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Rahimi M, Daneshvar S, Khabbazi A. Pregnancy-associated osteoporosis following in vitro fertilization: A case report. Clin Case Rep 2024; 12:e8702. [PMID: 38523825 PMCID: PMC10957487 DOI: 10.1002/ccr3.8702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
This case report illustrates that in vitro fertilization (IVF) may be a potential risk factor for pregnancy-associated osteoporosis (PAO), highlighting the need for awareness and monitoring of bone health in women undergoing IVF treatments. PAO is a rare disease resulting from an imbalance of calcium in the body during pregnancy and lactation and presenting with fragility fractures. PAO occurs in late pregnancy or early postpartum period. A 28-year-old woman who conceived through IVF experienced severe back pain 2 days after delivery. Magnetic resonance imaging of the spine showed wedge-shaped fractures of T9-T12 vertebrae. Bone mineral density (BMD) was low on dual-energy x-ray absorptiometry. The laboratory tests were within the normal range. Based on the clinical manifestations, osteoporotic spine fracture, results of BMD, and exclusion of other causes of osteoporosis, the patient was diagnosed with PAO. Considering the deleterious effect of treatment with gonadotropin-releasing hormone and repeated superovulation on bone, we hypothesized that IVF may be an etiological factor for PAO.
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Affiliation(s)
- Mehran Rahimi
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
| | - Sara Daneshvar
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
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2
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Misiorowski W. Pregnancy- and lactation-related osteoporosis: an important topic also for rheumatologists. Reumatologia 2023; 61:223-224. [PMID: 37745142 PMCID: PMC10515126 DOI: 10.5114/reum/171597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 09/26/2023] Open
Abstract
<b>Objectives</b>
<b>Material and methods</b>
<b>Results</b>
<b>Conclusions</b>
<b></b>
<b></b>
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Affiliation(s)
- Waldemar Misiorowski
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
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3
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Wang GX, Han JH, Zhou RZ, Gao CP. Response of vertebral fractures to treatment with denosumab in a patient with postpartum osteoporosis: a case report and literature review. J Int Med Res 2023; 51:3000605231187951. [PMID: 37523158 PMCID: PMC10392288 DOI: 10.1177/03000605231187951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Postpartum osteoporosis (PO) is a rare condition characterized by low bone mineral density (BMD) and an increased risk of vertebral fragility fracture. We encountered a 34-year-old woman who developed back pain 1 week after delivery. Magnetic resonance imaging of the lumbar spine revealed three vertebral compression fractures. Pretreatment BMD evaluation by dual-energy X-ray absorptiometry revealed a low T-score and Z-score (-2.0 and -2.0, respectively; BMD, 0.876 g/cm2) in the affected region of the spine. The patient was diagnosed with PO and treated with subcutaneous injection of denosumab 60 mg (Prolia; Amgen, Inc., Thousand Oaks, CA, USA) every 6 months. After two treatments, the BMD had significantly increased and the back pain was improved; the patient therefore decided to terminate the treatment. Two months later, her back pain worsened and BMD decreased as measured by dual-energy X-ray absorptiometry examination of the lumbar spine. Therefore, the patient resumed treatment with denosumab, and the BMD of the lumbar spine increased after another two treatments. Therefore, we consider denosumab to be promising in the management of PO with respect to increased BMD and decreased pain.
