[Proceedings: I. Elbow fractures in the adult. 2. Fresh fractures. c. Luxation fractures].
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Osteoarthritis and risk of falls, rates of bone loss, and osteoporotic fractures. Study of Osteoporotic Fractures Research Group.
OBJECTIVE: To examine the association between osteoarthritis (OA), as defined by radiographic evidence and self report, and osteoporotic fractures, falls, and bone loss in a cohort of elderly white women. METHODS: A cohort of 5,552 elderly women from the Study of Osteoporotic Fractures was followed up prospectively for a mean of 7.4 years. Self-reported, physician-diagnosed OA was recorded at interview, and radiologic OA of the hip and hand were defined from pelvis and hand radiographs obtained at baseline by validated techniques. Prevalent and incident vertebral fractures were detected by vertebral morphometry, and data on incident fractures and falls were collected by postcard surveys; fractures were confirmed by radiography. Bone mineral density (BMD) was measured on 2 occasions at the hip, lumbar spine, and calcaneus, and rates of bone loss were calculated. RESULTS: Women with radiographic hip OA had a reduced risk of recurrent falls in the first year (relative risk [RR] 0.7, 95% confidence interval [95% CI] 0.5-0.95). However, those with self-reported OA had an increased risk of falls (RR 1.4, 95% CI 1.2-1.5). Radiographic hip OA was associated with reduced bone loss in the femoral neck compared with controls (mean +/- SD -0.29+/-0.09%/year versus -0.51+/-0.03%/year; P = 0.018). However, radiographic hip OA showed nonsignificant trends toward increased bone loss at the calcaneus and lumbar spine. There was no significant association between self-reported OA or radiographic hand OA with bone loss. No definition of OA was associated with incident nonvertebral fracture, hip fracture, or vertebral fracture. CONCLUSION: Despite having increased BMD compared with controls, subjects with OA did not have a significantly reduced risk of osteoporotic fracture, although there was a trend toward a reduced risk of femoral neck fractures in subjects with severe radiographic OA. The failure of the observed increase in BMD to translate into a reduced fracture risk may be due, in part, to the number and type of falls sustained by subjects with OA. Patients with OA should not be considered to be at a lower risk of fracture than the general population. Physicians should be aware that a high BMD in patients with OA may be falsely reassuring.
Accidental Falls↗
Costs induced by hip fractures: a prospective controlled study in Belgium. Belgian Hip Fracture Study Group.
The economic burden of hip fractures is thought to be important, but the excess medical costs they induce remain largely unknown. We assessed the direct medical costs induced by hip fractures during and after hospitalization. Hospital costs of 170 consecutive Belgian women with hip fracture were gathered. During the year following discharge, all medical costs were collected for the 159 hip fracture women who survived the acute hospitalization stay. A similar collection of data was performed on a comparison group of 159 age-and residence-matched women without a history of hip fracture. The mean cost of the acute hospital stay was 8,667 Belgian francs and the mean 1-year hip-fracture-related extra costs after hospitalization was 6,636 Belgian francs. During the year following the acute hospital stay, 19% of the hip fracture women and 4% of the comparison women were newly admitted to nursing homes (p<0.001). Although health care costs increased with age, hip-fracture-related extra costs after hospitalization seemed similar in those below or above 81 years old. These extra costs amounted to 7,710 Belgian francs in women not living in nursing homes at the time of fracture, and to 3,479 Belgian francs in women who lived in nursing homes. Health or mental status before hip fracture seemed not to affect extra costs. Taking into account the higher mortality of women with hip fracture, the extra costs during the acute hospital stay and during the 1-year follow-up amounted to a mean 15,151 Belgian francs. In conclusion, both acute hospital stays and subsequent medical care contribute significantly to medical costs induced by hip fractures.
Age Factors↗
Is time since hip fracture influencing the discrimination between fractured and nonfractured subjects as assessed at the calcaneum by three technologically different quantitative ultrasound devices?
