Abnormal bone scanning following intraosseous access

A case of an abnormal bone scan following intraosseous access in a 12-month-old child is presented. Gallium scanning and follow-up showed no signs of possible complicating osteomyelitis. This case report suggests that an abnormal bone scan following intraosseous access is possible and should not be considered diagnostic for osteomyelitis.     

The development of the clavicle in man

The development of the human clavicle was studied in 50 to 60 d old human embryos. Our findings are summarized as follows: The whole clavicle develops from a cartilaginous anlage. In the middle part of the clavicle, an osseus cuff develops very early by the ossification in the perichondrium. In the lumen of this cuff, a cartilaginous cork persists which is resorbed and replaced by bone and marrow later than in other bones. It is possible that cartilaginous nests may persist in the middle part of the clavicle. In both extremities of the clavicle, the normal enchondral ossification exists as it is described in other anlages. It is difficult to explicate the syndrome of the cleido-facial and cleido-cranial dysostoses only as disturbances of the endesmal ossification.     

Trauma among the Shanidar Neandertals

Four of the adult Neandertals from Shanidar Cave, Iraq, Shanidar 1, 3, 4, and 5, show evidence of antemortem trauma. Shanidar 1 sustained injuries to the right frontal squama, the left lateral orbit, the right humerus and right fifth metatarsal. Associated with this trauma are hypoplasia or atrophy of the right clavicle, scapula, and humerus, osteomyelitis of the right clavicle, degenerative joint disease at the right knee, ankle, and first tarsometatarsal joint, and remodeling of the left tibia. Shanidar 3 experienced trauma-related degenerative joint disease at the right talocrural and talocalcaneal joints and sustained a penetrating wound across the left ninth rib. Shanidar 4 suffered a fracture of the right seventh or eighth rib, and Shanidar 5 had a scalp wound over the left frontal. A high frequency of antemortem trauma associated with the survival of the injured individuals appears to have been characteristic of the Neandertals.     

Titanium Elastic Nail (TEN) versus Reconstruction Plate Repair of Midshaft Clavicular Fractures: A Finite Element Study

BackgroundThe biomechanical characteristics of midshaft clavicular fractures treated with titanium elastic nail (TEN) is unclear. This study aimed to present a biomechanical finite element analysis of biomechanical characteristics involved in TEN fixation and reconstruction plate fixation for midshaft clavicular fractures.MethodsFinite element models of the intact clavicle and of midshaft clavicular fractures fixed with TEN and with a reconstruction plate were built. The distal clavicle displacement, peak stress, and stress distribution on the 3 finite element models were calculated under the axial compression and cantilever bending.ResultsIn both loading configurations, TEN generated the highest displacement of the distal clavicle, followed by the intact clavicle and the reconstruction plate. TEN showed higher peak bone and implant stresses, and is more likely to fail in both loading configurations compared with the reconstruction plate. TEN led to a stress distribution similar to that of the intact clavicle in both loading configurations, whereas the stress distribution with the reconstruction plate was nonphysiological in cantilever bending.ConclusionsTEN is generally preferable for treating simple displaced fractures of the midshaft clavicle, because it showed a stress distribution similar to the intact clavicle. However, TEN provides less stability, and excessive exercise of and weight bearing on the ipsilateral shoulder should be avoided in the early postoperative period. Fixation with a reconstruction plate was more stable but showed obvious stress shielding. Therefore, for patients with a demand for early return to activity, reconstruction plate fixation may be preferred.     

