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PubMed2001

Secondary prevention of osteoporosis: when should a non-vertebral fracture be a trigger for action?

The burden of non-vertebral fractures is enormous. Hip fractures account for nearly 10% of all fractures (and a much greater proportion in the elderly), while wrist fractures may account for up to 23% of all limb fractures. The best available predictors of non-vertebral fracture risk are low BMD and a tendency to fall. Hip, forearm, proximal humerus and rib fractures have all been associated with low BMD, though ankle fracture is not strongly related to osteoporosis. Although clinical risk factors identify only about one-third of postmenopausal women at increased risk of osteoporotic fracture, the occurrence of one fracture commonly predicts a second fracture. Guidelines are presented for identifying and treating patients at risk of non-vertebral osteoporotic fractures, especially those with a previous fracture, based on the algorithm recently published by the Royal College of Physicians and the Bone and Tooth Society. Prevention of falls and use of external hip protectors may reduce the occurrence of hip fracture. Treatment options for patients presenting with hip fracture include HRT, bisphosphonates, and calcium plus vitamin D, and for Colles' fracture include general measures, HRT, bisphosphonates, or calcitonin plus calcium.

Accidental Falls↗
PubMed1994

Child abuse, sudden infant death syndrome, infectious disease, and vaccinations.

Clinicians all too often face the difficult dilemma of deciding whether a bone fracture in a young child was intentional. A structured expert consensus process suggests that all rib fractures; midshaft or metaphyseal fractures of the humerus; and fractures of the radius, ulna, tibia, or fibula in children younger than 1 year of age are highly likely to have been caused by abuse. Abused children are more likely to have negative social relationships with other children than their school-aged peers. Research on the causes of sudden infant death syndrome is still confounded by the likelihood that some deaths for which the label was misapplied are included in many studies; however, the presence of smokers in the household in the postnatal period appears to be yet another factor associated with increased risk. Congenital syphilis is on the rise. Detection of infants who have been infected is incomplete. Lack of prenatal care is strongly associated with infection. Cord serology is not sensitive enough to detect all possible cases. Testing of both maternal and neonatal sera results in detection of more infants at risk. Current tests still result in the treatment of some infants who are not themselves infected. Amoxicillin clavulante given twice daily rather then thrice, cefixime given once a day, and a single intramuscular dose of ceftriaxone have all shown acceptable--though not exceptional--cure rates for otitis media. Price is a consideration. Fewer courses of antibiotics would be necessary if more infants were breastfed. Exclusively breastfeeding to at least 4 months cuts the number of bouts of otitis media almost in half.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial Capsules↗
PubMed1986

Cervical spine fractures with major associated trauma.

A detailed review of 88 consecutive patients placed in skeletal tong traction for cervical fractures by the University of Louisville Neurosurgical Service during a 5-year period from July 1, 1979, through June 30, 1984, was carried out. Of this group, 60% of the patients had a major associated injury consisting of major facial and skull fractures, cerebral contusions or intracerebral blood clots, cardiac or pulmonary contusions, major thoracic injuries including rib fractures and hemo- or pneumothoraces, intra-abdominal injuries, and major extremity fractures. An additional 24% of the patients had minor associated injuries, including facial or scalp lacerations, general body lacerations, or abrasions and cerebral concussions. Only 16% of patients with cervical fractures had no evidence of any other associated injury. Acute cervical spine fractures require prompt assessment and resuscitation by personnel from multiple specialties, usually available only in major trauma centers where experienced personnel capable of handling diverse injuries are always present.

Adolescent↗
PubMed1991

[The role of surgeon in treatment of chronic respiratory failure after pulmonary tuberculosis operations].

We analyzed pulmonary functions and rib cage-phrenic motions on 296 cases of chronic empyema patients who had surgical treatment. Pulmonary functions were better preserved in patients with a single step than in those with multi-step operations, and in those who had more than five operations the impairment was inevitable. Both %VC and rib cage-phrenic motions improved by decortication, and by air-plombage, but in those who developed multi-rib fractures after the latter procedure, ipsilateral chest wall motion almost disappeared. Since some restriction of rib cage-phrenic motion is inevitable after the surgery, we have developed a cuirass respirator which can synchronize with the respiration to assist the movement of the chest wall. The results attained so far are satisfactory.

Aged↗
PubMed1988

Fractures due to severe generalised osteoporosis in a 44-year-old male with diabetes mellitus.

