Pubic Rami Fractures Research Articles

Biomechanical comparison of three minimally invasive fixations for unilateral pubic rami fractures

BackgroundTo compare the mechanical characteristics of a percutaneous superior pubic intramedullary screw, percutaneous bridging plate and percutaneous screw-rod system of the anterior ring for the treatment of unilateral vertical pubic fractures to provide a reference for clinical application.MethodsA finite element model of pelvic anterior ring injury (unilateral vertical pubic fracture) was produced. The fractures were fixed with a percutaneous superior pubic intramedullary screw, percutaneous bridging plate and percutaneous screw-rod system of the anterior ring and their combinations in 5 types of models. The fracture stabilities under vertical, bilateral and anterior-posterior load were quantified and compared based on the displacement of the hip joints’ midpoint as quantificational index of fracture stability.ResultsIn the condition of bilateral and anterior-posterior load, the vertical, bilateral and anterior-posterior displacements of the hip joints’ midpoint of different models were significantly different respectively. In general, the displacements of the 5 pelvic anterior ring fixations were ranked from maximum to minimum as follows: bridging plate, pelvic anterior screw-rod system, combination of bridging plate and pelvic anterior screw-rod system, superior pubic intramedullary screw and combination of superior pubic intramedullary screw and pelvic anterior screw-rod system.ConclusionFor the fixation in unilateral pubic fractures of pelvic ring injury, the percutaneous superior pubic intramedullary screw is optimal, the percutaneous pelvic anterior screw-rod system is the second choice, and percutaneous bridging plate ranks the third. The percutaneous pelvic anterior screw-rod system can significantly increase fixation stability of the percutaneous superior pubic intramedullary screw and the percutaneous bridging plate.

Quelles caractéristiques indiquent une lésion postérieure de l’anneau pelvien concomitante à une fracture des branches pubiennes chez les personnes âgées ?

BackgroundPosterior pelvic ring injury (PPRI) can be challenging to diagnose and visualize using plain radiographs; sometimes, PPRI is even overlooked. This study aimed to investigate differences between isolated pubic ramus fractures and fractures concomitant with PPRI in elderly patients. HypothesisElderly patients with pubic ramus fractures and concomitant PPRI present different characteristics than patients with isolated ramus fractures. Patients and MethodsWe retrospectively reviewed data of 65 patients aged≥65 who visited the emergency department with a pubic ramus fracture on plain radiograph between January 2013 and December 2018. Patients were divided into two groups based on whether PPRI was found by computed tomography (CT). We then compared patient data and fracture characteristics between the two groups, including displacement and location of the pubic ramus fracture and presence of complete anterior pelvic ring disruption (i.e., concurrent superior and inferior rami fracture). ResultsPPRI was identified in 49 of 65 patients (75 %) on CT. There was greater displacement of the pubic ramus fracture in patients with concomitant PPRI than in those with isolated pubic ramus fractures (4.6mm and 2.2mm, respectively, p<0.001). PPRI more commonly accompanied ramus fractures located medially to the obturator foramen than ramus fractures located in the obturator foramen or laterally to the obturator foramen (96 %, 52 %, and 77 %, respectively, p=0.001). Complete anterior pelvic ring disruption was associated with significantly more concomitant PPRI relative to incomplete anterior pelvic ring disruption (84 % and 22 %, respectively, p<0.001). DiscussionWhen a pubic ramus fracture is markedly displaced, located medially to the obturator foramen and complete anterior pelvic ring disruption, care should be taken to assess PPRI. Level of evidenceIV, retrospective study.

Isolated Pubic Ramus Fractures Are Serious Adverse Events for Elderly Persons: An Observational Study on 138 Patients with Fragility Fractures of the Pelvis Type I (FFP Type I).