Skeletal Scintigraphy

Skeletal scintigraphy, using phosphates or diphosphonates labeled with technetium 99m, is a sensitive method of detecting bone abnormalities. The most important and most frequent role of bone scanning is evaluating the skeletal areas in patients who have a primary cancer, especially a malignant condition that has a tendency to spread to bone areas. The bone scan is superior to bone radiographs in diagnosing these abnormalities; 15 percent to 25 percent of patients with breast, prostate or lung cancer, who have normal roentgenograms, also have abnormal scintigrams due to metastases. The majority of bone metastases appear as hot spots on the scan and are easily recognized. The incidence of abnormal bone scans in patients with early stages (I and II) of breast cancer varies from 6 percent to 26 percent, but almost invariably those patients with scan abnormalities have a poor prognosis and should be considered for additional therapies. Progression or regression of bony lesions can be defined through scanning, and abnormal areas can be identified for biopsy. The incidence of metastases in solitary scan lesions in patients with known primary tumors varies from 20 percent to 64 percent. Bone scintigraphy shows positive uptake in 95 percent of cases with acute osteomyelitis. Stress fractures and trauma suspected in battered babies can be diagnosed by scanning before there is radiological evidence. The procedure is free from acute or long-term side effects and, except in cases of very young patients, sedation is seldom necessary.Although the test is sensitive, it is not specific and therefore it is difficult to overemphasize the importance of clinical, radiographic, biochemical and scanning correlation in each patient.     

Technical note: Virtual reconstruction of a fragmentary clavicle

We report a procedure for the virtual reconstruction of incomplete human bones applicable to skeletal remains from archaeological excavations or to reconstructive and prosthetic surgery. To test the procedure, we reconstructed a fragmented left clavicle on the basis of the contralateral clavicle. The procedure involved 3‐D laser scanner acquisition of the left clavicle (complete but broken into two parts), the same manually reconstructed bone, and the intact right clavicle, which was mirror‐imaged and used as a reference for the reconstruction of the whole left clavicle. Because it was not possible to recognize homologous anatomical landmarks, on the two reference models (a mirror‐image copy of the right clavicle and the main fragment of the left), we identified three grids with an increasing number of corresponding landmarks, which constituted the framework of the deformation process. The three reconstructed digital models of the clavicle closely approximated the model of the original clavicle. They also showed that an increasing number of landmarks did not significantly improve the reconstructed model. Am J Phys Anthropol 2009. © 2009 Wiley‐Liss, Inc.     

Pyogenic vertebral osteomyelitis: diagnosis and management.

Vertebral osteomyelitis represents a diagnostic challenge to the clinician. Two cases of pyogenic vertebral osteomyelitis occurring weeks to months after a urinary tract infection with Escherichia coli are described. The rarity and subtle clinical presentation of this condition, the presence of pre-existing degenerative arthritic changes, and delayed appearance of radiologic signs of progression to destructive osteomyelitis contributed to a significant delay in diagnosis. Increased awareness of vertebral osteomyelitis as a clinical entity combined with information from radionuclide scanning may permit earlier detection of this condition.     

Is the Clavicle of Apes Long? An Investigation of Clavicular Length in Relation to Body Mass and Upper Thoracic Width

An elongated clavicle is one of the distinct features of apes and humans. It plays an important role in providing mobility as well as stability for the shoulder joints. The relative length of the clavicle is an especially important factor in limiting the range of shoulder joint excursion. It is said that among primates, Asian apes, i.e., gibbons and orang-utans, have very long clavicles. At the same time, they also have a wide upper thoracic cage, which may diminish the effective length of the clavicle. To clarify the length of the clavicle in apes, from the standpoint of the functional anatomy of the shoulder girdle, we examined clavicular length in 15 anthropoid species exhibiting various positional behaviors. The results confirm that clavicle length in Asian apes is long, and chimpanzees have a short clavicle like that of Old and New World monkeys, when scaled to body mass. The clavicular length of chimpanzees, however, is intermediate between Old World monkeys and Asian apes when scaled against thoracic width. Therefore, living apes can be grouped together, albeit just barely, by possession of a relatively long clavicle for their thoracic cage size. Interestingly, New World monkeys tend to exhibit a longer clavicle than Old World monkeys of equivalent body mass or thoracic cage width. Although it is unclear whether the ancestral condition of clavicular length in anthropoids was similar to that of living Old or New World monkeys, an elongation of clavicle was an important step toward evolution of the modern body plan of hominoids.     

