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PubMed2005

Distinction of long bone stress fractures from pathologic fractures on cross-sectional imaging: how successful are we?

OBJECTIVE: The objectives of our study were to define CT and MRI features that distinguish pathologic fractures from stress fractures and to compare the performance of CT and MRI with radiography. MATERIALS AND METHODS: Two reviewers retrospectively reviewed 45 MR images, 37 CT scans, and 43 radiographs in 59 patients (30 biopsy-proven pathologic fractures and 29 stress fractures followed to resolution). The features observed on MRI were abnormal bone marrow (well-defined, ill-defined); intracortical, periosteal, or muscle T1 or T2 signal; endosteal scalloping; and a soft-tissue mass. The features seen on CT were marrow abnormality and character (well-defined, ill-defined, permeative, moth-eaten), endosteal scalloping, periosteal reaction (benign, aggressive), and a soft-tissue mass. Reviewers rated their confidence for diagnosing a pathologic fracture on a 1-3 scale (< 50%, 50-95%, > 95% sure, respectively) with each technique. Performance of each technique was defined by reviewer accuracy and area under the receiver operating characteristic curve (Az); the frequency with which the MRI and CT features were associated with pathologic and stress fractures was calculated. RESULTS: For both reviewers, accuracy for differentiating pathologic from stress fractures was highest on MRI (accuracy/Az: reviewer 1, 98%/0.97; reviewer 2, 93%/0.99); CT (reviewer 1, 88%/0.83; reviewer 2, 82%/0.90) was less accurate than radiography (reviewer 1, 94%/0.98; reviewer 2, 88%/0.96). On MRI, pathologic fractures compared with stress fractures exhibited well-defined T1 marrow signal (83% vs 7%, respectively; p < 0.001), endosteal scalloping (58% vs 0%, p < 0.001), muscle signal (83% vs 48%, p = 0.026), and a soft-tissue mass (67% vs 0%, p < 0.001). On CT, pathologic fractures compared with stress fractures exhibited marrow abnormality (84% vs 17%, respectively; p = 0.001), endosteal scalloping (44% vs 0%, p = 0.006), and aggressive periosteal reaction (36% vs 0%, p = 0.04). CONCLUSION: MRI is useful for distinguishing pathologic from stress fractures, especially after inconclusive radiographic findings. Specifically, pathologic fractures exhibit well-defined T1 marrow alterations, endosteal scalloping, and adjacent soft-tissue abnormalities.

Adolescent↗
PubMed2005

Effect of alendronate on vertebral fracture risk in women with bone mineral density T scores of-1.6 to -2.5 at the femoral neck: the Fracture Intervention Trial.

OBJECTIVES: To determine the efficacy of alendronate treatment on risk of vertebral fracture in a subgroup of women from the Fracture Intervention Trial who had bone mineral density T scores between -1.6 and -2.5 at the femoral neck and to describe how soon after initiation of therapy alendronate becomes effective and whether it is consistent in women with and without existing radiographic vertebral fracture. PATIENTS AND METHODS: From May 1992 to March 1997, postmenopausal women aged 55 to 80 years were randomized to receive alendronate at 5 mg/d for 2 years and 10 mg/d thereafter or placebo for up to 4.5 years (mean, 3.8 years) in a controlled, double-blind, multicenter study. RESULTS: A total of 3737 postmenopausal women were included in the study, 1878 in the alendronate group and 1859 in the placebo group. Risk of vertebral fracture was significantly reduced by alendronate compared with placebo for clinical (relative risk [RR], 0.40; 95% confidence interval [CI], 0.19-0.76; P=.005) and radiographic (RR, 0.57; 95% CI, 0.41-0.81; P=-.002) fracture. The reductions in vertebral fracture risk were consistent in women with and without an existing radiographic vertebral fracture for clinical (RR, 0.34; 95% CI, 0.12-0.84; and RR, 0.46; 95% CI, 0.16-1.17; respectively) and radiographic (RR, 0.53; 95% CI, 0.34-0.82; and RR, 0.64; 95% CI, 0.38-1.10; respectively) fractures. In both groups, the effect of alendronate on clinical vertebral fracture was noted soon after therapy was initiated. The absolute risk of vertebral fracture was low in women without a baseline radiographic fracture. CONCLUSIONS: In women with low bone mass who do not meet the bone mineral density criterion for osteoporosis, alendronate is effective in reducing the risk of vertebral fractures. The absolute benefit of this therapy in women with a T score between -1.6 and -2.5 is greater in women with an existing vertebral fracture and/or with other risk factors. The effect of alendronate occurs early.