Because quantitative ultrasound (QUS) instruments from different manufacturers have significant technical differences, it is difficult to assess whether all of them can discriminate similarly between osteoporotic fractures and age-matched controls. Thus, to avoid any bias, reliable comparative assessment of the QUS devices should be carried out on the same population. Few studies have fulfilled this condition. Another source of variability in cross-sectional studies in which fractured and nonfractured subjects are compared is the time since osteoporotic fracture. Our study evaluated the ability of three calcaneal QUS devices to discriminate patients with osteoporotic hip fracture from control subjects, using the same population. In addition, a subset of patients was re-measured about 9 months after the hip replacement surgery to check how the time since fracture affects the discriminatory ability of the different QUS devices. Fifty postmenopausal hip-fractured patients and 46 postmenopausal age-matched controls were included in this study and measured on three QUS devices, as well as 50 young healthy controls to calculate the T-score. Odds ratio results showed that a decrease in UBIS trade mark BUA of 1 SD was associated with a significant increase in fracture risk (odds ratio adjusted = 2.30) comparable with Sahara broadband ultrasound attenuation (BUA) (OR adj. = 2.30), and Achilles BUA (OR adj. = 3.5). However, given the large overlap between the 95% intervals of each OR and for the areas under ROC curves, no significant difference was found between them. In the subset of 15 hip-fractured subjects, no significant differences were found between ultrasound parameters of the first visit and 9 months after except for the heel width (soft tissue variation). Odds ratio and areas under the curve (AUC) tend to increase from visit 1 to 2 for the BUA and decrease substantially for the SOS for all but the Lunar Achilles+. Nonsignificant correlation was found between the absolute difference of the ultrasound parameters measured at the two visits and the time since fracture, except for the Sahara SOS (r = 0.45; P < 0.04). In conclusion, no significant differences between QUS technologies were observed in their positive and significant ability to discriminate hip-fractured patient from controls. However, this statement is shadowed when taking into account the time since fracture which seems to negatively influence results obtained on dry versus wet QUS systems. As a result, it is advisable that such parameters would be taken into account when designing a study aimed to demonstrate the discriminatory ability of heel ultrasound between normal and hip-fractured patients.
Adult↗
Prediction of the strength and fracture location of the femoral neck by CT-based finite-element method: a preliminary study on patients with hip fracture.
The purpose of this study was to predict fracture load and fracture location of the femora by means of the originally developed CT-based finite-element method (FEM). The femora of ten patients with contralateral hip fracture were analyzed to estimate fracture strength and to investigate whether the predicted fracture locations were similar to those of contralateral hip fractures. FEM has been utilized to determine the stress or strain distribution in bones under a certain load. FEM analyses of the strength of the femora in cadavers and patients have been reported, but those of hip fracture patients have not been analyzed. The femora of ten patients with contralateral hip fracture and those of three volunteers were analyzed based on the axial CT images of the whole femora. Prediction of hip fracture load and failure locations was made using CT-based finite-element analysis software. The predicted strength of the patients was less than half that of volunteers, and the predicted fracture lines existed at the proximal femur in all patients. It can be concluded that the FEM analyses adopted in this study are able to predict the fracture locations and load of the femora in patients with hip fracture.
Aged↗
Half the burden of fragility fractures in the community occur in women without osteoporosis. When is fracture prevention cost-effective?
To determine the age- and BMD-specific burden of fractures in the community and the cost-effectiveness of targeted drug therapy, we studied a demographically well-categorized population with a single main health provider. Of 1224 women over 50 years of age sustaining fractures during 2 years, the distribution of all fractures was 11%, 20%, 33%, and 36% in those aged 50-59, 60-69, 70-79, and 80+ years, respectively. Osteoporosis (T score < -2.5) was present in 20%, 46%, 59%, and 69% in the respective age groups. Based on this sample and census data for the whole country, treating all women over 50 years of age in Australia with a drug that halves fracture risk in osteoporotic women and reduces fractures in those without osteoporosis by 20%, was estimated to prevent 18,000 or 36% of the 50,000 fractures per year at a total cost of $573 million (AUD). Screening using a bone mineral density of T score of -2.5 as a cutoff, misses 80%, 54%, 41%, and 31% of fractures in women in the respective age groups. An analysis of cost per averted fracture by age group suggests that treating women in the 50- to 59-year age group with osteoporosis alone costs $156,400 per averted fracture. However, in women aged over 80 years, the cost per averted fracture is $28,500. We infer that treating all women over 50 years of age is not feasible. Using osteoporosis and age (>60 years) as criteria for intervention reduces the population burden of fractures by 28% and is cost-effective but solutions to the prevention of the remaining 72% of fragility fractures remain unavailable.
