Atraumatic osteolysis of the distal clavicle: MR findings

OBJECTIVE: The purpose of this study was to describe the MRI appearance in atraumatic osteolysis of the distal clavicle (AODC). MATERIALS AND METHODS: We retrospectively evaluated MRI, medical records, ancillary diagnostic imaging studies and clinical course in five men and two women (mean age, 39 years) in whom the final clinical diagnosis of AODC was established. None of the patients had significant shoulder injury, but all participated in activities involving repetitive strain of the acromioclavicular (AC) joint. In three of these patients, we performed follow-up MRI (ranging from 5 1/2 to 15 months after the initial MRI). RESULTS: In all seven patients, signal intensity changes within the intramedullary portion of the distal clavicle on MRI were consistent with diffuse bone marrow edema. Marrow edema was most conspicuous on STIR imaging and occasionally could be misinterpreted as normal marrow signal patterns on spin-echo imaging. Cortical thinning or irregularity of the distal clavicle was seen in six cases and tiny subchondral cysts were seen in three, corresponding to subtle cystic changes on shoulder radiography. Limited bone scans obtained in two patients showed markedly increased uptake of radiotracer at the distal clavicle and AC joint. Histologic examination in one case showed disruption of articular cartilage, subchondral cysts, and metaplastic bone formation with increased osteoclastic activity. Follow-up MRI in three patients who were asymptomatic following conservative therapy showed normalization of marrow signal intensity. CONCLUSION: Atraumatic osteolysis of the distal clavicle is a relatively uncommon but important cause of shoulder pain. Particularly when the clinical history is suggestive of repetitive AC joint stress, MRI of the distal clavicle should be examined closely for marrow edema, cortical irregularity, and cystic changes. Such abnormalities may be especially conspicuous when STIR imaging techniques are used.     

Resorption of the undersurface of the distal clavicle in rheumatoid arthritis

The authors communicate their experience in the treatment of ankylostomiase with levamisole; with a dose of 2.5 mg/kg body weight they achieved a positive result in two-thirds of the cases in a series of 119 without any toxic side effects.     

Characteristics of fractures of the distal part of the clavicle in children

Fractures of the clavicle are frequent in children and mostly affect the middle third. On the other hand, traumatic fractures of both medial and lateral thirds of the clavicle are rare. The lesions have special characteristics: difficulty in diagnosis for the medial third; risk of callus formation in the absence of surgical reduction of the lateral third. The authors report two observations of fractures of the medial and lateral thirds of the clavicle; they insist on the value of investigation by CT scan.     

Type 2 fractures of the distal clavicle: a new surgical technique

A rare case of frontal sinus carcinoma is reported. The patient developed early recurrence following surgery, and was managed by accelerated hyperfractionated radiation therapy and concurrent cisplatinum-based systemic chemotherapy. The patient has remained disease-free for 30 months following the end of treatment.     

Subcoracoid dislocation of the distal end of the clavicle. A case report

Subcoracoid dislocation of the outer end of the clavicle in association with an acromial fracture is a rare injury usually produced by high energy trauma that moves the clavicle posterior to the conjoined tendon and inferior to the coracoid process. To restore the acromioclavicular joint, open reduction is needed. After the reduction is accomplished, the clavicle has to be stabilized with a coracoclavicular screw. The acromial fracture can be reduced and held with nonabsorbable sutures placed through the bone. To avoid osteolysis of the distal end of the clavicle and to be able to repair the torn ligaments, treatment should not be delayed.     

Progressive scapulothoracic subluxation after fracture of the clavicle

Fracture of the clavicle is a common injury that usually heals without consequence. Instability of the scapulothoracic articulation does not usually occur. In this case, the scapulothoracic subluxation was not obvious at the time of injury, but progressively worsened over the following 2 weeks. Open reduction and internal fixation of the clavicle fracture restored stability to the shoulder girdle. The patient went on to regain full function of her injured extremity.     

