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Background Intra-articular distension is a validated treatment in adhesive capsulitis of the shoulder and is commonly followed by intensive in-patient physical therapy. A recent meta-analysis found that physical therapy is as effective as intra-articular distension (IAD) and that an early distension could be the primary choice for treating frozen shoulder. The question of the additional contribution of physical therapy prior to IAD compared with IAD followed by physical therapy has not been raised. Objectives We compared IAD preceded by physical therapy to that followed by physical therapy in terms of pain relief and functional outcome. Methods We enrolled patients with primitive adhesive capsulitis of the shoulder. The eligible patients were randomized into three groups: A, B and C. Group A received intra-articular distension followed by physical therapy, group B received intra-articular distension in the middle of physical therapy and group C received physical therapy alone. Patients were assessed at the beginning of the protocol (T0), after 6 weeks (T1) and after 12 weeks (T2). The main outcome measures were pain using a Visual Analog Scale and the Disabilities of Arm, Shoulder and Hand Questionnaire. Results Out of the 179 enrolled patients, only 122 completed the follow up: group A (n= 34), group B (n= 46) and group C (n= 42). Compared to intra-articular distension preceded by physical therapy, IAD followed by physical therapy did not improve significantly the outcome in terms of pain relief (p= 0.123) but it enhanced the upper extremity function (p= 0.002). Upper extremity pain and function were found to improve with time regardless of the protocol (p Conclusions IAD followed by physical therapy is more beneficial than IAD preceded by physical therapy in terms of upper extremity function. IAD, whether or not preceded by physical therapy, does not significantly improve pain compared to physical therapy alone. Time is a crucial factor to take into consideration while treating adhesive capsulitis of the shoulder.

Neurenteric cysts are the association of an endodermal cyst with a vertebral dysplasia. This congenital malformation can be asymptomatic or manifest itself through respiratory signs due to airway c...

L'osteogenese imparfaite (OI) est un groupe heterogene de maladies affectant le collagene de type I et caracterisees par une fragilite osseuse. Les formes letales sont rares et se caracterisent par une micromelie avec deformation des membres. Un diagnostic antenatal d'OI letale a ete fait dans deux cas, par echographie a 17 et a 25 semaines d'amenorrhee, complelees par un scanner du squelette fœtal dans un cas. Une interruption therapeutique de grossesse a ete indiquee dans les deux cas.

Extralobar pulmonary sequestrations (ELS) are masses of non-functioning lung tissue that are supplied by an anomalous systemic artery and do not have a bronchial connection to the native tracheobronchial tree. On prenatal ultrasonography, an ELS appears as a well-defined echodense, homogeneous mass. Detection by color flow Doppler ultrasonography of a systemic artery from the aorta to the fetal lung lesion is a pathognomonic feature of fetal ELS. MR imaging may help in the diagnosis of pulmonary sequestration by demonstrating a solid, well-defined mass, and the feeding artery. In this case report, we describe the sonographic and MR diagnosis of an ELS in a fetus at 22 weeks gestation with a review of the available literature.Key words: Extralobar pulmonary sequestration, antenatal diagnosis, ultrasonography, MRI

Complete tubular colonic duplication (CTCD) is exceedingly rare. The association of CTCD with an anorectal malformation is unusual. This malformation may be found unexpectedly at laparotomy. We present 3 cases of surgically proven neonate CTCD discovered at laparotomy for anal atresia. We reviewed the mode of clinical presentation, the imaging, and laparotomy findings. Our series illustrates that this rare disease presents perinatally in association with anal atresia, with or without other associated anomalies.

Total extrusion of the talus is an unusual injury, and the obvious risks of reimplantation of the extruded bone include infection and avascular necrosis. In this article, the authors present the case of a 34-year-old man who sustained an open ankle injury with complete extrusion of the talus. The talus was recovered at the scene of the accident, and subsequently reimplanted along with ankle stabilization with pins and an external fixator. At 6 weeks following the osseous surgery, final soft tissue reconstruction with a suralis flap was performed. At 3 years after the injury, radiographs revealed spontaneous fusion of the tibiotalar and subtalar joints, and the clinical examination and history indicated satisfactory weight-bearing function of the involved foot and ankle. The definitive treatment of this serious lower extremity injury remains controversial, and the use of large allogeneic bone grafts, vascularized bone grafts, and tibiocalcaneal fusion, as well as reimplantation of the extruded talus have been recommended.