Étude analytique d’une clavicule complète de subadulte d’Homo antecessor (site de Gran Dolina, Sierra d’Atapuerca, Burgos, Espagne)

This study reports on the skeletal remains of an infant clavicle - specimen ATD6-37 - belonging to the Homo antecessor species, unearthed at Lower Pleistocene level TD6 of the Gran Dolina site (Sierra de Atapuerca). Studied alongside a further adult specimen - ATD6-50 -, they provide us with significant information on two key paleobiological aspects of these early humans: body shape and development. Based on the analytical results, the paper proposes a more accurate proportional method for determining age at death is applied to the fossilized infant clavicle under study. It goes on to hypothesize on postcranial growth and body shape and discusses morphological patterns and age at death of these early humans through comparisons with a wide range of infant dental samples and clavicular specimens in early and modern humans.     

Dilemma in Differentiating between Acute Osteomyelitis and Bone Infarction in Children with Sickle Cell Disease: The Role of Ultrasound

Background

Distinguishing between acute presentations of osteomyelitis (OM) and vaso-occlusive crisis (VOC) bone infarction in children with sickle cell disease (SCD) remains challenging for clinicians, particularly in culture-negative cases. We examined the combined role of ultrasound scan (USS), C - reactive protein and White blood counts (WCC) in aiding early diagnosis in children with SCD presenting acutely with non-specific symptoms such as bone pain, fever or swelling which are common in acute osteomyelitis or VOC.

Methods

We reviewed the records of all children with SCD who were discharged from our department from October 2003 to December 2010 with a diagnosis of osteomyelitis based on clinical features and the results of radiological and laboratory investigations. A case control group with VOC who were investigated for OM were identified over the same period.

Results

In the osteomyelitis group, USS finding of periosteal elevation and/or fluid collection was reported in 76% cases with the first scan (day 0–6). Overall 84% were diagnosed with USS (initial +repeat). 16% had negative USS. With VOC group, USS showed no evidence of fluid collection in 53/58 admissions (91%), none of the repeated USS showed any fluid collection. Mean C-reactive protein (CRP), and white cell count (WCC) were significantly higher in the OM.

Conclusion

The use of Ultrasound in combination with CRP and WCC is a reliable, cost-effective diagnostic tool for differentiating osteomyelitis from VOC bone infarction in SCD. A repeat ultrasound and/or magnetic resonance imaging (MRI) scan may be is necessary to confirm the diagnosis.     

Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder

Clinical theory suggests that altered alignment of the shoulder girdle has the potential to create or sustain symptomatic mechanical dysfunction in the cervical and thoracic spine. The alignment of the shoulder girdle is described by two clavicle rotations, i.e, elevation and retraction, and by three scapular rotations, i.e., upward rotation, internal rotation, and anterior tilt. Elevation and retraction have until now been assessed only in patients with neck pain. The aim of the study was to determine whether there is a pattern of altered alignment of the shoulder girdle and the cervical and thoracic spine in patients with neck pain. A three-dimensional device measured clavicle and scapular orientation, and cervical and thoracic alignment in patients with insidious onset neck pain (IONP) and whiplash-associated disorder (WAD). An asymptomatic control group was selected for baseline measurements. The symptomatic groups revealed a significantly reduced clavicle retraction and scapular upward rotation as well as decreased cranial angle. A difference was found between the symptomatic groups on the left side, whereas the WAD group revealed an increased scapular anterior tilt and the IONP group a decreased clavicle elevation. These changes may be an important mechanism for maintenance and recurrence or exacerbation of symptoms in patients with neck pain.     

Local osteogenic expression of cyclooxygenase-2 and systemic response in porcine models of osteomyelitis

It is suggested that cyclooxygenase 2 (COX-2) derived prostaglandins contributes to the progressive bone loss seen in osteomyelitis lesions. In the present study we examined the expression of COX-2 in bones from 23 pigs with experimental osteomyelitis. Osteomyelitis was induced with Staphylococcus aureus and groups of animals were euthanized following 6 h, 12 h, 24 h, 2 days, 5 days, 11 days and 15 days, respectively. Expression of COX-2 was evaluated immunohistochemically and combined with characterization of morphological changes in bone tissue. Furthermore, the serum concentrations of alkaline phosphatase and haptoglobin were measured. Extensive COX-2 expression by osteoblasts was present 2 days after inoculation together with many activated osteoclasts. Simultaneously, the serum concentration of alkaline phosphatase decreased whereas the haptoglobin concentration increased. This is the first in vivo study showing an early wave of COX-2 mediated bone resorption during osteomyelitis. Therefore, treatment aiming to reduce the break down of bone tissue directed by the COX-2 pathway might be suggested early in the course of the disease.     