Age Distribution↗
Fracture rates and risk factors for fractures in patients with spinal cord injury.
AIM: To study fracture rates and risk factors for fractures in patients with spinal cord injuries. MATERIAL AND METHODS: A self-administered questionnaire was mailed to 646 members of the Danish Paraplegic Association and 1000 randomly selected normal controls. 438 patients (309 males, 129 females, 67.8%) and 654 controls (332 males, 322 females, 65.4%) returned the questionnaire. Median age in patients was 42, range 10-80 years, and in controls 43, range 19-93 years (2p = 0.25). RESULTS: The crude fracture rate was 2% per year in patients and 1% per year in controls (RR = 2.0, P < 0.001). Low-energy fractures were much more prominent in patients (19.0% of all fractures) than in controls (1.4%, P < 0.001). The fracture rate did not differ before the injury but increased after the injury to a constant level from the third year and forward. Fractures of the lower extremities were more prominent in patients than controls (femurs: RR = 23.4, P < 0.001, lower legs: RR = 5.2, P < 0.001, feet/toes: RR = 2.4, P = 0.006) while fractures of the forearms (P < 0.001) and clavicles (P = 0.03) were absent among patients. Fractures were more frequent in female patients (RR = 1.6, P = 0.008) and in male patients with a family history of fractures (RR = 2.0, P = 0.004). CONCLUSIONS: Low-energy fractures especially of the lower extremities are frequent in spinal cord injury patients and especially among female patients. The forearms seem protected from fractures.
Adolescent↗
Serum concentrations of steroids, parathyroid hormone, and calcitonin in postmenopausal women during the year following hip fracture: effect of location of fracture and age.
BACKGROUND: Hip fracture in the aged is a major health problem, especially considering the increasing proportion of the elderly in the population. This study examines changes in circulating levels of hormones, which are purported to affect bone metabolism, in response to hip fracture in postmenopausal women. METHODS: Patients consisted of women ages 65 and older who had surgery within 2 days of fracture. Serum samples were obtained at 3, 10, 60, 180, and 360 days postfracture. Healthy women without hip fractures from the same age range served as a control group (n = 17). Hormones were determined by radioimmunoassay. Subjects with fractures in the neck region of the femur (n = 78) were compared to subjects with fractures in the trochanteric region (n = 88). RESULTS: Estrone concentration (47.6 +/- 5.7 pg/mL; mean +/- SEM) at 3 days postfracture was elevated (p < .001) compared to control levels of 20.7 +/- 4.6 pg/mL. By 2 months, levels had declined to control levels. Androstenedione and the adrenal hormones, DHEAS and cortisol, displayed similar responses. Parathyroid hormone (PTH) levels were not significantly different from the control concentration at 3 days following fracture, but increased (p < .001) during the year following fracture. Calcitonin concentrations were much higher (p < .001) 3 days postfracture (42.1 +/- 3.7 pg/mL) compared to controls without fracture (9.8 +/- 3 pg/mL). Except for testosterone, no differences could be attributed to fracture location. Only PTH, with concentrations higher in the older age groups (p < .001), showed an age-related response. CONCLUSIONS: Following hip fracture, there are some dramatic responses in hormones that purportedly are mechanistically important in bone metabolism. These changes include transient increases in steroid hormones, chronic elevations in calcitonin, and rising levels of PTH during the year after fracture.
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Prediction of osteoporotic fractures in the general population by a fracture risk score. A 9-year follow-up among middle-aged women.
The possibility of predicting the occurrence of fractures on the basis of risk factors for osteoporosis was evaluated between 1975 and 1986 in a follow-up study of 1,014 women aged 45-64 years from a Dutch population sample. During the 9-year period of follow-up, 16% of the women experienced one or more fractures. Of 12 historical and radiologic risk factors for osteoporosis which are considered important in the biomedical literature, none were found to be strong indicators of future fractures. Complete information on risk factors was available for 742 women. A fracture risk score was calculated for each person by combining the simultaneous influence of several risk factors in a multivariate analysis. The risk score discriminated relatively well between women with high and low risks of fractures. The risk ratio between the highest and the lowest risk score quintiles was 6.4 for all fractures and 7.0 for type I osteoporotic fractures (fractures of the vertebral bodies and distal forearm). However, if belonging to the highest quintile was considered as a screening test for fracture prediction, the sensitivity and specificity were poor: 0.37 and 0.84, respectively, for all fractures and 0.48 and 0.83, respectively, for type I osteoporotic fractures. These results indicate that it might not be efficient to use risk factor status to select women for fracture prevention programs.