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Affiliation(s)
- Guan-Xi Wang
- Department of Radiology, Songshan Hospital of Qingdao University Medical College, Qingdao, China
| | - Jin-Hua Han
- Department of Radiology, Qingdao Central Hospital, Qingdao, China
| | - Rui-Zhi Zhou
- Department of Radiology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuan-Ping Gao
- Department of Radiology, the Affiliated Hospital of Qingdao University, Qingdao, China
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4
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Pregnancy-Associated Osteoporosis: A Literature Review. Clin Rev Bone Miner Metab 2023. [DOI: 10.1007/s12018-023-09287-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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5
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Cordell RF, Wickes CK, Casey A, Greeves JP. Female UK Army Service personnel are at greater risk of work-related morbidity on return to duty postpartum. BMJ Mil Health 2023; 169:46-51. [PMID: 32123003 DOI: 10.1136/jramc-2019-001282] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The 2016 Interim Report on the Health Risks to Women in Ground Close Combat Roles highlighted an increased risk of skeletal injury and significant physiological changes, including increased ligament laxity and decreased bone mineral content, during the postpartum period. The report called for further research and a re-evaluation of postpartum policy to optimise the return of female Service personnel to arduous employment. The purpose of this study was to determine whether returning to duty is at greater risk of injury and illness in the first year postpartum than they were prepregnancy. METHODS Fifty-five female UK Army Service personnel aged 18-41 years, who had given birth in the previous 4 years, completed a lifestyle questionnaire and gave written consent for a review of their medical records. The number of working days lost (WDL) due to illness, injury and combined illness and injury was obtained from medical records, for 1 year prepregnancy and 1 year postpartum. Female Service personnel returned to duty at different time-points postpartum, so data were expressed as WDL/week. RESULTS WDL/week due to illness and combined illness and injury were higher postpartum compared with prepregnancy (p<0.05). WDL/week due to combined illness and injury was significantly lower prepregnancy (p<0.05) and at 0-26 weeks postpartum (p<0.05), compared with 26-52 weeks postpartum. CONCLUSIONS Postpartum female UK Army Service personnel are at greater risk of illness and a combination of illness and injury in the year after giving birth, compared with prepregnancy. The study suggests female Service personnel are unprepared for the demands of full active duty in the first year postpartum.
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Affiliation(s)
| | | | - A Casey
- Women in Ground Close Combat Research Programme (WGCC), United Kingdom Ministry of Defence, Andover, UK
| | - J P Greeves
- Women in Ground Close Combat Research Programme (WGCC), United Kingdom Ministry of Defence, Andover, UK
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6
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Mills EG, Yang L, Nielsen MF, Kassem M, Dhillo WS, Comninos AN. The Relationship Between Bone and Reproductive Hormones Beyond Estrogens and Androgens. Endocr Rev 2021; 42:691-719. [PMID: 33901271 PMCID: PMC8599211 DOI: 10.1210/endrev/bnab015] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 12/20/2022]
Abstract
Reproductive hormones play a crucial role in the growth and maintenance of the mammalian skeleton. Indeed, the biological significance for this hormonal regulation of skeletal homeostasis is best illustrated by common clinical reproductive disorders, such as primary ovarian insufficiency, hypothalamic amenorrhea, congenital hypogonadotropic hypogonadism, and early menopause, which contribute to the clinical burden of low bone mineral density and increased risk for fragility fracture. Emerging evidence relating to traditional reproductive hormones and the recent discovery of newer reproductive neuropeptides and hormones has deepened our understanding of the interaction between bone and the reproductive system. In this review, we provide a contemporary summary of the literature examining the relationship between bone biology and reproductive signals that extend beyond estrogens and androgens, and include kisspeptin, gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, prolactin, progesterone, inhibin, activin, and relaxin. A comprehensive and up-to-date review of the recent basic and clinical research advances is essential given the prevalence of clinical reproductive disorders, the emerging roles of upstream reproductive hormones in bone physiology, as well as the urgent need to develop novel safe and effective therapies for bone fragility in a rapidly aging population.
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Affiliation(s)
- Edouard G Mills
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Lisa Yang
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Morten F Nielsen
- Department of Endocrinology, University Hospital of Odense & institute of Clinical Research, University of Southern Denmark, 5000 Odense C, Denmark
| | - Moustapha Kassem
- Department of Endocrinology, University Hospital of Odense & institute of Clinical Research, University of Southern Denmark, 5000 Odense C, Denmark.,Faculty of Health and Medical Sciences, Department of Cellular and Molecular Medicine, University of Copenhagen, 2200 Copenhagen N, Denmark
| | - Waljit S Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK.,Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK.,Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK.,Endocrine Bone Unit, Imperial College Healthcare NHS Trust, London, UK
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7
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Postpartum stress fracture of bilateral tibia: A case report. Turk J Phys Med Rehabil 2021; 67:254-258. [PMID: 34396078 PMCID: PMC8343162 DOI: 10.5606/tftrd.2021.4947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 12/12/2019] [Indexed: 01/10/2023] Open
Abstract
Stress fractures are overuse injuries of the bone characterized by a magnetic resonance imaging (MRI) finding of the fracture line with bone marrow edema. Clinical findings are tenderness and persistent pain. It is usually related to repetitive stresses. A 25-year-old woman was admitted with bilateral severe knee pain. She was in the postpartum period and the complaints started three days after the beginning of 2-h daily walk. The initial plain radiograph showed no abnormality, while MRI demonstrated bilateral incomplete fracture line at the proximal tibia. The patient had accompanying vitamin D deficiency and osteopenia, diagnosed with pregnancy-related osteopenia and stress fracture of bilateral proximal tibia. We advised cessation of weight bearing, resting, and supplementation of calcium and vitamin D. This report highlights that, in the postpartum period, persistent pain may indicate bone lesions such as stress fractures, particularly developing shortly after a vigorous physical activity. Detailed physical examination and further investigations are necessary to detect these fractures and risk factors.
