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Expression of galanin and galanin receptor-1 in normal bone and during fracture repair in the rat.
The neuropeptide galanin (GAL) has recognized physiological actions in the nervous system and other tissues, but there is no documented evidence of GAL influencing normal or pathological bone metabolism. GAL expression, however, is upregulated in central and peripheral nerves following axotomy and is known to influence neural regeneration. Thus, severance of skeletal-associated nerves during fracture could similarly increase local GAL concentrations and thereby influence fracture healing. The initial aim of this study was therefore to identify the presence of GAL in normal bone and/or fracture callus by assessing the concentration and cellular localization of GAL in intact and/or fractured rat rib, using radioimmunoassay and immunohistochemistry, respectively. Groups of Sprague-Dawley rats (13 weeks old) had their left sixth ribs surgically fractured or underwent sham surgery and then calluses and nonfractured rib samples were analyzed at 1 and 2 weeks postsurgery (n = 5-6 per group). Low (basal) concentrations of GAL were detected in control ribs, whereas at 1 and 2 weeks postfracture, callus samples contained markedly increased levels of peptide ( approximately 32- and 18-fold increase, respectively, relative to controls; P < 0.01), revealing a strong upregulation during bone healing. Plasma GAL concentrations were also increased at 2 weeks postfracture (P < 0.005). In normal (nonfractured) rib, minimal levels of GAL-like immunoreactivity (LI) were present in cortical bone, periosteum, endosteum, and surrounding skeletal muscle. In costal cartilage plates, intense GAL-LI was present in all chondrocytes of the hypertrophic zone and in a population of chondrocytes in the reserve zone. GAL-LI was not present, however, in chondrocytes in the proliferative zone of costal cartilage or skeletal muscle fibers. In fracture callus, levels of GAL-LI were moderate to intense in osteoprogenitor cells and osteoblasts, in some chondrocytes, and in cartilaginous, osseous, and periosteal matrices. Subsequent studies revealed the presence of galanin receptor-1-like immunoreactivity (GALR1-LI) in most cell types shown to contain GAL-LI, although the distribution of GALR1-LI was more extensive in reserve zone chondrocytes than that of GAL-LI; and GALR1-LI also appeared in late proliferative zone chondrocytes of costal cartilage. In summary, GAL concentrations were significantly increased in fracture callus and plasma of rats that underwent rib fracture. In addition, GAL- and GALR1-LI was also detected in specific cells and structures within costal cartilage, bone, and fracture callus. These results strongly implicate GAL in aspects of cartilage growth plate physiology and fracture repair, possibly acting in an autocrine/paracrine fashion via GALR1.
[Isolated fracture of the first rib].
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[Complications in fractures of the ribs].
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Spontaneous fracture of the lower angle of scapula. Possible role of cough.
We report a case of a fracture of the inferior angle of the scapula related to prolonged cough, without triggering trauma, sport, or occupational activity. Bone insufficiency was present in this patient. Stress fractures of the scapula are rare; the fatigue type is the most frequent, associated with sports or occupational activity. We do not find any published case report about scapula stress fracture related to cough, until rib fractures are frequent in this situation. Repetitive muscular activity of the serratus anterior and major rhomboid on the inferior angle of the scapula during cough may explain this avulsion fracture.
Manifestations of the shaken baby syndrome.
Retinal hemorrhages are the most common fundus finding in the shaken baby syndrome. They vary in type and location; no particular type is pathognomonic for the condition. Retinal hemorrhages are not needed to make a diagnosis of shaken baby syndrome. However, in a child under age 3 years, the presence of extensive bilateral retinal hemorrhages raises a very strong possibility of abuse, which must be investigated. The other possible causes for hemorrhages in this age child can be investigated and eliminated. The diagnosis of abuse should be made by someone particularly trained in this area, who can put together the entire picture of inadequate or changing history, fractures of various ages, particularly rib fractures, subdural hematoma of the brain, and retinal hemorrhages. Photographs of retinal hemorrhages are very helpful to child advocacy experts who take these cases to court.
Prospective clinical follow-up after percutaneous vertebroplasty in patients with painful osteoporotic vertebral compression fractures.
