[Bilateral pertrochanteric spontaneous fracture in chronic alcoholism and liver cirrhosis. A case report]

Fractures of the neck or the pertrochanteric region are often treated with dynamic hip screw especially in elderly patients. We give a case report covering treatment and follow-up for a bilateral spontaneous pertrochanteric fracture in a 45-year-old man as a result of hepatogenetic osteopathy.

[Vertebral deformity as an index of osteoporosis-induced spinal fracture--an external validity construct based on bone density data]

BACKGROUND

In order to test the validity of vertebral morphometry for the assessment of prevalent vertebral osteoporotic fractures, we examined the association between vertebral deformities and bone mineral density (BMD).

METHOD

The study population consisted of 595 postmenopausal women and 581 men aged 50 to 82 years who participated in the baseline survey of the European Vertebral Osteoporosis Study (EVOS) in Germany and received BMD measurements by dual-X-ray-absorptiometry (DXA) at the femur and the lumbar spine.

RESULTS

In both sexes only vertebral deformities defined by more stringent morphometric criteria (McCloskey; Eastell 4 SD criterion) were significantly and inversely related to BMD (odds ratios 1.42 to 3.21 for a 1 SD [standard deviation] reduction in BMD; p < 0.05). The strength of the association depended on the stringency of the morphometric algorithm applied, and on the site of BMD measurement. The strongest associations were observed with femoral neck BMD in women and with BMD at the lumbar spine in men. In contingency analyses between vertebral deformities and osteoporosis (WHO criteria; European young female BMD reference values), vertebral deformities proved to be highly specific by all methods, even slightly more so in men (87.8 to 97.5%) than in women (86.3 to 96.7%). The predictive value of a positive test with respect to vertebral osteoporosis reached a maximum value of about 50% in both sexes. It further increased up to 72%, when the definition of osteoporosis was based on low BMD values at either the spine or the femoral neck, but only in women.

CONCLUSIONS

In conclusion, for both men and women the likelihood of vertebral deformities to be related to osteoporosis increases with the stringency of the morphometric method, with a similar probability of major deformities to represent vertebral osteoporotic fractures in men as in women. Nevertheless, even the most stringent morphometric criteria are not sufficiently valid instruments for the assessment of the prevalence of vertebral osteoporotic fractures in epidemiological studies.

[Morphometric analysis of roentgen images of the spine for diagnosis of osteoporosis-induced fracture]

The European Vertebral Osteoporosis Study (EVOS) is one of the largest studies to investigate the prevalence of osteoporosis related vertebral fractures in a population based cross-sectional study. One of the main tasks was to create standards and logistics to obtain uniform and comparable radiographs in all 36 European centers. Furthermore the central reading of the X-rays and the morphometry of the vertebral bodies were 2 important challenges. This paper describes the standardized patient positioning and making of the radiographs as well as their morphometry, reading, and evaluation.

[Osteosonography of the phalanges of men]

BACKGROUND

The distal metaphysis of the first phalanx of the fingers II to V is, like the vertebral body, a useful site for the measurement of mineralisation and structure of the bone, because of the simultaneous presence of compact and trabecular bone.

METHOD

With an osteosonographic device (DBM sonic 1200, IGEA, Italy) we measured in 38 young and healthy men, 14 elderly and healthy men, 18 men with osteopenia, 8 men with osteoporosis and vertebral fractures and 10 men with long-standing cortisone medication, the adSOS (amplitude-dependent speed of sound) and the UBPS (ultrasound bone profile score) at the phalanges, as well as bone mineral density (BMD) at lumbar spine using dual-X-ray absorptiometry (DXA).

RESULTS

There was no correlation between adSOS or UBPS and lumbar BMD (DXA). There was a significant positive correlation between adSOS and UBPS, r = 0.826 (p < 0.00001). AdSOS declined with age (r = 0.694, p = 0.021); the UBPS was not age-dependent (r = -0.15, p = n.s.), as expected. AdSOS and UBPS could discriminate significantly between the young and healthy controls and the men with osteopenia/vertebral fractures or oral steroids (p < 0.00001). The DXA could be significantly discriminate all healthy controls from the patients with osteopenia or vertebral fractures. It could not significantly discriminate the healthy controls from the patients taking oral glucoconticoids. Only the UBPS could significantly discriminate this group from the healthy controls.

