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Tumors and tumor-like conditions of the spine in children.

Tumors and tumor-like conditions of the spine, although rare, should be included in the differential diagnosis of infants and children with back pain. Skeletal pathology is more frequently the cause of back pain in children than in adults. Although most tumors and tumor-like conditions of the spine in children are benign, many require surgery. Children with malignant tumors of the spine (with the exception of leukemia and lymphoma) may require multimodality therapy, including surgery, to achieve long-term cure. Advances in imaging, surgical technique, surgical technology, and adjuvant therapy have led to improvements in diagnosis and treatment and, thus, outcomes. In many cases, however, early and accurate diagnosis is often possible based on only clinical history, physical examination, and plain radiographic imaging.

Does time to surgery matter for type 2 supracondylar humerus fractures?

By Mary Ann Porucznik

Study finds no increase in complications for pediatric patients

A broken elbow—specifically a supracondylar humerus fracture—is a common pediatric injury. Gartland type II supracondylar humerus fractures are displaced fractures with the posterior cortex intact (Fig. 1). Based on an analysis of nearly 400 of these fractures treated at a level 1 pediatric trauma center, children treated with closed reduction and percutaneous pinning did not experience any increase in complications, even if surgical treatment was delayed more than 5 days after the injury (typically due to delayed presentation).

Revision ACL Reconstruction

The definition of an anterior cruciate ligament (ACL) failure is symptomatic instability, pain, extensor dysfunction, and arthrofibrosis following a surgical reconstruction. Although this is an oversimplification, and despite many ACL failures falling into one of these categories, there is still no universally accepted definition of unsatisfactory outcome following ACL reconstruction.

This article provides a working definition of revision ACL reconstruction and reviews the pathophysiology, incidence, and clinical presentation for patients who may be considered for a revision procedure. Indications, contradications and treatment options, including graft considerations, bone tunnels, femoral tunnels, and tibial tunnels are reviewed. An indepth presentation of the revision ACL reconstruction procedure is shown. Video is available. CME Credit will be available soon.

Primary and Metastatic Tumors of the Spine

Spine tumors can be broadly categorized as either primary spine tumors, which originate in the spinal elements, or metastatic tumors, which originate elsewhere in the body. As with all tumors, spine tumors can also be classified as malignant or benign. Spine tumors are relatively rare, and the related signs and symptoms are similar to those of degenerative spinal disorders. A comprehensive history and physical examination is essential to prevent a delay in diagnosis, which can have a significant effect on prognosis. Additionally, judicious use of imaging modalities and awareness of available nonsurgical treatments are necessary to achieve the best outcomes.

Aneurysmal Bone Cyst

Aneurysmal bone cyst (ABC) is a benign but locally aggressive bone tumor that most frequently involves the long bones of the extremities, pelvis, and the posterior elements of the spine. ABCs comprise 1% to 6% of all primary bone tumors and have an overall prevalence of 0.32 per 100,000 individuals. There is an equal prevalence among genders, and the median age at presentation is 11.1 years. The true etiology and natural history of ABCs are not well understood, but there is consensus that thorough intralesional curettage and removal of the entire tumor must be performed to minimize the risk of local recurrence. Other treatment options include en bloc excision, selective arterial embolization, external beam radiation therapy, and curettage with locally applied adjuvant therapy, such as argon beam coagulation, liquid nitrogen, phenol, or hydrogen peroxide.

Malignant Bone Tumors in Children

Osteosarcoma is the most commonly isolated malignant bone tumor in children, followed by Ewing's sarcoma and lymphoma. Classic osteosarcoma is the most common subtype of osteosarcoma. Lesions usually occur in the metaphyses of long bones, most frequently in the distal femur, proximal tibia, proximal humerus, and proximal femur, in that order. Treatment for osteosarcoma includes preoperative chemotherapy, wide surgical resection, and postoperative chemotherapy. Lymphoma of bone is a rare malignant tumor that originates from lymphoblastic tissue. Primary lymphomas are most common in the metaphyses of the major long and flat bones. Chemotherapy is the primary treatment modality. Radiation therapy is sometimes used, particularly when there is inadequate response to chemotherapy. Ewing's sarcoma is a highly malignant neoplasm that affects the long bones of the skeleton (femur, tibia, and humerus), as well as the spine, pelvis, and ribs. Standard treatment for Ewing's sarcoma is chemotherapy. Following a satisfactory response to chemotherapy, patients are evaluated to determine whether surgery, radiation therapy, or both are the best modalities to control the disease.

Giant Cell Tumor of Bone

Giant cell tumor (GCT) of bone is a relatively rare tumor characterized by the presence of multinucleated giant cells. Although usually regarded as benign, GCT of bone is locally aggressive and prone to local recurrence if inadequately treated. Metastasis to the lung and malignant transformation can also occur. GCT of bone has a distinctive histologic and radiographic appearance, and its diagnosis is usually not difficult; however, because histologic interpretation is not always reliable, diagnosis should be the end result of the integration of clinical, radiographic, and histologic information. Recommended treatment options for GCT of bone include thorough curettage and high-speed burring of the lesion followed by an adjuvant therapy, such as phenol, liquid nitrogen, or argon-beam coagulation. The recurrence rate of GCT of bone ranges from 3% to 25%, depending on which treatment option is employed; therefore, long-term follow-up of patients is necessary.