Background: Fractures of the pubic ramus without involvement of the posterior pelvic ring represent a minority of fragility fractures of the pelvis (FFP). The natural history of patients suffering this FFP Type I has not been described so far. Material and methods: All patients, who were admitted with isolated pubic ramus fractures between 2007 and mid-2018, have been reviewed. Epidemiologic data, comorbidities, in-hospital complications, and one-year mortality were recorded. Of all surviving patients, living condition before the fracture and at follow-up was noted. Mobility was scored with the Parker Mobility Score, quality of life with the European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), subjective sensation of pain with the Numeric Rating Scale (NRS). Results: A consecutive series of 138 patients was included in the study. There were 117 women (84.8%) and 21 men (15.2%). Mean age was 80.6 years (SD 8.6 years). 89.1% of patients presented with comorbidities, 81.2% of them had cardiovascular diseases. Five patients (4%) died during hospital-stay. Median in-hospital stay was eight days (2–45 days). There were in-hospital complications in 16.5%, urinary tract infections, and pneumonia being the most frequent. One-year mortality was 16.7%. Reference values for the normal population of the same age are 5.9% for men and 4.0% for women. One-year mortality rate was 22.2% in the patient group of 80 years or above and 8.8% in the patient group below the age of 80. The rate of surviving patients living at home with or without assistance dropped from 80.5% to 65.3%. The median EQ-5D-Index Value was 0.62 (0.04–1; IQR 0.5–0.78). Reference value for the normal population is 0.78. Average PMS was 4 and NRS 3. Within a two-year period, additional fragility fractures occurred in 21.2% and antiresorptive medication was taken by only 45.2% of patients. Conclusion. Pubic ramus fractures without involvement of the posterior pelvis (FFP Type I) are serious adverse events for elderly persons. During follow-up, there is an excess mortality, a loss of independence, a restricted mobility, and a decreased quality of life. Pubic ramus fractures are indicators for the need to optimize the patient’s general condition.

Single stage reconstruction of a neglected open book pelvic injury with bladder herniation into the upper thigh: a case-report

When open-book injuries are neglected and result into a pelvic malunion or nonunion, long-term problems, such as chronic pain, gait abnormalities, sitting discomfort, neurological symptoms and urogenital symptoms can occur. In this case report, we describe the repair of a neglected pelvic disruption with the dislocation of the urinary bladder in a one-stage procedure. The clinical image with which the patient presented could be split into unique sub-problems, for which separate solutions needed to be chosen: large symphysis diastasis, instability and pain in both SI joints, malunion of the superior and inferior pubic rami fractures; and urinary bladder herniation into the upper thigh. In a single-stage procedure, the pelvic ring was reconstructed and the bladder reduced. The patient was thereafter continent for urine and could walk independently. A complex clinical problem was divided into its sub-problems, for which specific solutions were found.

Clinical research on minimally invasive internal fixation for the treatment of anterior ring injury in tile C pelvic fracture.

The aim of this study is to explore the clinical outcome and indications in treating anterior ring injury of Tile C pelvic fracture with minimally invasive internal fixation.We retrospectively reviewed 18 patients (aged 25–62, 34.2 ± 7.4) with 26 pelvic anterior ring injuries of Tile C pelvic fracture treated with minimally invasive internal fixation in our hospital were from January 2012 to August 2016. Two cases were pubic symphysis diastasis, 15 were anterior ring fracture (7 were bilateral), and 1 was vertical displacement of pubic symphysis associated with pubic ramus fracture. According to Tile classification, 8, 4, and 6 cases were types C1, C2, and C3, respectively. All patients accepted the operation of pelvic fractures on both rings, while the anterior ring injuries were treated with minimally invasive internal fixation. The period from injury to operation was 5 to 32 days (11.2 ± 3.7). Four patients had pubic symphysis diastasis or pelvic anterior ring fracture medial obturator foramen reduced with modified Pfannenstiel incision and fixed with cannulated screws, 14 patients (22 fractures) had a fractured lateral obturator foramen reduced with modified Pfannenstiel incision associated with small iliac crest incision and fixed with locking reconstruction plates. Clinical data, such as operation time, intraoperative bleeding, Matta standard to assess the reduction quality of fracture, and complications, were collected and analyzed.The operation time ranged from 30 to 65 minutes (42.8 ± 18.7), and the intraoperative bleeding volume was 30 to 150 mL (66.5 ± 22.8). All cases were continuously followed-up for 16 to 42 months (30.2 ± 4.6). All fractures were healed between 3 and 9 months postoperatively (4.9 ± 2.7 months). According to the Matta standard assessment, 18, 7, and 1 cases were excellent, good, and fair, respectively, with a 96.2% (25/26) rate of satisfaction. Neither reduction loss, fixation failure, nor infection occurred; complications included 1 patient with fatal liquefaction, 1 patient had lateral femoral cutaneous nerve injury, and 1 patient complained of discomfort in the inguinal area due to fixation stimulation.Minimally invasive internal fixation for pelvic anterior ring injury in Tile C pelvic fracture has the advantages of less damage, safer manipulation, less complications, and good prognosis.