Headache after acoustic neuroma excision

The retrosigmoid approach to acoustic neuroma removal has recently been criticized for causing frequent and severe headache postoperatively. We review 331 patients who had acoustic neuroma removal by the retrosigmoid approach at one institution. The incidence of postoperative headache was 23 percent at 3 months, 16 percent at 1 year, and 9 percent at 2 years. Management was primarily with analgesics, physiotherapy, and reassurance. No patient had additional surgical treatment. Information available indicates that the incidence of postoperative headache associated with the translabyrinthine approach is similar to that of the retrosigmoid approach. Perhaps filling the craniectomy defect will decrease further the incidence of headache postoperatively.     

Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after excision of a skeletal tumor

Twenty-four patients had reconstruction of the distal aspect of the radius with use of an osteoarticular allograft, between 1974 and 1992, after excision of a giant-cell tumor (twenty patients), a desmoplastic fibroma (two patients), a chondrosarcoma (one patient), or an angiosarcoma (one patient). Nine giant-cell tumors were recurrent lesions, and eleven were extracompartmental primary lesions that had extended through the cortex or subchondral bone. The average age of the patients was 31.5 years (range, fifteen to sixty-one years); thirteen patients were female and eleven were male. Seventeen lesions involved the right wrist and seven involved the left wrist. The reconstruction was performed through a dorsoradial incision with use of a size-matched, preserved, fresh-frozen, distal radial allograft. All procedures included internal fixation and reconstruction of the radiocarpal ligaments. All patients were followed for a minimum of two years (average, 10.9 years; range, 2.1 to 22.3 years). At the time of follow-up, two patients -- one who had a giant-cell tumor and one who had a desmoplastic fibroma -- had a local recurrence. Eight patients needed a revision of the osteoarticular allograft, at an average of 8.1 years (range, 0.8 to 17.8 years) after the initial reconstruction. Seven of these patients had an arthrodesis and one had an amputation. The reason for the revision was a fracture of the allograft in four patients, recurrence of the tumor in one, pain in two, and volar dislocation of the carpus in one. There were fourteen other complications, including ulnocarpal impaction necessitating excision of the distal aspect of the ulna (four), painful hardware necessitating removal (four), rupture of the extensor pollicis longus tendon necessitating transfer of the extensor indicis proprius (two), fracture of the allograft necessitating open reduction and internal fixation (two), volar dislocation of the carpus necessitating closed reduction (one), and a ganglion of the dorsal aspect of the wrist necessitating excision (one). Of the sixteen patients in whom the osteoarticular allograft survived, three did not have pain, nine had pain in association with strenuous activities, and four had pain in association with moderate activities. Three patients reported no functional limitation, nine had limitation in the ability to perform strenuous activities, and four had limitation in the ability to perform moderate activities. The average range of motion of the wrist was 36 degrees of dorsiflexion, 21 degrees of volar flexion, 16 degrees of radial deviation, 15 degrees of ulnar deviation, 58 degrees of supination, and 72 degrees of pronation. Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft was associated with a low rate of recurrence of the tumor, a moderately high rate of revision, little pain in association with common activities, good function, and a moderate range of motion. Osteoarticular allografts are an option for reconstruction of the distal aspect of the radius after excision of a malignant tumor or a recurrent or locally invasive benign lesion.     

Radiation optic neuropathy after stereotactic radiosurgery

PURPOSE: The purpose of the study is to report the occurrence of optic neuropathy after stereotactic radiosurgery for perichiasmal tumors. METHODS: Records of four patients with visual deterioration after stereotactic radiosurgery were reviewed, including clinical findings, neuroimaging results, and treatment methods. RESULTS: Optic neuropathy developed 7 to 30 months after gamma knife radiosurgery. All patients experienced an abrupt change in visual function. Clinical findings indicated anterior visual pathway involvement. Patterns of field loss included nerve fiber bundle and homonymous hemianopic defects. Gadolinium-enhanced magnetic resonance imaging (MRI) showed swelling and enhancement of the affected portion of the visual apparatus in three patients. Systemic corticosteroids were administered in all patients and one partially recovered. One patient also received hyperbaric oxygen without improvement. CONCLUSIONS: Although rare, optic neuropathy may follow radiosurgery to lesions near the visual pathways. Careful dose planning guided by MRI with restriction of the maximal dose to the visual pathways to less than 8 Gy will likely reduce the incidence of this complication.     

