Solitary Osteitis Fibrosa Cystica, Complicated by Pathologic Fracture and Treated Locally by Roentgen Rays

Abstract

Osteitis fibrosa cystica in children is amenable to roentgen therapy; one must remember, however, that only moderate doses are indicated. If a pathologic fracture occurs in such an affected bone, it may heal satisfactorily following simple fixation (Geschickter). However, irradiation may definitely improve the end-result and hasten calcification of the cystic area. A case of this type will be reported below. D. R., x-ray No. 4,683, white female, aged 6 years, was admitted to the orthopedic service of the State of Wisconsin General Hospital on March 28, 1935. At the age of two, she had injured her right arm by falling from a chair. The arm hung limp at the side for several days but she then regained normal use of it. In February, 1934, after having fallen several times, an x-ray examination was reported as showing “infected” bone and an old fracture in good position. Three days before admission to this hospital she fell again and injured the arm. The referring physician examined the arm with x-rays and found a pathologic fracture. The past medical history, other than that referable to the arm, was essentially negative. Physical examination showed a child with normal development and nourishment for her age. The only pertinent findings were in the right arm. The right shoulder was depressed and the axillary fold was broadened anteriorly. The right arm measured seven and one-fourth inches in its greatest diameter as compared to six inches for the left. There was inability to abduct the shoulder or flex the forearm, and palpable crepitation and motion at the junction of the upper and middle thirds. A roentgenogram of the right humerus (Fig. 1) showed a pathologic fracture near the middle and osteitis cystica involving the proximal half of the humerus. No other bones were affected. Routine blood studies revealed a mild secondary anemia. The urine showed a trace of albumin on two occasions. The blood Wassermann was negative. On July 17, the blood calcium was 10.3 mg. per 100 c.c., while the blood phosphorus was 4.4 mg. (normal values: 10–12 mg., and 4–5 mg., respectively). Until April 29, 1935, orthopedic treatment consisted of adhesive traction. The fracture had healed (Fig. 2) and the patient was referred to us for irradiation of the cystic lesions. A total of three series of treatments directed to the anterior aspect of the upper right humerus was given in May, July, and October, 1935. Each series consisted of three sittings on alternating days; the dose amounted to 150 r (in air); half value layer in copper = 0.8 mm. Recalcification was noted in July (Fig. 3), and a more recent examination on Feb. 3, 1936, showed further calcification and reduction of the diameter of the involved bone (Fig. 4). The question arises, of course, whether or not the healing fracture alone with its accompanying shift of calcium would have brought about this end-result.