L’ostéomyélite multifocale chronique récidivante: Un diagnostic à ne pas oublier chez l’enfant : à propos de deux cas

Chronic recurrent multifocal osteomyelitis is an inflammatory and aseptic disorder, which can affect any bone and be associated with dermatologic lesions. Thanks to better knowledge, this condition is now more often diagnosed. We present two cases, with and without dermatologic lesions. The whole-body bone scintigraphy allows early detection of lesions and bone biopsy is of great help for diagnosis because it rules out tumor or infection. Disease course can be chronic and recurrent. The treatment of choice is non steroidal anti-inflammatory drugs which can be combined or alternated with osteotropic hormones.     

Potential conversion of adult clavicle-derived chondrocytes into neural lineage cells in vitro

Neural stem cells (NSC) can be isolated from a variety of adult tissues and become a valuable cell source for the repair of peripheral and central nervous diseases. However, their origin and identity remain controversial because of possible de-differentiation/trans-differentiation or contaminations by hematopoietic stem cells (HSCs) or mesenchymal stem cells (MSCs). We hypothesize that the commonly used NSC culture medium can induce committed cartilage chondrocytes to de-differentiate and/or trans-differentiate into neural cell lineages. Using a biological isolation and purification method with explants culture, we here show that adult rat clavicle cartilage chondrocytes migrate out from tissue blocks, form sphere-like structures, possess the capability of self-renewal, express nestin and p75NTR, markers for neural crest progenitors, and differentiate into neurons, glia, and smooth muscle cells. Comparing with adult cartilage, the spherical-forming neural crest cell-like cells downregulate the chondrocytic marker genes, including collagen II, collagen X, and sox9, as well as neural-lineage repressors/silencers REST and coREST, but upregulate a set of well-defined genes related to neural crest cells and pro-neural potential. Nerve growth factor (NGF) and glial growth factor (GGF) increase glial and neuronal differentiation, respectively. These results suggest that chondrocytes derived from adult clavicle cartilage can become neural crest stem-like cells and acquire neuronal phenotypes in vitro. The possible de-differentiation/trans-differentiation mechanisms underlying the conversion were discussed.     

Aspects des complications ostéoarticulaires de la drépanocytose en scintigraphie osseuse planaire (infection exclue). À propos de trois observations

Skeletal complications of sickle-cell anemia are multiple and can appear on the acute (osseous infarction, acute osteomyelitis) or chronic mode (osteonecrosis, chronic osteomyelitis). The radio-labelled diphosphonates bone scintigraphy remains an important tool in the early diagnosis and in the follow-up of these complications and must form part of the initial assessment of the disease. Through clinical observations, the authors undertake to sum up the bone scintigraphy aspects of these complications.     

Use of technetium antigranulocyte monoclonal antibody Fab' fragments for the detection of osteomyelitis