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8
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Yıldız AE, Özbalcı AB, Ergen FB, Aydıngöz Ü. Pregnancy- and lactation-associated vertebral compression fractures: MRI prevalence and characteristics. Osteoporos Int 2021; 32:981-989. [PMID: 33236194 DOI: 10.1007/s00198-020-05754-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/18/2020] [Indexed: 12/11/2022]
Abstract
UNLABELLED The frequency of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs) is not known. This study showed that MRI prevalence of PLVCFs was approximately 0.5% in females ≥ 15 and < 40 years of age over a 48-month period. PLVCFs did not display MRI features distinguishing them from other vertebral insufficiency fractures. PURPOSE We aimed to investigate the MRI prevalence and characteristics of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs). METHODS This retrospective cross-sectional observational study included all thoracic, lumbar, or thoracolumbar MRI examinations performed in our hospital (or at outside centers and referred to us for consultation) of females ≥ 15 and < 40 years of age during a 48-month period. Two radiologists independently reviewed all images for vertebral compression fractures and their disagreement was resolved by a third blinded senior radiologist with 24 years of dedicated musculoskeletal radiology experience. MRI features of PLVCFs (early/late stage, height loss, endplate involvement, retropulsion) were noted. RESULTS A total of 1484 MRI examinations-including 50 consultations from outside centers-of 1260 females (mean age, 27.7 years; range, 15-39) were included. Interobserver agreement of the two junior radiologists was substantial (κ = 0.607; 95% CI, 0.545-0.669). Vertebral compression fractures were identified in 177 of thoracic (n = 210), lumbar (n = 900), or thoracolumbar MRI (n = 374) examinations. Six women (7 MRI examinations; 4.0% of MRIs with vertebral fractures) had PLVCFs diagnosed on MRI (prevalence, 0.47%; mean age, 31 years; age range, 25-37). Number of fractured vertebrae in cases with PLVCF ranged between 1 and 11 (mean, 5.6). DEXA, available in all patients with PLVCFs, verified osteopenia/osteoporosis in four of six patients. CONCLUSION PLVCFs have an MRI prevalence of approximately 0.5% in the target population and do not display distinguishing features from other insufficiency type vertebral compression fractures.
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Affiliation(s)
- A E Yıldız
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey.
| | - A B Özbalcı
- Department of Radiology, Ondokuz Mayıs University School of Medicine, Atakum, 55139, Samsun, Turkey
| | - F B Ergen
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey
| | - Ü Aydıngöz
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100, Ankara, Turkey
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9
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Sakamoto A, Okamoto T, Matsuda S. Insufficiency fracture at an osteochondroma bridging the proximal fibula and the tibia: Case report. J Orthop 2018; 15:384-387. [PMID: 29881159 DOI: 10.1016/j.jor.2018.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/16/2018] [Indexed: 10/17/2022] Open
Abstract
Osteochondromas are benign bone tumors that protrude from underlying bone. A fracture of an osteochondroma is rare, and no insufficiency fractures of an osteochondroma have been reported. A 57-year-old female complained of pain in her proximal leg that increased during walking. A computed tomographic image depicted bridging that had extended to the tibia. An incomplete fracture line was observed at the osteochondroma. The osteochondroma was resected to remove the bridge. The preoperative symptoms disappeared after surgery. It was challenging to diagnose an osteochondroma with an insufficiency fracture because the symptoms varied in accordance with daily activity.