Anterior abdominal wall defects (AAWD) correspond to a wide spectrum of congenital defects affecting 6.3/10,000 pregnancies. They have in common a closure defect of the anterior abdominal wall and can be fatal or expose the fetus and the neonate (NN) to many complications. This study was based on a retrospective study of 22 cases of AAWD collected between May 2009 and December 2014. Its purpose was to specify the importance of prenatal ultrasonography in the diagnosis and prognosis assessment of these defects. These 22 AAWDs consisted in 13 cases of omphalocele (including four cases of Beckwith-Wiedemann syndrome), four of gastroschisis, one of pentalogy of Cantrell, three of vesical exstrophy and one of cloacal exstrophy. Prenatal ultrasonography provided the diagnosis of 14 of these defects with a changing sensitivity with the gestational age varying from 17% in the first trimester to 71.4% and 77.8% in the second and third trimesters, respectively. The relevance of this examination was improved when performed by an imaging specialist. The prenatal diagnosis of these defects indicated an amniocentesis in eight cases, allowing the diagnosis of two cases of trisomy 18. It also motivated a therapeutic termination of the pregnancy (TTP) in ten cases. Prenatal ultrasonography allowed better prenatal follow-up and planning of the delivery of the continued pregnancies. It indicated an emergency C-section in only one case by showing intestinal complications of gastroschisis. Four NNs died (two cases of omphalocele and two of gastroschisis), three of which postoperatively and the prenatal diagnosis did not improve survival. Prenatal ultrasonographic diagnosis provided a precise morphological study determining the type of the AAWD, a complete malformation assessment, and the prognosis factors. This resulted in adequate multidisciplinary pre and postnatal care, including a rigorous ultrasound follow-up, a TTP in case of associated defects, and emergency delivery once the complications of poor diagnosis are detected.

Le syndrome de Morel-Lavallée correspond à un épanchement sérolymphatique secondaire à un traumatisme tangentiel en regard d'un tissu richement vascularisé. Les aspects morphologiques sont variables en fonction de la durée d'évolution et de l'organisation éventuelle d'une capsule fibreuse. Le traitement conservateur associe bandage compressif et ponctions-aspirations. Le traitement chirurgical doit être envisagé dans les formes résistantes. Nous rapportons l'observation d'un homme âgé de 22 ans, sans antécédents pathologiques, qui avait présenté, à la suite d'un accident de la voie publique; motocycliste heurté par une voiture où il a été trainé par terre, plusieurs plaies au niveau de l'hémi-abdomen gauche qui avaient été suturées. Le scanner abdominal a montré un foyer de lacération splénique avec intégrité du pédicule, et un hémopéritoine de faible abondance. Devant la stabilité hémodynamique on a opté pour un traitement non opératoire qui a été un succès. Trois semaines après, le patient présentait une douleur lombaire gauche. Il avait une plaie fibrineuse en regard d'un édème douloureux lombaire gauche. La palpation trouvait une masse fluctuante sous la plaie. Il y avait un syndrome inflammatoire biologique. L'échographie des parties molles identifiait une collection liquidienne anéchogène homogène extra-aponévrotique lombaire gauche. Le diagnostic d'épanchement post-traumatique de Morel-Lavallée a été retenu. Il a été réalisé à deux reprises à dix jours d'intervalle, une ponction évacuatrice de la collection ramenant respectivement 120 cc et 70 cc de liquide séro-hématique, un pansement compressif puis une contention. Les suites étaient favorables avec amélioration de la symptomatolgie et dispariton de la collection lombaire.

Renal hydatid disease is rare in children. Open surgery is the traditional method of treatment, but minimally invasive techniques are being increasingly used. Herein, we report our experience with laparoscopic management of renal hydatid cyst in four children via a transperitoneal approach in three cases and a retroperitoneoscopy in one. We conclude that transperitoneal laparoscopy can be offered for the management of hydatid renal cyst associated with other intraperitoneal localizations, whereas the retroperitoneoscopy is limited for the treatment of isolated hydatid renal cysts.