Bilateral femoral neuropathy after vaginal hysterectomy

A case of bilateral femoral neuropathy as a complication of vaginal hysterectomy is presented. A 45-year-old woman developed weakness of both quadriceps, absence of bilateral knee jerks, and numbness over bilateral anteromedial thighs and medial lower legs after a vaginal hysterectomy. Electromyographic examination revealed evidence of denervation in the bilateral quadriceps. A nerve conduction study showed prolonged distal latencies and markedly reduced amplitude of the compound muscle action potentials in bilateral femoral nerves. It is suggested that this complication is caused by a microvascular and/or local mechanical injury of the femoral nerve, which is compressed beneath the tough inguinal ligament in a sustained posture with the hip joint in an extreme abduction and external rotation position. The prognosis was excellent with almost complete recovery within 10 weeks. The complication may be preventable by minimizing operating time, changing the patient's posture, and limiting the degree of flexion, abduction, and external rotation of the hip.     

Reconstruction of the tragus after tumour excision

Reconstruction of the tragus is very difficult to perform and most techniques are described for the treatment of microtia where remnants of ear are used. The goal always consists in achieving a prominence that covers the canal. We present a novel and safe method, based on the vascularity of the lobule, that also provides a good appearance.     

Endoscopic monitoring after excision of colorectal cancer

The aim of coloscopy after radical colorectal surgery for cancer is: to find another tumor or a local recurrence. The policy must be adapted. When the preoperative approach is inadequate, coloscopy must performed between 3 to 6 months. After complete polypectomy, a coloscopic survey significantly reduces mortality and the incidence of colorectal cancer and has to be done at 3 years and then every 5 years. Data are not sufficient to establish a strategy for the local recurrence survey. The patients aged 75 and over, do not necessarily require repeated coloscopy.     

Silent thyroiditis after excision of a thymoma

A 61-year-old man developed thyrotoxicosis after excision of a thymoma. His laboratory examination showed an increased level of thyroid hormone and a low thyroidal iodine uptake. No thyroidal autoantibody was detected. With the diagnosis of silent thyroiditis, he was treated with propranolol. He became euthyroid after 2 months. Thymoma often accompanies an autoimmune disease as a paraneoplastic syndrome, and an immunological mechanism is thought to be involved in the onset of silent thyroiditis. This case suggests the involvement of an immunological mechanism in the pathogenesis of silent thyroiditis.     

Neurobiology of postoperative impotence after rectal excision

OBJECTIVE: The present study was conducted to determine the changes in the neuro-andrologic profile of patients with impotence following rectal ablative surgery. METHODS/RESULTS: The study comprised 18 patients who had undergone rectal surgery: abdominoperineal resection of the rectum (AP) in 12 cases (67%), anterior resection of the rectum (AR) in 6 cases (33%). The pharmacologic erection test was negative in 60% of the patients (56% of the AP cases and 67% of the RA cases; differences not significant). Sympathetic lesion was demonstrated in 67% of the patients (50% of the AP cases and 100% of the AR cases; significant difference). Parasympathetic lesion was demonstrated in 38% of the patients (56% of the AP and in none of the RA cases; tendency towards statistical significance). Pudendal lesion was demonstrated in 83% of the patients, although no significant differences concerning pudendal involvement were observed between both types of surgery (92% of the AP group and 67% of the RA group). The frequency of the pudendal lesion was significantly greater than the parasympathetic lesion and the sympathetic lesion tended to be significantly greater than the parasympathetic lesion in patients undergoing ablative rectal surgery. No significant differences were observed between the pudendal and the sympathetic lesion in these patients. No relationship was observed between the type of neurologic lesion and the results of the pharmacologic erection test. CONCLUSIONS: The type of neurological lesion appears to be related with the level of the rectal surgery. The sympathetic innervation would be more frequently compromised in anterior resection of the rectum. The parasympathetic innervation would be more frequently compromised in abdominoperineal resection. The pudendal innervation would be affected by both types of surgical techniques.     