Management and retrospective analysis of pelvic ramus tumors and tumor-like lesions: Evaluation with 31 cases.

Objectives This study aims to investigate the characterization, treatment approaches, and follow-up results of tumors and tumor-like lesions located in the pelvic ramus.Patients and methods Thirty-one patients (9 males, 22 females; mean age 48.9 years; range, 7 to 79 years) with benign and malignant tumors or tumor-like lesions in the pelvic ramus region treated and followed-up in our clinic between January 2005 and January 2019 were evaluated retrospectively. Surgical procedures were performed with anterior approach or inner-thigh approach. Twelve patients were diagnosed with malignant tumors, 12 patients with benign tumors, and seven patients with tumor-like lesions.Results Seventeen patients who underwent surgical treatment were followed-up for a mean period of 61.7 months. The diameters of benign and malignant tumors were similar (p=0.425). Of all lesions, 64.5% were located in the pubis. Ischium location was significantly higher in patients with malignant lesions than tumor-like lesions. The most common complication was diffuse subcutaneous edema in the inguinal region and thigh (8.3%).ConclusionThere are many different tumoral lesions in the pelvic ramus. Pelvic ramus tumors tend to settle more frequently in pubic ramus, whereas ramus ischium tumors are more likely to be malignant. In addition, the diagnosis of insufficiency fracture should be considered primarily in pathologic fractures of pubic ramus in females over 50 years of age. In the postoperative follow-up of pelvic ramus tumors, diffuse edema may occur even if there is no intraoperative vascular damage.

Interdigitating percutaneous screw fixation for Rommens type IIIa fragility fractures of the pelvis: technical notes and preliminary clinical results.

Fragility fractures of the pelvis (FFPs) type IIIa in the Rommens classification include unilateral iliac fractures as well as pubic rami fractures. We devised a new, less-invasive fixation technique to achieve increased stability for FFPs type IIIa. The aim of this study was to describe this procedure and report the preliminary clinical results. A total of 14 geriatric patients (> 60years old) who sustained FFP type IIIa caused by low-energy trauma were surgically treated with interdigitating screw fixation including a trans-pubic screw in a retrograde manner and two trans-iliac screws from the anterior inferior iliac spine toward the posterior inferior iliac spine. All iliac fractures were displaced with external rotation, and closed reduction was performed. Percutaneous screw fixation, in which fully threaded screws were in contact with each other, provided stable fixation allowing early mobilization. A median decrease in pain levels by post-operative day two was 4.5 compared with pre-operatively using a numerical rating scale. While full weight-bearing was allowed from four weeks post-operatively in the initial five patients, immediate full weight-bearing was instructed as tolerated for the subsequent nine patients. No complications were encountered during the peri-operative period. At the final follow-up, all fractures were united without fixation loss, screw dislodgment, or hardware failure. This procedure of closed reduction and interdigitating screw fixation for FFP type IIIa appears to represent a safe, reliable technique. Our experience suggests that interdigitating fixation for FFP type IIIa is effective for relieving pain and promoting early mobilization in elderly patients.

What characteristics indicate concomitant posterior pelvic injury in pubic ramus fractures in the elderly?

BackgroundPosterior pelvic ring injury (PPRI) can be challenging to diagnose and visualize using plain radiographs; sometimes, PPRI is even overlooked. This study aimed to investigate differences between isolated pubic ramus fractures and fractures concomitant with PPRI in elderly patients. HypothesisElderly patients with pubic ramus fractures and concomitant PPRI present different characteristics than patients with isolated ramus fractures. Patients and methodsWe retrospectively reviewed data of 65 patients aged≥65 who visited the emergency department with a pubic ramus fracture on plain radiograph between January 2013 and December 2018. Patients were divided into two groups based on whether PPRI was found by computed tomography (CT). We then compared patient data and fracture characteristics between the two groups, including displacement and location of the pubic ramus fracture and presence of complete anterior pelvic ring disruption (i.e., concurrent superior and inferior rami fracture). ResultsPPRI was identified in 49 of 65 patients (75%) on CT. There was greater displacement of the pubic ramus fracture in patients with concomitant PPRI than in those with isolated pubic ramus fractures (4.6mm and 2.2mm, respectively, p<0.001). PPRI more commonly accompanied ramus fractures located medially to the obturator foramen than ramus fractures located in the obturator foramen or laterally to the obturator foramen (96%, 52%, and 77%, respectively, p=0.001). Complete anterior pelvic ring disruption was associated with significantly more concomitant PPRI relative to incomplete anterior pelvic ring disruption (84% and 22%, respectively, p<0.001). DiscussionWhen a pubic ramus fracture is markedly displaced, located medially to the obturator foramen and complete anterior pelvic ring disruption, care should be taken to assess PPRI. Level of evidenceIV, retrospective study.