PURPOSE: To prospectively assess short-term, midterm, and long-term pain relief in patients with painful osteoporotic vertebral compression fractures (VCFs) treated with percutaneous vertebroplasty (PV). MATERIALS AND METHODS: Visual analog scale (VAS) scores for pain at the treated vertebral level, analgesic use, and satisfaction with outcome were assessed in 112 patients after PV of 168 VCFs. Serial follow-up was performed at 24 hours and 3, 6, and 12 months and in a small number of patients at 1-3 years. Procedure-related complications were evaluated by physical examination and computed tomography of treated levels. RESULTS: After PV, VAS scores for pain at the individual vertebral levels treated and use of analgesic agents were significantly reduced compared with before treatment at every follow-up period. Within 24 hours after the procedure, the decreases in all scores were less compared with scores at later follow-up periods, but this was not significant. The preprocedural mean VAS score was 8.8 (range, 5-10). At follow-up, mean VAS scores ranged from 2.5 to 3.3 (range, 0-10). In the short term after PV, patients used significantly less analgesic drugs and 86% of patients were satisfied with the outcome. At midterm and long-term follow-up, patients used even less analgesic drugs and 95%-100% of patients were satisfied with the outcome of PV. Procedure-related complications with clinical consequences occurred in three patients (2.7%): one patient experienced a cardiovascular reaction, one patient had a pedicle chip fracture, and one had a rib fracture. CONCLUSION: PV of painful osteoporotic VCFs provides significant pain reduction in nearly all treated patients.
INJURY TO THE RESPIRATORY TREE. ROENTGENOLOGIC FINDINGS AFTER SEVERE BLUNT TRAUMA.
The roentgenologic signs of free air in the subcutaneous, mediastinal pleural spaces may be indicative of fractures of the trachea and bronchi and injuries to the larynx. While these findings are also present in otherwise uncomplicated rib fracture and following tracheostomy, care must be taken to make sure that the cause of these abnormalities is not an unrecognized bronchial or tracheal rupture.
Terrible triad of the elbow: a case report of a new variant.
The usual terrible triad of the elbow consists of posterior dislocation of the elbow, radial head fracture and coronoid fracture. We describe a new variant of the terrible triad of the elbow consisting of fracture of the capitellum involving the full length of the trochlea and posterolateral dislocation of the elbow associated with coronoid fracture (type 1 Regan-Morrey). A 25-year-old girl was brought to the emergency ward with the history of having jumped from the third floor with an intention of committing suicide. She sustained multiple fractures, i.e, fracture ribs, bilateral intra-articular fracture of the lower end of the radius, left-side elbow injury, left subtrochanteric fracture femur and left zygomatic fracture with head injury. The elbow was stable after stabilization of the capitellum fracture through a collateral approach. Coronoid fragment was left alone, as it was a very small fragment.
[Tumors of the ribs in children].
We here present a review of ten pediatric patients with rib tumors that were treated in our hospital since 1970: a juvenile bone cyst, an aneurysmal bone cyst, an eosinophilic granuloma, a Ewing sarcoma, a metastasis of a neuroblastoma, an osteochondroma, a hemangiopericytoma, and a callous tumor at the site of a previous single rib fracture. The relative frequency of rib tumors is similar to that of bone tumors in other locations. A biopsy of the affected bone should be the first step of the operative intervention. As demonstrated in a case of eosinophilic granuloma, the indication for subperiosteal rib resection can be defined generously. A completed regrowth of the rib defect can be expected. Even the loss of a complete rib is generally well tolerated, as shown in an infant with an aneurysmal bone cyst, a rare disease in this age group. Malignant tumors of the chest wall, however, require special experience in thoracic surgery and necessitate close interdisciplinary cooperation. Complete primary resection of a malignant rib tumor and its plastic reconstruction is demonstrated in a case of a Ewing sarcoma in childhood. In children and adolescents a vicryl net should generally be used to reconstruct extended chest wall defects reliably and functionally stable.
Save the trees: a comparative review of skier-tree collisions.
From 1981 to 1989, 323 patients whose diagnoses resulted from ski injuries were emergently admitted to a Class 1 Trauma Hospital. Of this group, 107 (33%) were injured in skier-tree collisions. This tree collision group (TC group) was compared with a group that did not hit a tree (non-tree-collision group or NTC group). The average age of the TC group was 26 years, compared with 31 years in the NTC group. The Revised Trauma Score (RTS) was recorded for each patient. The TC group's average trauma score was 7.205, compared with 7.7395 for the NTC group. The Injury Severity Score (ISS) was also recorded. The TC group's ISS averaged 14.7, compared with 9.1 for the NTC group. Both of these scores demonstrated statistical significance. Certain injuries such as skull fractures, head injuries, pelvic fractures, and chest injuries (including rib fractures, pneumothoraces, and pulmonary contusions) were more common in the TC group. Tibia fractures were more common in the NTC group. Femur fractures and upper extremity fractures were evenly distributed between the two groups. Seven deaths were recorded in the TC group and five deaths occurred in the NTC group.
