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Conditions affecting the musculoskeletal system constitute a significant portion of medical emergencies in the United States, with traumatic injury and infection being two of the most common etiologies. Although physical examination and plain radiographs are often sufficient to guide diagnosis and treatment, there are myriad traumatic and infectious pathologies that are commonly missed or simply not detectable on plain radiographs. Advanced imaging is subsequently warranted for additional workup.Magnetic resonance imaging (MRI) has become an increasingly used imaging modality for musculoskeletal complaints in the emergency department due to its superior visualization of soft tissues, focal edematous changes, and occult osseous insults often not visible on plain radiographs. Although multiple studies have evaluated its utility in the workup of emergency musculoskeletal complaints, there remains a dearth of literature examining the use of MRI for certain occult diagnoses.Radiologists, emergency clinicians, and orthopedic surgeons must be knowledgeable of the indications for MRI in the emergency setting, as delayed diagnosis may contribute to increased morbidity and possibly mortality. This review summarizes the use of MRI in diagnoses relating to trauma or infection among patients presenting to the emergency department with a musculoskeletal complaint.

BACKGROUND Injury to and rupture of the flexor pollicis longus (FPL) tendon are known complications after volar locking plate fixation for distal radial fractures. Recent investigations have demonstrated that plate positioning contributes to the risk of tendon rupture; however, the impact of plate design has yet to be established. The purpose of this study was to compare FPL tendon-to-plate distance, FPL tendon-plate contact, and sonographic changes in the FPL tendon for 2 volar locking plate designs (ADAPTIVE compared with FPL) using ultrasound examination. METHODS We identified patients who underwent distal radial fracture fixation by 2 fellowship-trained hand surgeons with either standard (ADAPTIVE) or FPL plates. Patients were matched by age, sex, and Soong grade. Enrolled patients returned for a research-related office visit for a clinical examination and bilateral wrist ultrasound. We measured plate-tendon distance, plate-tendon contact, sonographic changes in the FPL tendon, and postoperative radiographic parameters in the operatively treated wrist and the uninjured wrist. RESULTS Forty patients with Soong grade-1 or 2 plate prominence underwent bilateral wrist ultrasound examination; all of the patients had distal radial fracture fixation, 20 with the standard volar locking plate and 20 with the FPL volar locking plate. Similar proportions of patients with the FPL plate (65%) and those with the standard plate (79%) had plate-tendon contact (p = 0.48); however, the FPL volar locking plate group had significantly less of the FPL tendon in contact with the volar plate than the standard volar locking plate group at wrist extension at both 0° (p < 0.001) and 45° (p < 0.001). There was no difference (p = 0.5) in the proportion of patients with sonographic changes in the FPL tendon between the FPL volar locking plate group (25%) and the standard volar locking plate group (21%). The postoperative volar tilt was significantly lower in patients with FPL plate-tendon contact (p = 0.01) and correlated moderately with the percentage of FPL tendon-plate contact at 0° (r = -0.51; p < 0.001) and 45° (r = -0.53; p < 0.001). There were no cases of tendon rupture in the cohort. CONCLUSIONS We found that the FPL volar locking plate and increased volar tilt significantly reduced the plate-tendon contact area compared with the standard volar locking plate. In our asymptomatic cohort, we were unable to find a difference in sonographic changes in the FPL tendon. Further studies are needed to determine the clinical importance of decreased tendon-plate contact area seen in modified volar locking plate designs. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Purpose The purpose of this study was to identify associations between the clinical manifestations of carpal tunnel syndrome (CTS) and the sonographic measurements of the median nerve in the carpal tunnel. We hypothesized that sonographic changes in the median nerve from proximal to distal along the carpal tunnel would be associated with symptom severity scores. Methods We report on 38 patients with clinical signs and symptoms of CTS in a prospective investigation. Subjects underwent sonographic evaluation with measurement of median nerve cross-sectional area (CSA) at 3 locations: the level of the pronator quadratus, pisiform, and hamate. In addition, we measured dimensions of the carpal tunnel at the levels of the pisiform (inlet) and hamate (outlet). Finally, we recorded maximal thickness of the transverse carpal ligament (TCL). Patients underwent routine clinical evaluation and 31 patients had electrodiagnostic examination. Patients completed the Levine Katz Questionnaire (LKQ) to characterize severity of clinical symptoms. Each clinician was blinded to symptom severity scores. Pearson correlation coefficients were calculated to measure the relationship between LKQ score and sonographic measures. Results Median nerve CSA decreased over the course of the carpal tunnel from proximal to distal in 30 of 38 wrists. A greater absolute change in CSA of the median nerve over the course of the carpal tunnel between the pisiform and the hamate as well as between the pronator quadratus and the hamate correlated with increased severity of clinical symptoms. Increased thickening of the TCL also correlated with greater symptom severity scores. Conclusions Changes in CSA of the median nerve as well as thickening of the TCL correlate with CTS severity. Type of study/level of evidence Diagnostic II.