Integrity of the pectineal ligament in MRI correlates with radiographic superior pubic ramus fracture displacement.

Estimating the stability of pelvic lateral compression fractures solely by static radiographs can be difficult. In this context, the role of anterior pelvic soft tissues as potential secondary stabilizer of the pelvic ring has hardly been investigated. To correlate the initial radiographic appearance of the pubic ramus fracture with the integrity of the pectineal ligament, a strong ligament along the pecten pubis. In total, 31 patients with a pelvic lateral compression fracture (AO/OTA 61- B1.1/B2.1) with 33 superior pubic ramus fractures and available post-traumatic radiographs (pelvis anteroposterior, inlet, outlet) and magnetic resonance imaging (MRI) of the pelvis with fat-suppressed coronal images were reviewed retrospectively. Radiographic superior pubic ramus fracture displacement was measured and correlated to the degree of MR-morphologic alterations of the pectineal ligament (grade 0 = intact, grade 3 = rupture). In the majority of fractures (72.7%), associated MR-morphologic alterations of the pectineal ligament were present. Radiographic displacement and MRI grading showed a strong positive correlation (Spearman rho = 0.783, P < 0.001). The sensitivity and specificity for a radiographic displacement of >3 mm on plain radiographs to detect a structural ligament lesion on MRI (grade 2 and higher) were 73% and 100%, respectively. Radiographic displacement of superior pubic ramus fractures >3 mm is a strong indicator for a structural lesion of the pectineal ligament. Future studies should investigate the potential biomechanical importance of this ligament for pelvic ring stability.

The truth behind the pubic rami fracture: identification of pelvic fragility fractures at a university teaching hospital

Older patients presenting on the acute medical take with pelvic fragility fractures (PFF) represent an increasing epidemic.[1][1] The most common pelvic fracture identified by plain X-ray is that of the pubic rami.[2][2] PFF are painful and despite optimal analgesia, many of these patients struggle

88 The Truth Behind the Pubic Rami Fracture: Identification of Pelvic Fragility Fractures at A University Teaching Hospital

Abstract Introduction Older patients presenting with pelvic fragility fractures (PFF) is an increasing epidemic. The most common pelvic fracture identified by plain radiograph is pubic rami fracture. These fractures are painful and often require admission to hospital. However, despite optimal analgesia, many of these patients struggle to mobilise and may have fractures of the posterior pelvic ring, which are overlooked and not visible on plain radiograph imaging. We aimed to quantify the number of patients progressing to further pelvic imaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) and the presence of concurrent fractures. Methods Prospective screening of pelvic imaging in patients aged over 70 years was undertaken at Nottingham University Hospitals NHS Trust over an 8-month period from October 2018. Results 103 predominantly female (83%) patients were confirmed to have an acute fragility fracture of the pubic rami on plain radiograph. 19% of patients were discharged direct from the Emergency Department, 45% were admitted to Health Care of Older People (HCOP) teams, 30% to Trauma and Orthopaedic (T&amp;O) teams and 6% to other specialities. 25% of the patients admitted underwent further pelvic imaging, which confirmed fragility fractures of the pubic rami in 88%, with 40% showing acetabular fractures and 68% showing sacral fractures of all types. A further 10 patients were diagnosed with pubic rami insufficiency fractures on further imaging, having had a normal initial radiograph, but had been admitted with poor mobility due to groin pain. In these 10 patients, 20% also had an acetabular fracture and 60% sacral fractures. Overall, 59% of patients with pubic rami fractures had an ipsilateral sacral fracture; a Type 1 Lateral Compression pelvic fracture by AO classification. Conclusions Pubic rami fractures are a significant problem in older people and often require admission to hospital. Further imaging confirms these fractures are complex, with co-existing fractures of the acetabulum and sacrum common. However despite this, only a quarter of patients admitted had further imaging. Where pelvic fractures are missed or severity not appreciated, appropriate pain control can be more difficult to achieve. With the potential for minimally invasive surgical options to aid pain management in sacral fractures, it may be prudent for all patients hospitalised with suspected or confirmed pelvic fracture to undergo further imaging.