Age Factors↗
Isolated fractures of the greater tuberosity of the humerus: solutions to recognizing a frequently overlooked fracture.
BACKGROUND: Although isolated fracture of the greater tuberosity of the humerus had been regarded as an easily overlooked fracture, recent literature focusing on its diagnosis is scarce. The purpose of this study was to elucidate the rate of missed diagnosis of isolated humeral greater tuberosity fracture and pitfalls in diagnosis and to ascertain the most effective method for preventing missed diagnosis. METHODS: One hundred sixty-three shoulders, of which diagnosis was made by radiography for all and by proving a localized tenderness on the lateral wall of the greater tuberosity for the acute cases, were retrospectively reviewed. The diagnoses made at the previously visited clinic were analyzed, as was the relationship between missed diagnosis and other pertinent factors such as the extent of fracture and the amount of displacement of the fractured fragment. RESULTS: Fractures were overlooked in 58 of the 99 shoulders (59%) that had been initially examined at other clinics. The rate (64%) of missed diagnosis in one-part fractures was significantly higher than that (27%) in two-part fractures (p < 0.01). Twenty-five (76%) of 33 isolated supraspinatus (SSP) (facet for the SSP), 26 (57%) of 46 SSP + infraspinatus (ISP) (facet for the infraspinatus ISP), and 6 (33%) of 18 SSP + ISP + teres minor (facet for the teres minor) fractures were overlooked at previous clinics. The smaller the fragment, the higher the rate of missed diagnosis (p < 0.05). CONCLUSION: Isolated fracture of the greater tuberosity remains an easily overlooked injury. The likelihood of this missed diagnosis increases with the fracture being limited to the SSP facet and decreases as the fracture extends posteriorly. Confirming the presence of tenderness on the lateral wall of the greater tuberosity is a clinically effective method for preventing missed diagnosis.
Adolescent↗
Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: a prospective radiographic investigation of fracture stability.
Subsequent displacement of nondisplaced or minimally displaced fractures of the lateral humeral condyle while immobilized in plaster may contribute to severe complications. The possibility of assessing the stability of such fractures may be a help in planning the initial treatment. Our prospective investigation of 112 children aged 1-11 years aimed at describing radiographic criteria for prognosticating the stability of the fractures. According to the radiographic findings, the fractures were allocated to one of three groups representing stable fractures, fractures with undefinable risk, and fractures with high risk of later displacement. All children were treated with splinting only. Sixty-five fractures were classified as stable and turned out to be so without exception. Displacement occurred in six of 35 (17%) of the fractures judged uncertain and in five of 12 (42%) of those judged unstable. The subsequent displacement was 1 or 2 mm, and in one case, 3 mm. The defined criteria were found to be efficient in separating the stable and the high-risk fractures with acceptable confidence. The group of fractures with undecided risk of subsequent displacement was fairly large--one third of the total material. The implication the findings may bear to the treatment strategy of fractures is analyzed in a work in progress.
Child↗
Classification of fractures of the talus: clear differentiation between neck and body fractures.
The treatment and prognosis of neck fractures (extra-articular) and body fractures (intra-articular) of the talus are different. Ratios between neck fractures and body fractures reported by different investigators vary widely (from 6:1 to 1:1), because it is difficult to differentiate fractures crossing the anteromedial aspect of the trochlea. We examined 215 fractures of the talus. By examining the inferior surface fracture line, we found that the 61 fractures crossing the anteromedial aspect of the trochlea could be differentiated into 28 neck fractures and 33 body fractures. We suggest classifying fractures of the talus based on the inferior, not superior, surface fracture line.
Diagnosis, Differential↗
Freeze-fracture cytochemistry: thin sections of cells and tissues after labeling of fractures faces.
