Definite Fracture Research Articles

ANALYSIS OF RESULTS OF FOLLOW-UP SKELETAL SURVEYS IN SUSPECTED CHILD ABUSE CASES.

The skeletal survey is an important imaging technique used in the evaluation of suspected child abuse. It is particularly helpful in the identification of fractures that are not clinically apparent in infants and young children. The American Academy of Pediatrics (AAP) recommends skeletal survey in cases of suspected child abuse for children less than 2 years of age. The AAP further recommends that the skeletal survey be repeated 2 weeks after the initial skeletal survey in cases in which child abuse is strongly suspected. The follow-up skeletal survey allows for identification of fractures that may have had too subtle a radiographic presentation to be seen when imaged acutely. Objective The purpose of this study was to further clarify and assess the additional information gained from a repeat skeletal survey in identifying and characterizing skeletal injury for cases in which child abuse was strongly suspected. Materials and Methods In this retrospective study, 27 infants and toddlers suspected of being physically abused had a recommended initial skeletal survey and underwent a follow-up examination approximately 2 weeks after the initial examination. The Child Protection Medical Team evaluated all children suspected of possible physical abuse. Nonaccidental trauma was determined by the Child Protection Medical Team. The medical records and radiologic reports of the 27 children with follow-up skeletal surveys were reviewed over a 3-year period. The number and location of the fractures were identified for the initial skeletal survey and for the follow-up skeletal survey in each case. Results The follow-up skeletal survey yielded additional information regarding skeletal injury in 7 (29%) of 24 cases. A different pediatric radiologist evaluated the initial and subsequent repeated study in 19 of the 24 cases. In all but one of these cases, at least one fracture was visible on the initial study. Follow-up study increased the number of definite fractures detected from 72 to 82 (14%). These additional injuries were either rib fractures (30%) or long bone injuries (70%). The majority of the long bone injuries were classic metaphyseal lesions (5/7, 71%). Conclusion A follow-up skeletal survey identified additional fractures or added additional information for findings in children who were suspected victims of physical abuse. It is recommended that a repeat skeletal survey 2 weeks after the initial skeletal survey be conducted for concerning cases of suspected child abuse. The addition of oblique views of the ribs may also enhance detection of occult rib fractures.

Magnetic Resonance Imaging Evaluation of Biodegradable Transfemoral Fixation Used in Anterior Cruciate Ligament Reconstruction

The study was designed to evaluate bioabsorbable transfemoral fixation in anterior cruciate ligament (ACL) reconstruction using hamstring tendon as graft. Magnetic resonance imaging (MRI) was used to assess the continuity of the bioabsorbable implant at different stages of the patients' rehabilitation. Retrospective case series. Forty-nine patients underwent ACL reconstruction performed by a single surgeon. The graft, a tensioned quadrupled semitendinosus tendon, was fixed proximally using a bioabsorbable TransFix implant (Arthrex, Naples, FL). The patients underwent an accelerated rehabilitation program and were assessed clinically at regular intervals postoperatively using MRI, with specific attention focused on the implant. The average time from surgery to MRI was 28 weeks (range, 4 to 54 weeks). All implants were fully visible with no evidence of resorption. Five implants were fractured at an average of 20 weeks postoperatively (range, 9 to 47 weeks). Three implants showed deformation but no definite fracture at an average of 14 weeks (range, 12 to 17 weeks). This amounts to 16% of implants with fractures or deformation, many close to the period of theoretical graft incorporation. All patients were clinically stable with no symptoms or signs or instability on clinical review and all had returned to preinjury sporting activities. Transfemoral biodegradable implants have the potential to fracture or deform during their postoperative course in tensioned hamstring tendon ACL reconstruction. Although no apparent detrimental effect was found in our series, further research is needed on this device before it can be recommended for ACL reconstruction. We also question the idea that rigid fixation for the ACL graft for the entire healing process is required. Level IV, retrospective case series.