CONCLUSION

These results show, that adSOS and UBPS are precise parameters to be measured at the phalanges. The detection level of pathological changes in osteoporosis are similar between adSOS and lumbar BMD (DXA) and improved by using UBPS. This might be explained by the influence of structural changes in bone on UBPS, rather than changes in bone mineral alone. Prospective studies have to clarify the role of adSOS and UBPS in fracture prediction.

Pathologic fracture of the scaphoid due to enchondroma: treatment with vascularized bone grafting. report of a case

Enchondroma of the scaphoid has been rarely reported. A young male manual worker presented with a pathologic fracture on the lesion. It was successfully managed with a vascularized bone graft from the dorsum of the distal radius.

Pelvic insufficiency fracture with diastasis of the pubic symphysis after irradiation: a case report

A 61-year-old woman was seen with diastasis of the symphysis pubis and insufficiency fractures of the wings of both ilia after irradiation for carcinoma of the cervix. The characteristics and treatment of these fractures are discussed.

Retrograde nailing of femoral fracture below a hip prosthesis: a case report

In a frail elderly patient a pathological fracture of the femur at the lower end of a loose femoral stem was treated by the retrograde insertion of an intramedullary nail over the tip of the prosthesis.

Unusual evolution of a benign-looking cortical defect of the proximal humerus. A case of intracortical osteosarcoma?

A case of an osteosarcoma following a pathological fracture through a small benign-looking cortical lesion of the proximal humerus is described. The unusual evolution from a small cortical lesion to a malignant lesion raises the question whether this is a case of an intracortical osteosarcoma that has some distinct features from those of previously reported cases.

Accuracy and diagnostic sensitivity of radiographic absorptiometry of the second metacarpal

The accuracy of a radiographic absorptiometry (RA) technique called digital image processing (DIP), discriminative ability of RA for osteoporotic fracture, and the relationship between RA and dual X-ray absorptiometry (DXA) of the spine and forearm were evaluated. We measured 16 cadaver hands, 32 healthy non-black premenopausal women, 39 healthy non-black postmenopausal women, and 35 non-black osteoporotic postmenopausal females. The overall correlation between the ash weights of the entire metacarpal and the DIP values was excellent (r = 0.954, P < 0.001, SEE = 0.14, CV = 6.4%). Short-term precision error of DIP was 3.5%. Age-related bone loss determined by DIP is comparable to that of spinal and forearm DXA: annual BMD decreases were 0.46% for DIP, 0.45% for forearm, and 0.32% for the spine. DIP of the 2nd metacarpal shows a gradient of risk for spinal fracture only slightly below that of forearm DXA, but substantially below that of spinal DXA. Age-adjusted odds ratios were 1.81 for RA, 2.45 for spinal DXA, and 1.94 for forearm DXA.

Pseudotumor formation in tibia in Gaucher's disease

A very rare case of type 1 Gaucher's disease with pseudotumor formation in the right tibia is presented. In addition to the characteristic radiographic finding of distal femoral flaring (Erlenmeyer flask deformity), a lobulated osteolytic area with surrounding sclerosis was seen in the proximal metaphysis of the right tibia. Adjacent to this pseudotumor appearance was an old pathologic fracture and no significant soft tissue swelling was evident, both of these features being reported for the first time in association with Gaucher's disease.

Posterior surgery for the treatment of thoracolumbar pathologic fractures in metastatic patients

A total of 25 pathologic fractures in patients affected with thoracolumbar vertebral metastases associated with neurologic deficit are reported. None of the pathologic fractures were stable, while 14 were unstable and 11 were very unstable. Decompression with intralesional excision of the neoplastic mass compressing the dural sac was performed in all of the cases. Posterior stabilization was performed in the first cases using systems of sublaminar segmental fixation, and thereafter using systems of pedicle fixation. Removal of the vertebral body followed by anterior fusion after preventive posterior stabilization was performed in 2 cases. Pain symptoms regressed in 85% of the cases and in more than 50% of the patients there was improvement in the neurologic findings and in vertebral deformity consequent to fracture. Mean survival rate was 12 months. Despite the limited number of cases posterior stabilization of pathological fractures is a good choice of treatment in patients with severe neurologic deficit.