Pyloric atresia (PA) is uncommon. It occurs in 1:100000 live births. Neonates usually present soon after birth with copious non-bilious vomiting. The treatment is surgical and its prognosis is poor, especially, when it is associated with epidermolysis bullosa (EB). The aim of this study was to evaluate the clinical presentation, diagnosis, operative management, post-operative courses, and outcome in infant with PA, based in our cases and literature review. Charts of 10 patients who underwent surgery for PA in the department of paediatric surgery in a Teaching Hospital in Tunisia (Monastir) between 1990 and 2012 were reviewed. Data were analysed for demographic, clinical, therapeutic, and prognostic characteristics. The average of age at presentation was 2 days and there were six males and four females. The main presenting symptoms were non-bilious vomiting in 90% of cases. Abdominal X-ray showed gastric dilatation with an absence of gas in the rest of the intestinal tract in 90%, and a pneumoperitoneum in one. The surgical approach was laparotomy in all cases. Gastric perforation was observed in one patient and was completely repaired. The distribution of the anatomic variations was type A in nine cases and type B in one. Five patients underwent excision of the diaphragm and Heineke-Mikulicz pyloroplasty and gastroduodenostomy in the other five cases. Identifi ed associated anomalies were Down’s syndrome in one and EB in 2 (20%), one family has three affected sibling. Post-operative mortality rate was 70%. No standard surgical approach can be adopted a better management of PA or the associated anomalies depends on an early diagnosis and the availability of neonatal intensive care unit.Key words: Epidermolysis bullosa, pyloric atresia, surgery

Pyogenic sacroiliitis is a rare entity in children. Diagnosis is often delayed because of its variable clinical presentation, low suspicion by the examining physician, and rare findings on radiographs. Delayed diagnosis, however, results in complications such as iliopsoas abscess. We report the case of a 12-year-old girl hospitalized with a 21-day history of fever, pain in the left iliac fossa, and flexion contracture of the hip. On examination, she had fever (38.9 degrees C), psoitis, localized tenderness at the left sacroiliac joint, and pain elicited by lateral compression of the pelvis. The abdominal examination was normal. The erythrocyte sedimentation rate was 130 mm in the first hour, C-reactive protein was 186 mg/l, and the white blood cell count was 18,400/mm(3), with 79% neutrophils. Urinalysis was normal. Blood cultures were negative. Radiographs of the pelvis showed irregular left sacroiliac borders. The CT scan provided the diagnosis of sacroiliitis complicated by an ilioapsoas abcsess. Treatment was based on antibiotic therapy associated with surgical drainage. Bacteriologic investigation revealed Staphylococcus aureus. The patient's temperature returned to normal on the second day. Antibiotics were continued for 3 months, leading to full recovery.

Lipoblastoma is a rare, benign, fatty tissue tumor that occurs in childhood. The location of this tumor in the mediastinum and extension to the chest wall is uncommon. We describe a 12-month-old male infant with a mediastinal lipoblastoma discovered because of a chest wall swelling. Computed tomography showed the deep component and fatty content of the lesion suggestive of the diagnosis. Total excision of the mass was carried out. The histologic examination of the lesion confirmed the diagnosis of lipoblastoma. Mediastinal lipoblastoma should be considered among the possible diagnoses of a fatty mediastinal tumor in childhood.

We report an unusual case of a type I Monteggia equivalent lesion in a 6-year-old girl consisting of fracture of the ulnar diaphysis and fracture of the neck of the radius without dislocation of the radial head. Manual reduction and immobilization in a plaster cast were performed. At 10 years of follow-up, the patient had regained full flexion and extension of the elbow, and nearly full pronation and supination. In the literature, this lesion has been reported only in two paediatric patients indicating that this is an extremely rare trauma.

SummaryOsteomyelites, bone infections of a hematogenous origin, are rare in the pelvis (2.3%) and are extremely rare in the ischium. Ischiatic osteomyelitis is usually found in children and adolescents, but has rarely been described in adults. The clinical presentation varies and the diagnosis is based on magnetic resonance imaging (MRI). The most frequently isolated germ is the staphylococcus, while Escherichia coli has been found in a few cases. We report a case of osteomyelitis from E. coli in a 46-year-old woman revealed by persistent fever. The point of entry was a septicemia from gastrointestinal origin, related to colon polyps. The clinical picture was also complicated by an antiphospholipid antibody syndrome (superior mesenteric vein and splenomesenteric branch thrombosis). The course was favorable thanks to appropriate antibiotic treatment and surgical debridment of the infection.