Survival and complications are similar after Swanson and Sutter implant replacement of metacarpophalangeal joints in patients with rheumatoid arthritis

We compared the survival, fracture, and deformation rates of Swanson and Sutter implants in a prospective series of 53 patients with rheumatoid arthritis (RA). Fifty-eight hands were operated on with 215 silastic implants. The Swanson group comprised 25 hands and 89 implants, and the Sutter group 33 and 126, respectively. Follow up was 58 (37-80) months. During a period of 48 months the survival of Swanson and Sutter prostheses did not differ significantly: 92% (95% CI 84% to 96%) and 97% (95% CI 92% to 99%), respectively. The fracture rate was high in both groups: 26 (34%) in the Swanson and 25 (26%) in the Sutter group. There was no significant difference between the groups in definite fracture rates of implants. The Sutter prosthesis appears to be at least as durable an implant in rheumatoid patients' metacarpophalangeal arthroplasty as the Swanson.

Clinical Triad For Diagnosing Occult Hip Fractures With Normal Radiographs

Study Design: Prospective observational study Objectives: The critical appraisal of the three clinical signs in the validation of patients with symptoms of hip pain with negative X-rays. Methods: 30 consecutive patients admitted with hip pain following a fall with no evidence of fracture on hip X-ray underwent MRI scanning. Mean age was 78 (range 67 88) years. 12 patients were male and rest were female. Results: All patients with three positive signs — tenderness in groin area; unable to straight leg raise and painful limitation of rotation of hip movements had MRI scans which showed definite fracture neck of femur. Patients with only one positive sign had normal MRI scans. Conclusion: The clinical triad of signs had 100% reproducibility and sensitivity in reliably diagnosing hip fractures in patients with normal radiographs.

Personal Computer versus Workstation Display: Observer Performance in Detection of Wrist Fractures on Digital Radiographs

To retrospectively compare the accuracy of observer performance with personal computer (PC) compared with that with dedicated picture archiving and communication system (PACS) workstation display in the detection of wrist fractures on computed radiographs. This study was conducted according to the principles of the Declaration of Helsinki (2002 version) of the World Medical Association. The institutional clinical board approved the study; informed consent was not required. Seven observers independently assessed randomized anonymous digital radiographs of the wrist from 259 subjects; 146 had fractures, and 113 were healthy control subjects (151 male and 108 female subjects; average age, 33 years). Follow-up radiographs and/or computed tomographic scans were used as the reference standard for patients with fractures, and follow-up radiographs and/or clinical history data were used as the reference standard for controls. The PC was a standard hospital machine with a 17-inch (43-cm) color monitor with which Web browser display software was used. The PACS workstation had two portrait 21-inch (53-cm) monochrome monitors that displayed 2300 lines. The observers assigned scores to the radiographs on a scale of 1 (no fracture) to 5 (definite fracture). Receiver operating characteristic (ROC) curves, sensitivity, specificity, and accuracy were compared. The areas under the ROC curves were almost identical for the PC and workstation (0.910 vs 0.918, respectively; difference, 0.008; 95% confidence interval: -0.029, 0.013). The average sensitivity with the PC was almost identical to that with the workstation (85% vs 84%, respectively), as was the average specificity (82% vs 81%, respectively). The average accuracy (83%) was the same for both. The results of this study showed that there was no difference in accuracy of observer performance for detection of wrist fractures with a PC compared with that with a PACS workstation.