Prevention of bone loss after heart transplantation with antiresorptive therapy: a pilot study.
BACKGROUND: Heart transplantation, with its attendant glucocorticoid and cyclosporine therapy, has deleterious effects on the skeleton. We have previously reported rapid bone loss and high fracture rates (36% of patients) during the first year after heart transplantation. The bone loss was accompanied by declines in serum 1,25-dihydroxyvitamin D and osteocalcin levels and increased urinary excretion of markers of bone resorption (hydroxyproline, pyridinoline, and deoxypyridinoline). We therefore investigated whether bone loss could be prevented by bisphosphonates, agents that inhibit bone resorption. METHODS: Serial measurements of bone mineral density (BMD) and biochemical indexes of mineral metabolism were compared in 18 group A patients who received a single intravenous infusion of pamidronate (60 mg) within 2 weeks of heart transplantation, followed by 4 cycles of oral etidronate (400 mg daily for 14 days every 3 months) and oral calcitriol 0.25 microg daily, to those of 52 patients who previously underwent transplantation (group B) who did not receive antiresorptive therapy. Both groups received elemental calcium 1000 mg and vitamin D 400 IU daily. RESULTS: At 12 months after transplantation, there was virtually no lumbar spine bone loss in group A patients, whereas lumbar spine BMD had declined significantly in group B patients (0.2% +/- 0.9% vs 6.8% +/- 1.0%, respectively; P < .0001). Similarly, femoral neck BMD fell by 10.6% +/- 1.1% in group B patients and by only 2.7% +/- 1.4% in group A patients (P < .0001). Three incident vertebral fractures occurred in two group A patients, whereas 17 group B patients sustained 30 incident vertebral fractures, one hip fracture and three episodes of rib fractures (P < .02; test of proportions). With respect to markers of bone resorption, urinary deoxypyridinoline fell by 51% +/- 9% in group A patients and increased by 65% +/- 22% in group B patients by 3 months after transplantation (P < .0001). CONCLUSION: In summary, heart transplant recipients treated with bisphosphonates and replacement doses of calcitriol sustained less bone loss and fewer fractures than those treated with calcium and vitamin D. We conclude that bisphosphonate therapy, in conjunction with calcitriol, shows promise for prevention of transplantation-related osteoporosis.
[111InCl3 uptake in ununited fractures: a case report].
111InCl3 scintigraphy was performed in a 37-year-old male with pancytopenia. Intense tracer uptake in the ununited rib fractures was recognized. There are few descriptions of 111InCl3 uptake in ununited fracture, and this case indicated that ununited fracture should be added to the differential diagnosis of 111InCl3 uptake.
Brachial plexus injuries from blunt trauma--a harbinger of vascular and thoracic injury.
We reviewed the records of 59 patients who suffered brachial plexus injuries following blunt trauma between the years 1974 and 1984. The age of the patients ranged from 2 to 84 years, with a mean of 35.3 years. Forty-five were male patients. The majority of injuries (53%) were caused by motor vehicle accidents. Direct trauma was the mechanism of injury for 33 patients, traction for 18, shoulder dislocation for six, and acromioclavicular separation for two. The injuries occurred on the left side in 33 (56%); the right side in 23 (39%), and bilaterally in three (5%). Eight patients (14%) suffered complete brachial plexus palsies, and 51 (86%) incurred partial palsies. Nine patients (15.2%) presented in shock. Severe associated injuries occurred in this group of patients and included multiple rib fractures, hemopneumothorax, pulmonary contusion, head injuries, and upper extremity fractures. Subclavian artery injuries occurred in three patients, axillary artery in two patients, and an internal carotid injury in one patient. Complete resolution of the palsy occurred in 25 patients, partial resolution occurred in 17 cases, and the brachial plexus palsy remained permanent in nine. Eight patients were lost to follow-up. Brachial plexus injuries frequently occur in association with severe trauma, are usually partial palsies, and resolve partially or completely in two-thirds of cases. In addition, 10% of these patients suffered major vascular injuries and 10% incurred significant chest trauma.
