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BACKGROUND Deformity and growth arrest of the humerus in children may result as sequelae of proximal humerus fractures and unicameral bone cysts, or as complications of their treatment. As approximately 80% of the growth of the humerus arises from the proximal physis, the resultant upper limb-length discrepancy can be substantial. Benefits to lengthening the shortened arm have been previously demonstrated with the use of external fixation devices. To our knowledge, no reports have been published on the use of intramedullary implants for this purpose. METHODS A 15-year-old girl with humeral shortening secondary to proximal humeral growth disturbance following treatment for a unicameral bone cyst was treated with humeral osteoplasty and gradual lengthening with an off-label use of a fully implantable motorized intramedullary lengthening nail. A varus proximal humeral deformity and lateral starting point allowed for avoidance of the rotator cuff insertion. RESULTS Humeral lengthening (5 cm) was achieved at 9 weeks, with bony union at 7 months, and hardware removal at 9½ months. Shoulder and elbow motion was maintained during and after treatment. CONCLUSIONS This is the first case report of humeral lengthening using a fully implantable motorized intramedullary lengthening nail. Although some technical limitations remain when compared with other methods, the procedure was well tolerated throughout the course of treatment. LEVEL OF EVIDENCE Level IV-case report.

Bone tumors are rare in children. Most bone tumors tend to involve the areas of fastest growth. Lower extremity tumors are more common than upper extremity ones, however upper extremity bone tumors do occur and can have a negative impact in the child's activities. Luckily, most bone tumors seen in children are benign and can be effectively treated by means of observation or local control by surgery. In this article we review and discuss the diagnosis and management of the most common pediatric benign bone tumors seen in the upper extremities including unicameral bone cyst, aneurysmal bone cyst, fibrous cortical defect, non-ossifying fibroma, osteochondroma, osteoid osteoma and enchondroma.

BACKGROUND Unicameral bone cyst (UBC) is a benign bone lesion, recognized for its high rate of recurrence and need for repeat procedures to achieve healing. We hypothesized that the osteoconductive material apatitic calcium phosphate (alpha-BSM) could be effective in filling and stimulating resolution of UBC. The purpose of this study was to evaluate clinical and radiographic outcomes of UBC treated by a single injection of alpha-BSM. METHODS Thirteen patients (6 male, 7 female) with a mean age of 10.5 years, underwent single percutaneous injection of alpha-BSM for presumed UBC. The aspiration of the cysts was followed by vigorous saline lavage using 2 wide bore needles to disrupt the cyst walls. alpha-BSM "paste" was then injected under fluoroscopic guidance. Radiographs were digitized to measure cystic area (millimeter squares) on 2 orthogonal views. Healing was rated according to a modified Neer outcome grading system. Nine of the 13 patients had had pathologic fractures in the past. Eleven of the 13 patients had had past unsuccessful treatment: multiple steroid injections in 6, curettage and bone grafting in 3, and bone marrow and demineralized bone matrix (Grafton) injection in 2. RESULTS Five cysts were grade 1 (healed 100%), 6 grade 2 (healed >50%), 2 grade 3 (healed

Several treatment options exist for unicameral bone cysts (UBCs), including observation, steroid injection, bone marrow injection, and curettage and bone grafting. These are all associated with high recurrence rates, persistence, and occasional complications. Newer techniques have been described, most with variable success and only short follow-up reported. Because of these factors, a new minimally invasive percutaneous technique was developed for the treatment of UBCs in children. Twenty-eight children with UBCs who underwent percutaneous intramedullary decompression, curettage, and grafting with medical-grade calcium sulfate (MGCS) pellets by the senior author (J.P.D.) between April 2000 and April 2003 were analyzed as part of a pediatric musculoskeletal tumor registry at a large tertiary children's hospital. Four patients were lost to follow-up, and the remaining 24 patients had an average follow-up of 21.9 months (range 4-48 months). Twelve patients were followed for at least 24 months. Six of the 24 children had received previous treatment of their UBC, most often at an outside institution. Follow-up was performed through clinical evaluation and radiographic review. Postoperative radiographs at most recent follow-up showed complete healing, defined as more than 95% opacification, in 22 of 24 patients (91.7%). One patient (4.2%) demonstrated partial healing, defined as 80% to 95% opacification. One patient had less than 80% radiographic healing (4.2%). All 24 patients returned to full activities and were asymptomatic at most recent follow-up. The only complication noted was a superficial suture abscess that occurred in one patient; this resolved with local treatment measures. The new minimally invasive technique of percutaneous intramedullary decompression, curettage, and grafting with MGCS pellets demonstrates favorable results with low complication and recurrence rates compared with conventional techniques. The role of intramedullary decompression as a part of this percutaneous technique is discussed.

The calcaneus is an uncommon site for a unicameral bone cyst. However, because of the concentration of forces through the heel, such cysts are usually symptomatic and require treatment. Because of the lack of attention paid to calcaneal unicameral bone cysts, as well as the controversy concerning their appropriate treatment and ultimate outcome, a retrospective study of our experience was undertaken. Over a 15-year period, we treated six children with calcaneal unicameral bone cysts. The diagnosis was confirmed pathologically at the time of treatment for all six. The most common presenting complaint was heel pain upon weight-bearing, secondary to microfracturing of the cyst. Although conservative treatment, which entailed casting and sponge fillers in the shoes, was attempted for most patients, none responded to this form of management. One child had three separate injections of methylprednisolone acetate without any radiographic or clinical change in the cyst, which ultimately required curettage and bone grafting. Bone grafting with either autogenous or allograft bone was successful in eradicating the cyst in all six patients, with no symptoms of recurrence at an average follow-up of 4 years. No resultant treatment complications were encountered. Unicameral bone cysts of the calcaneus, when symptomatic, respond well to curettage and bone grafting, and this type of treatment is recommended.

Summary An 8-year-old boy sustained a fracture of the distal fibula. The fracture resulted from Ewing's sarcoma infiltrating a unicameral bone cyst. Ewing's sarcoma has not previously been described in association with a unicameral bone cyst.

Extremely favorable results are obtained with the use of microcrystals of methylprednisolone acetate for treatment of bone cysts. These results have led to a complete suspension of surgical treatment of bone cysts since 1974. On the basis of these results with corticosteroids, a surgical procedure that involves an incision at the fracture location and bone graft inserted is not indicated. Results following surgery indicate a recurrence rate of approximately 25% to 30%. Since we are as yet unable to explain the mechanism by which the local injection of MPA promotes bone replacement of the cyst, the present observations only reaffirm the hypothesis (presented in our early publications) that the corticosteroid exerts a destructive action on the pathological tissue of the lesion, thus favoring a progressive process of repair. We consider this explanation valid even for lesions, e.g., eosinophilic granulomas and nonossifying fibromas, in which this method of treatment has had varying degrees of success.