Subperiosteal abscess of the orbit: computed tomography and the clinical course

In an earlier study, a trial of i.v. antibiotics, with surgical drainage reserved for failure to respond, was recommended for children aged < 9 years with medial subperiosteal abscesses (SPAs) of modest size and without compromised vision. Careful monitoring is mandatory in these cases, and comparison of serial computed tomography (CT) scans frequently guides therapy. The present study examines how the CT findings actually relate to the clinical course of SPA. Initial and subsequent CT scans in 37 cases were analyzed with respect to the subperiosteal material encountered at surgery and the response to treatment. The subperiosteal material could not be predicted from the size or relative radiodensity of the collections in CT scans. Initial scans were not predictive of the clinical course. Serial scans showed enlargement of abscesses during the first few days of i.v. antibiotic therapy, regardless of the ultimate response to treatment. It is concluded that expansion of an SPA in serial CT scans during the first few days of treatment should not be equated to failure of the infection to respond to antibiotics alone. In interpreting serial scans, the time-dependent pharmacokinetics of antibiotic therapy should be considered.

Relationship of the subperiosteal bone collar to metaphyseal lesions in abused infants

We studied the relationship between the subperiosteal bone collar and forty metaphyseal lesions in specimens obtained at autopsy from ten infants who died with evidence of abuse. The fracture specimens were studied with high-detail radiography and light microscopy. The typical morphological pattern was a fracture extending through the primary spongiosa adjacent to the chondro-osseous junction. As the fracture line approached the cortex, it veered away from the growth plate, undercutting a fragment of bone that was thicker peripherally than it was centrally. Histological examination showed that this peripheral fragment of bone included the subperiosteal bone collar. Inclusion of the subperiosteal bone collar within the peripheral portion of the metaphyseal fracture fragment explains the radiographic appearance of corner fractures and bucket-handle patterns described by Caffey in abused infants.

Quantitative analysis of the plain radiographic appearance of eosinophilic granuloma

RATIONALE AND OBJECTIVES

To quantitate features that distinguish the plain radiographic appearance of eosinophilic granuloma (EG) from other solitary lesions of bone.

MATERIALS AND METHODS

Seven hundred nine focal bone lesions, including 26 EGs, were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of EG in contrast to other lesions in the data base.

RESULTS

The radiographic appearance of EGs was most consistently that of a medullary based lytic lesion (100%) with geographic destruction (76.9%), lobular contour (73.1%), and well-defined edges (73.1%). Long bone lesions showed these features more frequently than EGs in other locations. Periosteal reaction was visible in all long bone lesions but in only one nonlong bone lesion (5.9%). Characterization of EG in long bones as a lytic, medullary-based metaphyseal or diaphyseal lesion with geographic destruction, lobular contours, periosteal reaction, no matrix, and no subarticular extension showed a sensitivity of 55.6% of EG and prevalence of 22.7%. The vector analysis-generated differential diagnoses include unicameral bone cyst, aneurysmal bone cyst, giant cell tumor, Brodie's abscess, enchondroma, chondrosarcoma, and malignant fibrous histiocytoma.

CONCLUSIONS

The radiographic appearance of EG is relatively nonspecific but, using vector analysis, can be better elucidated than in current textbook descriptions.

Quantitative analysis of the plain radiographic appearance of nonossifying fibroma

RATIONAL AND OBJECTIVES

To quantitate radiographic features that distinguish the plain radiographic appearance of nonossifying fibroma (NOF) from other solitary lesions of bone.

MATERIALS AND METHODS

Seven hundred nine cases of focal bone lesions, including 34 NOFs, were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of NOF in contrast to other lesions in the data base.

RESULTS

The radiographic appearance of NOFs was most consistently a medullary based (97%), lytic lesion (100%) with geographic bone destruction (100%), marginal sclerosis (97%), and well-defined edges (94%). A statistically significant number of lesions were located in the distal aspect of long bones. Unicameral bone cyst shared the most radiographic features with the NOF. Vector analysis showed a large degree of overlap between NOF and other lesions such as aneurysmal bone cyst, chondromyxoid fibroma, and eosinophilic granuloma. The description that optimized sensitivity and prevalence for detection of NOF is a medullary based, ovoid lesion in the distal or proximal portions of a long bone with well-defined edges, a partial or complete rind of sclerosis, and absence of fallen fragment, periosteal reaction, and cortical disruption.

CONCLUSION

The radiographic appearance of NOF is relatively nonspecific but, using vector analysis, can be better elucidated over current textbook descriptions.

Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused b Arcanobacterium haemolyticum

PURPOSE/METHODS

A 16-year-old boy had orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia. Arcanobacterium haemolyticum was identified as the causative organism.

RESULTS/CONCLUSIONS

This organism is a cause of orbital cellulitis and may require aggresive therapy in order to achieve a therapeutic response.

Quantitative analysis of the plain radiographic appearance of aneurysmal bone cysts

RATIONAL AND OBJECTIVES

To quantitate radiographic features that distinguish the plain radiographic appearance of aneurysmal bone cyst (ABC) from other solitary lesions of bone.

MATERIALS AND METHODS

Seven hundred nine cases of focal bone lesions, including 32 ABCs were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of ABC in contrast with other lesions in the data base.

RESULTS

Aneurysmal bone cysts most consistently are medullary-based, either eccentric or centric (94%), show lysis (100%), cortical thinning (97%), enlargement of the host bone (100%), and geographic bone destruction (94%). They have well-defined edges (84%), no fallen fragment (100%), no evidence of periosteal reaction (75%), and no visible matrix (91%). Although they typically occur in the metadiaphysis of long bones, the anatomic location and demographic data did not significantly affect the sensitivity or specificity for detection of ABCs. The vector analysis-generated differential diagnoses include giant cell tumor, unicameral bone cyst, nonossifying fibroma, enchondroma, and fibrous dysplasia as the major lesions.

Quantitative analysis of solitary lesions of bone

RATIONALE AND OBJECTIVES

To quantitate the radiographic features of common solitary lesions of bone using vector analysis to optimize their radiographic description.

METHODS

Plain radiographs of 709 solitary bone lesions were reviewed. Relevant demographic, anatomic, and structural data were cataloged. These data were used to approximate the vector space defined by all possible solitary lesions of bone. Vector space analysis on the entire set of lesions was performed to determine similarities among and between lesion types.

RESULTS

The 709 lesions generated 614 separate vectors within the appearance vector space. Only 10 vectors were represented more than 3 times, indicating great variability among and between most lesion types. Osteochondromas (with two vectors repeated 10 and 15 times, respectively) and peripheral chondrosarcomas (with one vector repeated 5 times) were relatively uniform in appearance. Gender bias was present for multiple types of lesions. Larger lesions that involved more than one anatomic center were more likely to be malignant. Lesions occurring in the femoral diaphysis and pelvic flat bones were statistically more likely to be malignant.

CONCLUSIONS

Analysis shows that most lesions have highly varied vectors in the appearances within the vector space. More in-depth analysis of each lesion type using this quantitative technique is required to better define individual lesion subspaces and hence their radiographic appearances with respect to other bone lesions.

Angiography of osteosarcoma

During the last two decades, the excellent sectional imaging provided by computed tomography and magnetic resonance has determined that conventional angiography no longer be routinely performed in the diagnosis of sarcomas. Conventional angiography, however, is a helpful adjunct to the biopsy of parosteal osteosarcoma when chemotherapy is administered intraarterially.

[Sinus pericranii and developmental venous anomalies: a frequent association]

The authors describe 2 cases of congenital sinus pericranii associated with intracranial venous anomalies. After a review of the literature concerning this association they consider the possible etiopathogenic mechanisms and treatment implications.

Osteogenesis in muscle with composite graft of hydroxyapatite and autogenous calvarial periosteum: a preliminary report

To investigate the bone forming activity of composite grafts of hydroxyapatite (HA) and autogenous calvarial periosteum, porous HA rods with or without the periosteum were implanted into the back muscle of white rabbits. They were harvested 3 and 6 months after implantation and studied histologically and microradiographically. Bone formation in the pores of HA occurred in three out of four composite implants of the 3 month group, and four out of five implants of the 6 month group. The two specimens without bone formation revealed irregular calcified tissue outside the HA implant. No formation of bone and calcified tissue took place in any of the specimens with HA alone. These results indicate the potential of this new experimental system of ectopic osteogenesis and offer the possibility of a new improved bone graft consisting of HA and autogenous periosteum.

MRI of eosinophilic granuloma

The imaging studies of nine histologically proven eosinophilic granulomas were reviewed. Radiographs and MRI studies were performed on all patients, with eight patients being examined by bone scintigraphy and six by CT. Matrix calcification, not evident on radiography, was demonstrated in two cases by CT. MRI proved superior to both the radiographs and CT in defining the medullary extent of the lesion and the surrounding soft tissue changes. In eight of nine cases, on STIR sequences, an endosteal rim of low signal intensity surrounding the main lesion was present and may be an early feature of healing. The degree of peritumoral oedema accompanying eosinophilic granuloma was less extensive than that seen in either Ewing's sarcoma or osteomyelitis. The presence of both a low signal endosteal rim and limited peritumoural oedema on STIR sequences may be a useful indicator to the diagnosis of underlying eosinophilic granuloma.