The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture

At the onset of acute diabetic Charcot foot, therapeutic intervention may be delayed because plain X-rays may not show fractures. To assess the clinical course of acute Charcot foot in 24 patients without evidence of definite fractures on the first X-ray after onset of symptoms, who were referred to the foot clinic for diagnosis and treatment either early or delayed, i.e. before or after definite fractures were detectable on repeat X-rays. Eleven patients were referred early (incipient Charcot foot, case group), and 13 patients were referred delayed (overt Charcot foot, control group). In the foot clinic, both groups were immediately treated with off-loading and total contact casting. After the healing process of the Charcot foot was complete, the extent of fractures and subsequent deformities were evaluated. Based on X-rays at the onset of symptoms, in 19 of the 24 patients the condition had been misdiagnosed prior to referral (in 11 patients as sprain injury). Additional imaging techniques (MRI, CT scan or bone scintigraphy) had been performed in 10 patients prior to referral. While these techniques had been used more frequently in the cases vs. the controls (P=0.012), misdiagnosis was less frequent in the cases vs. the controls (P=0.013). Only one out of 11 case patients developed extended foot fractures and severe deformity, vs. 12 out of 13 control patients (P<0.001). Early detection of incipient Charcot foot is facilitated by imaging techniques other than plain X-rays. Immediate off-loading of incipient Charcot foot appears to minimize fractures and incapacitating deformities.

A specimen for studying the resistance to ductile crack propagation in pipes

The paper describes a novel DCB-like specimen designed for studying the resistance of running axial cracks in pipelines. It is long enough for steady-state conditions to govern a large proportion of the crack growth, a condition monitored by direct observation of the crack tip opening angle (CTOA) using video cameras. To avoid possible inaccuracies due to pre-straining the material, realistic specimens must be cut from the pipe and tested without flattening. The geometry of the specimen design allows this, and also includes a measure of gauge-length thinning. Extra thickness due to loading side-plates accentuates two desirable features of gauge thinning, by providing directional stability in the advancing crack tip, and by increasing the level of constraint. Tests on specimens from API X80 grade pipe demonstrated a common pattern of CTOA development for 4, 8 and 10 mm gauge thickness material. All showed a reduction of CTOA with growth towards a constant, steady-state value, with the steady state being associated with slant fracture. The region of reducing CTOA started with flat fracture, and gradually developed increasingly definite slant fracture. The most accurate tests produced a steady-state mean value of CTOA of 11.2° and a standard deviation of 1°.

Inferior Marginotomy for Retrieval of Entrapped Diplopia of Orbital Floor Blowout Fracture

The treatment of entrapped diplopia using blunt traction of the herniated hour-glass orbital contents often leads to inadequate exposure or secondary trauma. Inferior marginotomy which allows temporary displacement of the inferior orbital rim provides direct visualization and complete retrieval of the herniated tisue without further complication. We reported seven patients with definite orbital floor fractures which confirmed by the thin-slice computed X-ray tomography and they received inferior marginotomy through the subciliary incision. We covered the floor defect by the usage of curved sizable silastic sheet implant. Diplopia resolved within 2 months postoperation and restored full ocular motility. Only three patients experienced side effects of mild cheek numbness. The use of inferior marginotomy to treatment orbital floor blowout fracture provided excellent expousure which allowed complete retrieval of entrapped orbital soft tissue with no trauma, It was also used to obtained definite and uncomplicated, quick resolved results in these difficult to treat patients with diplopia.

Insufficiency stress fractures of the foot and ankle in postmenopausal women.

Eleven consecutive patients with 12 stress fractures of the foot or ankle were seen between October 1992 and July 1995. Charts were reviewed retrospectively for clinical information. The patients were all postmenopausal females. Average age was 62 years. Onset of symptoms was not associated with a specific episode of trauma. There were eight metatarsal fractures, three distal fibular fractures, and one fracture of the medial malleolus. Fractures were confirmed by radiographs, bone scan, or MRI in 9 of the 11 cases. Nonsurgical treatment utilizing rest, decreased activity, mechanical support, and analgesics resulted in successful union of the fracture except in one patient. Only four of the patients had been taking hormone or calcium supplements before injury. Just one patient had a prior bone density measurement, although four had a definite fracture previously and two had history suggestive of previous stress fracture. A careful history considering risk factors for osteoporosis should be obtained when an insufficiency type stress fracture is diagnosed. Bone density measurements should be considered for patients with this type of injury. Appropriate medical therapy directed at the treatment of the underlying osteoporosis in addition to orthopaedic management of the fracture constitute the treatment objectives. This dual approach may prevent subsequent injury.