BACKGROUND Peripheral cupping of the capital femoral epiphysis over the metaphysis has been reported as a precursor of cam morphology, but may also confer stability of the epiphysis protecting it from slipped capital femoral epiphysis (SCFE). The purpose of this study was to investigate the relationship between a novel morphologic parameter of inherent physeal stability, epiphyseal cupping, and the development of SCFE in a dual-center matched-control cohort study. METHODS We performed a dual-center age-matched and sex-matched cohort study comparing 279 subjects with unilateral SCFE and 279 radiographically normal controls from 2 tertiary children's hospitals. All SCFE patients had at least 18 months of radiographic follow-up for contralateral slip surveillance. Anteroposterior and frog lateral pelvis radiographs were utilized to measure the epiphyseal cupping ratio and the current standard measure of inherent physeal stability, the epiphyseal extension ratio. RESULTS Control hips were found to have greater epiphyseal cupping than the contralateral uninvolved hip of SCFE subjects both superiorly (0.28±0.08 vs. 0.24±0.06; P

BACKGROUND The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. METHODS This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. RESULTS Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. CONCLUSIONS Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.

Background: Cherubism is an autosomal dominant syndrome characterized by excessive bilateral maxillomandibular bony degeneration and fibrous tissue hyperplasia. Conservative management is the preferred treatment as cherubism has a self-limiting course. Functional or emotional disturbances may, however, demand surgical intervention. We report a patient who underwent surgical intervention. Method/Description: He had significant enlargement of lower cheeks and bilateral lower lid scleral show. On computed tomography of the face, the patient had significant fibrous tissue involving bilateral maxilla and mandible. The mandibular tumor was excised. Given normal inferior border, bilateral sagittal split osteotomy was performed to infracture and inset the outer cortex. During the procedure, patient required blood transfusion intraoperatively, so the maxillary portion of the procedure was delayed until 6 months later. For the maxilla, bilateral transconjunctival approach was used to resect parts of the orbital floors that were concave, resulting in 1 × 2 cm defects bilaterally which were reconstructed using resorbable plates. Then the anterior maxillary tumor was excised. Results: The patient and his parents were satisfied with his appearance after surgery. The patient was noted to have improvement in contour and decreased scleral show. He has most recently followed up 15 months after the initial surgery. There were no long-term complications. Conclusions: Severity of cherubism influences the type of surgical intervention. The present case is innovative because this is the first reported case of recontouring orbital floors with resorbable plates and infracturing of the mandible using sagittal split osteotomies for surgical treatment of cherubism.

Acute myeloid leukemia carries a dismal prognosis in older patients. The objective of this study was to investigate the safety and efficacy of decitabine combined with the CXCR4 antagonist plerixafor in newly diagnosed older patients with acute myeloid leukemia and to evaluate the effects of plerixafor on leukemia stem cells. Patients were treated with monthly cycles of decitabine 20 mg/m2 days 1–10 and escalating doses of plerixafor (320–810 mcg/kg) days 1–5. Sixty-nine patients were treated, with an overall response rate of 43%. Adverse karyotype did not predict response (P=0.31). Prior hypomethylating agent treatment was the strongest independent predictor of adverse overall survival (hazard ratio 3.1; 95%CI: 1.3–7.3; P=0.008) and response (14% in previously treated patients, 46% in treatment naïve; P=0.002). As expected, the most common toxicities were myelosuppression and infection. Plerixafor induced mobilization of leukemia stem and progenitor cells, but did not cause clinically significant hyperleukocytosis. Reduction in leukemia stem cells appeared to correlate with duration of response. Plerixafor can be safely added to decitabine in poor-prognosis, elderly acute myeloid leukemia patients. The maximum tolerated dose of the combination was 810 mcg/kg. While mobilization of leukemia stem cells was observed in some patients, the clinical benefit of adding plerixafor was uncertain. This trial was registered at clinicaltrials.gov identifier: 01352650.

