Appendicular Fractures Research Articles

Associated Injuries in Children and Adolescents With Spinal Trauma

Over half of children and adolescents with spinal trauma have associated injuries, most commonly involving the appendicular skeleton, head and neck, and thorax. The incidence and characteristics of these associated injuries have been well described, but to our knowledge there has been no evaluation of the relationship between the injury characteristics and the patient age. Data were obtained from the trauma registries of the local pediatric and adult level 1 trauma centers, and patients aged 0 to 19 years with spinal trauma were identified. For analysis, patients were divided into 3 age groups: 0 to 3, 4 to 12, and 13 to 19 years. Associated injuries were divided into 5 groups: head, thoracic, abdominal, appendicular skeletal fracture, and neurological. Overall, 25 patients had isolated dislocations and 307 patients had 366 spinal fractures or fracture-dislocations: 36% cervical, 31% thoracic, and 51% lumbar. Most (84%) of the injuries occurred in the 13- to 19-year-old group. Sixty-two percent of patients had associated injuries, most commonly thoracic injuries (pulmonary contusion, pneumothorax, rib fracture); 45% had multilevel spinal fractures, 39% of which were noncontiguous. Nearly three fourths of the noncontiguous fractures occurred in a different spinal region; cervical fracture with concomitant thoracic fracture was the most frequent pattern. This large series of consecutive patients highlights several important concepts concerning pediatric spinal fractures, including age-related patterns of injury, frequent associated injuries, and a high rate of multiple spinal injuries, especially noncontiguous injuries. It also emphasizes the importance of careful full-body examination and imaging of the entire spine in children and adolescents with a known spinal injury. Level IV-case series.

Experiences using the Fixin locking plate system for the stabilization of appendicular fractures in dogs

To retrospectively evaluate the stabilization of appendicular fractures in dogs using the Fixin locking plate system. Medical records and radiographs of dogs with fractures stabilized with the Fixin system in the period from May 2005 to September 2010 were reviewed. For each patient, data pertaining to signalment, the nature of the fracture, implants used, and evidence of fracture healing were recorded. The outcome and complications were determined from clinical and radiographic follow-up examinations. Limb function was evaluated between 40 days and 90 days postoperatively. Owners of pets with complications were contacted by phone for long-term follow-up. Eighty-two fractures in seventy-five dogs met the inclusion criteria for the study. Radiographic re-examinations were carried out between eight days to two years (median 60 days) following surgery. Seventy-three out of 82 fractures (89%) reached union without complications. Major complications were seen in six dogs (7%). Limb function was graded as 'normal' in 73/75 (97%) dogs and 'mild lameness' in 2/75 (3%) cases. Despite a modest complication rate, the Fixin locking bone plating system appears to be an acceptable choice of implant for the stabilization of appendicular fractures in dogs.

Prevalence of vitamin D insufficiency in Swiss teenagers with appendicular fractures: A prospective study of 100 cases

The significance of subclinical vitamin D deficiency in the pathogenesis of fractures in children and adolescents currently remains unclear. We aimed to determine the prevalence of vitamin D insufficiency and its effect on bone mineral density (BMD) and bone mineral content (BMC) values in a collective of Swiss Caucasian children with a first episode of appendicular fracture. One hundred teenagers with a first episode of appendicular fracture [50 upper limb fractures (group 1) and 50 lower limb fractures (group 2)] and 50 healthy controls (group 3) were recruited into a cross-sectional study. The BMC and BMD values were measured by dual-energy X-ray absorptiometry, and serum 25 hydroxyvitamin D [25(OH)D] was assessed by electrochemiluminescence immunoassays. From the 100 injured teenagers in the study, 12% had deficient vitamin D levels (<20ng/mL;<50nmol/L) and 36% had insufficient levels (≥20<30ng/mL;≥50<78nmol/L), whereas 6and 34% of healthy controls were, respectively, vitamin D deficient and insufficient. There were no significant differences for serum 25(OH)D levels, L2-L4 BMD Z-score, and L2-L4 BMC Z-score variables (p=0.216) between the three groups nor for the calcaneal BMD Z-score variables (p=0.278) between healthy controls and lower limb fracture victims. Investigations on the influences of serum 25(OH)D on BMD and BMC showed no correlation between serum 25(OH)D and L2-L4 BMD Z-scores (r=-0.15; p=0.135), whereas low but significant inverse correlations were, surprisingly, detected between serum 25(OH)D and calcaneal BMD Z-scores (r=-0.21; p=0.034) and between serum 25(OH)D and L2-L4 BMC Z-scores (r=-0.22; p=0.029). A significant proportion of Swiss Caucasian teenagers were vitamin D insufficient, independent of limb fracture status, in our study. However, this study failed to show an influence of low vitamin D status on BMD and/or BMC of the lumbar spine and heel.