Short tau inversion recovery magnetic resonance imaging in occult scaphoid injuries: Effect on management

Over a 21-month period, 16 patients with possible scaphoid fractures, where conventional radiographs were essentially normal on the day of injury and 10 days later, were examined by coronal short tau inversion recovery (STIR) and T1 weighted sequences on a 0.2 Tesla scanner. The magnetic resonance (MR) examinations were done in between electively booked patients and management was altered in 50% of patients. It was expedient to do MR as radio-isotope facilities were not available at the hospital. In four patients, the examination was entirely normal. In another four patients, intercarpal fluid collections only were demonstrated (two generalized and two localized). In these patients a plaster cast was not re-applied. In two patients, bony injuries of the distal radius were demonstrated instead, with the scaphoid being normal. In the remaining six patients, variable appearances were shown, ranging from an actual fracture line demonstrated on both STIR and T1-weighted images with the remainder of the scaphoid being hyperintense on STIR and hypointense on T1, to non-visualization of the actual fracture line, which appeared to be represented by a much more hyperintense band through the waist of an otherwise hyperintense scaphoid on the STIR sequence. In all these patients a plaster cast was re-applied empirically, including those patients with a definite fracture and those patients with apparent bone contusion only. Although the T1-weighted images were anatomically superior, their addition did not alter management and it is suggested that coronal STIR images should suffice to demonstrate occult fractures of the scaphoid.

Age-related changes in vertebral height ratios and vertebral fracture.

Because no gold standard for the definition of vertebral fracture exists, there has been controversy about whether mild vertebral deformities are truly fractures or simply normal variation in vertebral size and shape. The aim of this study was to assess the associations of mild variations of vertebral height ratios to definite vertebral fractures. In 479 Japanese women (aged 53.9 +/- 9.1 years) who visited our institute for a medical checkup, we performed lateral lumbar radiographs and morphometric parameters were derived by measuring the anterior (Ha), middle (Hm) and posterior (Hp) height of each vertebral body from T12 to L4. Vertebral height ratios, Ha/Hp, Hm/Hp or Hp/Hp' of adjacent vertebrae that were more than 3 SD different from vertebra-specific means of normative data were considered to indicate fractures. Forty-five women were diagnosed with at least one fracture. After excluding the subjects with vertebral fracture, we examined the associations of the variations in vertebral height ratios with age, anthropometric parameters and lumbar bone mineral density (BMD) measured by dual-energy X-ray absorptiometry. Vertebral height ratios, especially Hm/Hp in postmenopausal women, tended to decrease with age and were positively associated with BMD. No significant correlation was observed between anthropometric parameters and vertebral height ratios. Aged-related decrease in vertebral height ratios (Ha/Hp and Hm/Hp, each averaged from T12 to L4) was significant even after the correction for BMD. Mean values of height ratios of non-fractured vertebrae adjusted for age and BMD were significantly lower in postmenopausal women with vertebral fracture than in those without vertebral fracture. Logistic regression analysis showed that BMD and height ratios of non-fractured vertebrae were independent predictors of vertebral fracture risk. The results suggest that older women, and women with at least one obvious (3 SD) fracture, tend to have mild deformities which do not qualify using the 3 SD definition. These mild deformities may represent real consequences of osteoporosis, because they are more pronounced among women with obvious fracture.

Body composition and bone mineral density of Chinese women with vertebral fracture.