Anterior subcutaneous internal fixation combined with posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures

To assess the effectiveness of anterior subcutaneous internal fixation (INFIX) combined with posterior percutaneous iliosacral screw for the treatment of unstable pelvic fractures. Between August 2016 and November 2017, 19 cases of unstable pelvic fractures were treated with anterior subcutaneous INFIX combined with posterior percutaneous iliosacral screw. There were 14 males and 5 females, with an average age of 40.6 years (range, 17-69 years). Causes of injury included traffic accident injury in 11 cases, falling from height in 5 cases, bruise injury by heavy object in 3 cases. According to Tile classification, there were 2 cases of type B1, 6 cases of type B2, and 11 cases of type C. Anterior ring injuries included bilateral pubic ischial ramus fractures in 12 cases, unilateral pubic ischial ramus fractures in 5 cases, and symphysis pubis separation in 2 cases. Posterior ring injuries included sacroiliac ligament injuries in 2 cases, unilateral iliac bone fractures in 3 cases, unilateral sacral fractures in 11 cases, unilateral sacroiliac joint dislocation in 2 cases, and bilateral sacral fracture in 1 case. The intraoperative blood loss and operation time were recorded, and the fracture healing and postoperative complications were observed. Matta score was used to evaluate the reduction of fracture, and Majeed score was used to evaluate the postoperative function of patients. The operation time was 47-123 minutes (mean, 61.4 minutes) and the intraoperative blood loss was 50-115 mL (mean, 61.1 mL). One case had superficial infection at the site of screw implantation, and 1 case had unilateral cutaneous nerve stimulation, which were cured after corresponding treatment. There was no damage of urinary system, reproductive system, and intestine. All cases were followed up 12-25 months (mean, 18.1 months). All the fractures healed after operation, the average healing time was 9.5 weeks (range, 8-13 weeks); no nonunion, delayed healing, internal fixation loosening, fracture, and other situations occurred. Of the 2 patients with lumbosacral plexus injury before operation, 1 recovered completely and 1 had residual mild claudication. At last follow-up, the reduction of fracture was evaluated by Matta scoring standard, the results were excellent in 13 cases and good in 6 cases, with an excellent and good rate of 100%; the function was evaluated by Majeed scoring standard, the results were excellent in 15 cases and good in 4 cases, with an excellent and good rate of 100%. Minimally invasive pelvic stabilization by using anterior subcutaneous INFIX and posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures, can achieve good fracture reduction and definitive stabilization with minimum complications and obtain excellent functional outcomes.

Minimal-invasive stabilization of anterior pelvic ring fractures with retrograde transpubic screws

BackgroundIn the vast majority of patients with pelvic ring lesions, there is a combination of fractures of the posterior and anterior pelvic ring. Anterior fractures are painful and contribute to loss of stability of the pelvic ring. For these reasons, stabilization of pubic rami fractures is recommended together with posterior pelvic ring fixation. Retrograde transpubic screw osteosynthesis enjoys increasing acceptance due to its minimal invasive technique and adequate stability. Patients and methodsWe retrospectively reviewed the results of 158 retrograde transpubic screw osteosyntheses in 128 patients with pelvic ring lesions including a pubic ramus fracture. Sixty-three patients suffered a high-energy injury, 65 a fragility fracture of the pelvis. ResultsOne hundred and forty-six screws (92.4%) were inserted through a percutaneous procedure. There were no vascular, neurological or urological complications. Fifty-nine screws (39%) yielded an excellent reduction with less than one cortical width of displacement. Slight secondary displacement was seen in 33 of these fractures (55.9%). Early surgical complications were seen in 16 screws (10.1%): suboptimal pathway in 10, local hematoma in 4 and local infection in 3. Early revision surgery was done in 7 screws (4.4%). Median follow-up was 27.6 weeks, 83 screws (52.5%) had a follow-up of more than 6 months. During follow-up, 7.6% of screws loosened. Operative revision was performed in 13%. 75 fractures (90.3%) with a follow-up of ≥ 6 months showed radiographic evidence of healing. There was no difference in the healing rate of high-energy and fragility fractures. Nonunion rate was not dependent on the quality of primary reduction, secondary displacement, or screw loosening. Infection (p 0.001) and surgery ≥ 6 months after trauma (p 0.02) more often led to nonunion. ConclusionRetrograde transpubic screw osteosynthesis is a reliable method for splinting pubic rami fractures in high and low energy pelvic trauma. Although a slight secondary fracture displacement is seen in most cases, it does not affect fracture healing. Retrograde transpubic screw is a adequate minimal-invasive osteosynthesis to stabilize the anterior pelvic ring, especially in fragility fracture of the pelvis. Delayed operation (> 6 months) and infection show higher rate of nonunion.