Experimental details of a new method for the cytochemical characterization of the membrane faces and cytoplasm produced by freeze-fracture of isolated cells and tissues are presented. This new method-"fracture-label"-involves grinding of frozen samples immersed in liquid nitrogen, thawing, cytochemical labeling of the fractured faces, and processing for thin section electron microscopy. Cationized ferritin (at pH. 7.5 and 4.0), colloidal iron, as well as concanavalin A are used to label the fractures faces of leukocytes and Hela cells embedded in a cross-linked matrix of bovine serum albumin and of liver and spleen tissues. Our results show the presence of numerous anionic binding sites on the fracture faces of all plasma and cytoplasmic membranes, and of concanavalin A binding sites preferentially associated to the exoplasmic fracture faces of plasma and nuclear envelope membranes. A proportion of the anionic sites appears to be revealed by, or during, the freeze-fracture process. Colloidal iron labeling also shows preferential association with the chromatin areas of cross-fractured nuclei. The results show that "fracture-label", i.e., the combined application of freeze-fracture and cytochemical labeling techniques, can be used to study the surface chemistry of the fractures faces of biological membranes as well as of cross-fractured cytoplasm.
Animals↗
How well can a previous fracture indicate a new fracture? A questionnaire study of 29,802 postmenopausal women.
In a population-based, retrospective study, we investigated the effect of a previous fracture on the risk of a later fracture. A questionnaire was mailed to 46,353 postmenopausal women aged 50-80 years and 29,802 (64%) responded. Questions were asked about fractures after age 25 and in what year they had occurred. The fractures were grouped according to whether they occurred within 5 and 10 years before answering the questionnaire. The occurrence of a fracture preceding these time intervals increased the odds ratio (OR) of having sustained a hip fracture to 1.6 (95% CI 1.1-2.3) for a previous ankle fracture and to 3.5 (95% CI 2.4-5.0) for a previous humerus fracture. Corresponding figures for having sustained a spine fracture were 1.5 (95% CI 1.1-2.1) for a previous ankle fracture and 4.5 (95% CI 3.4-5.9) for a previous spine fracture. It seems possible to select women for evaluation and intervention against osteoporosis by using information on previous fragility fractures.
Age Distribution↗
Estrogen replacement therapy and fractures in older women. Study of Osteoporotic Fractures Research Group.
OBJECTIVE: To determine the relation between estrogen replacement therapy and fractures. DESIGN: Prospective cohort study. SETTING: Four clinical centers in Baltimore County, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania. PARTICIPANTS: 9704 ambulatory, nonblack women 65 years of age or older. MEASUREMENTS: Estrogen use, medical history, and anthropometric data were obtained by questionnaire, interview, and examination. Appendicular bone mass was measured by single-photon absorptiometry. Incident fractures were validated by radiographic report. RESULTS: After adjustment for potential confounders, current estrogen use was associated with a decrease in the risk for wrist fractures (relative risk [RR], 0.39; 95% CI, 0.24 to 0.64) and for all nonspinal fractures (RR, 0.66; CI, 0.54 to 0.80) when compared with no estrogen use. Results were similar for women using unopposed estrogen or estrogen plus progestin, for women younger or older than 75 years of age, and for current smokers or nonsmokers. The effect of estrogen remained after adjustment was made for appendicular bone mass. The relative risk for hip fracture tended to be lower among current users (RR, 0.60; CI, 0.36 to 1.02) than among never-users. Estrogen was most effective in preventing hip fracture among those older than 75 years. Current users who started estrogen within 5 years of menopause had a decreased risk for hip fractures (RR, 0.29; CI, 0.09 to 0.92), wrist fractures (RR, 0.29; CI, 0.13 to 0.68), and all nonspinal fractures (RR, 0.50; CI, 0.36 to 0.70) when compared with women who had never used estrogen. Previous use of estrogen for more than 10 years or use begun soon after menopause had no substantial effect on the risk for fractures. CONCLUSIONS: Current use of estrogen appears to decrease the risk for fracture in older women. These results suggest that for protection against fractures, estrogen should be initiated soon after menopause and continued indefinitely.
Age Factors↗
Functional ability after hip fracture among patients home-dwelling at the time of fracture.
