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PubMed2006

[Primary hyperparathyroidism complicated with flail chest due to severe osteoporosis].

We report a 61-year-old woman who was admitted to our hospital in August 2004 with severe hypercalcemia and osteoporosis. Although she was found to have hypercalcemia five years earlier, she has never been treated. The patient was transferred to our hospital for further management of a recently-identified left neck mass. Serum calcium level was 15.0 mg/dL and intact parathyroid hormone (PTH) 3,321 pg/mL. (99m)Tc-methoxyisobutylisonitrile (MIBI) scintigraphy showed marked accumulation in the left neck. We diagnosed the tumor as parathyroid gland tumor and it was enucleated surgically. Although serum Ca level returned to normal after surgery, the patient suffered multiple rib fractures, complicated with marked paradoxical breathing. Internal fixation of the thorax was necessary due to deterioration of the heart failure. Progression of severe osteoporosis was associated with multiple fractures of the ribs and other serious complications including congestive heart failure occurred after surgery, reflecting the extreme difficulty in treating this patient.

Female↗
PubMed2000

Body size and risk for clinical fractures in older women. Study of Osteoporotic Fractures Research Group.

BACKGROUND: Small body size predicts hip fractures in older women. OBJECTIVE: To test the hypothesis that small body size predicts the risk for other clinical fractures. DESIGN: Prospective cohort study. SETTING: Population-based listings in four areas of the United States. PATIENTS: 8059 ambulatory nonblack women 65 years of age or older. MEASUREMENTS: Weight, weight change since 25 years of age, body mass index, lean body mass and percent body fat, and nonspine fractures during 6.4 years of follow-up. RESULTS: Compared with women in the highest quartile of weight, women in the lowest quartile had relative risks of 2.0 (95% CI, 1.5 to 2.8) for hip fractures, 2.3 (CI, 1.1 to 4.7) for pelvis fractures, and 2.4 (CI, 1.5 to 3.9) for rib fractures. Adjustment for total-hip bone mineral density eliminated the elevated risk. Results were similar for other body size measures. Smaller body size was not a risk factor for humerus, elbow, wrist ankle, or foot fractures. CONCLUSIONS: Total body weight is useful in the prediction of hip, pelvis, and rib fractures when bone mineral density has not been measured.

Adipose Tissue↗
PubMedDate not supplied

Long-term use of oral anticoagulants and the risk of fracture.

BACKGROUND: Vitamin K participates in bone metabolism and, since oral anticoagulants antagonize vitamin K, their use may increase the risk of osteoporosis. OBJECTIVE: To evaluate fracture risk at all skeletal sites following exposure to oral anticoagulants. METHODS: In a population-based retrospective cohort study, 572 Olmsted County, Minnesota, women 35 years or older at their first lifetime venous thromboembolism event between 1966 and 1990 were followed up for fractures. Risk was assessed by comparing new fractures with the number expected from sex- and age-specific fracture incidence rates for the general population (standardized incidence ratio [SIR]). RESULTS: Altogether, 480 fractures occurred during 6314 person-years of follow-up. Increasing exposure to oral anticoagulation was associated with an increased SIR for vertebral fractures: at less than 3 months of exposure, 2.4 (95% confidence interval [CI], 1.6-3.4); 3 to less than 12 months, 3.6 (95% CI, 2.5-4.9); and 12 months or more, 5.3 (95% CI, 3.4-8.0); and for rib fractures: at less than 3 months, 1.6 (95% CI, 0.9-2.7); 3 to less than 12 months, 1.6 (95% CI, 0.9-2.6); and 12 months or more, 3.4 (95% CI, 1.8-5.7). The data revealed no increased risk for other types of fractures. Oral anticoagulation for 12 months or more was an independent predictor of vertebral fractures (P = .009) and rib fractures (P = .02), but not other fractures. CONCLUSIONS: Long-term exposure to oral anticoagulation is associated with an increased risk of vertebral and rib fractures. The mechanism by which this occurs is still unclear and needs further investigation.

Administration, Oral↗
PubMed2001

Vertebral deformities and low bone mineral density in adults with cystic fibrosis: a cross-sectional study.

