphometry for inflammation and necrosis at 2 weeks., Results: Radiofrequency energy application on skin at 190f or greater had more than 80% hemostasis and dose-dependent contraction, inflammation, and necrosis. Radiofrequency energy application on bone had good (70%) hemostasis at 190f and complete (> 95%) hemostasis at 380f and 570f, without histologic or clinically detectable necrosis., Conclusions: Hemostasis can be achieved with radiofrequency energy at 190f in skin and bone. Bone necrosis was not detected at up to 570f. Using fluence greater than 190f in skin achieved dose-dependent necrosis and incisional contraction., Clinical Relevance: Radiofrequency energy can be used on bone and skin for hemostasis, but potential incisional complications, such as necrosis and an atypical firm and desiccated surface, should be expected.

Objective: Patterns of periosteal disruption are important factors in assessing the mechanism of injury of radiologically evident Salter-Harris (SH) fractures. The purpose of this study is to assess the frequency of posterior periosteal disruption on MRI in radiographically occult or subtle SH type II fractures of the distal femur and to evaluate associated soft-tissue findings that support a hyperextension mechanism of injury., Conclusion: We found that all children in our experience with occult or subtle SH type II fractures of the distal femur have posterior periosteal disruption and other MRI findings to indicate a hyperextension mechanism of injury. Direct indicators of fracture may be inconspicuous, and the presence of posterior periosteal disruption is a clue that should prompt a search for other features of this serious pediatric injury, which may be followed by limb shortening or angular deformity.

Retrograde labeling has been used to identify sensory neurons in the lumbar dorsal root ganglia (DRG) that innervate the rat tibial periosteum, medullary cavity, and trabecular bone. The size, neurochemical profile [isolectin B4 (IB4) binding, substance P (SP), calcitonin gene-related peptide (CGRP), and NF200 immunoreactivity (-IR)], and segmental distribution of sensory neurons innervating each of these bony compartments are reported. After injections of fast blue into the periosteum, medullary cavity, and trabecular bone (epiphysis), retrogradely labeled neurons were observed throughout the ipsilateral (but not contralateral) lumbar DRG. They were predominantly small (<800 microm(2)) or medium-sized (800-1,800 microm(2)) neurons. CGRP-IR and SP-IR were found in 23% and 16% of the retrogradely labeled neurons, respectively. IB4 binding was observed in 20% and NF200-IR in 40% of the retrogradely labeled neurons. There were no significant differences in the percentage of neurons labeled with any one of the antisera following injections into each of the three bony compartments. To allow a direct comparison with sensory neurons innervating cutaneous tissues, injections of fast blue were also made into the skin overlying the tibia. The percentage of CGRP-IR neurons innervating bone was significantly lower than the percentage of CGRP-IR neurons innervating skin (ANOVA; P < 0.05). No other significant differences in the neurochemical profiles of neurons labeled from bone vs. skin were observed. The findings of the present study show that the periosteum, medullary cavity, and trabecular bone are all innervated by sensory neurons that have size and neurochemical profiles consistent with a role in nociception.

Subperiosteal hematoma arises usually after blunt trauma to the bone. It is due to disinsertion or rupture of a muscle tendon or injury of nutrient artery of bone. Subperiosteal hematoma is a rare condition and develops mainly in the orbit because the periosteum is more loosely attached to the bone. Thus, few cases of subperiosteal hematoma in iliac bone are reported. Traumatic pseudoaneurysm develops mainly after penetrating or blunt trauma. It can be easily diagnosed by intravenous contrast computed tomography or magnetic resonance imaging by seen extravasation of contrast dye. We present a case of subperiosteal hematoma with subperiosteal pseudoaneurysm after blunt pelvic trauma in a 17-year-old adolescent boy. The pseudoaneurysm arose from a branch of superior gluteal artery, but it was not seen in the initial contrast computed tomography scan.