Accurate early diagnosis of osteomyelitis is critical for optimal clinical management. Conventional radiology (X-rays, CT) and nuclear medicine scans (bone, gallium, and technetium/indium white blood cell [WBC]) have limitations and drawbacks. The monoclonal antibody (MAb) ImmuRAID^TM-MN3 (Immunomedics Inc., Morris Plains, NJ), a 99m-Tc Antigranulocyte Fab' fragment, recognizes a surface glycoprotein NCA-90/95 shared by granulocytes, carcino-embryonic antigen (CEA), and meconium antigen (MA). Intravenous injection of radiolabeled MAb enables in vivo labeling of human granulocytes and targets infected lesions in the bone and throughout the body. Technetium labeled Fab' fragments rapidly clear the blood pool and high-quality images can be obtained the same day, as early as 1 h postinjection. Results at our institution on 13 patients with clinically suspected osteomyelitis of infected long bones, prostheses, and diabetic foot ulcers were compared with the surgical/bacteriological verification of the presence or absence of infection. The MAb scan showed six true positives, six true negatives, and one false negative (very low grade infection). The procedure was safe, no clinical or laboratory adverse reactions were encountered. The MAb fragments are markedly less immunogenic than whole IgG, resulting in lower induction of human antimouse antibody (HAMA) titers. No HAMA to this MAb fragment has been detected in 24 patients (data from multiple institutions). Our preliminary results suggest that 99m-Tc ImmuRAID^TM-MN3 is highly accurate for detection of osteomyelitis. This study is part of an on-going multiinstitutional project sponsored by Immunomedics, Inc. to evaluate the efficacy and safety of this radiopharmaceutical.     

Distinct cytokine profiles of circulating mononuclear cells stimulated with Staphylococcus aureus enterotoxin A in vitro during early and late episodes of chronic osteomyelitis

We investigated the cytokine profile of peripheral mononuclear cells from chronic osteomyelitis (OST) patients following in vitro stimulation with staphylococcal enterotoxin A (SEA). We demonstrate that stimulation with SEA induced prominent lymphocyte proliferation and high levels of tumour necrosis factor (TNF)-α, interleukin (IL)-4 and IL-10 secretion in both OST and non-infected individuals (NI). Even though stimulation with SEA had no impact on IL-6 production in either patient group, the baseline level of IL-6 production by cells from OST patients was always significantly less than that produced by cells from NI. After classifying the osteomyelitic episodes based on the time after the last reactivation event as "early" (1-4 months) or "late" osteomyelitis (5-12 months), we found that increased levels of TNF-α and IL-4 in combination with decreased levels of IL-6 were observed in the early episodes. By contrast, increased levels of IL-10, IL-2 and IL-6 were hallmarks of late episodes. Our data demonstrate that early osteomyelitic episodes are accompanied by an increased frequency of "high producers" of TNF-α and IL-4, whereas late events are characterised by increased frequencies of "high producers" of IL-10, IL-6 and IL-2. These findings demonstrate the distinct cytokine profiles in chronic osteomyelitis, with a distinct regulation of IL-6 production during early and late episodes.     

Osteomyelitis in children: comparison of hematogenous and secondary osteomyelitis.

Summary: A review of osteomyelitis in 54 patients treated at the Dr. Charles A. Janeway Child Health Centre over a 4-year period revealed equal frequencies of secondary and hematogenous osteomyelitis. Although the clinical picture in patients with hematogenous osteomyelitis was classic, patients with secondary osteomyelitis presented with an altered clinical response. Patients with secondary osteomyelitis have a history of an antecedent puncture wound or an inadequately treated contiguous focus of infection; antistaphylococcal antimicrobial therapy was ineffective for most because gram-negative bacilli were isolated in this group of patients. In contrast to patients with hematogenous osteomyelitis, who frequently respond to intensive antimicrobial therapy, those with secondary osteomyelitis will frequently require surgical intervention to eradicate the infection.     

Enriched collagen as coadjuvant therapeutic agent in experimental osteomyelitis in dogs

Osteomyelitis was induced in the tibiae of dogs by injecting hemolytic strain of Staphylococcus aureus. Clinical, radiological and histomorphological reactions in the diseased tibiae were studied up to 15 weeks to evaluate the response of infected bone to parenteral oxytetracycline in cases of closed wounds and surgical curettage, antimicrobial irrigation along with parenteral oxytetracycline therapy in animals carrying open wounds. Enriched collagen as a constituent of therapeutic regimen was also administered locally and its efficacy during resolution of osteomyelitis was compared with other treatments. Surgical curettage along with irrigation of lesions was observed to be an effective method for bringing an early recovery in aggravated cases of osteomyelitis. The addition of collagen enhanced the healing process in comparison with non-collagen treated animals.