This study was designed to compare the body composition and bone mineral density measurements (BMD) in Chinese women with vertebral fracture and normal controls. A total of 400 community dwelling Chinese women aged 70-79 years old were studied. Vertebral height ratios were calculated from lateral thoracic and lumbar spine X-rays and subjects were classified into definite cases (n = 122), doubtful cases (n = 138) and normal controls (n = 140). Bone mineral density and body composition measurements were made by dual X-ray densitometry. The height, fat mass, lean mass, and BMD at all sites were significantly lower in patients with definite fracture than normal controls. Nevertheless, BMD at the hip was more predictive of vertebral fracture than BMD at the spine, the odds ratio in the lowest quartile of hip BMD being 3.8 (95% C.I. = 1.3 to 10.9). Finally, the extent of spinal deformity was poorly predicted by a combination of the anthropometric and BMD measurements, as only 12% of the total variance in TD1 was accounted for.

Follow-up skeletal surveys in suspected child abuse.

The purpose of this study was to assess the additional yield of a repeat skeletal survey in identifying and dating skeletal injury for cases in which child abuse was strongly suspected. Twenty-three infants and toddlers strongly suspected of being physically abused on the basis of findings on the initial skeletal survey, other imaging studies, history, or physical examination underwent a follow-up examination approximately 2 weeks after the initial examination. The high-detail imaging system included a single-emulsion, single-screen combination with a low-absorption carbon-fiber cassette. The skeletal survey protocol entailed tightly collimated anteroposterior views of the appendicular skeleton and anteroposterior and lateral views of the axial skeleton. Between the two studies, all children were in Department of Social Services custody or living in a safe home. The follow-up skeletal survey yielded additional information regarding skeletal injury in 14 (61%) of 23 cases. Follow-up study increased the number of definite fractures detected from 70 to 89 (27%) (p = .005). Most of these additional injuries were classic metaphyseal lesions or rib fractures. In 13 of the 70 fractures previously detected, the follow-up skeletal survey also provided important information about the age of those injuries. When child abuse is strongly suspected on the basis of the findings on the initial skeletal survey, other imaging studies, history, or physical examination, a follow-up skeletal survey is recommended to provide a through and accurate assessment of osseous injuries.

Dietary calcium intake, physical activity and the risk of vertebral fracture in Chinese

To study the relationship between dietary calcium intake, load-bearing activity, reproductive factors, anthropometric factors and vertebral fracture in Chinese, a case-control study was carried out on 481 women (aged 70-79 years) who lived in three housing blocks under the Geriatric Priority Housing Scheme in Shatin, Hong Kong. Lateral spine radiographs were taken from the T4 to L4 level. Definite and doubtful vertebral fractures were diagnosed when any of the three vertebral height (anterior to anterior, middle to posterior and posterior to posterior) ratios was 3 SD and 2-2.99 SD below the mean respectively. Women with one or more definite fractures were classified as definite cases, those with one or more doubtful fractures were classified as doubtful cases, and the rest as controls. The mean dietary calcium intake and load-bearing activities were obtained by interview, using a structured questionnaire. Detailed information on cigarette smoking, alcohol consumption and reproductive factors was also obtained. The grip strength, body weight and height were measured. Doubtful cases were found to differ little from the controls in their lifestyle and anthropometric factors. The odds ratio (OR) for being a definite case was 2.1 (95% CI = 1.1-3.9) when the dietary calcium intake was in the lowest quartile. The OR was 1.8 (95% CI = 0.8-4.4) for subjects who walked or exercised outdoors for less than an hour a day. Giving birth to or breast-feeding three children or more was protective against definite fracture. The definite cases were significantly lighter and shorter than controls; they also had a weaker grip strength. It is concluded that a low dietary calcium intake was significantly associated with an elevated risk of vertebral fracture, while the effect of infrequent load-bearing activity was uncertain. Giving birth to or breast-feeding three or more children was protective against vertebral fracture in our population.

Risk of vertebral fractures in men: relationship to mineral density of the vertebral body.