Evaluating the true clinical utility of the red dot system in radiograph interpretation

The 'red dot', or 'asterisk', system is used in many hospitals as a method for radiographers to identify potential abnormalities on plain radiographs prior to reporting by radiologists. While published studies into the accuracy of the 'red dot' system exist, analysis of its reliability in identifying subtle pathology is lacking. This is relevant because the prevalence and apparent success of the 'red dot' system has been cited by some authors as justification for non-radiologist reporting of medical imaging. It is important that all systems within medical imaging add value, and this audit evaluates the accuracy and clinical value of the 'red dot' system, particularly in the critical area of detecting undisplaced fractures. All appendicular musculoskeletal trauma radiographs performed in the Department of Emergency Medicine at a major Australian metropolitan hospital over a continuous four-month period were retrospectively assessed to evaluate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the 'red dot' system. The presence or absence of an asterisk was correlated with validated radiologist reports. A sub-analysis of fractures displaced <1mm was also performed. A total of 3638 radiographs were assessed and 938 (25.8%) fractures identified; 338 (9.3%) contained undisplaced fractures. Overall sensitivity and specificity of the 'red dot' in detecting appendicular fractures are 80.4% and 98.0%, respectively. PPV is 93.6% and NPV is 93.5%. However, the accuracy of the 'red dot' in detecting undisplaced fractures is significantly reduced, with a sensitivity of 45.9% and a PPV of 74.8%. Detection of subtle abnormalities is fundamental to the service provided by radiologists. The 'red dot's' inability to reliably detect undisplaced fractures following trauma limits its value within a tertiary radiology department and suggests that role extension of plain film reporting to non-radiologists has potential to yield less accurate assessments. To maintain the highest quality of medical imaging services and standards of patient care, it is optimal that clinical decisions are based upon radiograph reports issued by medical specialists who have completed appropriate radiology training. Strategies to maintain this are suggested.

High-rise syndrome ou syndrome du chat parachutiste: études rétrospectives et comparatives de 204 cas

High-rise syndrome : comparative and retrospective study of 204 cases. The high-rise syndrome (HRS) is used to describe traumatic injuries resulting from falls from a height greater than two stories. Apart from the shock, lesions most frequently include the triad of lung injury (contusion, pneumothorax), appendicular fractures and contusions of the head. The average mortality rate is 11% in cats. Unlike humans and dogs, cats are able to survive falls from heights greater than 6 stories, due to the effectiveness of their vestibular system and low body mass.

Teriparatide is safe and effectively increases bone biomarkers in institutionalized individuals with osteoporosis

Institutionalized adults with severe developmental disabilities have a high rate of minimal trauma and appendicular fracture. There is little information about osteoporosis treatment in this population. In this efficacy and safety study, men and women with severe developmental disabilities and osteoporosis received 20 mcg teriparatide subcutaneously daily for 18-24 months. Markers of bone formation [procollagen type 1 intact N-terminal propeptide (P1NP)] and resorption [C-telopeptide (CTx)] were measured at three-month intervals. Serum calcium was measured at two-week intervals for 12 weeks and thereafter at three-month intervals. Twenty-seven individuals received at least one injection. The incidence of hypercalcemia was 11.1% but was persistent and led to medication discontinuation in only one participant. Biomarkers of bone formation increased rapidly, doubling by three months. At 12 months, P1NP and CTx remained elevated from baseline; P1NP had risen from 66.95 +/- 83.71 microg/l (mean +/- SD) to 142.42 +/- 113.85 microg/l (P = 0.05), and CTx had increased from 0.377 +/- 0.253 to 1.016 +/- 1.048 ng/ml (P = 0.01). The majority of participants had an increase in P1NP of over 10 microg/l. In conclusion, teriparatide is safe and effective in developmentally disabled institutionalized adults. Serial calcium measurements are warranted, particularly during the first three months of therapy.