The aim of the study was to assess the change in function and residential status four months after hip fracture in patients over 50 years of age and living independently at home at the time of fracture. All consecutive hip fracture patients treated at Oulu University Hospital during 1989--1999 were followed up. Data collection was done on standardized hip fracture forms, which were filled in at admission and at four months postoperatively. The forms included demographic data, place of residence, locomotor ability, use of walking aids, data on the fracture and its treatment, hospital stay, place of discharge and pain. At four months, 16.0% of the men and 14.3% of the women were permanently institutionalized. Preoperatively, 81.1% of the patients had been able to walk out of doors either alone or accompanied, while at 4 months, less than half of the patients (149 men, 391 women) were able to do so. Two thirds of the hip fracture patients had been able to walk without walking aids before the fracture, the corresponding proportion being one fifth at four months after the fracture. Cumulative mortality at 4 months was 9.9%, being higher among the male (15.5%, n=53) than the female patients (7.9%, n=75). The original study population was also divided into two subgroups operated at different period of time (1989--92 and 1993--99), the functional results seemed to improve with time. Hip fracture leads to the institutionalization of every seventh patient able to live at home at the time of fracture and impairs markedly one's functional capacity. To restore the pre-fracture status as well as possible and to reduce the burden of the consequences of hip fracture, it might be beneficial to evaluate and improve the existing rehabilitation system.
Activities of Daily Living↗
[Fractures of the pelvis in children excluding isolated fractures of the acetabulum and sacrum. Apropos of 267 cases. Anatomic study, contribution of modern radiologic studies, therapeutic management].
This work studies the combined experience of several orthopedic services of 267 pelvic fractures (excluding isolated iliac and sacral fractures) in childhood. The mechanism of these fractures was studied, the majority were the result of road traffic accidents. Among the complications lesions of the urinary tract were most common. Hypotensive states secondary to retroperitoneal bleeding were common but their exact incidence was difficult to estimate accurately. In association with these pelvic lesions it is necessary to emphasize the high incidence of associated cranial, abdominal and skeletal injuries. Computed tomography represents a considerable advance in the assessment of these fractures, demonstrating fractures not visible on standard radiographs and permitting a more precise analysis of displacement. The same type of fractures were in infants as has been reported in adults. However in addition in childhood fractures involving the cartilaginous growth plate are also seen. These include true separation of the growth plate at the triradiate cartilage, the iliac crest and the pubic symphysis. Surgical treatment is only considered for fractures interrupting the pelvic ring and particularly in the context of anterior and posterior column fractures. However, these displaced fractures may leave, contrary to popular opinion sequelae such as leg length discrepancies, ankylosis of the sacro iliac joint, malunited fractures and pain. Therefore it is necessary to adopt a more rigorous attitude in the management of pelvic fractures in the child to avoid these sequelae and to aid in the treatment of associated injuries.
Adolescent↗
Fracture of the hyoid bone in strangulation: comparison of fractured and unfractured hyoids from victims of strangulation.
The hyoid is the U-shaped bone of the neck that is fractured in one-third of all homicides by strangulation. On this basis, postmortem detection of hyoid fracture is relevant to the diagnosis of strangulation. However, since many cases lack a hyoid fracture, the absence of this finding does not exclude strangulation as a cause of death. The reasons why some hyoids fracture and others do not may relate to the nature and magnitude of force applied to the neck, age of the victim, nature of the instrument (ligature or hands) used to strangle, and intrinsic anatomic features of the hyoid bone. We compared the case profiles and xeroradiographic appearance of the hyoids of 20 victims of homicidal strangulation with and without hyoid fracture (n = 10, each). The fractured hyoids occurred in older victims of strangulation (39 +/- 14 years) when compared to the victims with unfractured hyoids (30 +/- 10 years). The age-dependency of hyoid fracture correlated with the degree of ossification or fusion of the hyoid synchondroses. The hyoid was fused in older victims of strangulation (41 +/- 12 years) whereas the unfused hyoids were found in the younger victims (28 +/- 10 years). In addition, the hyoid bone was ossified or fused in 70% of all fractured hyoids, but, only 30% of the unfractured hyoids were fused. The shape of the hyoid bone was also found to differentiate fractured and unfractured hyoids. Fractured hyoids were longer in the anterior-posterior plane and were more steeply sloping when compared with unfractured hyoids. These data indicate that hyoids of strangulation victims, with and without fracture, are distinguished by various indices of shape and rigidity. On this basis, it may be possible to explain why some victims of strangulation do not have fractured hyoid bones.
Adult↗