A 44-year-old Chinese male with a 7-year history of diabetes developed spontaneous fractures affecting the femur and distal tibia and fibula within a period of 4 months. Spontaneous rib fractures were also present. There was additional evidence of extensive tissue damage with retinopathy, proteinuria, necrobiosis lipoidica diabeticorum, peripheral neuropathy and autonomic neuropathy. Investigation confirmed the presence of generalised osteoporosis and showed no evidence of other metabolic bone disease or abnormal vitamin D metabolism. Mild hypogonadism was also present and investigation suggested a disturbance of hypothalamic-pituitary control of gonadal function. It is suggested that the severe generalised osteoporosis resulted from poorly controlled diabetes with a possible additional contribution from androgen deficiency secondary to the diabetes.

Adult↗
PubMed1994

Traumatic diaphragmatic hernia presenting as an intercostal hernia: case report.

Intercostal hernias are rarely reported in the literature. We report a case of intercostal hernia secondary to a ruptured right hemidiaphragm and fractured costal margin caused by blunt trauma. The patient was ventilated at initial hospitalization because of rib fractures and advanced age, and the intercostal hernia was not evident. After physical rehabilitation treatment elsewhere, a painful chest wall bulge developed. A chest film and computed tomographic scan revealed the hernia. Surgery with a thoraco-abdominal incision in the line of the hernia allowed reduction of the hernial contents.

Aged↗
PubMed1996

Arachnoid cyst and chronic subdural haematoma in a child with osteogenesis imperfecta type III resulting from the substitution of glycine 1006 by alanine in the pro alpha 2(I) chain of type I procollagen.

The features of a child with osteogenesis imperfecta type III (OI III) resulting from the heterozygous substitution of glycine 1006 by alanine in the pro alpha 2(I) chain of type I procollagen were studied. He was born at term with the clinical features of severe OI, including deep grey-blue sclerae. He had severe osteopenia and all long bones were smaller than normal with cortical thinning, metaphyseal expansion, poor metaphyseal modelling, and multiple fractures. However, the vertebrae, pelvis, and shoulder girdle were of normal shape and there were few rib fractures. Histological examination of the calvarium and tibial shaft showed woven bone without lamellar bone or Haversian systems. The shafts of the long bones were widened owing to repeated fractures. Progressive enlargement of the calvarium occurred between 3 and 4.5 months of age owing to bilateral chronic subdural haematomata and a large arachnoid cyst in the Sylvian fissure. The cyst was probably developmental in origin while the subdural collections were probably the result of perinatal skull trauma. The cyst and the subdural collections resolved following drainage but ventricular dilatation with normal cerebrospinal fluid pressure followed. The proband is the first reported case of OI with a glycine substitution by alanine in the pro alpha 2(I) chain of type I procollagen.

Adult↗
PubMed2006

Skeletal complications of breast cancer therapies.

Nonsurgical treatment options, such as hormonal therapy, chemotherapy, radiation, and bisphosphonate therapy, are undoubtedly improving outcomes for women with breast cancer; however, these therapies also carry significant skeletal side effects. For example, adjuvant hormonal treatments, such as aromatase inhibitors that disrupt the estrogen-skeleton axis, have the potential to cause decreased bone mineral density. Similarly, chemotherapy often induces primary ovarian failure in premenopausal women, resulting in decreased levels of circulating estrogen and subsequent osteopenia. In both cases, women receiving these therapies are at an increased risk for the development of osteoporosis and skeletal fracture. Furthermore, women undergoing radiation therapy to the upper body may have an increased incidence of rib fracture, and those receiving bisphosphonates may be vulnerable to the development of osteonecrosis of the jaw. Therefore, women with breast cancer who are undergoing any of these therapies should be closely monitored for bone mineral loss and advised of skeletal health maintenance strategies.

Antineoplastic Agents↗
PubMed2004

Evaluation of a prediction model for long-term fracture risk.

UNLABELLED: The NOF cost-effectiveness model, based on clinical risk factors and femoral neck aBMD, predicted overall fracture risk in a cohort of postmenopausal women followed for up to 22 years. INTRODUCTION: To assess the ability of a statistical model to predict long-term fracture risk for a population of postmenopausal women, we compared observed fractures to those predicted by the National Osteoporosis Foundation's (NOF) cost-effectiveness model. MATERIALS AND METHODS: In this population-based study, 393 postmenopausal Rochester, MN, women had baseline measurements of femoral neck areal BMD (aBMD) and assessment of the clinical risk factors (personal fracture history, family history of osteoporotic fracture, low body weight, and smoking status) that were included in the NOF model. They were then followed prospectively for up to 22 years. Fractures were ascertained by periodic interview and review of community medical records. Standardized incidence ratios (SIRs) compared observed fractures to predicted numbers. RESULTS: During 4782 person-years of follow-up, 212 women experienced 503 fractures, two-thirds of which were caused by moderate trauma. When undiagnosed (incidentally noted) vertebral and rib fractures were excluded, there was general concordance between observed and predicted fractures of the hip (SIR, 0.78; 95% CI, 0.56-1.01), distal forearm (SIR, 1.22; 95% CI, 0.86-1.68), spine (SIR, 0.76; 95% CI, 0.50-1.11), and all other sites combined (SIR, 1.18; 95% CI, 0.97-1.42). Fracture prediction by the NOF model was about as good after 10 years as it was earlier during follow-up. CONCLUSIONS: This study validates the ability of a statistical model based on femoral neck aBMD and common clinical risk factors to predict the actual occurrence of fractures in a cohort of postmenopausal white women.