Appendicular fracture repair in dogs using the locking compression plate system: 47 cases

The locking compression plate (LCP) has combination screw holes, making it possible to use the implant in three different ways; as a pure internal fixator using locking head screws, as a conventional compression plate using compression screws, or as a hybrid of the two. The experience with the LCP system in veterinary fracture repair is limited. The objective of this study was to evaluate the outcome of appendicular fractures in dogs, which were repaired with the LCP system combined with less invasive surgical techniques. Medical records and radiographs from 47 dogs were studied retrospectively. Thirty-four percent of the fractures were simple, six percent wedge and 60% comminuted fractures of the humerus (11 %), radius and ulna (30 %), femur (34 %) and of the tibia and fibula (25 %). The fractures were treated using the LCP as an internal fixator; in some cases as a plate and rod construct. Forty-six of 47 fractures reached radiographic union. Mean healing time of the fractures was seven weeks (95% confidence interval from 5.8 to 8.3 weeks). There were statistically significant differences in healing time between juvenile (age under one year) and adults. Complications in the form of implant failures and infections were encountered in approximately 11% of the cases. All implant failures were due to surgical errors. The LCP system in combination with a less invasive surgical approach was found advantageous in comminuted fractures where the LCP was used as a bridging plate, in situations when exact plate contouring was difficult, and when other implants prevented the use of bi-cortical screws.

Comment on Reid et al.: Effect of calcium supplementation on hip fractures

Dear Editors, As researchers whose work is referred to in support of the hypothesis that calcium causes hip fractures, we feel entitled to comment on the ‘review’ in a recent issue of your journal [1]. The article could perhaps be better labelled ‘for debate’, since it is certainly not an objective review of the subject but rather the presentation of an idiosyncratic opinion. The authors postulate that calcium therapy weakens the femoral neck by inhibiting its expansion, but their published data on hip status assessed by DXA BMD do not support their case nor is it supported by the abstract they quote. Furthermore, they do not report the effect of calcium on the femoral neck in their own study, which would be of great interest. Periosteal expansion occurs on all long bones [2] and is likely to occur at the femoral neck, but whether the process is suppressed by calcium, and if so whether that is of any significance, is another matter. They do not quote our RCT data on the forearm, which shows that calcium supplementation is associated with increased cortical thickness and increased calculated strength in bending at the proximal radius [3]. Nor do they quote Boonen’s metaanalysis [4], which showed a pooled RR of 1.10 (0.89– 1.36; NS) in patients on vitamin D alone in four RCTs on 9,083 patients. By contrast, the pooled RR was 0.82 (0.71– 0.94; P=0.0005) in six RCTs on 45,509 patients on vitamin D with calcium. How can they reconcile their hypothesis with this much larger meta-analysis, which clearly shows the benefit of calcium in hip fracture prevention? But above all, they do not make it clear that the hip fracture data, which they derive from their original paper [5] (17/732 hip fractures on calcium and 5/739 in controls), was the intention-to-treat analysis; in those who actually took the tablets, there were six hip fractures on calcium and two on placebo (NS). How can anyone build such a far-reaching claim on such small numbers? How did it get past the reviewers? We also question the use of the word ‘trend’ by Reid and co-authors in this and their previous paper [6]. They appear to use trend to mean an effect that does not even meet the conventional level of weak statistical significance (P 800 U/day) with calcium (at least 1,200 mg per day) reduces appendicular fractures of all kinds and thus should be the first intervention to reduce fracture risk in the elderly. Osteoporos Int (2009) 20:831–832 DOI 10.1007/s00198-008-0755-3

Long-term Fracture Risk in Patients with Celiac Disease: A Population-Based Study in Olmsted County, Minnesota