Patients with cystic fibrosis (CF) have low bone mineral density (BMD). The clinical relevance of this is not clearly established. The aim of this study was to determine the prevalence of low BMD and vertebral deformities in CF adults with varied disease severity. One hundred and seven patients (58 men) aged 18-60 years underwent dual-energy X-ray absorptiometry scanning of the lumbar spine and hip, radiology of the spine and biochemical studies. Thirty-eight percent had a Z-score of < -1, with 13% having Z-scores < -2. Seventeen percent had evidence of vertebral deformity on radiography, mostly in the thoracic spine. Thirty-five percent reported past fractures, of which 9% were rib fractures. Percent predicted forced expiratory volume in 1 second (FEV1) and the amount of daily physical activity were positively related to BMD. The number of intravenous antibiotic courses in the previous 5 years was negatively related to BMD. Patients with a history of rib fracture and CF-related diabetes had significantly lower femoral neck BMD (p < 0.02). The median serum 25-hydroxyvitamin D was 28 nmol/l, with 36% of patients having levels below 25 nmol/l despite vitamin D supplementation. Forty-four percent had raised levels of urinary pyridinium crosslinks (NTx). In conclusion, fragility fractures and hypovitaminosis D occur commonly in adult patients with CF. Low BMD occurs in patients with more severe disease and significantly relates to FEV1, infective exacerbations and daily energy expended in physical activity.

Absorptiometry, Photon↗
PubMed2005

Chest deflection tolerance to blunt anterior loading is sensitive to age but not load distribution.

Ninety-three human cadaver tests are used in the development of thoracic injury risk functions with consideration of age and restraint condition. Linear logistic regression models are developed with the set of potential predictors including the maximum chest deflection, the age of the cadaver at death, gender, and the loading condition on the anterior thorax: blunt hub (41 tests), seat belt (26 tests), air bag (12 tests), and combined belt-and-bag (14 tests). Predicted outcomes were the probability of any rib fractures (onset of injury) and the probability of greater than six rib fractures (severe injury). The analysis shows that the injury risk function was not dependent on the loading condition, but was strongly dependent on age. A significant injury risk model with good ability to discriminate injury from non-injury tests (P < 0.0001, chi-square = 21.49, area under receiver operator characteristic curve (ROC) = 0.867, Kruskal's Gamma = 0.732) is presented using only maximum chest deflection and cadaver age as predictors of injury risk. The 50% risk of any rib fractures is found to occur at 35% chest deflection for a 30-year-old, but at 13% deflection for a 70-year-old. The 50% risk of severe injury is shown to occur at 33% chest deflection for a 70-year-old, but at 43% for a 30-year-old.

Accidents, Traffic↗
PubMedDate not supplied

Injuries to emergency medicine residents on EMS rotations.

OBJECTIVES: To study the incidence and nature of injuries sustained by emergency medicine (EM) residents during EMS rotations, and steps taken at EM residency programs to increase resident safety during field activities. METHODS: An eight-question survey form was mailed to all 114 U.S. EM residency directors, with a second mailing to nonresponders eight weeks after the initial mailing. RESULTS: A total of 105 surveys were returned (92%). Six surveys were from new programs whose residents have not yet rotated on EMS. These were excluded from further analysis, leaving 99 programs. Of these, 91 (92%) reported no injuries. One EM resident died in a helicopter crash in 1985. Seven other injury events were reported: 1) facial lacerations, rib fractures, and a shoulder injury in an ambulance accident; 2) an open finger fracture (crushed by a backboard); 3) contusions and a concussion when an ambulance was struck by a fire engine; 4) a groin pull sustained while entering a helicopter; 5) bilateral metatarsal fractures in a fall; 6) rib fractures, a pneumothorax, and a concussion in an ambulance accident; and 7) "minor injuries" sustained in a crash while responding to a scene in a program-owned response vehicle. Actions taken at residency programs to reduce the risk of injury include the use of ballistic vests (four programs), requiring helmets on flights (five programs), and changing flight experience from mandatory to optional (two programs). Ten programs (10%) reported using ground scene safety lectures, and nine programs (15% of those offering flights) reported various types of flight safety instruction. Sixty-nine programs (70%) reported no formal field safety training or other active steps to increase resident safety on EMS rotations. CONCLUSIONS: Injuries sustained by EM residents during EMS rotations are uncommon but nontrivial, with several serious injuries and one fatality reported. The majority of EM residency programs have no formal safety training programs for EMS rotations.

Accidents, Occupational↗
PubMed1994

Missed scapular fracture after trauma. A case report and a 23-year follow-up report.