A 3.5 x 4 mm tubular osteochondral defect was created on the right medial femoral condyles of 51 adult rabbits. In the control group (CG), defects were left untreated. In the early-(ETG) and late-(LTG) treatment groups, defects were treated by an osteoperiosteal graft 1 and 12 weeks, respectively, after the index procedure. Synovial fluid (SF) samples were collected regularly and proteoglycan fragments (PF), total collagen (TC) and collagenase (MMP-1) levels were measured. Rabbits were killed at 4 (early period), 12 (intermediate period), or 24 (late period) weeks postoperatively. Histological examination indicated a more successful healing in both grafting groups than in the CG, but without any difference at any time period between the grafting groups. In the CG, PF, and TC levels in SF increased continuously until the late period, indicating an ongoing degenerative activity in the joints. In contrast, SF marker levels in both grafting groups indicated that normalization in joint metabolism could be achieved-at least partially-after treatment. However, PF levels in the SF showed that the treatment of defects in earlier stages might result in better outcomes since the negative effects were more prominent in chronic stages, presumably due to the more prolonged period of disturbed homeostasis. Thus, histological values and SF marker levels indicated that treatment of osteochondral defects at any time of the disease had a positive effect on healing when compared to no treatment. Early treatment might better assist the recovery of joint homeostasis than late treatment.

A unique case of anterior knee pain in an active adolescent is described: a periosteal sleeve avulsion and quadriceps rupture in a young basketball player. The trauma mechanism was without any direct trauma on the knee. A review of overuse-related anterior knee pain in the young and active is presented. A quadriceps rupture with a periosteal sleeve avulsion fracture in an active adolescent is very rare. To our knowledge there are no similar cases described. This article presents a case of a 14-year-old adolescent boy who sustained a quadriceps rupture with a periosteal sleeve avulsion.

US, a non-irradiating imaging modality, is complementary to radiographs in the evaluation of limb fractures. US may in some cases demonstrate or suggest the presence of a fracture without corresponding abnormality on radiographs, or confirm or exclude a possible fracture detected on radiographs. Knowledge of the US features of fractures is necessary. In this article, the different direct and indirect US findings of fractures will be reviewed, with radiographic correlation. Direct findings include cortical discontinuity or irregularity. Indirect findings include subperiosteal or juxtaphyseal hematoma suggesting cortical or physeal fractures respectively.

The origin of cranial epidermoid cysts (EC) remains controversial, and although generally considered to be congenital, acquired origin has been reported. EC represent 0.2 to 1.8% of all brain tumours, and only one fourth are intradiploic in location. We report of a 44-year-old woman with a giant intradiploic EC of the occipital bone with intracranial extension confirmed on brain MRI. Three years previously, in the same location, she underwent resection of an intradermal melanocytic naevus of the skin under local anaesthesia with lidocaine infiltration of skin and periosteum. Brain CT scan performed at the time of naevus surgery because of associated headache did not show a lesion of the cranial vault. Iatrogenic epidermoid tumours are extremely rare, and although seeding of epidermal cells has been classically described only after lumbar puncture, the same mechanism may be involved after head injury, cranial surgery or cranial periosteal iatrogenic puncture.

We report the case of an 11-year-old girl with sickle cell disease who presented to the emergency room after being hit by a mud pie in the left frontal region. Examination evidenced left eye proptosis, eyelid swelling, reduced visual acuity and afferent pupillary defect, without any inflammatory signs such as fever, hyperemia or tenderness. Computed tomography of the orbits showed a large superomedial subperiosteal hematoma in the left orbit. The patient was treated with canthotomy, cantholysis and surgical draining of the hematoma. Two days after drainage she persisted with a subperiosteal hematoma and low visual acuity. A wide exploration of the orbital roof through a lid crease approach disclosed a thickened superior orbital rim with multiple bone defects along the roof and with continuous bleeding. Hemostasis was accomplished with bone wax. Orbital compression was resolved and the patient recovered her previous normal visual acuity.

Introduction: Huge subperiosteal hematomas extending beyond the cranial sutures are rare and clinically, their distinction from subgaleal hematomas may be difficult., Case Report: We report a subperiosteal hematoma that involved the entire scalp including the orbit and recurred within 6 months., Discussion: We discuss our neuroradiologic and histopathologic findings and our management strategy.

We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).

We describe a sixteen years old male patient that suffered a craniocerebral trauma and presented at the emergency room, with ocular pain, palpebral hematoma and left eye proptosis. Orbital computed tomography showed left subperiosteal orbital hematoma. A surgical drainage was performed. Subperiosteal hematoma of the orbit is a rare cause of proptosis; its early diagnosis must be made in order to avoid possible complications.

Sleeve fractures of the upper pole of the patella in children are rare; only 2 cases have been reported in the English literature and 1 case in the German literature. We present a case of this unusual lesion in order to stress the importance of being aware of the existence of upper pole sleeve fractures of the patella. We review the literature and we describe the symptoms, the clinical and radiological signs and the treatment. The diagnosis may be missed, the treatment is relatively simple and rewarding, and un- or mistreating this fracture leads to permanent disability.