Acute osteomyelitis of the clavicle accounts for less than 3% of osteomyelitis cases, with its usual location in the middle third. It may be hematogenous, due to contiguity, or secondary to catheterization of the subclavian vein or neck surgery. The diagnosis is often delayed, and clinical symptoms may simulate obstetric brachial plexus palsy in young children. We report a new case of osteomyelitis of the clavicle in a 30-day-old newborn.

Human cystic echinococcosis (CE) is a worldwide parasitic infection in which the larval cysts of Echinococcus granulosus develop in some tissue or organ, very often in the liver and/or the lungs. On very rare occasions, a cyst may be found inside the pulmonary artery, the result of the rupture of an intracardiac cyst or, more rarely, dissemination from a hepatic infection (Bulman et al., 2007). Most cysts in the pulmonary artery have only been detected at autopsy (Gilsanz et al., 1977). Surgery is usually the therapeutic approach of choice. Two Tunisian patients with Echinococcus-attributable pulmonary embolism, as a rare complication after the surgical removal of a hepatic cyst (Case 1) or a cardiac cyst (Case 2) are described below. In both cases, who presented at the Fattouma Bourguiba University Hospital in Monastir, diagnosis was based on medical history and imaging features and chemotherapy led to a good outcome.

Summary Introduction Nasal meningocele, which is usually congenital, is a rare anomaly resulting from meningeal herniation into the nasal cavities through a bone defect in the skull base. Case report An 8-day-old boy was referred with respiratory disturbance and nasal obstruction. Examination showed a cyst-like grayish swelling filling the right nasal cavity. CT scan showed opacity, of fluid-like density, filling the right nasal fossa, in contact with a small bony defect in the right cribriform plate. MRI ruled out herniated brain parenchyma and enabled diagnosis of meningocele. The patient was operated on at the age of 2 months through a transnasal endoscopic approach. Immediate postoperative course was favorable. MRI control at 8 months was normal. Discussion Modern imaging (CT scan and MRI) is of paramount importance in the preoperative evaluation of nasal meningocele. Endoscopic endonasal (EE) surgery is currently the treatment of choice. Conclusion Steady progress in instrumentation, technique and skills will increase the feasibility of skull-base surgery using an endonasal approach in the pediatric population.

Diabetic mastopathy is a recently described pathological entity. Little is known about this benign condition. It usually occurs in young patients with type 1 diabetes, or having an autoimmune disorders. Clinically, this mastopathy simulates a breast cancer. Graphic tests are not very informative. The diagnosis is histological. Through a case of diabetic mastopathy occurring in a patient with diabetes on insulin for 16 years and carries multiple degenerative complications, we recall the clinical, radiological and outcome of this disease.

Li Fraumeni Syndrome (LFS) is a rare autosomal disorder characterized by a familial clustering of tumors. Analysis of several series of LFS families have shown that 70% of such families are attributable to germ-line mutations in TP53. We report the case of a patient who had a first degree family antecedent of cancer in young ages. At the age of 31 years, the patient was operated of bladder papillary superficial carcinoma; five years later, he was treated for a high grade pleomorphe sarcoma of the left thigh and treated by surgery, adjuvant chemotherapy and radiotherapy. At the age of 38 years, after abdominal pain, radiologic examination reveled pancreatic tumor with bone and lymphatic metastases. The patient died one month later from pulmonary embolism. Sequencing revealed a germiline mutation of this patient that was confirmed in a member of his family in codon 1009CT, protein Arg337Cys, exon 10 of TP53 gene this mutation was revealed in his nephew (died at the age of 20 from bone sarcoma).

Intercondylar fracture of the distal humerus in youth is an extremely rare injury. Three cases have been reported in the literature to date. We describe two cases, aged 15 and 14 years, both of whom were boys. The stability in this injury allowed non-operative treatment and a favorable outcome.

Traumatic hip dislocation is rare in children. The purpose of this study was to investigate the epidemiological features, dislocation types, treatments, and clinical and radiological outcomes. Seven cases of traumatic hip dislocation in children treated between 1996 and 2006 were included in this study. There were six boys and one girl with a mean age of 6.5 years. Six children had a low-energy injury. One child had a road traffic accident. All had a posterior dislocation of the hip without any associated fracture. All children underwent closed reduction of their dislocation. The mean time interval between dislocation and reduction was 4 hours and 50 minutes. Following reduction, they were immobilised for six weeks: skin traction was applied for 3 weeks, followed in six children by a hip spica cast and in one child by non weight bearing mobilization. The mean follow-up was 6.7 years. After clinical examination the hip was classified as normal in 6 children. One child had a stiff hip and a radiograph showed signs of avascular necrosis. The severity of injury was related to the age at the time of injury. Factors predisposing to avascular necrosis were delayed reduction and severity of trauma.