Aged↗
PubMed2005

Relative fracture risk in patients with diabetes mellitus, and the impact of insulin and oral antidiabetic medication on relative fracture risk.

AIMS/HYPOTHESIS: We studied the association between fractures and type 1 and type 2 diabetes mellitus. METHODS: In this case-control study, all subjects diagnosed with a fracture (n=124,655) in Denmark served as cases, and for each case three control subjects (n=373,962) matched for sex and age were retrieved from the general population. RESULTS: Type 1 and type 2 diabetes were associated with an increased risk (1) of any fracture (odds ratio [OR]=1.3, 95% CI: 1.2-1.5 for type 1 diabetes and 1.2, 95% CI: 1.1-1.3 for type 2 diabetes after adjustment for confounders) and (2) of hip fractures (OR=1.7, 95% CI: 1.3-2.2 for type 1 diabetes, and 1.4, 95% CI: 1.2-1.6 for type 2 diabetes). Furthermore, type 2 diabetes was associated with a significant increase in forearm fractures (OR=1.2, 95% CI: 1.0-1.5), and type 1 diabetes was associated with an increased risk of spine fractures (OR=2.5, 95% CI: 1.3-4.6), whereas type 2 diabetes was not. Use of metformin and sulphonylureas was associated with a significantly decreased risk of any fracture, whereas a non-significant trend towards decreased risk of any fracture was associated with the use of insulin. Except for a decrease in hip fractures with use of sulphonylureas, no change in fracture risk in the hip, spine or forearm was associated with the use of insulin or oral antidiabetic drugs. CONCLUSIONS/INTERPRETATION: Type 1 and type 2 diabetes are associated with an increased risk of any fracture and hip fractures. The use of drugs to control diabetes may reduce the association between diabetes and fractures.

Administration, Oral↗
PubMedDate not supplied

Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures.

OBJECTIVE: This study was instituted to evaluate patients operated on for traumatic facial paralysis. STUDY DESIGN: A prospective study and literature review. MATERIALS AND METHODS: Between 1996 and 2001, 10 patients with 11 temporal bone fractures resulting in facial paralysis, who were treated by surgical exploration, were handled. One patient had bilateral facial paralysis because of a bilateral temporal bone fracture. All patients had immediate facial paralysis after trauma. The sample included 7 males and 3 females, aged between 8 and 43 years. RESULTS: Of the 11 fractures, 7 (63%) were longitudinal and 4 (37%) were mixed type. There were no transverse fractures. The longitudinal fractures were operated on by the middle cranial fossa (MCF) approach, whereas the mixed fractures were operated on by using a combined approach, consisting of both MCF and transmastoid approaches. The first neurotologic examination and electrophysiological evaluation of the patients were carried out at the earliest 5 days and at the latest 50 days (mean, 25.6 days). The decision for surgery based mainly on electroneurography (ENoG) was possible only in one fracture. In the remaining 10 fractures, the decision for surgery was based mainly on the high-resolution computed tomography (HRCT), taking into account that electromyography (EMG) showed no regeneration potentials. The timing of the surgical intervention ranged from 14 to 75 days (mean, 37.9 days). During the operation, fibrosis at the geniculate ganglion was seen in 5 fractures, impingement of the facial nerve by bone spicules at the geniculate ganglion in 2 fractures, disruption or laceration at the origin of major superficial petrosal nerve also in 2 fractures, and edema around the geniculate ganglion, which is considered a mild form of injury, seen in only 2 fractures. Five fractures showed House-Brackmann (HB) grade 1, 4 patients showed HB grade 2, and 2 patients showed HB grade 3 facial recovery. There were no hearing deterioration or permanent complications related with the procedures. CONCLUSIONS: It is rarely possible to see the patients with traumatic facial paralysis in the early period and thus to perform ENoG in the critical 6 days after facial paralysis. HRCT, with the contribution of EMG and clinical judgment, has the greatest impact in decision making in patients seen late. On the basis of the facial outcomes observed in the present prospective surgical series, the recovery of satisfactory facial nerve function could be achieved, regardless of timing of surgery performed, within the first 3 months after the onset of paralysis. This study demonstrates that unless there is a disruption of the main trunk, necessitating primary end-to-end anastomosis or grafting, the type of injury does not have any clear effect on the facial outcome, as long as appropriate surgical management is applied.