[Periostal effusion in hypernatremic dehydration with disseminated intravascular coagulation]

BACKGROUND

Several cases of hypernatremic dehydration complicated by consumption coagulopathy and peripheral gangrene have been reported.

CASE REPORT

A 4.5 month-old boy was admitted suffering from acute gastroenteritis with cyanotic edema of the distal part of the left leg and foot. His serum sodium was 160 mEq/l, potassium 5.8 mEq/l and urea 27.6 mMol/l. His prothrombin level was 44%, fibrinogen 0.65 g/l and the number of platelets was 20,000/mm3. Blood cultures were negative. Ultrasonography showed a subperiostal effusion in the posterolateral part of the left tibia with edema of the adjacent soft tissues. Culture of the fluid was negative. The patient was rehydrated. Several phlyctenes appeared on the left foot; cultures of the exudate remained sterile. His condition gradually normalized within two weeks and ultrasonography performed at the 15th day was normal.

CONCLUSION

The subperiostal effusion seen in our patient could have been due to microthrombosis of the metaphyseal vessels, following severe dehydration.

Myelofibrosis associated with prominent periosteal bone apposition. Report of two cases

Myelofibrosis is a myeloproliferative disorder that is characterized by splenomegaly and bone marrow replacement by fibrous tissue. The predominant radiographic feature is osteosclerosis; however, in rare instances, periosteal bone apposition or periostitis is apparent in the metaphysis of the distal femura and proximal tibiae. It has been suggested that periostitis, when associated with fever and bone pain, is indicative of more aggressive disease. We report this unusual radiographic finding and its similar appearance to hypertrophic osteoarthropathy in two patients with myelofibrosis. In our patients, the presence of periosteal bone apposition did not correlate with increased disease aggressiveness.

Anterior cruciate ligament allograft reconstruction in the skeletally immature athlete

The purpose of this study was to evaluate anterior cruciate ligament allograft reconstruction in skeletally immature athletes. Eight patients (mean age, 13 years, 6 months; range, 10 to 15 years) with radiographic documentation of open growth plates had anterior cruciate ligament repair and reconstruction with fascia lata or Achilles tendon allograft tissue. A 7-mm graft was centrally placed across the tibial physes and in an over-the-top position on the femur. All patients returned for followup a mean of 58 months (range, 22 to 94) postoperatively. All had an immediate knee motion and rehabilitation exercise program. The results were rated on a comprehensive rating system that assessed 20 variables. At followup, all patients showed closure of the growth plates. The difference in lower limb length, measured on scanograms, was not clinically significant. On KT-1000 arthrometer testing, 5 patients had less than 3 mm of increased anterior-posterior displacement (normal knee minus reconstructed knee) and 3 patients had between 3 and 5 mm. The final overall ratings were 6 excellent, 1 good, and 1 fair. The procedure is infrequently used, but appears to have merit in select, skeletally immature athletes who desire not to modify athletic activity or when associated meniscal repairs warrant consideration for reconstruction.

Monostotic fibrous dysplasia in the hand. A case report

We present in this paper a new case of monostotic fibrous dysplasia in the hand. The reason for this communication is the rarity of this osseous dystrophy in the hand as well as its radiologic features as a malignant osseous tumor, being a lytic lesion with incomplete periostic reaction.

Femoral periosteal thickening in pustulotic arthroosteitis, including 3-year followup by magnetic resonance imaging

We describe 2 female patients with femoral periosteal thickening, in association with signs of pustulotic arthroosteitis in the sternocostoclavicular region and spine. In one patient, inflammatory changes were seen in muscular tissue surrounding this area of periosteal thickening, with fibrosis in the corresponding marrow. Over a period of up to 4 years after bone biopsy, cortical hyperostosis was observed spreading over a longer segment of her femoral diaphysis, while its thickness decreased over the longterm. Bone biopsy probably contributed to the striking periosteal thickening surrounded by inflammatory lesions in the surrounding muscles of this patients.