OBJECTIVEPatients undergoing open cranial vault remodeling for craniosynostosis frequently experience substantial blood loss requiring blood transfusion. Multiple reports in the literature have evaluated the impact of individual blood conservation techniques on blood transfusion rates during craniosynostosis surgery. The authors engaged a multidisciplinary team and assessed the impact of input from multiple stakeholders on the evolution of a comprehensive quality improvement protocol aimed at reducing or eliminating blood transfusion in patients undergoing open surgery for craniosynostosis.METHODSOver a 4-year period from 2012 to 2016, 39 nonsyndromic patients were operated on by a single craniofacial plastic surgeon. Initially, no clear blood conservation protocol existed, and specific interventions were individually driven. In 2014, a new pediatric neurosurgeon joined the craniofacial team, and additional stakeholders in anesthesiology, transfusion medicine, critical care, and hematology were brought together to evaluate opportunities for developing a comprehensive blood conservation protocol. The initial version of the protocol involved the standardized administration of intraoperative aminocaproic acid (ACA) and the use of a cell saver. In the second version of the protocol, the team implemented the preoperative use of erythropoietin (EPO). In addition, intraoperative and postoperative resuscitation and transfusion guidelines were more clearly defined. The primary outcomes of estimated blood loss (EBL), transfusion rate, and intraoperative transfusion volume were analyzed. The secondary impact of multidisciplinary stakeholder input was inferred by trends in the data obtained with the implementation of the partial and full protocols.RESULTSImplementing the full quality improvement protocol resulted in a 66% transfusion-free rate at the time of discharge compared to 0% without any conservation protocol and 27% with the intermediate protocol. The administration of EPO significantly increased starting hemoglobin/hematocrit (11.1 g/dl/31.8% to 14.7 g/dl/45.6%, p < 0.05). The group of patients receiving ACA had lower intraoperative EBL than those not receiving ACA, and trends in the final-protocol cohort, which had received both preoperative EPO and intraoperative ACA, demonstrated decreasing transfusion volumes, though the decrease did not reach statistical significance.CONCLUSIONSPatients undergoing open calvarial vault remodeling procedures benefit from the input of a multidisciplinary stakeholder group in blood conservation protocols. Further research into comprehensive protocols for blood conservation may benefit from input from the full surgical team (plastic surgery, neurosurgery, anesthesiology) as well as additional pediatric subspecialty stakeholders including transfusion medicine, critical care, and hematology.

BACKGROUND: Limited evidence informs whether pre-operative values of two-point discrimination (2PD) in patients with carpal tunnel syndrome predict response to surgery. QUESTIONS/PURPOSES: The primary aim of this study was to determine the predictive value of pre-operative 2PD scores on outcomes following carpal tunnel release (CTR). In particular, we sought to evaluate whether a clinically relevant 2PD threshold exists that can predict symptomatic response after surgery. METHODS: Patients who underwent CTR between 2014 and 2018 were retrospectively reviewed. Static 2PD scores in each digit, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Levine-Katz scores, were collected from pre- and post-operative records. Pearson correlation coefficients assessed the relationship between pre-operative 2PD, early post-operative 2PD, and patient-reported outcome scores. Poor 2PD was defined as 2PD greater than 10 mm. RESULTS: Eighty-nine hands in 73 patients with a mean follow-up of 1.8 years were analyzed. Mean pre- and post-operative 2PD was 7.2 mm and 6.4 mm, respectively, in the most affected digit when measurable. Twenty patients had poor 2PD scores pre-operatively and 14 post-operatively. There was a positive correlation between pre- and early post-operative 2PD scores but no correlation between pre-operative 2PD score and final post-operative functional scores. Only 30% of patients with poor pre-operative 2PD scores demonstrated improvement, compared with 69% of patients with measurable 2PD. CONCLUSION: We found that greater pre-operative 2PD scores predicted greater early post-operative 2PD scores but did not lead to worse functional outcome scores post-operatively. Patients with poor pre-operative 2PD scores were likely to demonstrate improvement in functional outcomes scores, while having less reliable improvement in 2PD after CTR. Patients with poor 2PD should be counseled that improvement of tactile perception is less predictable. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09694-y) contains supplementary material, which is available to authorized users.

Case: A 77-year-old woman presented with volar wrist pain 1.5 years after undergoing distal radius volar locked plating for fracture. Radiographs and CT were notable only for plate prominence, and she was admitted for removal of hardware. Intraoperatively, a large cavitary bone lesion was found. Histopathology demonstrated a giant cell tumor of the bone. Definitive management consisted of wide en bloc resection and osteoarticular allograft reconstruction, which achieved local control and an acceptable clinical result. Conclusion: Although not previously described, a giant cell tumor of the bone may develop after fracture. Metal artifact in an area of previous internal fixation can make recognition challenging, but dual-energy CT can be used to decrease this artifact. Local control can be achieved with wide excision and reconstruction.