Adult↗
PubMed2006

Diagnostic strategy for suspected scaphoid fractures in the presence of other fractures in the carpal region.

Bone scintigraphy will identify up to 25% of occult scaphoid bone fractures after negative scaphoid X-rays. Consequently, it deserves a place in the diagnostic process of suspected scaphoid fractures. However, the role of bone scintigraphy is less clear if scaphoid X-rays show other fractures in the carpal region. We analysed 111 consecutive patients with a suspected scaphoid fracture on physical examination. Scaphoid X-rays revealed 61 fractures. Fifty-five patients had scaphoid fractures only and six patients had other fractures in the carpal region but no scaphoid fracture. In 50 cases, no bone injury was seen on these X-rays. In three out of the six patients with other fractures in the carpal region, bone scintigraphy revealed four occult concomitant fractures: one scaphoid, one scaphoid and trapezial and one capitate fracture. In conclusion, bone scintigraphy is required when scaphoid X-rays do not confirm a suspected scaphoid fracture, even in the presence of other fractures in the carpal region.

Carpal Bones↗
PubMed1995

The patient with fracture: the risk of subsequent fractures.

This article reviews the available data considering the question of whether patients who have suffered one fragility fracture are at an increased risk of a subsequent fracture. A number of methodologic concerns are highlighted. There are also a relatively limited number of datasets available for consideration. There is, however, a consistent observation that patients who have had one fracture are at an increased risk of having subsequent fractures. The earlier the age at fracture and the greater the number of previous fractures, the greater the subsequent risk. Many recent population surveys on osteoporotic fracture have focused on screening populations for vertebral deformity as a useful population guide to osteoporotic fracture occurrence. The same conclusions apply to the risk of subsequent fractures. It is difficult to distinguish three possible hypotheses to explain this increased risk. First, and intuitively most likely, risk factors for the development of one fracture are still operative to increase susceptibility to a second and subsequent event. Second, the occurrence of a fracture, particularly in the limbs, is followed by bone loss, not completely reversible, which could lead to an increased risk of subsequent fracture. Finally, there may be mechanical influences caused by having had one fracture, and it may be these mechanical effects that increase this subsequent risk.

Fractures, Bone↗
PubMed1997

Evaluation of fracture planes and cell morphology in complementary fractures of cultured cells in the frozen-hydrated state by field-emission secondary electron microscopy: feasibility for ion localization and fluorescence imaging studies.