Bizarre parosteal osteochondromatous proliferation of bone (Nora's lesion)

Bizarre parosteal osteochondromatous proliferation was first described in 1983, when Nora et al. reported 35 examples of a proliferative lesion involving the small bones of the hands and, less often, the feet. No examples involving the large bones were reported. We present 65 cases of this condition, five from the Mayo Clinic files and 60 from our consultation files, including 34 females and 31 males; patients' ages ranged from 8 to 73 years (average, 33.9 years). Thirty-six lesions involved the hands, 10 the feet, 17 the long bones, one the skull, and one an unknown site. The long bones involved were the radius (three lesions), ulna (six), fibula (two), femur (three), tibia (two), and humerus (one lesion). Roentgenograms typically showed a heavily calcific mass attached to the underlying cortex and having a broad base. Histologically, a large amount of hypercellular cartilage showed maturation to trabecular bone, which frequently contained spindle cells in the intertrabecular spaces, an appearance that could lead to a mistaken diagnosis of parosteal osteosarcoma. A helpful feature was the distinct blue tinctorial characteristic of the bone in the lesion. Follow-up information was available for 40 patients; approximately 55% had a recurrence. No metastasis had been reported in any of the 65 cases. Bizarre parosteal osteochondromatous proliferations are a form of heterotopic ossification and should not be mistaken for chondrosarcoma or osteosarcoma.

Orthopaedic manifestations of leukemia during childhood: a rare case of isolated periosteal reaction

The authors describe one case of acute lymphoid leukemia during childhood manifested by migrant arthralgias. The only radiographic signs were constituted by a periosteal reaction in the left fibula. The main clinical symptoms and radiographic signs described in the literature and used to diagnose leukemia are reported.

Eosinophilic granuloma: MRI manifestations

The appearance on magnetic resonance imaging (MRI) of 16 cases of pathologically proven eosinophilic granuloma were reviewed retrospectively and correlated with the radiographic appearance of the lesion. The most common MR appearance (ten cases) was a focal lesion, surrounded by an extensive, ill-defined bone marrow and soft tissue reaction with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images, considered to represent bone marrow and soft tissue edema (the flare phenomenon). The MRI manifestations of eosinophilic granuloma, especially during the early stages, are nonspecific, and may stimulate an aggressive lesion such as osteomyelitis or Ewings sarcoma, or other benign bone tumors such as osteoid osteoma or chondroblastoma.

Assessment of tumorous mandibular involvement by transcutaneous ultrasound and flexible endosonography

Tumorous involvement of the mandible affects the prognosis and choice of treatment. To evaluate the usefulness of transcutaneous ultrasound and recently-developed flexible endosonography and their ability to display bone invasion in the lower jaw, we studied 33 non-selected patients with extensive, histologically-verified oral and oropharyngeal carcinomas. Both sonographic examinations were performed prospectively in all patients prior to surgery, without knowledge to the sonographer of the results of other imaging methods. Histological findings served as gold standards and offered 14 mandibular involvements. Flexible endosonography is characterized by high accuracy data in assessment of mandibular involvement occurring in tumors of the floor of the mouth and of the tonsil. On the other hand acceptable results by transcutaneous ultrasound could only be obtained in assessing bone invasion of oral tumors. However, osseous destruction in patients with oropharyngeal tumors were not detectable as the involved medial surface of the mandibular ramus was inaccessible to the extraorally placed transducer. Both sonographic methods, especially endosonography, enabled the examiner to differentiate cortical bone as opposed to spongiosa involvement in many cases, but failed in assessment of tumorous periosteal involvement. Pitfalls in detection and differentiation of bone invasion with false positive and false negative findings are discussed with regard to mandibular anatomy, for both intra- and extraoral examination.

Periosteal reaction of the ribs in neonates treated with extracorporeal membrane oxygenation: prevalence and association with soft-tissue swelling

OBJECTIVE

The objectives of the study were to determine the prevalence of periosteal reaction of the ribs in infants treated with extracorporeal membrane oxygenation and to evaluate its association with soft-tissue swelling.

MATERIALS AND METHODS

The chest radiographs of 100 consecutive neonates treated with extracorporeal membrane oxygenation were evaluated to determine the maximal soft-tissue swelling during therapy and whether periosteal reaction of the ribs developed. The length of extracorporeal membrane oxygenation and the time elapsed before periosteal reaction developed were recorded. The medical records of those with periosteal reaction were reviewed to determine known causes of this condition. The records of a control group of 11 neonates were evaluated in the same manner.

RESULTS

Periosteal reaction of the ribs developed in 13 (21%) of the 61 neonates who had less than 11 mm of soft-tissue swelling. In 69% of those with periosteal reaction, the finding first was seen 21-32 days after birth. In the control group, periosteal reaction developed in only one, a neonate who had vibrator chest physiotherapy.

CONCLUSION

Periosteal reaction of the ribs in patients treated with extracorporeal membrane oxygenation is associated with soft-tissue swelling greater than 11 mm. The periosteal reaction appears to be a self-limiting and benign process.