Objectives We report the radiographic and clinical outcome of patients treated with an angled blade plate (ABP) for hip fracture nonunion. We also provide a review of the literature on joint preserving treatment approaches to hip fracture nonunions. Design Retrospective, case series. Setting Tertiary academic hospital. Patients/Participants Three. Intervention We treated three patients with varied hip fracture nonunions using a joint preserving approach with an ABP. Main outcome measurements Radiographic union and clinical outcome. Results All three patients achieved radiographic union, and were ambulating without pain at final follow-up. Conclusions The treatment approach to hip fracture nonunions is either restorative (joint preserving) or reconstructive (joint replacing). The primary restorative approach to nonunions around the hip consists of revision open reduction and internal fixation with or without bone grafting. Though a variety of implants and treatment techniques have demonstrated excellent success in this setting, revision open reduction and internal fixation with an ABP remains an efficacious implant selection in hip nonunion surgery.

The myelodysplastic syndromes (MDS) pose a unique diagnostic challenge for clinicians and pathologists due to the clinicopathologic heterogeneity of the disease and overlapping features with other benign and malignant disorders. Currently, the initial evaluation of a patient with suspected MDS centers around a detailed medical history, review of the peripheral blood and bone marrow by an expert hematopathologist and risk stratification using laboratory results, morphology and cytogenetics. More sophisticated technologies, including multi-color flow cytometry, fluorescence in-situ hybridization (FISH), next-generation sequencing, and others are emerging and promise to offer significant refinements in diagnostic, prognostic and, hopefully, therapeutic information. With the incidence and prevalence of MDS increasing worldwide, it is critical for clinicians to optimize the initial evaluation of a patient with suspected disease, using a standard schema, to facilitate accurate diagnosis, risk stratification and treatment.

Background Age and cytogenetics are the strongest predictors of overall survival (OS) in older patients with acute myeloid leukemia (AML), but practitioners recognize that outcomes are also affected by medical comorbidities, physical function and a variety of psychosocial factors. Recent data suggest that geriatric assessment, including measures of physical, cognitive and psychological function, may be predictive of OS and helpful for risk stratification in AML (Klepin 2013). We evaluated the ability of a comprehensive geriatric assessment (CGA) to predict overall survival in newly diagnosed older patients with AML. Patients and Methods All newly diagnosed AML patients age ≥60 years treated at Weill Cornell Medical Center and The New York Presbyterian Hospital completed a CGA including the OARS Physical Health Section, Mental Health Inventory (MHI-17), MOS Social Activity Survey, Activities of Daily Living (ADL) subscale of the MOS Physical Health, OARS Instrumental ADL subscale, Timed Up & Go, Blessed-Orientation-Memory-Concentration Test, and Karnofsky Performance Status (KPS). Laboratory data, medications, transfusions and days of hospitalization were also collected. Comorbidities were assessed using the Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI). OS was estimated by the Kaplan-Meier method and the log-rank test was used to compare survival profiles. The independent effects of the CGA and clinical risk factor variables on OS were estimated using hazard ratios in an adjusted Cox regression model. Results In total, 126 patients were evaluated (median age 74, range 60-90). Fifty-one percent of patients had a HCT-CI score >1, with the most common comorbidities being a history of cancer (28.57%), cardiac disease (20.6%), and psychiatric disturbances (17.5%). Half of the patients had prior hematologic disorders and 29% had poor-risk cytogenetics. Most patients (84.9%) received decitabine-based induction strategies; 44 of these patients (34.9%) subsequently received intensive salvage regimens (median age 69). The other 19 patients (15.1%) were treated with standard induction chemotherapy, and 29 patients (21%) underwent allogeneic stem cell transplantation (median age 68). One hundred twenty-three patients (96.6%) completed the CGA with a mean time to completion of 26 minutes (± 8.9 minutes). Thirty-five percent of patients did not complete the entire assessment and only 61.1% completed the follow up CGA. Median OS was 11.1 months (range 0.36-52.64), with 1-year survival of 47.6%, complete remission (CR) rate of 39.8%, and 30-day mortality of 2.4%. In univariate analysis, age (P=0.0289), physician-assigned KPS (P=0.0031), sex (P=0.0074), ELN cytogenetic risk (P=0.0194), creatinine (P=0.027), albumin (P=0.0052), white blood cell (WBC) count (P=0.0135), LDH (P=0.0004), and treatment response (P=0.0001) were significant clinical predictors of OS. Significant CGA variables included Blessed Orientation-Memory-Concentration score (P=0.0035), Bend-Kneel-Stoop (P=0.0239), “someone to prepare your meals” (P=0.0253) and self-reporting of heart disease (P Conclusion In this study, age and cytogenetics remain the strongest predictors of OS in older patients with AML. While completion of the CGA was feasible, only performance status (KPS) was predictive of OS. Many measures previously reported as significant predictors of outcome, including impaired physical function (Klepin 2013), medication intake (Hurria 2011), pain (Sherman 2013), and HCT-CI score (Sorror 2005, 2009) were not predictive in our study population. The role of the CGA as a predictor of OS in AML requires further evaluation. The utility of the CGA in predicting functional performance and/or quality of life for older AML patients throughout treatment should also be investigated. Disclosures Ritchie: Celgene, Incyte: Speakers Bureau. Feldman:Ariad: Honoraria, Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau.