Celiac disease is associated with decreased bone density, but there are conflicting data regarding fracture risk. We determined the fracture incidence relative to matched controls in a population-based cohort with celiac disease before and after diagnosis. Olmsted County residents with celiac disease (n = 83) diagnosed between 1950 and 2002 were compared with 166 gender and age matched controls. Fracture histories were ascertained from each subject's medical records. Celiac disease is linked to an increased fracture risk before and after diagnosis. Before the index date, cases had a fracture rate twice that of controls (CI: 1.0-3.9, P = 0.045) and 2.5-fold greater after the index date (CI: 1.1-5.6, P = 0.026). Appendicular and axial fractures were 2.5 (CI: 0.9-6.5) and 3.2 times more likely (CI: 1.0-10.5) after the index date. These observations support a rationale for earlier detection of celiac disease, and active management of bone disease before bone effects have occurred, to reduce the persistent risk of fractures.

The Treatment of Severe Postmenopausal Osteoporosis

Several chemical entities have shown their ability to reduce axial and/or appendicular fractures in patients with osteoporosis. Since patients who have experienced a previous fracture are at high risk for subsequent vertebral or hip fracture, it is of prime importance to treat such patients with medications that have unequivocally demonstrated their ability to reduce fracture rates in patients with prevalent fractures. Results obtained with calcium and vitamin D, in this particular population, are not fully satisfactory and these medications are probably better used in conjunction with other therapeutic regimens. Bisphosphonates have shown their ability to reduce vertebral (alendronate, risedronate, ibandronate) and non-vertebral (alendronate, risedronate) fractures in patients with established osteoporosis. Raloxifene has also shown similar properties, notwithstanding its effect on non-vertebral fractures, which has only been derived from a post hoc analysis limited to patients with prevalent severe vertebral fractures at baseline. This compound also has interesting non-skeletal benefits, including effects on the breast and heart. Teriparatide, a bone-forming agent, promptly reduces the rate of vertebral and all non-vertebral fractures, without significant adverse effects. Strontium ranelate, the first agent shown to concomitantly decrease bone resorption and stimulate bone formation, has also shown its ability to reduce rates of vertebral and non-vertebral fractures in patients with established osteoporosis. It significantly reduces hip fractures in elderly individuals at high risk for such events. Its safety profile is also excellent.

Prevalence of low trauma fractures in long-term kidney transplant patients with preserved renal function

We evaluated the prevalence of low bone mineral density (BMD) and osteoporotic fractures in kidney transplantation (KT) patients and determined risk factors associated with osteoporotic fractures. The study was conducted on 191 patients (94 men and 97 women) with first KT for 3 years or more presenting stable and preserved renal function (serum creatinine levels lower than 2.5 mg/dl). KT patients were on immunosuppressive therapy and the cumulative doses of these drugs were also evaluated. BMD was determined by dual-energy X-ray absorptiometry at multiple sites (spine, femur and total body). Quantitative ultrasound of the calcaneus (broadband ultrasound attenuation, speed of sound, and stiffness index, SI) was also performed. Twenty-four percent (46) of all patients had either vertebral (29/46) or appendicular (17/46) fractures. We found osteoporosis and osteopenia in 8.5-13.4 and 30.9-35.1% of KT patients, respectively. Women had more fractures than men. In women, prevalent fractures were associated with diabetes mellitus [OR = 11.5, 95% CI (2.4-55.7)], time since menopause [OR = 3.7, 95% CI (1.2-11.9)], femoral neck BMD [OR = 1.99, 95% CI (1.4-2.8)], cumulative dose of steroids [OR = 1.1, 95% CI (1.02-1.12)] and low SI [OR = 1.1, 95% CI (1.0-1.2)]. In men, fractures were associated with lower lumbar spine BMD [OR = 1.75, 95% CI (1.1-2.7)], lower SI [OR = 1.1, 95% CI (1.03-1.13)], duration of dialysis [OR = 1.3, 95% CI (1.13-2.7)], and lower body mass index [OR = 1.24, 95% CI (1.1-1.4). Our results demonstrate high prevalence of low BMD and osteoporotic fractures in patients receiving a successful kidney transplant and indicate the need for specific intervention to prevent osteoporosis in this population.