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Affiliation(s)
- Akio Sakamoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-cho 54, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takeshi Okamoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-cho 54, Sakyo-ku, Kyoto 606-8507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Kawahara-cho 54, Sakyo-ku, Kyoto 606-8507, Japan
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10
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11
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Laroche M, Talibart M, Cormier C, Roux C, Guggenbuhl P, Degboe Y. Pregnancy-related fractures: a retrospective study of a French cohort of 52 patients and review of the literature. Osteoporos Int 2017; 28:3135-3142. [PMID: 28879474 DOI: 10.1007/s00198-017-4165-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/17/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED A retrospective, multicentre study involving 52 patients was carried out to define the causes and characteristics of pregnancy-related osteoporosis. The mean number of vertebral fractures occurring during the last trimester of pregnancy or at the time of delivery was 3.8. This is often promoted by risk factors before or during pregnancy. INTRODUCTION In order to define the causes or predisposing factors of pregnancy-related osteoporosis and its clinical, radiological and bone density characteristics, laboratory findings, course and outcome, we carried out a retrospective multicentre study. METHODS The records of 52 women hospitalised over the last 10 years in the rheumatology departments of six French university hospitals and with a diagnosis of pregnancy-related osteoporosis were examined. RESULTS The patients' mean age at time of fracture was 32.1 years. In 10 patients, the fractures had occurred during the last trimester of pregnancy, and in 36 at the time of delivery or during the first 2 months post-partum. The mean number of vertebral fractures was 3.8 ± 2.0. Thirty three of the 52 patients had a risk factor of low bone mass before pregnancy. Twelve had disorders or treatments (heparin) that might promote osteoporosis during pregnancy, while 14 had no trigger factors before or during pregnancy. Overall, phosphate and calcium levels were normal, except for hyperphosphoraemia in lactating women (90%). On DXA scan, osteoporosis predominated in the trabecular bone (spinal T-score - 3.4, hip T-score - 2). Only 10 patients had a repeat fracture, and the increase in bone mineral density during follow-up was considerable, and improved by bisphosphonates (annual gain + 10% in the spine) or teriparatide (+ 15%). CONCLUSIONS Pregnancy-related osteoporosis gives rise to multiple vertebral fractures. It is often promoted by risk factors before or during pregnancy. Its mechanism is still unknown. Treatment with bisphosphonates or teriparatide appears to improve the recovery of bone mineral density.
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Affiliation(s)
- M Laroche
- Department of Rheumatology, Toulouse University Hospital, Toulouse, France.
- Centre de Rhumatologie, Hôpital Pierre Paul Riquet, CHU Purpan, 1 place du Dr Baylac, 31059, Toulouse Cedex, France.
| | - M Talibart
- Department of Rheumatology, Toulouse University Hospital, Toulouse, France
| | - C Cormier
- Department of Rheumatology, Cochin University Hospital, Paris, France
| | - C Roux
- Department of Rheumatology, Cochin University Hospital, Paris, France
| | - P Guggenbuhl
- Department of Rheumatology, Rennes University Hospital, Amiens, France
| | - Y Degboe
- Department of Rheumatology, Toulouse University Hospital, Toulouse, France
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12
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Pregnancy-related osteoporosis and spinal fractures. Obstet Gynecol Sci 2017; 60:133-137. [PMID: 28217686 PMCID: PMC5313358 DOI: 10.5468/ogs.2017.60.1.133] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/22/2016] [Accepted: 07/27/2016] [Indexed: 11/08/2022] Open
Abstract
Pregnancy-related osteoporosis is a very rare condition characterized by the occurrence of fracture during pregnancy or the puerperium. Despite its relative rarity, it can be a dangerous condition that causes severe back pain, height loss and disability. Normal physiologic changes during pregnancy, genetic or racial difference, obstetrical history and obstetrical disease, such as preterm labor or pregnancy-induced hypertension, are presumed risk factors of pregnancy-related osteooporosis. However, exact etiology and pathogenesis are uncertain. The management and natural history are still poorly defined. Traditional medications for osteoporosis are calcium/vitamin D and bisphosphonate. Concerns with bisphosphonate include accumulation in bone and fetal exposure in subsequent pregnancies. The newly developed medication, teriparatide, has shown good results. We report six cases of pregnancy-related osteoporosis and spinal fracture with literature review.
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13
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Kim TH, Lee HH, Jeon DS, Byun DW. Compression fracture in postpartum osteoporosis. J Bone Metab 2013; 20:115-8. [PMID: 24524068 PMCID: PMC3910316 DOI: 10.11005/jbm.2013.20.2.115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 04/10/2013] [Accepted: 04/10/2013] [Indexed: 11/11/2022] Open
Abstract
Osteoporosis is mainly a problem in postmenopausal women. However, we had a case of postpartum compression fracture associated with osteoporosis. A 42-year-old multiparous woman had undergone tertiary cesarean section without complications 1 month before. She was breast-feeding her baby and had no other bone-related complication history. She did not exercise on a regular basis. She experienced back pain abruptly and was diagnosed with a recent compression fracture of T12, L1, and L3. We evaluated this rare case of postpartum osteoporosis and compression fracture.