Vertebral fracture is the most frequent manifestation of osteoporosis in women. Because there is a lack of information about bone density and the occurrence of fractures in men with osteoporosis, we evaluated the relationship between vertebral fractures and spinal bone mineral density (BMD) to determine if there is a threshold of BMD below which fractures are likely to occur. Radiographs of the spine and BMD measurements of the lumbar spine as measured by quantitative CT were obtained in 201 men 21-86 years old (mean age, 68 +/- 4 years) who were referred consecutively for osteoporosis screening. Radiographs were interpreted for the presence or absence of vertebral fractures. The probability of fractures was determined after classifying the patients into subgroups according to their quantitative CT values. The relationship of spinal bone mass to spinal fracture was examined by both logistic regression and receiver operating characteristic (ROC) analysis. Seventy-one patients were classified as having definite vertebral compression fractures. Spinal BMD was 132 +/- 34 mg/ml for the 130 men without vertebral fractures and 75 +/- 22 mg/ml for the 71 men with vertebral fractures (p < .001). The number of fractures per patient and the BMD were negatively correlated (r = -0.71, p < 0.0001). When a BMD of 100 mg/ml was given as a fracture threshold, 15% of the patients without fractures were below this value and 14% of the patients with fractures were above this threshold. Quantifying the overlap between values from patients with and without fractures by ROC analysis, the value of 100 mg/ml gave a sensitivity of 86%. Logistic regression showed 105 mg/ml as the most discriminate value, resulting in a sensitivity of 90%. Logistic regression analysis of the predicted fracture probability also indicated that age does not significantly influence the regression curve. We found that direct quantitative CT measurement of the BMD of the vertebral body is a highly efficient approach to distinguish men without vertebral fractures from those with fractures. Thus, a fracture-threshold concept could provide a quantitative criterion to identify men at high risk for vertebral fractures.

Atrial “J” Pacing Lead Retention Wire Fracture: Radiographic Assessment, Incidence of Fracture, and Clinical Management

In November 1994, Telectronics Pacing Systems issued a voluntary recall of their Accufix 330-801 and 329-701 "J"-shaped atrial pacemaker leads. To assess the integrity of the lead, 156 consecutive patients with the Accufix 330-801 atrial lead implanted underwent fluoroscopic screening. Leads were visualized in at least two orthogonal views. When identified, fractured retention wires were classified into one of four groups, depending on the degree of wire extrusion outside of the lead insulation. Of the 156 patients, 35 patients (22.4%) had a definite retention wire fracture, and an additional 13 patients (8.3%) had indeterminate leads. Neither the age of the patients, the time since lead implant, nor the site of fracture correlated with the incidence of wire fracture. When analyzed to include indeterminate leads that were re-evaluated and found to be fractured, as well as two leads that were identified as being radiographically normal but found to be fractured after extraction, the incidence of retention wire fracture is 25.6% (40 of 156 leads evaluated). The incidence of retention wire fracture in the Accufix 330-801 lead is significantly higher than originally reported. Patients should be notified of the potential dangers associated with this lead. Cardiac digital fluoroscopy is an effective method of screening for wire fracture. Leads with fractured retention wires should be extracted and those with normal fluoroscopic appearance should undergo regular fluoroscopic screening.

茎状突起骨折によると推察されためまいの症例

Since he received a stranglehold during a judo bout, the patient had experienced repeated episodes of paroxysmal vertigo. The patient was a 16-year-old male with a chief complaint of horizontal oscillating vision. Plain X-ray examination during the initial consultation did not show a definite fracture of the styloid process. Balance testing disclosed no significant finding. Helical scan CT delineated a fracture in the center of the left styloid process and anterior deviation of the fractured segment.The mechanisms of oscillopia in this patient were considered to be the following; 1) the fractured segment of the styloid process stimulated the tensor muscle of the velum palatini causing a spasm, and induces symptoms of the inner ear, which is similar to the mechanism of Costen syndrome. 2) the fractured segment stimulated the autonomic nerves near the carotid artery, especially the vagal nerve when he raised his head, and induces transient hypotension, which caused an ischemic brain stem lesion.The present case was an extremely rare case involving a fracture of the styloid process with paroxysmal vertigo.