Acute myeloid leukemia (AML) carries a dismal prognosis in older patients, with median survival 8-12 months and especially poor outcomes in patients with unfavorable cytogenetics and/or poor performance status. Decitabine (5-aza-2’-deoxycytidine) has single-agent efficacy in older AML patients, with 40-50% CR (Blum et al, Proc Natl Acad Sci,107(16):7473-8,2010; Ritchie et al Leuk Lymphoma, 2013). AML originates from a rare population of leukemia stem cells (LSCs) that are capable of self-renewal, proliferation and differentiation into malignant blasts. LSCs may persist after treatment and contribute to disease relapse. Drugs that release LSCs from their protective microenvironment may leave them more vulnerable to therapy, as they are strongly dependent on the niche for proliferation and survival. Plerixafor blocks SDF1-mediated CXCR4 signaling and significantly decreases the survival of AML cells in vitro. The objective of this study was to investigate the safety and efficacy of decitabine combined with plerixafor in newly diagnosed older patients with AML and to evaluate the clinical and biological effects of plerixafor on LCSs. Patients were treated with repeated monthly cycles of decitabine 20 mg/m2 days 1-10 combined with escalating doses of plerixafor (320-810 μg/kg) days 1-5. Plerixafor was administered every other cycle so patients could serve as their own control when assessing the effects of CXCR4 blockade. Two cohorts of patients were treated at each dose level: cohort A received plerixafor only during even-numbered cycles and cohort B received plerixafor only during odd-numbered cycles. Patients achieving a clinical response received ongoing monthly maintenance cycles with 5 days of decitabine and plerixafor during alternate cycles. Sixty-nine patients were treated. Baseline patient characteristics were 55% male with a median age of 73 (56-87) yrs; ECOG 0 17%, 1 64%, 2 19%; cytogenetics intermediate 57%, adverse 44%; antecedent hematologic disorder 44%; secondary AML 45%; prior hypomethylating agent treatment (HMA) 20%. The overall response rate was 43% (36% CR, 7% CRi), with median time to response 1.9 mos (2 cycles) and median response duration 4.5 mos. Adverse karyotype did not predict overall response (P=0.31) and 53% of patients with adverse cytogenetics responded to treatment (43% CR, 7% CRi). Median overall survival (OS) for responders was significantly longer (18 mos) than for nonresponders (5 mos, P Toxicities were predictable and typical of older AML patients. Cytopenias and infections were the most common adverse events. There was no clinically significant hyperleukocytosis with plerixafor. Fourteen (56%) patients treated with 810 ug/kg plerixafor experienced reversible, treatment-associated insomnia. Immunophenotypically-defined leukemia stem and progenitor cells (LSPCs) were mobilized in a subset of patients as a consequence of CXCR4 blockade. Importantly, increased proliferation of LSPCs was also observed by Ki-67 staining. Decitabine-induced hypomethylation of AML-specific DNA methylation biomarker regions was observed in LSPCs of responders, but not in non-responders. Interestingly, this biochemical response preceded clinical response by at least one month in the subset of 7 patients analyzed to date. The combination of decitabine and plerixafor resulted in a high response rate with a favorable toxicity profile in poor-prognosis elderly AML patients. The MTD of plerixafor was 810 ug/kg and results from ongoing translational studies suggest that measures to optimize the regimen based on LSPC mobilization and DNA methylation may be feasible. Disclosures: Off Label Use: decitabine for AML.