Apophyseal avulsion fractures of the hip and pelvis are infrequent pediatric fractures. However an increase of adolescent participation in competitive sporting activities and better musculoskeletal imaging techniques has led to an increased awareness of these injuries by the medical community. These fractures can be easily missed. When these fractures are diagnosed and treated appropriately, nonsurgical protocol has bee proposed in the literature. Surgical treatment is usually reserved for certain indications. Complications of these injuries include painful nonunion, exostosis, osteonecrosis, and mechanism of injury and treatment options, these fractures can be successfully diagnosed and treated.

Patient comprehension and recall immediately following a thorough discussion of the consent form was unexpectedly low. This poor recall deteriorated further between the preoperative visit and the first postoperative visit (a period of no more than two weeks). Greater age and lower education level were associated with poorer comprehension. Sex did not affect any of the scores.

Surgical skin flaps are frequently used in plastic and reconstructive surgery to repair acquired or congenital defects. Necrosis is a common complication associated with these flaps postoperatively as a result of inadequate blood supply. Stem cells are precursor cells with the potential to differentiate into more specialized cells. Angiogenic factors act to direct cellular differentiation and organization to form new vascular elements. Our theory was that the combination of angiogenic growth factors with stem cells derived from the subject preoperatively would augment neovascularization, thereby increasing blood supply to the flap, which may ultimately improve flap survival. In phase I, 40 Lewis rats were randomized into 4 groups of 10. Random dorsal skin flaps were elevated and treated at the same time. The first group was injected with only medium, the second with stem cells, the third with stem cells and angiogenic factors, and the fourth with angiogenic growth factors. Millimetric measurements of flap viability at 7 and 14 days did not show any statistically significant differences between the studied groups. In phase II, 24 rats were also randomized into 4 groups of 6, but this time were treated 1 week before flap elevation. The viability measurements showed an increased rate of viability in the group in which stem cells and the angiogenic factors were administered simultaneously (84.5% +/- 3.2%) as compared with the unmodified control group (62.6% +/- 7.3%) or to the groups in which only precursor cells (60.4% +/- 7.9%) or angiogenic factors (62.3%+/- 10.1%). Increased blood supply brought by these manipulations is believed translated to increased tissue flap survival. Punch biopsies showed that "green fluorescent protein"-labeled precursor cells was noted to form luminal structures in the treated flaps. The vascular cast of all flaps was filled with Mercox plastic resin. After euthanasia, the soft tissues of the harvested flaps were dissolved and the remaining vascular cast was weighted. The weight-based ratio of the vascular composition was determined. The flaps injected with both stem cells and angiogenic factors showed higher values. We conclude that the administration of bone marrow stem cells with angiogenic factors 1 week before flap creation improves the survival of ischemic random skin flaps.

The knee extensor mechanism is composed of the quadriceps tendon, patella and patellar tendon. Rupture of either the quadriceps tendon or patella tendon is a rare but significant injury. The purpose of our study is to determine if there are any associated injuries with these ruptures necessitating the need for further evaluation such as MRI or arthroscopy. We retrospectively reviewed all patients with ruptures of the knee extensor mechanism who required operative repair at our institution over the last 10 years. We reviewed the chart for any documented associated injury. The type and incidence of associated injuries were recorded. We further divided these patients into two groups: low energy indirect mechanism or high-energy direct impact mechanism. Sixty-four patients met our requirements for inclusion in this study. Thirty-three patients with patellar tendon ruptures and thirty-one patients with quadriceps tendon ruptures were included. Ten out of 33 (30%) patients with a patellar tendon rupture had an associated injury. Four out of 25 (16%) patients with patellar tendon ruptures in the low energy mechanism category had an associated injury. Six out of 8 (75%) patients with a high-energy direct impact patellar tendon rupture had an associated injury. Three out of 31 (10%) patients with quadriceps tendon rupture had an associated injury. The most common associated injuries in the patellar tendon rupture patients were anterior cruciate ligament tears (18%) and medial meniscus tears (18%). We found almost one-third of all patients with a patellar tendon rupture had an associated intra-articular knee injury. We found 10% of patients with quadriceps tendon rupture had an associated intra-articular knee injury. We also found an even higher incidence of associated injuries in patients with high-energy direct impact mechanism patellar tendon ruptures (75%). The most common associated injuries in patients with patellar tendon ruptures were tears of the anterior cruciate ligament (18%) and medial meniscus (18%). We recommend that consideration be given in obtaining a MRI or diagnostic arthroscopy in patients with patellar tendon ruptures especially those with high-energy direct impact mechanism. To our knowledge this has not previously been documented in the literature.

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