Actions of the inspiratory intercostal muscles in flail chest.
We have previously shown in dogs that the ribs in flail chest move paradoxically inward during inspiration but continue to move cranially. We have also shown that flail elicits, probably via an increased activation of the muscle spindles, a threefold to fourfold increase in external intercostal inspiratory EMG activity without inducing any changes in parasternal intercostal activity. Therefore, the present studies were undertaken to test the hypothesis that the persistent cranial motion of the fractured ribs resulted primarily from the action of the external intercostals. A flail was induced in seven supine anesthetized animals by fracturing both dorsally and ventrally ribs 3 to 6 on the right side of the chest, after which the external intercostal muscles in interspaces 1 to 7 were severed. Severing the external intercostals caused a small increase in the inspiratory inward displacement of the fractured ribs, from 2.76 +/- 0.31 to 3.25 +/- 0.38 mm (p < 0.05), but it did not affect the parasternal intercostal EMG activity or the cranial rib displacement (before, 3.61 +/- 1.03 mm; after, 3.22 +/- 1.43 mm; NS). However, when the parasternal intercostals in interspaces 1 to 7 were also denervated, the inspiratory inward displacement of the ribs increased markedly to 5.95 +/- 0.48 mm (p < 0.01), and their inspiratory cranial displacement was reversed into a 1.05 +/- 0.58 mm inspiratory caudal displacement (p < 0.01). We conclude, therefore, that in dogs with flail chest the respiratory displacements of the ribs are still primarily determined, besides pleural pressure, by the action of the parasternal intercostals. These observations also suggest that in anesthetized dogs, spindle-induced excitation of the external intercostals has little impact on the mechanical behavior of the ribs.
The abused child: a radiological reappraisal.
Radiological findings in 563 abused infants and children who were studied retrospectively emphasize the limitations of diagnostic imaging, specifically radiographic examination of the skeleton. Skeletal trauma was detected in less than one-third of all patients and was uncommon beyond two years of age. Fractures were rarely present without clinical evidence of physical abuse. Radiographic features considered specific for child abuse (epiphyseal-metaphyseal, rib fractures) or highly suggestive (occult, multiple/repetitive fractures) were distinctly infrequent and limited to infancy. A more efficacious approach to radiological evaluation based on clinical presentation is offered.
[The unstable thoracic wall: possibilities for treatment].
In the treatment of severe chest injuries with flail chest either positive-pressure mechanical ventilation (and tracheostomy) is necessary or the surgical stabilisation of the chest wall by osteosyntheses of the broken ribs. Fourteen patients (age 27-73) with severe chest injuries and paradoxical respiration were operated and the rib fractures stabilized by means of small reconstruction plates and cerclage wires. Three patients died due to other reasons. There were no serious complications. The results are reported. In severe chest injuries surgical treatment seems to be justified; it reduces the need of artificial respiration and can be recommended.
Determinants of rib motion in flail chest.
We have previously developed a canine model of isolated flail chest to assess the effects of this condition on the mechanics of breathing, and these studies have led to the conclusion that the respiratory displacement of the fractured ribs is primarily determined by the fall in pleural pressure (Delta Ppl) and the action of the parasternal intercostal muscles. The present studies were designed to test the validity of this conclusion. A flail was induced in six supine anesthetized animals by fracturing both dorsally and ventrally the second to fifth ribs on the right side of the chest, after which the phrenic nerve roots were bilaterally sectioned in the neck. Sectioning the phrenic nerves caused a 34% decrease in Delta Ppl, associated with a 39% increase in parasternal intercostal inspiratory EMG activity (p < 0.05), and resulted in a marked reduction in the inspiratory inward displacement of the ribs. In three animals, the inward rib displacement was even reversed into a small outward displacement. When the airway was then occluded at end-expiration to increase Delta Ppl during the subsequent inspiration, all animals again showed a clear-cut inward rib displacement. These observations therefore confirm that in dogs with flail chest, the inspiratory displacement of the fractured ribs is set by the balance between the force related to pleural pressure and that generated by the parasternal intercostals. These observations also point to the critical importance of the pattern of inspiratory muscle activation in determining the magnitude of rib cage paradox in such patients.