A 10-year-old boy presented with pain and soft tissue swelling of the left cheek. A CT scan demonstrated an extensive soft tissue mass centered in the left maxilla with associated cortical erosion of the left alveolar ridge and left maxillary sinus walls. Contralateral involvement of the right alveolar ridge and anterior maxillary sinus wall was also noted. Several teeth appeared to be “floating” within the maxilla. There was absence of adjacent soft tissue fat stranding (Fig. 9.1a–c).

HISTORY: 9 yo female competitive Irish dancer "felt a tweak" in right foot while dancing in early July. History of traumatic forearm fracture and lower extremity stress fractures but otherwise healthy. Held out of dance for two weeks before seeing sports medicine. Plain film XR are negative. Immobilized with walking boot for 4 weeks for Salter I fibular fracture based on exam. No improvement in symptoms at follow-up (6 weeks post injury), but she had been non-compliant with walking boot. Made partial-weight bearing with crutches and continued immobilization for 4 additional weeks. No improvement at follow-up (10 weeks post injury) so orthopedic surgery consulted and gabapentin initiated for consideration of CRPS. MRI in interim shows cystic abnormality at posterior fibula and medullary edema at medial malleolus. Family is very competitive in Irish dance with stress injuries in other family members. PHYSICAL EXAM: Normal appearance without skin lesion, discoloration or swelling. At initial exam she is tender only over distal fibula. Throughout the course, the site of maximum tenderness migrates to the medial malleolus. Throughout the course, active ankle and foot range of motion is full and pain-free, muscle strength is full, ligamentous testing causes no pain and reveals no laxity. Skin, circulation and neurologic exams remain normal. DIFFERENTIAL DIAGNOSIS: Stress fracture/reaction Osteoid osteoma Osteomyelitis OCD Complex Regional Pain Syndrome TEST & RESULTS: Plain film imaging is normal. MRI shows cystic abnormality at posterior fibula and medullary edema at medial malleolus. FINAL/WORKING DIAGNOSIS: Stress fracture/reaction with possible osteoid osteoma. TREATMENT & OUTCOMES: Failure to improve with immobilization and non-weight bearing argue against sprain and stress fracture. She remains immobilized in a walking boot with partial weight-bearing. Orthopedic follow-up is scheduled.

The incidence of chronic osteomyelitis is increasing because of the prevalence of predisposing conditions such as diabetes mellitus and peripheral vascular disease. The increased availability of sensitive imaging tests, such as magnetic resonance imaging and bone scintigraphy, has improved diagnostic accuracy and the ability to characterize the infection. Plain radiography is a useful initial investigation to identify alternative diagnoses and potential complications. Direct sampling of the wound for culture and antimicrobial sensitivity is essential to target treatment. The increased incidence of methicillin-resistant Staphylococcus aureus osteomyelitis complicates antibiotic selection. Surgical debridement is usually necessary in chronic cases. The recurrence rate remains high despite surgical intervention and long-term antibiotic therapy. Acute hematogenous osteomyelitis in children typically can be treated with a four-week course of antibiotics. In adults, the duration of antibiotic treatment for chronic osteomyelitis is typically several weeks longer. In both situations, however, empiric antibiotic coverage for S. aureus is indicated.

Head and neck injuries account for a disproportionate number of cases of severe trauma and death among skiers and snowboarders. Helmets have been recommended in the literature for over 25 years, however their true effectiveness at preventing severe head injury (SHI) has been difficult to ascertain. Many studies have used data gathered by ski patrol reports however it is not clear that ski-patrol assessment of SHI accurately corresponds to final medical assessment. PURPOSE: The purpose of this study was threefold. First, to examine the rate of agreement between ski patrol and ER diagnosis of SHI. Second, to examine the relationship between helmet use and patient's age, sex, self-reported ability, and mode (i.e., ski or snowboard). Finally, to examine whether the use of a helmet predicted final diagnosis of SHI. METHODS: This study conducted a retrospective review of existing patient data from the Killington Ski Clinic between the 2001-2009 ski seasons. Inclusion criteria included any patient who was identified as having a SHI by ski patrol. Data was collected from a total of 57 patients, 71.9% males, average of 30 (SD=14.9) years old, 53.8% snowboarders and 46.2% alpine skiers. Rate of ski patrol and ER agreement was calculated as a percentage. Chi-square analyses were conducted to examine relationships between helmet use patient demographics. Logistic regression was conducted to examine helmet use as a predictor of SHI. RESULTS: Results indicate a 17% rate of agreement between ski patrol and ER diagnosis of SHI. There was a significant relationship between age and helmet use χ2=9.12 (2,48), p<.01, with older patients (40-70 yrs) wearing helmets more frequently. Helmet use was not a significant predictor of SHI. CONCLUSION: Helmet use did not influence ski patrol assessment of the risk of SHI. There is a discrepancy between ski patrol assessment of the risk of SHI and ultimate clinical diagnosis. Future studies examining the occurrence of SHI among skiers and snowboarders should focus on data from physician diagnosis for more accurate results.

Brachial plexus injuries are frequently encountered in sports. Classically, the symptoms include transient burning, pain, and occasionally weakness of an isolated upper extremity resulting from a peripheral nerve injury of varying degrees. Persistent symptoms or recurrent injuries may necessitate imaging such as electromyography. Medical personnel should be familiar with brachial plexus anatomy and the common nerve injury mechanisms of compression or traction. On-field assessment includes evaluation for potentially more serious neurologic injuries and possible return to play when symptoms have resolved and the athlete has good range of motion and strength. Evidence-based guidelines are largely lacking, resulting in challenging evaluation and return-to-play decisions. Management focuses on improving neck range of motion and strength in addition to assessing for proper sport-specific technique. Additionally, enhancing protective equipment may prevent brachial plexus injuries. Currently, global screening via imaging of athletes is not recommended.

Brachial plexus injuries are frequently encountered in sports. Classically, the symptoms include transient burning, pain, and occasionally weakness of an isolated upper extremity resulting from a peripheral nerve injury of varying degrees. Persistent symptoms or recurrent injuries may necessitate imaging such as electromyography. Medical personnel should be familiar with brachial plexus anatomy and the common nerve injury mechanisms of compression or traction. On-field assessment includes evaluation for potentially more serious neurologic injuries and possible return to play when symptoms have resolved and the athlete has good range of motion and strength. Evidence-based guidelines are largely lacking, resulting in challenging evaluation and return-to-play decisions. Management focuses on improving neck range of motion and strength in addition to assessing for proper sport-specific technique. Additionally, enhancing protective equipment may prevent brachial plexus injuries. Currently, global screening via imaging of athletes is not recommended.