Suprascapular nerve entrapment in a basketball player

A basketball player was shown to have a suprascapular nerve lesion without any history of shoulder girdle trauma. This acute neuropathy, never previously described in basketball players, is a result of repeated micro-trauma, due to nerve traction over the coracoid notch during violent movement ("dunking" most probably). Clinically, he was unable to abduct his arm and had some difficulty in external rotation. He developed atrophy in both the supra- and the infraspinatus muscles. Nerve conduction latency to the supraspinatus muscle was 8.0 ms, and to the infraspinatus, 8.5 ms. The compound muscle action potential registered in the supraspinatus was 1.224 mV, and in the infraspinatus, 1.237 mV. After 3 weeks of inactivity, recovery was spontaneous and practically complete.     

Newborn clavicle fractures

A prospective screening program of 9106 newborns identified 43 infants with clavicle fractures for a prevalence of 1 fracture in every 213 live births (0.5%). The fractures were equally distributed by right and left side involvement, and male and female sex. All fractures occurred during vaginal deliveries. None were breech presentation. Risk factors for fracture included large birth-weight, shoulder dystocia, mechanically assisted delivery, and prolonged gestational age. One in 11 newborns with a clavicle fracture also had a brachial plexus palsy.     

Transitory osteonecrosis of the head of humerus after fracture of the clavicle

The authors present a rare case of transitory osteonecrosis of the humeral head with anterior instability of the glenohumeral joint, which occurred in a young male aged 19 years, three months after fracturing his clavicle in a fall. Core decompression of the humeral epiphysis and anterior capsulomioplasty according to Symeonides was performed. Five months after surgery the patient was clinically cured. After having excluded the possibility of metabolic imbalance in the patient, we presumed a direct relationship between the trauma and degenerative pathology affecting the humeral epiphysis.     

Screening for distal sensory peripheral neuropathy in HIV-infected persons in research and clinical settings

OBJECTIVE: To determine the accuracy of a screening examination for distal sensory peripheral neuropathy (DSPN) performed by nonphysician clinicians and to explore the associations between DSPN and clinical features in HIV-infected persons. METHODS: A case-control study of a volunteer sample of 226 HIV-infected individuals was performed. An interview, focusing on risks and symptoms of DSPN, and a screening neurologic examination were performed. RESULTS: Compared with the neurologist's examinations, the clinicians' examination was sensitive (92 to 95%) but not as specific (71 to 84%) for the diagnosis of DSPN. After excluding 27 patients with confounders, 42 of 199 patients (21%) had DSPN. This was associated significantly with neurotoxic nucleoside antiretroviral use and with more advanced HIV disease. Of the 42 patients with DSPN, 30 (71%) had no neuropathy symptoms. CONCLUSIONS: A brief examination performed by trained nonphysician clinicians can be used to screen for DSPN in HIV-infected persons. Asymptomatic DSPN is common in these individuals.     

Six-year survival after excision of cardiac malignant lymphoma

We report a patient with a postoperative survival period of 6 years after the surgical excision of a cardiac malignant lymphoma. A 35-year-old woman underwent total excision of the tumor arising from the left ventricular outflow tract. After the operation, she was treated with chemotherapy for 6 months. She has been doing well thereafter without any medication. To date there is no evidence of recurrence.