We have employed field-emission secondary electron microscopy (FESEM) for morphological evaluation of freeze-fractured frozen-hydrated renal epithelial LLC-PK1 cells prepared with our simple cryogenic sandwich-fracture method that does not require any high-vacuum freeze-fracture instrumentation (Chandra et al. (1986) J. Microsc. 144. 15-37). The cells fractured on the substrate side of the sandwich were matched one-to-one with their corresponding complementary fractured faces on the other side of the sandwich. The FESEM analysis of the frozen-hydrated cells revealed three types of fracture: (i) apical membrane fracture that produces groups of cells together on the substrate fractured at the ectoplasmic face of the plasma membrane; (ii) basal membrane fracture that produces basal plasma membrane-halves on the substrate; and (iii) cross-fracture that passes randomly through the cells. The ectoplasmic face (E-face) and protoplasmic face (P-face) of the membrane were recognized based on the density of intramembranous particles. Feasibility of fractured cells was shown for intracellular ion localization with ion microscopy, and fluorescence imaging with laser scanning confocal microscopy. Ion microscopy imaging of freeze-dried cells fractured at the apical membrane revealed well-preserved intracellular ionic composition of even the most diffusible ions (total concentrations of K+, Na+ and Ca2+). Structurally damaged cells revealed lower K+ and higher Na+ and Ca2+ contents than in well-preserved cells. Frozen-freeze-dried cells also allowed imaging of fluorescently labelled mitochondria with a laser scanning confocal microscope. Since these cells are prepared without washing away the nutrient medium or using any chemical pretreatment to affect their native chemical and structural makeup, the characterization of fracture faces introduces ideal sample types for chemical and morphological studies with ion and electron microscopes and other techniques such as laser scanning confocal microscopy, atomic force microscopy and near-field scanning optical microscopy.

Animals↗
PubMed1992

Fracture rates calculated from fracture histories in normal postmenopausal women.

STUDY OBJECTIVE: The aim was to estimate fracture rates and fracture prevalence from fracture histories in normal postmenopausal women. DESIGN: Apparently healthy postmenopausal women were recruited by advertising in the media. Fracture histories were obtained by personal interview in 1983 and again by interview or questionnaire in 1988. Fracture rates were calculated prospectively and retrospectively. PARTICIPANTS: 492 women (mean age 58.6 years) were selected from over 1000 applicants on the basis that they were suffering from no disease nor taking any therapy which might affect their bones. MEASUREMENTS AND MAIN RESULTS: Retrospective premenopausal and postmenopausal fracture rates were calculated in 1983, prospective rates calculated from 1983 to 1988, and retrospective rates checked again on the second occasion. The retrospective and prospective fracture rates were very similar. The five year fracture rates were low and steady until the menopause, when they rose by a factor of 10 and reached a new plateau after about 15 years. The results were comparable to those obtained from hospital statistics. CONCLUSIONS: The menopausal rise in fracture rates not only involves wrist fractures but most peripheral fractures, and probably reflects postmenopausal loss of trabecular bone. Meaningful fracture rates can be calculated from individual fracture histories in a well defined population. This technique may be particularly useful in developing countries where public health data may be incomplete.

Age Factors↗
PubMed2002

Radiologic and clinical spectrum of occipital condyle fractures: retrospective review of 107 consecutive fractures in 95 patients.

OBJECTIVE: We proposed to characterize the radiologic spectrum of occipital condyle fractures in a large series of patients and to correlate fracture pathology with neurosurgical treatment and patient outcome. MATERIALS AND METHODS: We conducted a retrospective review of the findings on conventional radiography, CT, and MR imaging in 95 patients with 107 occipital condyle fractures. We described fracture patterns according to two previously published classification systems. Clinical findings, neurosurgical management, and patient outcome were obtained from the medical records. RESULTS: Inferomedial avulsions (Anderson and Montesano type III) were the most common type of occipital condyle fracture, constituting 80 (75%) of 107 overall fractures. Unilateral occipital condyle fractures were found in 73 (77%) of 95 patients, and 58 patients were treated nonoperatively; occipitocervical fusion was required in nine patients for complex C1-C2 injuries, and six patients died. Bilateral occipital condyle fractures or occipitoatlantoaxial joint injuries were seen in 22 (23%) of 95 patients. Occipitocervical fusion or halo traction for the craniocervical junction was required in 12 patients, all of whom had CT evidence of bilateral occipitoatlantoaxial joint disruption and six of whom showed normal craniocervical relationships on conventional radiographs. Six patients with nondisplaced fractures were treated nonoperatively, and four patients died. Thirty (32%) of 95 patients showed continued disability, whereas 55 (57.5%) of 95 patients had good outcomes at 1 month. Associated cervical spine injuries were present in 29 (31%) of 95 patients. CONCLUSION: Given their associated traumatic brain and cervical spine injuries, occipital condyle fractures are markers of high-energy traumas. That conventional radiographs alone may miss up to half of the patients with acute craniocervical instability has not been well established. Avulsion fracture type and fracture displacement are associated with both injury mechanism and the need for surgical stabilization. In this series, most unilateral occipital condyle fractures were treated nonoperatively, whereas bilateral occipitoatlantoaxial joint injuries with findings of instability usually required surgical stabilization.