Intra-Abdominal Solid Organ Injury Management in Pediatrics

Abdominal trauma is relatively uncommon in children but can leads to a significant morbidity and mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities. The abdomen is the most common site of initially unrecognized fatal injury in traumatized children. We are reporting a case of a child with multiple solid organ injury that was successfully treated non-operatively at our center. We presented a previously healthy 9-month-old girl, presented with fluctuating GCS secondary to motor vehicle accident with borderline hemodynamic stability. She was intubated, blood transfusion commenced and a single inotrope support started. She subsequently diagnosed with grade III liver injury, grade II splenic injury, right grade IV renal injury with large perinephric and retroperitoneal hematoma and moderate hemoperitoneum, a non-displaced left superior pubic rami fracture and cerebral edema on computed tomography (CT). She was admitted to pediatric intensive care unit (PICU). Her intra-abdominal injury injuries were successfully treated conservatively. She required a right chest tube on post trauma day 2, for right hemothorax. The chest tube was removed 3 days later following adequate drainage. She eventually was weaned off from ventilator on post trauma day 11. Feeding was commenced on day 7 of post trauma. She was discharge home well after 3 weeks post trauma with periodical follow up. Conclusion: Pediatric intra-abdominal solid organ injury is relatively uncommon, but a potential source of significant morbidity. Non-operative management is the standard of care for the majority of these injuries, which have shown successful rate more than 95%, although continued hemodynamic instability mandates operative intervention.

MON-410 Ectopic ACTH- Secreting Tumor Causing Rapidly Progressive Cushing’s Syndrome Remains an Elusive Localization Diagnosis

Background: 68Ga-DOTATATE PET-CT (DOTATATE-PET) has higher sensitivity and positive predictive value than other studies, reason for which it has become the imaging modality of choice for Neuroendocrine tumor (NET) localization, but data on ACTH-secreting NET is scarce. Case summary: 61 year old female with history of right hepatic lobe lipoma resection, T2DM (A1c 9.4%), HTN, and benign thyroid nodule that was evaluated for cushingoid features with facial and lower extremity edema, progressive generalized weakness, difficulty climbing stairs, 20 lbs weight loss and intermittent hypokalemia while on a diuretic plus three other antihypertensives over a six month period. ACTH-dependent hypercortisolism was confirmed with a non-suppressed ODST 11.27mcg/dL (normal <1.8), elevated 24 hr urine free cortisol 525 mcg/24h (RR 4.0-50.0, total volume 3.85 L, creatinine 0.92 g/24 hr), midnight salivary cortisol 1.13 mcg/dL(RR ≤0.09), and ACTH 122 pg/mL (RR 6-50). Additionally, plasma metanephrines were negative, aldosterone <1 ng/dl (RR ≤21) and renin activity 0.58 ng/mL/h (RR 0.25-5.82). Cushing’s disease was suspected since her 8am cortisol suppressed >50% after 8 mg dexamethasone (dexa) overnight (pre-dexa cortisol 33.78 mcg/dL, post-dexa cortisol 6.59 mcg/dL). However, MRI Sella did not show a pituitary adenoma and IPSS was compatible with Ectopic ACTH-secretion (EAS). CT chest, abdomen, pelvis with contrast did not reveal any frank lesion that could be the culprit of EAS. Octreoscan and FDG-PET were negative. DOTATATE-PET reported a mild focus of uptake on the medial aspect of the right upper lung lobe, thought to be a branching blood vessel since no anatomic lesion was seen on CT Chest that would correspond to the possible area of uptake. In the interim, she developed diffuse ecchymosis with worsening of her functional status, needing a walker and assistance with activities of daily living. She had several falls complicated by multiple lumbar compression fractures, rib, right pubic ramus and bilateral sacral insufficiency fractures for which she received reclast, a back brace and physical therapy. She was started on ketoconazole and titrated up, but due to rapid progression of her Cushing syndrome over five months without an identifiable source of EAS, the decision was made to proceed with bilateral adrenalectomy and perform surveillance imaging to identify growth of a possible occult NET. Conclusion: In our case, DOTATATE-PET did not help to localize an ACTH-secreting NET, suggesting that the sensitivity of this study might not be as good as reported for other types of NET. Therefore, Occult EAS remains a diagnostic challenge and clinicians may resort to bilateral adrenalectomy for permanent biochemical control and serial CT imaging to detect an incipient NET.