A comparison of morphometric definitions of vertebral fracture : J. Bone Miner. Res. 1991 6/1 (25–34)

To compare the accuracy of several approaches for defining prevalent vertebral fractures from measurements of vertebral dimensions (morphometry), we measured the lateral dimensions of vertebral bodies of 115 normal premenopausal and 100 postmenopausal women. Of the postmenopausal women two observers agreed that 49 had definite vertebral fractures and 38 were definitely normal. Using these classifications as an independent reference, women were then classified as fractured or normal by several definitions based on vertebral morphometry. No morphometric definition of vertebral fracture agreed perfectly with the consensus classifications. In general, definitions that involved combinations of measurements of anterior (Ha), middle (Hm), and posterior (Hp) vertebral height classified women more accurately than did definitions based on a single measurement or ratio. The Ha/Hp ratio produced many false positives unless it was adjusted for normal variations in the shapes of different vertebral bodies. Definitions of fracture based on a greater than 15% reduction in heights or ratios had higher sensitivity but more false positives than definitions that used a more stringent (greater than 20%) criterion. All morphometric definitions of vertebral fracture separated the post-menopausal women into two groups (fractured and normal) that had significantly (P less than 0.001) different mean spine bone density by quantitative computed tomography. Definitions that had the lowest rates of false positives also produced the largest differences in bone density between those defined as fractured and those defined as normal.

A comparison of morphometric definitions of vertebral fracture

To compare the accuracy of several approaches for defining prevalent vertebral fractures from measurements of vertebral dimensions (morphometry), we measured the lateral dimensions of vertebral bodies of 115 normal premenopausal and 100 postmenopausal women. Of the postmenopausal women two observers agreed that 49 had definite vertebral fractures and 38 were definitely normal. Using these classifications as an independent reference, women were then classified as fractured or normal by several definitions based on vertebral morphometry. No morphometric definition of vertebral fracture agreed perfectly with the consensus classifications. In general, definitions that involved combinations of measurements of anterior (Ha), middle (Hm), and posterior (Hp) vertebral height classified women more accurately than did definitions based on a single measurement or ratio. The Ha/Hp ratio produced many false positives unless it was adjusted for normal variations in the shapes of different vertebral bodies. Definitions of fracture based on a greater than 15% reduction in heights or ratios had higher sensitivity but more false positives than definitions that used a more stringent (greater than 20%) criterion. All morphometric definitions of vertebral fracture separated the post-menopausal women into two groups (fractured and normal) that had significantly (P less than 0.001) different mean spine bone density by quantitative computed tomography. Definitions that had the lowest rates of false positives also produced the largest differences in bone density between those defined as fractured and those defined as normal.

Scaphoid tubercle tenderness: a better indicator of scaphoid fractures?

Tenderness in the anatomical snuff box (ASB) has long been accepted as an indicator of a possible scaphoid fracture. The longitudinal axis of the scaphoid lies in an anteroposterior plane, perpendicular to the remainder of the carpal bones, in the radially deviated wrist. The scaphoid tubercle can therefore be easily and accurately palpated on the palmar aspect of the radially deviated wrist. This study was devised to determine if tenderness over the scaphoid tubercle (ST) was superior to ASB tenderness in identifying definite fractures. Over a 10-month period 246 patients were seen who were suspected of having a scaphoid injury. Thirty (12%) were eventually proven to have definite fracture. Tenderness in the ASB had a sensitivity rate of 90% (95% confidence limits 80-100%) and specificity of 40% (33-47%) as an indicator of a definite fracture. ST tenderness had a sensitivity of 87% (75-99%) and specificity of 57% (50-64%). There is therefore no significant difference in the sensitivity between ASB and ST tenderness but ST tenderness is significantly more specific. However, the presence of either ASB or ST tenderness should be used in order to identify all fractures. Patients with neither ASB nor ST tenderness require symptomatic treatment only.