Adolescent↗
PubMed2000

Low fractional calcium absorption increases the risk for hip fracture in women with low calcium intake. Study of Osteoporotic Fractures Research Group.

BACKGROUND: Decreased ability to absorb calcium with age limits adaptation to low calcium intake and is thought to lead to secondary hyperparathyroidism and increased risk for hip and other fractures. However, the associations between fractional calcium absorption, dietary calcium intake, and risk for fracture have never been studied. OBJECTIVE: To determine whether low fractional calcium absorption in women with low calcium intake increases the risk for subsequent hip and other nonspine fractures. DESIGN: Prospective cohort study. SETTING: Four clinical centers in Baltimore County, Maryland; Portland, Oregon; Minneapolis, Minnesota; and the Monongahela Valley, Pennsylvania. PARTICIPANTS: 5452 nonblack women 69 years of age or older participating in the fourth examination of the Study of Osteoporotic Fractures. MEASUREMENTS: Fractional calcium absorption was measured by using a 3-hour single isotope (45Ca) technique. Incident fractures were identified prospectively and were confirmed by radiographic report. RESULTS: During an average of 4.8 years, 729 women (13%) experienced at least one nonspine fracture; 153 of these women had hip fractures. After adjustment for age, women with lower fractional calcium absorption were at increased risk for hip fracture (relative risk per 1-SD [7.7%] decrease in fractional calcium absorption, 1.24 [95% CI, 1.05 to 1.48]). Women with low fractional calcium absorption and low calcium intake were at greatest risk for subsequent hip fracture; among women whose dietary calcium intake was less than 400 mg/d, those who had fractional calcium absorption at or below the median value of 32.3% had a 2.5-fold (CI, 1.29-fold to 4.69-fold) increase in risk for hip fracture compared with those who had greater absorption efficiency. Fractional calcium absorption was not related to risk for other nonspine fractures (relative risk per 1-SD [7.7%] decrease in fractional calcium absorption, 1.05 [CI, 0.96 to 1.14]). CONCLUSIONS: In elderly women, low fractional calcium absorption in the setting of low calcium intake increases the risk for hip fracture. Our findings support the hypothesis of type II osteoporosis, which postulates that decreased calcium absorption is an important risk factor for hip fracture in older persons.

Aged↗
PubMed1995

Epidemiology of hip fractures among the elderly. Risk factors for fracture type.

A study was undertaken in September 1988 of 169 patients who were > 50 years of age receiving care for hip fractures at 4 university-affiliated hospitals during a 2-year period. Demographics, medical history, cognitive function, mobility, and environmental factors surrounding the hip fractures were ascertained by patient or proxy interview and review of medical records. These were then related to the type and severity of hip fracture. Eighty-three (49%) patients had intertrochanteric fractures, 23 (14%) had subtrochanteric fractures, and 63 (37%) had intracapsular fractures. Walking versus standing, sitting, or getting up at the time of fracture (relative odds = 3.2, p = .041), and no mobility difficulty versus some mobility difficulty (relative odds = 5.2, p = .047) were associated with increased comminution in intertrochanteric or subtrochanteric fractures. The location of the fracture occurrence (indoor versus outdoors) was associated with greater displacement in intracapsular fractures (relative odds = 6.7, p = 0.021). Only 2 of 169 patients had spontaneous hip fractures, defined as hip pain that preceded the fall. Because spontaneous fractures are rare, efforts directed toward preventing falls would be expected to decrease the incidence of hip fractures. Future possibilities include the development of protective garments that can reduce impact loading to the hip during a fall.