MON-501 A Hemangioma Causing Tumor Induced Osteomalacia

Introduction: TIO (Tumor induced osteomalcia) is a rare paraneoplastic syndrome due to ectopic production of FGF23 (Fibroblast growth factor 23) from a mesenchymal tumor that results in renal phosphate wasting and impaired calcitriol synthesis. We present a case of TIO from a benign hemangioma which is an uncommon occurrence. Clinical case: A 68-year-old female presented with a history of multiple fractures; right pelvic fracture 8 years ago, bilateral pubic rami fractures 3 months ago, left femoral neck fracture and left humeral shaft fracture 1 month ago due to trivial traumas. She also complained of chronic generalized muscle pain and severe fatigue that essentially made her bedbound. Her past medical history was significant for DM type II, hypertension, hyperlipidemia, osteoarthritis and chronic anemia. She was diagnosed with a right inferior parathyroid adenoma after noting high PTH of 281pg/ml [15-65] and increased uptake on a parathyroid scan. Following a right inferior parathyroidectomy, the PTH was 51pg/ml [15-65]. Current workup: Vitamin D 7.4pg/ml [30-80], Calcium 7.0mg/dl [8.6-10.2] (corrected calcium 8.0mg/dl), Phosphorous 1.4mg/dl [2.7-4.5], Magnesium 1.6mg/dl [1.7-2.6], Alkaline phosphatase 222U/l [35-104] , Creatinine 0.6mg/dl [0.5-1.2], PTH 214.4pg/ml [15-65] and normal transaminases. Whole body bone scan showed increased uptake in multiple foci in the bilateral ribs, sternum, both shoulders and left humerus. About 2 weeks following vitamin D and calcium supplementation, serum calcium normalized, vitamin D improved to 15pg/ml [30-80] and PTH trended down to normal limits at 52.4pg/ml [15-65]. But the phosphorous level was never >1.6mg/dl [2.7-4.5] despite vigorous IV and oral replacement. This raised concern for hypophosphatemic osteomalacia. Incidentally, as workup for back pain and acute on chronic anemia, a CT abdomen was done which showed a heterogeneously enhancing right pelvic mass measuring up to 7.5 cm extending into the spinal canal from approximately L4-5 level into the upper sacrum. MRI confirmed the presacral mass. A CT guided biopsy was done and final pathology reported hemangioma by STAT6 immunostain. 1,25 (OH)2 Vitamin D was 24 pg/ml [18-78] and an FGF23 level was very high at 3980 RU/mL [<=180] confirming our diagnosis of TIO. Although surgery would have been curative in TIO, this patient was tired of surgeries and decided to go with medical management. Calcitriol 0.25mcg bid, K-Phos Neutral 1 tablet four times a day at equal intervals throughout the awake hours was recommended. Conclusion: TIO is a rare disorder that is usually caused by benign mesenchymal tumors. Although rare, hemangiomas can cause TIO.

Phosphaturic Mesenchymal Heel Tumor Presenting with Tumor-Induced Osteomalacia

To help clinicians identify and treat patients with tumor-induced osteomalacia (TIO) resulting from a phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT). Describe the history, presentation, laboratory findings, diagnostic studies, treatment, and literature review. A 58-year-old female with no significant past medical history presents with ongoing multiple bone pain for years. She had a bone scan showing multiple focal areas of increased uptake involving bilateral ribs, distal right tibia, and left femoral neck, representing previously healed fractures. Her bilateral lower-extremity magnetic resonance imaging showed stress fractures of the anteromedial cortex, right tibia, and the left femoral neck. Phosphorus was noted to be 1.9 mg/dL (normal range, 2.0 to 4.0 mg/dL), and alkaline phosphatase was 179 U/L (normal range, 25 to 110 U/L). Tubular maximum re-absorption of phosphate to glomerular filtration rate ratio was 0.438, which was low. An outside physician initiated patient on teriparatide, which showed bone mineral density improvement after 1 year, and then the teriparatide was stopped. Later, she developed a nontraumatic pubic ramus fracture; teriparatide was resumed. While on teriparatide, she developed several new rib fractures. Due to declining phosphorus levels, further investigation led to an elevated fibroblast growth factor 23 (FGF-23) level of 243 RU/mL (normal, <50 RU/mL). TIO was strongly suspected, and a nuclear medicine positron emission tomography/computed tomography trunk with 68Ga-1,4,7,10-tetraazacyclododecane 1,4,7,10-tetraacetic acid tyrosine-3-octreotate (i.e., 68Ga-DOTATATE) showed a right heel soft-tissue nodule. Fine-needle aspiration biopsy was performed, confirming PMTMCT, positive for FGF-23 mRNA. After surgery, her symptoms resolved and her phosphorus normalized. TIO is a rare paraneoplastic syndrome characterized by bone pain, muscle weakness, and fractures associated with persistent hypophosphatemia. Clinicians now have new imaging tools to help identify and treat patients with PMTMCT.