Absorptiometry, Photon↗
PubMed1986

Unilateral chest wall paradoxical motion mimicking a flail chest in a patient with hemilateral C7 spinal injury.

After a lower hemi-cervical spinal cord injury, a patient presented with a left hemiplegia and on the same side a unilateral chest wall paradoxical motion mimicking a flail chest. X-rays demonstrated a left hemilateral C6 injury but no rib fractures. We demonstrated that the paradoxical motion was due to the action of the diaphragm acting on the rib cage with intercostal respiratory paralysis on the side of hemiplegia.

Diagnosis, Differential↗
PubMed1996

Traumatic thoracic aortic rupture in the pediatric patient.

BACKGROUND: Traumatic thoracic aortic rupture is a rare injury in the pediatric patient. Experiences with thoracic aortic rupture in patients less than 17 years of age are needed to help identify factors that can influence injury occurrence, diagnosis, management, and outcome. METHODS: Between July 1989 and December 1995, 6 children were treated operatively for thoracic aortic rupture from blunt trauma at a level I pediatric trauma center. The average age was 13.2 years (range, 8 to 16 years). There were 4 females and 2 males. There were 5 motor vehicle accidents and 1 bicycle accident. Aortic injury was suspected based on the mechanism of injury and abnormal chest roentgenogram results, and was confirmed by aortography (3 cases) or chest computed tomography (2) and transesophageal echocardiography (3). Life-threatening central nervous system or gastrointestinal injuries were evaluated or treated first. Operative repair of the thoracic aorta was performed by cardiopulmonary bypass (2 patients) and clamp and sew technique (4). RESULTS: Aortic ruptures were complete transections at the ligamentum arteriosum in 5 of 6 (83%); the other case was a cervical arch pseudoaneurysm. Associated injuries included pulmonary contusion (100%), pelvic/long bone fractures (50%), visceral laceration/perforation (50%), central nervous system (33%), paraplegia (17%), and myocardial contusion (17%). There were no rib fractures. Four of 5 patients (80%) were not wearing seat belts, and 2 of these were ejected. The average time from injury to the operating room was 17.6 hours (range, 5 to 48 hours); the time from diagnosis to the operating room exceeded 5 hours with aortography and was less than 3 hours with chest computed tomography and transesophageal echocardiography. Each diagnostic modality accurately identified an aortic injury. The average time for cardiopulmonary bypass and for clamp and sew was 52 minutes (range, 49 to 55 minutes) and 34 minutes (range, 16 to 45 minutes), respectively. One patient with preoperative paraplegia regained partial function; there were no other patients with paraplegia. There were no deaths. All patients are alive 2 months to 7 years after repair. CONCLUSIONS: The multiply injured child with severe blunt trauma and an abnormal chest roentgenogram requires a search for aortic injury. We believe the most effective algorithm to follow for the diagnosis of traumatic thoracic aortic rupture in the child involves selective performance of chest computed tomography and transesophageal echocardiography. Our experience suggests that the mechanism of injury, the duration to diagnosis of an aortic injury, and failure to use seat belts may contribute to morbidity. A high index of suspicion and a systematic approach to the diagnosis and to the management strategy for injuries to the thoracic aorta can contribute to a good outcome in those few children who survive the injury.

Adolescent↗
PubMed1998

When to use bone scintigraphy. It can reveal things other studies cannot.

Despite advances in nuclear medicine, bone scintigraphy remains an important imaging technique. It is sensitive in detecting stress fractures and bone metastases and can assess suspected injury that is difficult to see on plain films (e.g., rib fracture). Scintigraphy is useful in evaluating new symptoms, response to therapy, and prognosis in patients with known malignant tumor. In patients with low back pain, the technique can determine the age of fractures to help identify osteoporosis and can uncover other causes of the pain (e.g., spondylolysis, arthritis). When Paget's disease is suggested by unexplained bone pain or an elevated serum alkaline phosphatase level, bone scintigraphy is a useful screening test. Combined with other appropriate nuclear medicine studies, it helps in early identification and localization of osteomyelitis. Scintigraphic scans can provide a general indicator of malignant versus benign disease (according to the amount of lesion activity seen) and may produce characteristic findings in certain primary tumors (e.g., osteoid osteoma) that are difficult to evaluate with other methods.

Bone Diseases↗