Accidental Falls↗
PubMed2005

Surgical treatment of intertrochanteric hip fractures with associated femoral neck fractures using a sliding hip screw.

OBJECTIVE: The purpose of this study was to report the results of surgical treatment of a subset of intertrochanteric fractures with posteromedial comminution and extension of the fracture line into the femoral neck using a sliding hip screw. DESIGN: Retrospective review. SETTING: Level I county trauma center. PATIENTS: Twenty-nine fractures (8%) with this pattern were identified from 381 intertrochanteric hip fractures treated at a single institution over a 10-year period. Nine patients were excluded (2 died, 7 had incomplete radiographic follow-up), leaving 20 patients for assessment. INTERVENTION: All fractures were treated with a sliding hip screw. MAIN OUTCOME MEASUREMENTS: Radiographs at a mean follow-up of 17 months were recorded as demonstrating: 1) fixation failure; 2) fracture union; or 3) fracture nonunion. The tip-apex distance, amount of lag screw collapse, screw position in the femoral head, and adequacy of reduction were determined. RESULTS: Treatment failed according to these radiographic measures in 5 of 20 (25%) fractures. Failures included fracture nonunion (1 case), lag screw cutout (2 cases), and combined nonunion/lag screw cutout (2 cases). All 5 failures had complete collapse of the lag screw, whereas 4 of the 15 successfully treated fractures had complete collapse. The amount of collapse was significantly greater for the treatment failures (mean, 38 mm) than in the successfully treated hips (mean, 20 mm). There was no significant association between treatment success or failure and tip-apex distance, lag screw position, and adequacy of reduction. CONCLUSION: We conclude that intertrochanteric hip fractures with associated femoral neck fractures should not be managed with a standard sliding hip screw.

Adult↗
PubMed1999

Vitamin D receptor gene polymorphisms and the risk of fractures in older women. For the Study of Osteoporotic Fractures Research Group.

The association between vitamin D receptor gene polypmorphisms and bone mineral density is controversial. The relationship between vitamin D receptor genotype and risk of fracture is uncertain. To determine whether vitamin D receptor polymorphisms were associated with the risk of hip, vertebral, and other (nonhip, nonvertebral) fractures in elderly women, we conducted a case-cohort study within a prospective study of 9704 community-dwelling women aged 65 years and older. Vitamin D receptor allele and genotype frequencies in women who experienced first incident hip (n = 181), vertebral (n = 127), and other (n = 223) fractures were compared with those of control women selected randomly from the cohort. Average length of follow-up was 6.5, 3.7, and 5.4 years for women in hip, vertebral, and other fracture analyses, respectively. Vitamin D receptor polymorphisms were determined by polymerase chain reaction amplification of genomic DNA using TaqI and ApaI restriction site endonuclease digestion. All nonvertebral fractures were confirmed by X-ray reports; hip fractures were validated by review of X-ray films. Vertebral fractures were defined by morphometry using lateral spine radiography at baseline and an average of 3.7 years later. Allele or genotype frequencies did not differ between fracture cases and their respective controls. Vitamin D receptor genotype (defined by TaqI, ApaI, or the combination of TaqI and ApaI) was not significantly associated with the risk of hip, vertebral, or other fractures. For example, compared with the referent group of women with TT genotype, those with Tt and tt genotypes had similar age- and weight-adjusted risks of fracture at the hip (hazard ratios 0.9, 95% confidence interval [CI] 0.6-1.3, and 0.8, 95% CI 0.5-1.2, respectively), spine (odds ratios 1.1, 95% CI 0.7-1.8, and 0.7, 95% CI 0.4-1.3, respectively), or other skeletal site (hazard ratios 1.0, 95% CI 0. 7-1.4, and 1.0, 95% CI 0.7-1.5, respectively). These findings were not altered in additional analyses including those adjusted for and stratified by age, ethnic ancestry, calcaneal bone density, dietary calcium intake, use of calcium supplements, use of vitamin D supplements, and oral estrogen use. We conclude that Vitamin D receptor polymorphisms defined by TaqI and ApaI are not associated with the risk of fracture in older women. Our results suggest that determination of these vitamin D receptor polymorphisms is not a clinically useful test for the prediction of fracture risk in elderly women.