Parathyroid Hormone and Teriparatide for the Treatment of Osteoporosis: A Review of the Evidence and Suggested Guidelines for Its Use

All therapies currently recommended for the management of osteoporosis act mainly to inhibit bone resorption and reduce bone remodeling. PTH and its analog, teriparatide [recombinant human PTH(1-34)], represent a new class of anabolic therapies for the treatment of severe osteoporosis, having the potential to improve skeletal microarchitecture. Significant reductions in both vertebral and appendicular fracture rates have been demonstrated in the phase III trial of teriparatide, involving elderly women with at least one prevalent vertebral fracture before the onset of therapy. However, there is as yet no evidence that the antifracture efficacy of PTH will be superior to the bisphosphonates, whereas cost-utility estimates suggest that teriparatide is significantly more expensive. Teriparatide should be considered as treatment for postmenopausal women and men with severe osteoporosis, as well as for patients with established glucocorticoid-induced osteoporosis who require long-term steroid treatment. Teriparatide should also be considered for the management of individuals at particularly high risk for fractures, including subjects who are younger than age 65 and who have particularly low bone mineral density measurements (T scores < or = 3.5). Teriparatide therapy is not recommended for more than 2 yr, based, in part, on the induction of osteosarcoma in a rat model of carcinogenicity. Total daily calcium intake from both supplements and dietary sources should be limited to 1500 mg together with adequate vitamin D intake (< or =1000 U/d). Monitoring of serum calcium may be safely limited to measurement after 1 month of treatment; mild hypercalcemia may be treated by withdrawing dietary calcium supplements, reducing the dosing frequency of PTH, or both. At present, concurrent therapy with antiresorptive therapy, particularly bisphosphonates, should be avoided, although sequential therapy with such agents may consolidate the beneficial effects upon the skeleton after PTH is discontinued.

Cranial neural crest-derived cells participate in craniofacial skeletal repair

Abstract Introduction: Similarities between skeletal formation and repair have led to the theory that adult fracture repair may parallel development. We hypothesize that since the mandible is derived from cranial neural crest (CNC) and forms via intramembranous ossification, non-stabilized mandibular fractures will heal in a similar fashion. Methods: Non-stabilized osteotomies were created in the right hemi-mandible of adult male mice. Mandibles were harvested at 7, 14, 21, and 28 days and processed for histology. Ossification was assessed and the presence of cartilage determined using histology and in situ hybridization (ISH). To determine the embryologic origins of the regenerate, transgenic mice were generated where CNC cells express GFP constitutively under the Wnt-1 promoter. Fractures were created as described above and processed for frozen section. CNC cells were localized using immunohistochemistry (IHC) for GFP. Closed, non-stabilized tibial fractures were also performed to determine the presence, if any, of CNC-derived cells in appendicular skeletal fractures. Results: In contrast to non-stabilized fractures of the appendicular skeleton, mandibular fractures healed predominantly via intramembranous ossification, with minimal and delayed cartilage production seen via histology and collagen2 ISH. IHC for GFP revealed that the mandibular fracture callous and regenerate was comprised primarily of GFP+, CNC-derived cells. In contrast, the tibial fracture callous was devoid of any CNC-derived cells. Conclusions: These data suggest that mandibular fractures heal by recapitulating their developmental program. These findings have important implications for designing appropriate cell-based approaches to craniofacial regeneration.

Tibial fractures

Tibial fractures are common in small animal practice. As with other appendicular fractures, the patient's age, fracture location, and fracture type must be considered thoroughly. While methods for tibial fracture repair are similar to those used for appendicular fractures elsewhere, there are some unique considerations, both anatomically and functionally, that must be contemplated before repair. The following article will review the incidence of tibial fractures, tibial fracture types, and options for tibial fracture management and treatment. The use of external fixators, orthopedic bone plates, open reduction with internal fixation (ORIF), and external coaptation will be discussed. An emphasis will be placed on the most common types of tibial fractures, as well as those best suited for repair by general practitioners of veterinary medicine. Three case based examples will follow the overview.

Reduced bone mineral density in male renal transplant recipients: evidence for persisting hyperparathyroidism.