Vertebral fracture assessment using the lateral scoutview of computed tomography in comparison with radiographs

Semiquantitative vertebral fracture assessment was compared between lateral computed tomography (CT) scoutviews and conventional thoracolumbar spinal radiographs. Vertebral levels T4-L4 were assessed by both techniques in a group of 56 women (mean age 60 +/- 13 years). In order to compare inter- and intra-observer variabilities for the two techniques, the images were analyzed twice by two independent observers, and percentage agreement and kappa statistics were measured both between readings and between observers. Percentage agreement and kappa statistics were also used to quantify differences between techniques. In the CT scoutviews, noise and artifacts from overlying tissues in the thoracic spinal levels rendered 3.4% of the vertebrae unreadable for the first observer and 8.3% for the second observer. For the CT scoutviews the agreement between readings was 98.1%, 97.3% and 100% (kappa = 0.87, 0.83 and 1.0) on T4-L12, T4-12 and L1-4, respectively for the first observer, and 97.8%, 97.1% and 99.5% (kappa = 0.79, 0.73 and 0.92) for the second observer. For the lateral radiographs, the agreement between readings was 97.7%, 96.9% and 100% (kappa = 0.87, 0.85 and 1.0) on T4-L12, T4-12 and L1-4, respectively for the first observer, and 98.4%, 97.7% and 99.5% (kappa = 0.86, 0.82 and 0.95) for the second observer. The agreement between observers was 96.1%, 94.4% and 100% (kappa = 0.68, 0.58 and 1.0) on T4-L12, T4-12 and L1-4, respectively for the CT scoutviews and 96.8%, 95.9% and 99.0% (kappa = 0.79, 0.76 and 0.91) for the lateral radiographs. The inter-technique was 95.8%, 94.2% and 99.5% (kappa = 0.73, 0.68 and 0.95) on T4-L12, T4-12 and L1-4, respectively for the first observer and 95.6%, 94.2% and 99.0% (kappa = 0.64, 0.55 and 0.90) for the second observer, with the scoutview technique detecting, on average, 23% fewer fractures than the lateral radiographs. Although the vertebral fracture detection in lumbar spine is quite comparable to that of conventional radiographs, given its reduced sensitivity for vertebral fracture detection in thoracic spine, the lateral CT scoutview technique should not be substituted for conventional radiographs where diagnosis of all vertebral fractures is of primary importance.

Percutaneous vertebroplasty treatment of steroid-induced osteoporotic compression fractures

This report describes the case of a woman in whom multiple compression fractures of the lower thoracic and lumbar spine occurred in association with long-term corticosteroid therapy for systemic lupus erythematosus. Pain markedly limited the patient's mobility and daily activities, and conservative therapy with bracing and narcotic analgesics gave little improvement. Affected vertebrae were treated with polymethylmethacrylate, introduced percutaneously under fluoroscopic guidance. The resulting reinforcement of the fractured vertebral bodies eliminated the pain and the need for narcotic analgesics. The utilization of percutaneous verterbroplasty as a therapeutic alternative for the treatment of pain resulting from osteoporotic compression fractures is described.

Quantitative heel ultrasound in 3180 women between 45 and 75 years of age: compliance, normal ranges and relationship to fracture history

There is growing evidence to support the use of quantitative ultrasound (QUS) to identify fracture risk in late postmenopausal women but few data are available in younger women. In order to address this issue all women between 45 and 75 years of age registered in two general practices in Bournemouth, Dorset, UK were invited to attend for heel QUS. Measurements were made in 79% of the 4018 women identified. The mean QUS results for 5-year age groups were very similar to those from reported reference ranges from North America and the north of England. The odds ratios (95% confidence limits) for self-reported fractures after 45 years per standard deviation of age-adjusted QUS parameters were: broadband ultrasound attenuation (BUA) = 1.40 (1.26-1.56), speed of sound (SOS) = 1.56 (1.41-1.74) and Stiffness = 1.52 (1.37-1.68). The results suggest that QUS is associated with fracture history in early postmenopausal women.

Bone and joint involvement in adults with Werner's syndrome

A 45-year-old man with Werner's syndrome had large asymptomatic calcium deposits about the elbows, hips, and shoulders. During the four-year follow-up, he developed insufficiency fractures of the pelvis, both ulnas, one radius and one metatarsal, all of which failed to heal. Bone mineral densities evaluated by dual-energy X-ray absorptiometry were at the lower end of the normal range, but a histomorphometric study showed a reduction in trabecular bone volume and marked decreases in osteoid parameters with a calcification rate of zero. Serum assays of 25 hydroxy vitamin D3, 1,25 dihydroxy vitamin D3, osteocalcin and alkaline phosphatase were normal. The nonunions in this patient may have been caused by impaired osteoblast function associated with Werner's syndrome and/or by decreased activity of growth factors involved in bone repair.