Aged↗
PubMed1981

The treatment of unstable fractures of the tibia and fibula with flexible medullary wires. A review of two hundred and thirty-five fractures.

A retrospective study was done of the treatment of closed and open unstable fractures of the tibia and fibula with flexible intramedullary wires in 223 patients with 235 fractures. The surgical procedure is relatively atraumatic to the tibia, can be learned easily by the surgeon, and does not require complicated or expensive instrumentation. The flexible intramedullary wires permit stabilization of the fractures in a functional position. External support by a long cast in the initial phase of treatment is necessary, but full weight-bearing is usually allowed during the third to fourth week. This has proved to be a beneficial method of treatment for bilateral fracture of the tibia and fibula and for combined femoral and ipsilateral tibiofibular fractures. Of the 235 fractures, fifty-seven (24.3 per cent) were closed and 178 (75.7 per cent) were open. Primary healing of soft tissue and bone occurred in fifty-three (92.9 per cent) of the closed fractures and in 117 (65.7 per cent) of the open fractures. The complication rate in closed fractures was 7.1 per cent, primarily due to delayed bone union. There was a 34.3 per cent complication rate in the open fractures, of which thirty-one (17.4 per cent) showed delayed soft-tissue healing, ten (5.6 per cent) had delayed bone union, and eight (4.4 per cent) resulted in deep infection with osteomyelitis. There were eight non-unions in the open, uninfected fractures, five of which healed after bone-grafting. Flexible intramedullary wiring of the tibia should be considered as an alternate method of treatment in the presence of an unstable fracture.

Adolescent↗
PubMed1994

Cranial fractures associated with facial fractures: a review of mechanism, type, and severity of injury.

A 100-month retrospective review was undertaken to identify the population characteristics of patients with both facial and cranial fractures and to establish the relationships between them. A 4.4% incidence of cranial fractures was found in the 882 patients with facial fractures. These patients tended to be males (85%) between the ages of 16 and 30 years (54%) who were involved in motor vehicle accidents (64%). Patients with midfacial fractures predominated (70%), and these injuries were most frequently associated with fractures of the frontal (38%), sphenoid (24%), or temporal (22%) bones. No relationship was noted between mandibular fractures and cranial fractures. Midfacial fractures were related to individual cranial bone fractures by sutural attachment. The presence of cranial fractures did not play a role in the development of complications associated with facial fractures.

Accidents, Traffic↗
PubMed1993

Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up.

OBJECTIVE: To determine the long-term risk of hip fracture following fracture of the distal forearm. DESIGN: Registry-based cohort study comparing patients with a fracture of the distal forearm with a population-based cohort. FRACTURE COHORT: All women and men above 40 years of age with a radiologically verified fracture of the distal forearm during a 5-year period, 1968-1972, in all 1,126 women and 212 men. CONTROL COHORT: An equal number of population-based, age- and sex-matched control persons selected from a population register. MEASUREMENTS: All cohort members were followed up individually through record linkage until the first hip fracture, emigration, death, or the end of 1991. The cohort members contributed a total of 40,832 person-years of observation, and altogether 365 cases of hip fractures were observed. RESULTS: Both women and men with a fracture of the distal forearm ran an increased risk of sustaining a subsequent hip fracture. The overall relative hazard for the women was 1.54 and for men 2.27. The increased risk in the women was independent of age at inclusion, but that in the men was more pronounced in the younger age groups. CONCLUSIONS: Patients with a fracture of the distal forearm run an increased risk of sustaining a subsequent hip fracture. They therefore appear to constitute a group in which appropriate prophylactic measures against osteoporosis and fractures should be considered.