Scapular fractures are important in that they are often associated with high morbidity and mortality. Frequently they are overlooked because of the severity of other associated injuries. Extraarticular scapular fractures are often treated conservatively, even when displaced. There is no significant long-term evaluation on this type of treatment and on the management of scapular malunion. This case report presents a missed scapular fracture and associated rib fractures with subsequent malunion and a 23-year follow-up assessment. Surgical resection of a distorted inferior medial border of the scapula and dorsal rib prominences relieved the patient's symptoms. The case presentation, diagnostic modalities, treatment, and possible long-term sequelae of this complex fracture are reviewed.

Accidents, Traffic↗
PubMed1989

Chest injuries sustained in severe traffic accidents by seatbelt wearers.

In Finland during the period 1972-1985, there occurred 3,468 severe traffic accidents in which one or more of the drivers or passengers sustained an injury leading to a fatal outcome within 30 days. Of the victims who had been wearing seatbelts, 207 had fatal and 73 had severe chest injuries. The four leading causes of fatalities resulting from chest injuries were ruptures of the aorta (37%), ruptures of the heart (28.4%), and bilateral lung contusions (31.1%) or lacerations (15.5%). Seatbelt wearers with heart ruptures more often had concomitant rib fractures, lung injuries, and sternum fractures than those who had sustained ruptures of the aorta. The side of rib fractures was associated with the victim's location in the car, drivers seated on the left having more right-sided and right front passengers more left-sided rib fractures. In addition to chest injuries, 87% of the victims had other concomitant injuries, the most common abdominal injuries being liver injuries (40.2%) and spleen ruptures (26.5%). In seatbelt wearers chest injuries with a fatal outcome appear to be caused by impacts of exceptional severity, since in more moderate accidents seatbelt wearing has proved to save lives.

Accidents, Traffic↗
PubMed2006

[Applicational study of 3D reconstruction with spiral computed tomography in evaluation of anatomical complicated bones fracture].

OBJECTIVE: To investigate forensic diagnosis application of three-dimentional reconstruction with spiral computed tomography in fracture of anatomical complicated bones. METHODS: Selected eleven patients of bone fracture who were examined with SCT 3D and conventional X-ray examination. The location, number and characteristics were observed and analyzed. RESULTS: In all of eleven patients with bone fractures, X-ray examination could detect thirty-four rib fracture, one scapula fracture, two nasal fracture, one metacarpal bone incomplete fracture and one left tibia-fibula fracture, one pubis fracture. While there were forty-seven rib fracture, one scapula smash fracture, one nasal fracture with obvious displacement and eliminate one misplace, one left tibia-fibula obsolete fracture and one sacroiliac joint dislocation, one No 5 lumbar vertebrae pedicle of vertebrae arch fracture. Combining 3D reconstruction images, coronary and sagittal reconstruction images could show clearly the fracture line, location of fracture, number of fracture, displacement and recovery. CONCLUSION: 3D reconstruction technique of SCT is a very useful examination method in the objective forensic diagnosis of anatomical complicated bones fracture, it excels the routine X-ray examination.

Adult↗
PubMed2000

Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making.

BACKGROUND: Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma. METHODS: A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated. RESULTS: A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (< or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693). CONCLUSION: Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.

Adolescent↗
PubMed2003

Thoracic trauma in foals: post mortem findings.

REASONS FOR PERFORMING STUDY: Thoracic trauma occurs in newborn foals and may cause associated clinical signs; this condition remains poorly documented. OBJECTIVES: The purpose of this study was to describe the pathological features of thoracic trauma in newborn foals presented for necropsy examination between 1990 and 2000. METHODS: Necropsy reports of foals with thoracic trauma from 1990-2000 were reviewed. Subject details, clinical signs, thoracic and abdominal lesions were noted and analysed statistically. RESULTS: Sixty-seven (9%) of 760 necropsied foals had thoracic trauma. In 19 foals, fractured ribs were considered to be the cause of death (Group A). The remaining foals had fractured ribs (Group B, n = 20) or rib contusions (Group C, n = 28) that were incidental findings. Ribs 3 to 8 accounted for 86% of the traumatised bones. The most common site of injury was the costochondral junction and an area immediately above it (94%). In Group A, all but 2 foals died within the first 8 days postpartum. Haemothorax and subsequent pulmonary collapse was cited most commonly as the cause of death (53%). Diaphragmatic rupture and hernia (n = 2) also occurred. CONCLUSIONS: The focal site, consistent location and presence of lesions during the first week post partum, all suggest that thoracic trauma in newborn foals probably occurs during parturition. POTENTIAL RELEVANCE: The description of lesions and site of occurrence of thoracic trauma in foals will increase awareness and improve the diagnosis and treatment of this life threatening condition.

Animals↗