Avulsion fractures of the tibial tuberosity are rare. In general, juvenile male athletes sustain this fracture. A combination of Ogden type 3A fracture in combination with a posterior fracture of the proximal tibial epiphysis type Salter 2 is described for the first time. The necessity for immediate surgical intervention to prevent secondary soft tissue injury is stressed.

Background: Despite the fact that wound irrigation is a common surgical procedure, there are many variables, including delivery device, irrigant type, and fluid volume, that have yet to be optimized. The purpose of this study was to compare, with use of transgenic bioluminescent bacteria and standard quantitative microbiological methods, the efficacy of pulsed lavage and bulb syringe irrigation in reducing wound bacterial counts., Methods: A caprine model of a complex, contaminated musculoskeletal wound was developed with use of a bioluminescent strain of Pseudomonas aeruginosa that can be quantified. Luminescent activity was recorded as relative luminescent units with use of a photon-counting camera six hours after the wound was created and inoculated. Twelve goats were randomly assigned to either the pulsed lavage group or the bulb syringe irrigation group. Each wound was irrigated with normal saline solution in 3-L increments for a total of 9 L and was imaged after each 3-L increment. In addition, quantitative culture samples were obtained from different tissues within the wound before and after irrigation., Results: Pulsed lavage decreased the amount of relative luminescent units by 52%, 64%, and 70% at 3, 6, and 9 L, respectively. The bulb syringe irrigation reduced the amount of relative luminescent units by 33%, 44%, and 51% at these same time-points. Significant differences in luminescence were noted between the two groups after both 6 and 9 L of irrigation (p < or = 0.04). The correlation coefficients between relative luminescent units and quantitative cultures for the condition before irrigation and after irrigation were r = 0.96 and 0.83, respectively., Conclusions: Pulsed lavage was more effective than bulb syringe irrigation in reducing bacterial luminescence after both 6 and 9 L of irrigation. Both device and volume effects can be demonstrated with use of this model. Bioluminescent bacteria provide a method to visualize bacterial distribution and to quantify the bacteria in a wound., Clinical Relevance: Pulsed lavage is a more effective and efficient method of irrigation to remove bacteria in a complex musculoskeletal wound. In the model we used, pulsed lavage irrigation with 3 L of saline solution resulted in a reduction of approximately the same amount of bacteria as did irrigation with 9 L with use of a bulb syringe.

Objective: The purpose of this study was to determine the minimum size defect in a canine mandible that would not spontaneously heal during the dog's natural life (the critical size defect)., Study Design: Sixteen adult female mongrel dogs underwent continuity resection on both sides of the mandible to create bilateral defects. In 8 dogs, mandibular defects ranging from 5 to 20 mm were created with periosteal resection. In the other 8 dogs, mandibular defects ranging from 30 to 60 mm were created preserving the periosteum. The dogs were then killed at 6 months and the defects examined using radiographs and histologic analysis., Results: When the periosteum was removed, mandibular defects greater than 15 mm failed to heal across the entire defect. However, when the periosteum was preserved, mandibular defects needed to be greater than 50 mm in order to fail to heal., Conclusion: The critical size defect in a canine mandible model is 15 mm when the periosteum is removed and 50 mm when the periosteum is preserved.

Bony exostosis (BE) is described as a benign localised overgrowth of bone of unknown aetiology. Buccal bony exostosis (BBE) development secondary to soft tissue graft procedures has been reported in a small number of cases. The dental literature describes BBE development also at sites where free gingival grafts (FGG) have been used to increase the amount of gingiva. The following case series describes BBE development at nine sites (five cases) at which FGG was performed to increase the width of the attached gingiva. The presence of exostoses has been recognised during postoperative visits. Histological examination revealed osseous enlargements compatible with the diagnosis of exostoses at two re-entry procedures. In conclusion, based on previous reports, periosteal trauma, eg fenestration, seems to be the main aetiologic agent associated with the development of BBE in areas where FGG were placed.

Contact gunshot wounds are usually characterized by a muzzle imprint, a powder cavity ("pocket"), the presence of carboxyhemoglobin and often also stellate tears of the skin radiating from the bullet entrance hole. In shots to the cerebral cranium an additional sign may be observed around the bone defect: the periosteum is detached and reflected with soot on the underside. The frequency and possible causes of these periosteal findings are discussed on the basis of 68 contact gunshot wounds from forensic autopsy material and experimental shots fired against the frontal bone of a slaughtered calf.