Adult↗
PubMed2005

Fracture length scales in human cortical bone: the necessity of nonlinear fracture models.

Recently published data for fracture in human humeral cortical bone are analyzed using cohesive-zone models to deal with the nonlinear processes of material failure. Such models represent the nonlinear deformation processes involved in fracture by cohesive tractions exerted by the failing material along a fracture process zone, rather than attributing all damage to a process occurring at a single point, as in conventional linear-elastic fracture mechanics (LEFM). The relationship between the tractions and the net displacement discontinuity across the process zone is hypothesized to be a material property for bone. To test this hypothesis, the cohesive law was evaluated by analyzing published load vs. load-point displacement data from one laboratory; the calibrated law was then used to predict similar data taken for a different source of bone using a different specimen geometry in a different laboratory. Further model calculations are presented to illustrate more general characteristics of the nonlinear fracture of bone and to demonstrate in particular that LEFM is not internally consistent for all cases of interest. For example, the fracture toughness of bone deduced via LEFM from test data is not necessarily a material constant, but will take different values for different crack lengths and test configurations. LEFM is valid when the crack is much longer than a certain length scale, representative of the length of the process zone in the cohesive model, which for human cortical bone ranges from 3 to 10mm. Since naturally occurring bones and the specimens used to test them are not much larger than this dimension for most relevant orientations, it is apparent that only nonlinear fracture models can give an internally consistent account of their fracture. The cohesive law is thus a more complete representation of the mechanics of material failure than the single-parameter fracture toughness and may therefore provide a superior measure of bone quality. The analysis of fracture data also requires proper representation of the approximately orthotropic elasticity of the bone specimen; if the specimen is incorrectly assumed to be isotropic, the initial measured compliance cannot be reproduced to within a factor of four and the fracture toughness deduced from the measured work of fracture will be overestimated by approximately 30%.

Bone and Bones↗
PubMed2006

Histomorphometric analysis of fracture healing cascade in acute osteoporotic vertebral body fractures.

BACKGROUND: While fracture healing has been well characterised in long bones, there is scant data relating to this process in acute vertebral body fractures. AIM: To characterise the histological process of fracture healing in acute osteoporotic vertebral body fractures using qualitative and quantitative bone histomorphometry. SUBJECTS AND METHODS: Transpedicular bone biopsy was performed in patients undergoing percutaneous vertebroplasty. Undecalcified biopsy specimens were prepared from cores of cancellous bone harvested from vertebral bodies with MRI evidence of bone marrow oedema. These were analysed by light microscopy using grid analysis and defined using bone histomorphometry criteria. Normative data obtained from 5 age-matched volunteers without evidence of metabolic bone disease or osteoporosis was used for comparison. RESULTS: Adequate biopsy specimens were obtained in 72 of 90 patients (15 men and 57 women), mean age 75.6 years. All biopsies confirmed severe osteoporosis with reduced cancellous bone volume (mean of 13.5%; P<0.001 compared to controls). The timing of biopsies varied from 1 to 24 weeks (median of 6 weeks) after the fracture event. There were 4 stages of fracture callus healing observed: Stage I in 17 (24%) patients, Stage II in 16 (22%), Stage III in 22 (30%) and Stage IV in 17 (24%). An overlap between the various stages was evident with 55 (76%) patients demonstrating at least 2 or more of the stages of fracture healing in the same biopsy specimen. The time interval since fracture event was the most important predictor of the stage of the fracture callus (R=0.32; P<0.001). CONCLUSION: Our data demonstrates a mixed fracture callus with overlapping of the various stages of fracture healing. This suggests that individual vertebra may be susceptible to multiple fractures over the course of the healing process.

Aged↗