Bone assessment in patients with ileal pouch-anal anastomosis for inflammatory bowel disease

BACKGROUND

Patients with ulcerative colitis are at risk of low bone mineral density (BMD). Proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis diminishes the risk of bone disease. The aims of this study were to assess the mechanism of low BMD and to measure bone density changes after IPAA.

METHODS

Twenty patients with IPAA for ulcerative colitis, of mean(s.d.) age 38(9) (range 21-58) years, had measurements of lumbar spine and femoral neck BMD by dual energy X-ray absorptiometry, a mean(s.d.) 28(23) (range 3-84) months after proctocolectomy. Serum levels of calcium, phosphate, parathyroid hormone, osteocalcin and 25-hydroxy vitamin D were determined. Fifteen patients were followed for 28(12) (range 8-50) months.

RESULTS

At baseline, six patients had spine BMD more than two standard deviations below the normal value, and three had vertebral crush fractures. Mean vitamin D values were normal and no patient had osteomalacia. BMD increased with time elapsed since IPAA (spine: r = 0.71, P = 0.005). During follow-up, mean(s.d.) changes in bone density were +2.3(3.8) and +2.1(5.6) per cent per year at the spine and femoral neck respectively.

CONCLUSION

These results suggest that in patients with IPAA for ulcerative colitis, low BMD is not associated with vitamin D malabsorption and may be reversible after surgery.

Orthopedic surgical management of skeletal complications of malignancy

Coincident with improved overall cancer palliation during the past 2 decades has been an increasing incidence of clinically apparent bone metastases, and from these metastases subsequent pathologic fractures of the long bones, spine, and pelvis. Current techniques for surgical management of these fractures are extremely effective in alleviating pain and allowing patients to resume an ambulatory status, often without the need of external support. This, in turn, has significantly improved the quality of the remaining months or years of these individuals' lives. In fact, the long term survival of patients after their first long bone pathologic fracture from malignancy has more than tripled for the most common cancers (breast carcinoma, prostate carcinoma, lymphomas, and myelomas) during the past 25 years. Surgical techniques for stabilizing pathologic or impending fractures must be individualized for the area of involvement, the particular qualities of the bone involved, and the potential for involvement of adjacent soft tissue structures. Long bone fractures most commonly occur in the femur and humerus and are typically internally fixed by intramedullary devices that control impaction, distraction, and torquing stresses by the use of proximal and distal interlocking fixation. Such fixation must be able to withstand weight-bearing stresses on lower extremity long bones. Upper extremity pathologic fractures are often subjected to distractive forces inherent in lifting and pulling, but they are also subjected to heavy compressive forces, particularly in patients who require crutches or other devices to assist them in walking. Fixation of upper or lower extremity long bone fractures ordinarily may be accomplished with minimal blood loss or morbidity. In contrast, fractures or impending fractures involving the acetabulum necessitate extensive joint reconstruction, with inherent increased potential for morbidity and complications. For this reason, the anticipated prognosis for survival and mobility should be greater preoperatively for patients with acetabular fractures than for patients with fractures of either upper or lower extremity long bones. Most spinal metastases can be managed conservatively. Those requiring surgical intervention present with progressive neurologic compromise, which requires decompression, or spinal instability, which requires stabilization. Constructs for internal stabilization of the spine must not be adversely affected by local postoperative irradiation. Ninety-six percent of patients experience good or excellent relief of pain after internal fixation of pathologic malignant long bone fractures. Eighty-four percent of patients with acetabular fractures experience good or excellent relief of pain after joint reconstruction. Eighty-two percent of patients with neurologic compromise secondary to vertebral malignancy improve at least one functional grade after decompression and stabilization, and 88% experience good or excellent relief of spinal pain with restoration of walking ability. Thirty-two percent survived for more than 2 years after spinal decompression and stabilization. Patients with pathologic fractures from metastatic carcinoma of the breast had a mean survival of 24.6 months after surgical management of their fractures. There was a similarly encouraging improvement in the survival statistics for patients with other primary tumor types. Most malignant pathologic fractures of the pelvis, long bones, or spine are amenable to effective stabilization by the techniques described in this article. These techniques allow resumption of weight-bearing ambulation in all but a few patients, good or excellent relief of pain in the vast majority, and an enhanced anticipation of survival and improvement in quality of life.