The authors report a case of shoulder bilateral posterior fracture dislocation in a 42-year-old man with osteogenesis imperfecta history. The importance of the communition, the large size of articular surface involved and the poor quality of the bone indicate a bilateral total shoulder arthroplasty. At midterm outcome, a good range of motion of both shoulders was registered.

This article describes a case of a 11-year-old boy with an osteochondroma of the peroneal head causing peroneal nerve palsy. Physical examination disclosed large exostoses palpated at the right fibular head. Neurological examination revealed paresis of the tibialis anterior, lateral peroneal, and extensor digitorum muscles with a muscle strength grade of 2. Electrophysiological studies confirmed denervation of the muscles supplied by the right peroneal nerve. Radiological examination showed an osteochondroma in the head of the right fibula. The patient underwent surgical decompression of the right peroneal nerve after resection of the bone tumor. At 36-month follow-up, there was a complete recovery of the deficits. Peroneal mononeuropathy in children is uncommon. Osteochondroma is a benign tumor consisting of projecting bone capped by cartilage. These tumors may be solitary or multiple and occur in hereditary multiple exostoses syndrome. The conjunction of this lesion with peroneal nerve palsy has been exceptionally reported for children, usually linked to hereditary multiple exostoses syndrome. Most peroneal nerve trauma occurs at the fibular head, where the common nerve has not yet divided into its deep and superficial peroneal nerve and where most peroneal nerve lesions, therefore, involve both branches, although motor deficits are more frequently involved than sensory ones. Surgical treatment should not be delayed because neurological improvement may be achieved if surgery is performed before severe neurological deficits become irreversible.

Congenital infantile fibrosarcoma is a rare soft tissue neoplasm in the infant of which only a few cases are reported as congenital. This tumor has a rapid growth and extensive local invasion, but metastasis rarely occurs. Distal extremities involvement is more common and metastasis are rare. We report a case of a congenital infantile fibrosarcoma of the forearm, which was initially confused with a hemangioma, treated successfully by surgical resection.

SummaryWe report the case of a left superior pubic ramus osteochondroma occurring in a 29-year-old man. The patient consulted for a multiple exostoses disease revealed by a painful induration at the base of his penis. This induration was increasing in volume and causing discomfort during sexual intercourse and when sitting for a prolonged period of time. CT-scan examination showed a pedunculated osteochondroma of the left superior pubic ramus compressing the urethra. Surgical resection of the tumor confirmed the diagnosis of osteochondroma. At a 2-year follow-up delay, all symptoms had regressed with no evidence of recurrence.Level IV: Case report.

Palmar dislocation of the metacarpophalangeal joint of the long finger is a rare injury. The authors report a case of palmar dislocation of the metacarpophalangeal joint of the ring finger. The presumed mechanism is a combination of active flexion and forceful hyperextension. The dislocation was treated successfully by closed reduction shortly after injury. Closed reduction should be attempted in all cases of this injury.

We present the case of a patient with a fracture-dislocation of the fifth metacarpal and a dislocation of the metacarpophalangeal joint (floating fifth metacarpal) combined with a fracture of the fourth metacarpal. The mechanism of injury and management of this uncommon injury is reported. The "floating fifth metacarpal" and the fourth metacarpal fracture were reduced by closed techniques with percutaneous fixation. Twelve months later, the patient had a full range of wrist and finger movement, he was pain-free and without any residual disability.