Osteoporosis is increasingly recognized as a major source of morbidity following renal transplantation. The aim of this cross-sectional study was to determine the prevalence of osteoporosis in a cohort of male transplant recipients and examine factors that may influence their bone loss. Bone mineral density (BMD) and biochemical markers of bone metabolism were measured in 134 out of 154 male renal allograft recipients in our center. The mean age of the patients was 49.7 years (range 26-76) with a median of 6 years post-transplant. Only 17% had normal BMD, 30% were osteoporotic at either hip or spine, and this proportion rose to 41% if the ultradistal radius was included. Parathyroid hormone (PTH) was negatively correlated with BMD at all skeletal sites. In a multiple regression model, independent predictors of femoral neck BMD included body mass index (p=0.004), diabetes (p=0.025), and PTH (p=0.049). The only independent predictor of BMD at the ultradistal radius was PTH (p<0.001). Nineteen men sustained a total of 25 appendicular fractures after transplantation (median time to fracture was 3 years). Prevalent vertebral fractures were only identified in five men. PTH was elevated in 72.4% of patients (mean PTH 142 +/- 118 pg/ml). Bone resorption markers were increased in 48% of patients. PTH was positively correlated with serum carboxyterminal telopeptide of type 1 collagen (r=0.473, p<0.001) and procollagen type 1 amino terminal propeptide (r=0.419, p<0.001). Osteopenia and osteoporosis are common in male transplant recipients, and the hip and radius are the most severely affected sites. Elevated rates of bone resorption driven by hyperparathyroidism appear to be the most important contributing factor.

Teriparatide (Biosynthetic Human Parathyroid Hormone 1–34): A New Paradigm in the Treatment of Osteoporosis

The ideal treatment of osteoporosis should preferably prevent fractures through normalization of bone mass and bone micro-architecture. Biosynthetic human parathyroid hormone 1-34 (teriparatide) was recently approved in the EU and the USA as the first anabolic treatment of osteoporosis. The effects of teriparatide are mediated by the G-protein-dependent, parathyroid hormone receptor-1 in the cell membrane. The binding of the ligand to the receptor activates adenylate cyclase and a number of phospholipases (A, C, and D) and increases intracellular levels of cAMP and calcium. Intermittent teriparatide increases the number of osteoblasts and bone formation by activation of pre-existing osteoblasts, increased differentiation of lining cells, and reduced osteoblast apoptosis. Anabolic effects of teriparatide on bone have been demonstrated in several species. It increases bone mass, structural integrity, bone diameter, and bone strength. Clinical efficacy was demonstrated in a randomized study comprising 1637 post-menopausal women with osteoporosis showing a 65% and 35% reduction of the relative risk of vertebral and appendicular fractures, respectively, during 18 months of treatment. Moreover, bone mineral density in the lumbar spine and hip increased by 9.7% and 2.6%, respectively. Similar effects on bone mineral density have been reported in men with osteoporosis and in glucocorticoid-induced osteoporosis, however, fracture data are limited in these groups. Direct comparison with alendronate revealed that teriparatide has a more pronounced effect on bone mineral density. Teriparatide should be used in combination with calcium plus vitamin D, and may be combined with hormonal replacement therapy. In contrast, alendronate attenuates the effect of teriparatide. The efficacy of other combinations remains uncertain. After termination of teriparatide, bone mineral density of the lumbar spine is reduced by approximately 2-3% after 2 1/2 years. This decrease is prevented by treatment with bisphosphonates. The most frequent adverse effects with teriparatide are nausea, headache, dizziness, and leg cramps, however, only the latter two differed significantly between the groups receiving teriparatide 20 microg/day and placebo. In the pivotal clinical study, reduced dosage or termination of therapy due to hypercalcaemia was necessary in 3% and 0.2%, respectively. In a rat toxicology study, in which teriparatide was administered in high dosages for an extended period of time, osteosarcoma was seen in a significant number of animals. However, none of the approximately 2800 patients in clinical trials has developed osteosarcoma. Teriparatide constitutes a break-through in the treatment of severe osteoporosis, although a number of issues about the optimal use of teriparatide remains unsettled. The published data provide proof of concept on anabolic therapy which changes several paradigms of bone physiology. Other parathyroid hormone analogues are being investigated in clinical trials and the development of non-peptide, small molecules targeted at the parathyroid hormone receptor may be envisaged.