Finite element analysis of anterior ring injuries in unstable pelvic fractures treated by different methods

To compare the biomechanical stability of different fixation methods for anterior ring injury of unstable pelvic fractures, and to provide reference for clinical treatment. An unstable pelvic fracture model (Tile C) with one side of the sacroiliac joint dislocation and the pubic rami fracture was constructed via three-dimensional finite element analysis. Five different fixation methods were used in the front, and the rear was fixed with sacroiliac screws. The von Mises stress and strain distributions of different combinations of fixation methods were analyzed under mimicking standing conditions. After being loaded with 500 N vertically, the maximum stress in the anterior fracture was 3.56 MPa in anterior pelvic external fixation (AEF) group, the total displacement and the vertical displacement of the Y axis at the sacroiliac joint and the fracture were not more than 1.5 mm. The maximum stress at fixation, the front of the fracture and sacroiliac joints in the anterior pelvic subcutaneous approach(APA) group and AEF, was significantly higher than anterior modified Stoppa approach(ASA) group, anterior pelvic Ilioinguinal approach (AIA) group, and canulated screw fixation(CSF) group. The total displacement and the vertical displacement of the Y axis at the sacroiliac joint and the fracture in APA group and AEF group were also greater than the other three groups. Anterior ring injury of unstable pelvic fractures can be significantly improved after the fixation of the implants in the five combined methods. However, overall biomechanical properties of ASA, AIA and CSF group are superior to APA and AEF group.

Intramedullary Stabilization of Pubic Ramus Fractures in Elderly Patients With a Photodynamic Bone Stabilization System (IlluminOss).

Introduction:A photodynamic bone stabilization system (PBSS) is a percutaneous operating method that provides intramedullary stabilization. The purpose of the study was to assess the clinical and radiological outcome after treatment of pubic ramus fractures with the PBSS.Materials and Methods:In a retrospective study, patients with osteoporotic pubic ramus fractures were included. The patients were treated with the PBSS in a percutaneous method. In the routine follow-up examination, pain was measured with the visual analog scale (VAS) and the type of mobilization was verified. Computer tomography of the pelvis was carried out in the follow-up examination (mean of 7.5 months after surgery) to investigate bone healing.Results:A total of 32 patients (25 females and 7 males) were included in the study. The average hospital stay was 16.5 ± 7.9 days (range: 5-37 days) and the mean operation time was 116.8 ± 47.1 minutes (range: 33-255 minutes). Two cases of wound infections and 1 case of misplacement of the PBSS implant with revision surgery have been documented. The mean VAS score for pelvic/hip pain at the day of inpatient discharge was 4.4 ± 1.4 (range: 2-7). A total of 25 patients could attend the follow-up examination 7.5 ± 1.7 months (range: 6-14) after the procedure, reporting a mean VAS for pelvic/hip pain of 3.0 ± 2.2 (range: 0-8). A total of 11 patients could walk without an orthopedic walking device, 7 patients needed underarm crutches, 6 patients used a walker-rollator, and 1 patient was immobilized. Consolidated pubis ramus fractures were described in 24 (96%) cases.Discussion:The results of our study reveal adequate clinical and radiological outcomes after treatment of osteoporotic pubic ramus fractures with the PBSS. This is the first study investigating the outcome after treating pubic ramus fractures with the PBSS.Conclusion:Based on our findings, the PBSS is an alternative to known techniques for the stabilization of the pubic ramus.

Massive Hemorrhage Caused by a Non-Displaced Pubic Ramus Fracture from Low-Energy Trauma

Massive Hemorrhage Caused by a Non-Displaced Pubic Ramus Fracture from Low-Energy Trauma