Trochanteric fractures are a major source of mortality, morbidity and functional impairment in the elderly. Morbidity is closely related to the degree of instability and comminution and is substantially influenced by the quality of reduction and internal fixation. Advanced age and associated co-morbidities are two decisive factors of mortality secondary to trochanteric fracture.This prospective study examined the epidemiological profile of trochanteric fractures and assessed mortality and morbidity with the aim of establishing management guidelines and improving prevention strategies.One hundred patients were included; 60% were male. Mean age was 76 years (range, 60-96 yrs). One, or more than one, co-morbidities were present in 68% of cases. The fractures were caused by a simple fall in 90% of cases. Fractures were classified according to the criteria of Ramadier and the ones of Ender. Sixty-five percent of these fractures were unstable. A dynamic hip screw was systematically used as the standard means of internal fixation.Anatomic and functional results were analyzed in 82 patients (18 had died within the first year following fracture occurrence). Mean follow-up period was 24 months (range, 12-36 months). Bone healing was achieved in 96% of cases. There were numerous postoperative complications (four cases of thromboembolism, fourteen immobility-related complications, two infections, six secondary displacement combined to loss of fixation, four non-unions, and nine malunions). At 2 years follow-up, 28 patients had died. Mortality was strongly correlated with older age (over 90 years), associated co-morbidity and fracture instability. Good functional outcomes (72%) correlated with younger age (60-74 years), fracture stability, adequate reduction and internal fixation.In stable trochanteric fractures, osteosynthesis by dynamic screw-plate is more effective than alternative techniques (blade-plate, nail-plate, Ender nail or even trochanteric nail). In unstable trochanteric fractures, delayed weight-bearing should be preferred to avoid mechanical complications. In fractures that are unstable or extend far below the lesser trochanter, trochanteric nailing is indicated since providing enhanced stability, but sometimes at the cost of insufficient reduction. The treatment objective should be the complete resumption of weight-bearing as early as possible with the fewest possible complications. Prevention consists in detecting and treating osteoporosis and countering the causes of falls in elderly subjects (muscular reinforcement and correction of neurosensory deficit).Level III: Prospective diagnostic study.

Intraosseous ganglion (IOG) cyst of the scaphoid is an infrequent cause of hand and wrist pain. Intraosseous ganglia located in the scaphoid have rarely been described in the literature. We report the case of a 30-year-old right-handed woman who presented with a more than 24-month history of progressive right-wrist pain. No history of trauma was reported.Conservative treatment with anti-inflammatory medications before referral was unsuccessful. Examination revealed a small palpable mass in the carpal navicular region with no limitation of normal wrist motion. An IOG cyst of the scaphoid was found on standard radiograph and CT-scan of the wrist. Treatment consisted in curettage of the cyst followed by packing of the defect with autologous cancellous bone graft harvested in the distal end of the radial metaphysis. Satisfactory functional recovery was achieved. The clinical, radiographic and therapeutic aspects of this rare condition are discussed by the authors.

The authors report two cases of concomitant scaphoid and distal radial fractures, a rare combination of lesions in children. The first case was in a 14-year-old boy who presented a midscaphoid fracture associated with a distal forearm fracture. The second case concerned a 13-year-old boy who presented a midscaphoid fracture associated with a Salter type II distal radial fracture. Both fractures were reduced under general anaesthesia. The total period of immobilisation was 3 months, using a large arm thumb cast. Associated scaphoid fractures should be suspected with all types of distal forearm injuries in children. Reduction of the radius fracture should be done carefully to avoid possible displacement of the scaphoid fracture.

Physical exercise has beneficial effects on a number of physiologic systems, including the skeleton. However, combined with potential risk factors, unwise training practises may harm theses systems. A stress fracture represents one from of breakdown in the skeletal system.Assess the usefulness of MRI and kinesitherapy.14 patients in military circles had a stress facture. Most of the fractures are located at the upper metaphysis of the tibia.The radiography was poor, the MRI was the investigation of choice. The images show a FREDERICSON grade 4 lesion. Treatment is mainly non or partially weight bearing until consolidation.Although stress fracture results from unbalance between the bone and the forces applied, the injury occurs as a result of summation of various extrinsic and intrinsic factors at a given point in time.

The association of a toxic multinodular goitre with papillary thyroid carcinoma and primary hyperparathyroidism is very rare. Only one case is reported in the literature, we present the second one. It is a 51 year old woman, who initially presented with a toxic nodular goitre. The diagnosis of primary hyperparathyroidism was made following renal complications and the discovery of papillary thyroid carcinoma was incidental during the surgical treatment of parathyroid adenoma. Whilst the association of those three diseases is exceptional, the coexistence of any two of them is relatively frequent without any known common etiopathogenetis. It is recognised that hyperparathyroidism can be found in hyperthyroid patients, but the diagnosis of hyperparathyroidism in these cases is very difficult. The fortuitous discovery of papillary thyroid carcinoma during parathyroid surgery has already been reported but in most cases it is a microcarcinoma. In patients presenting with hyperthyroidism the risk of an associated carcinoma is generally felt to be negligeable. However, this associations is not rare. The association of primary hyperparathyroidism, hyperthyroidism and papillary carcinoma of the thyroid is rare. However, the authors suggest that the presence of any of the pathologies should trigger a search for the other two.