Recovery pattern of patients with osteitis fibrosa cystica in primary hyperparathyroidism after successful parathyroidectomy

Background. After parathyroidectomy, recovery of osteitis fibrosa cystica, which continues to dominate presentation of primary hyperparathyroidism in India has not been documented objectively. Methods. We followed up clinical recovery, biochemic markers of bone turnover, bone mineral density, and skeletal radiology in 51 patients with primary hyperparathyroidism and osteitis fibrosa cystica for 9 to 124 months (median, 32 months). Results. After parathyroidectomy, 46 patients had hypocalcemia. During postoperative week 1, bone pain improved in 71%. During 3 months, appendicular fractures healed in all 33 such patients, and 6 of 7 patients who were bedridden could walk. Mean bone mineral density increments (percent change/y) seen at various sites at 1 week, 3, 6, and 12 months were distal forearm — 37, 28, 23, 21; lumbar spine — 165, 104, 101, 106; and total hip — 168, 157, 166, 133. Follow-up radiographs demonstrated prompt recovery though disorderly remineralization. Brown tumors and fractures showed hyperdensities within 3 months. Brown tumors regressed partially in 6 of 27 patients after 6 months. Conclusions. After parathyroidectomy, patients with primary hyperparathyroidism have early, marked, and sustained recovery of osteitis fibrosa cystica. Early (1 week) bone mineral density increments of > 100%/y hint at the skeleton's ability to promptly restore itself. Densitometric recovery is prompt at cancellous (lumbar spine), but not at cortical (forearm) bone sites. Contour defects and bony tumors persist, and may need corrective osteotomies. (Surgery 2002;132:·1075-85.)

Osteopenia risk factors in “tooth-losing” postmenopausal women: second report

The stability and mechanical functioning of teeth is related to the amount and architectural quality of periodontal tissue. In previous reports, we demonstrated that most postmenopausal (PM) women lose their teeth three times more quickly (Amaro et al., J Bone Miner Res, 1999). This loss was not found to be related to measurements of peripheral bone density (Amaro et al., Bone, in press). In this second report, a group of 426 PM women with and without atraumatic fractures were analyzed for their anthropomorphometric and age-related features using known risk factors for bone mass loss in order to describe probable predictors in the subgroup of “tooth-losing” women. The selection of patients and survey was carried out by physicians trained in the management of odontologic files and epidemiological characteristics of osteopathies using the ad hoc format. Details are provided in the aforementioned work. Daily consumption of calcium was found to be very low throughout most of the study and it was not correlated with the conservation of teeth (tooth losers 666.8 6 509.5 mg/day vs. tooth preservers 691.8 6 524.1 mg/day; p 5 n.s.). Menopause, cigarettes smoked per day, and physical activity did not differ statistically among the groups. The use of osteotropic medicines was more frequent among tooth preservers (26.7% vs. 15.2%; p 5 0.07). Except for those who received hormone replacement therapy (HRT; intent to treat), those patients treated with pamidronate, alendronate, or calcitonin did not differ from controls. Patients with HRT presented with a mean of 16 teeth vs. 12 in the remaining patients, but they were a mean of 10 years younger, with this being a significant difference. Women with appendicular fractures presented with 24.0 teeth and those with axial fractures 22.5 teeth, as compared to those with no fractures. We conclude that the risk of accelerated tooth loss cannot be predicted based on the existence of relevant risk factors of osteopenia, except in the presence of settled osteoporosis (fractures) and, consequently, it is advisable to perform maxillary exploration during menopause in women with no previous fractures.

Prevalent appendicular fractures in elderly women are associated with low dexa and ultrasound measurements

Prevalent appendicular fractures in elderly women are associated with low dexa and ultrasound measurements

EMERGENCY MR IMAGING OF ORTHOPEDIC TRAUMA: Current and Future Directions

Fast MR imaging protocols pave the way for more widespread use of MR imaging to evaluate emergency room trauma patients. This article reviews technical developments and protocols facilitating rapid imaging, conventional applications of MR imaging to evaluate soft tissue injuries, and newer applications in which MR imaging is used to image both axial and appendicular fractures.