There is increasing interest in sagittal balance as an important element when planning treatment of spinal deformations. Posture disorders, particularly flatback, can be observed after surgical treatment of scoliosis. The frequency of flat back syndrome has increased with the development of spinal surgery.Posterior osteotomy is designed to resolve these problems. Two techniques are used: the Smith-Petersen procedure and transpedicular subtraction osteotomy. We adopted the second procedure, adding two technical modifications: installation on an orthopaedic table and intracorporeal cancellous impaction. We performed closed posterior osteotomy by intracorporeal impaction and report here our results in a series of 22 patients with postoperative flat back treated between July 1999 and June 2002. Mean age at surgery was 52 years. There were sixteen women and six men. All patients had a history of spinal surgery with fusion. They had had 2.1 spinal operations on average with a maximum of seven. All patients complained of severe postural pain. They had difficulty bending forward and standing back up. Radiographically, we noted altered spinal and pelvic angles and an abnormal plumb line from C7 to the promontory.We analyzed outcome at 21 months on average. Preoperatively five patients had 12 levels of non-union. Osteotomy was performed at L4 in nineteen patients and L3 in three. A rigid instrumentation was used in all cases. Osteosynthesis material was implanted after correction of the deformation with no particular problem for spinal stability or reduction. Mean operative time was 180 minutes and mean blood loss was 1680 ml. A complementary anterior approach was required in one patient. Intraoperative complications were dominated by dural breaches in five patients, high paraplegia not directly related to the osteotomy in one patient, regressive S1 paresia occurred in one patient and transient cruralgia which regressed in 4 to 6 months in four patients. We also observed functional intestinal obstruction in one patient and severe depression in another. There were no infections or deaths. We also observed two cases of predominant correction at the discal level and not the vertebral level. All operated patients felt their posture was improved and were able to maintain the upright position for prolonged periods. Flexion of the lower limbs was improved. Mean correction of lumbar lordosis was 25.1 degrees (range 12-39). Mean sacral slope was 33 degrees . Mean correction of the position of C7 on the promontory plumb line was 72 mm. This variable was highly altered preoperatively (95.6 mm) and was improved after osteotomy in all patients. At last follow-up, there was one case of nonunion which had been successfully revised.The literature on osteotomy for the treatment of flat back is sparse. Our series of subtraction osteotomy is the largest reported to date. Preoperative and intraoperative planning remain a topic of debate and require further study.

Dermoid cysts of the oral cavity are rare and most commonly involve the floor of mouth. Intralingual dermoid cysts are extremely rare and usually large at the time of diagnosis in adult patients. We report the case of 6 year old girl with macroglossia and swallowing and respiratory difficulties due to a giant intralingual dermoid cyst. Ultrasonography showed a large cystic intralingual lesion. MRI allowed accurate evaluation of the size, the extension and the relationship of the cystic mass with adjacent structures, the fat component of the cystic mass confirmed the dermoid origin. This case illustrates the diagnostic contribution of US and MRI in this disease.

Summary Purpose of the study Osteomyelitis of the scapula is uncommon, often with a misleading clinical presentation. We report four cases of osteomyelitis of the scapula to illustrate the particular clinical imaging findings and treatment related to this location. Case reports Between 1996 and 2006, four children were treated for osteomyelitis of the scapula, three boys and one girl, with a mean age of 8 years (range, 5–11 years). The time from symptom onset to hospitalization was 2 days. Pain was noted for all patients and total functional incapacity of the upper extremity was noted for three patients. The diagnosis of osteomyelitis of the scapula was established on the basis of imaging (ultrasound and CT scan). All patients were given medical treatment and underwent surgery. A positive bacteriology was noted in all patients. The bacterium isolated from blood cultures (two cases) and local samples obtained at the surgical site (four cases) were Meti-S Staphylococcus aureus . Results The results were analyzed by studying the anatomic and functional outcome at a mean follow-up of 36 months (range, 16–60 months). The patients were pain-free and had full range of motion in their shoulders. There were no complications. Discussion Few reports are available in the literature on osteomyelitis of the scapula. We discuss the specific clinical and imaging features as well as the treatment for this location.