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Affiliation(s)
- Tae-Hee Kim
- Department of Obstetrics and Gynecology, College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Hae-Hyeog Lee
- Department of Obstetrics and Gynecology, College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Dong-Su Jeon
- Department of Obstetrics and Gynecology, College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Dong Won Byun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
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14
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Klontzas ME, Akoumianakis ID, Vagios I, Karantanas AH. MR imaging findings of medial tibial crest friction. Eur J Radiol 2013; 82:e703-6. [DOI: 10.1016/j.ejrad.2013.07.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/24/2013] [Accepted: 07/31/2013] [Indexed: 11/28/2022]
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15
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Charpidou T, Lang F, Langenegger T, Dedes KJ, Honegger C. Bilateral transient osteoporosis of the knee during pregnancy. Arch Gynecol Obstet 2012. [DOI: 10.1007/s00404-012-2628-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Krestan C, Hojreh A. Imaging of insufficiency fractures. Eur J Radiol 2009; 71:398-405. [PMID: 19700255 DOI: 10.1016/j.ejrad.2008.04.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2008] [Accepted: 04/30/2008] [Indexed: 11/30/2022]
Abstract
This review focuses on the occurrence, imaging and differential diagnosis of insufficiency fractures. Prevalence, the most common sites of insufficiency fractures and their clinical implications are discussed. Insufficiency fractures occur with normal stress exerted on weakened bone. Postmenopausal osteoporosis is the most common cause of insufficiency fractures. Other conditions which affect bone turnover include osteomalacia, hyperparathyroidism, chronic renal failure and high-dose glucocorticoid therapy. It is a challenge for the radiologist to detect and diagnose insufficiency fractures, and to differentiate them from other bone lesions. Radiographs are still the most widely used imaging method for identification of insufficiency fractures, but sensitivity is limited, depending on the location of the fractures. Magnetic resonance imaging (MRI) is a very sensitive tool to visualize bone marrow abnormalities associated with insufficiency fractures. Thin section, multi-detector computed tomography (MDCT) depicts subtle fracture lines allowing direct visualization of cortical and trabecular bone. Bone scintigraphy still plays a role in detecting fractures, with good sensitivity but limited specificity. The most important differential diagnosis is underlying malignant disease leading to pathologic fractures. Bone densitometry and clinical history may also be helpful in confirming the diagnosis of insufficiency fractures.
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Affiliation(s)
- Christian Krestan
- Department of Radiology, Medical University of Vienna, Vienna General Hospital, Waehringerstr. 18-20, 1090 Vienna, Austria.
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17
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Abstract
Life-history trade-offs between components of fitness arise because reproduction entails both gains and costs. Costs of reproduction can be divided into ecological and physiological costs. The latter have been rarely studied yet are probably a dominant component of the effect. A deeper understanding of life-history evolution will only come about once these physiological costs are better understood. Physiological costs may be direct or indirect. Direct costs include the energy and nutrient demands of the reproductive event, and the morphological changes that are necessary to facilitate achieving these demands. Indirect costs may be optional 'compensatory costs' whereby the animal chooses to reduce investment in some other aspect of its physiology to maximize the input of resource to reproduction. Such costs may be distinguished from consequential costs that are an inescapable consequence of the reproductive event. In small mammals, the direct costs of reproduction involve increased energy, protein and calcium demands during pregnancy, but most particularly during lactation. Organ remodelling is necessary to achieve the high demands of lactation and involves growth of the alimentary tract and associated organs such as the liver and pancreas. Compensatory indirect costs include reductions in thermogenesis, immune function and physical activity. Obligatory consequential costs include hyperthermia, bone loss, disruption of sleep patterns and oxidative stress. This is unlikely to be a complete list. Our knowledge of these physiological costs is currently at best described as rudimentary. For some, we do not even know whether they are compensatory or obligatory. For almost all of them, we have no idea of exact mechanisms or how these costs translate into fitness trade-offs.
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Affiliation(s)
- John R Speakman
- Aberdeen Centre for Energy Regulation and Obesity (ACERO), School of Biological Sciences, University of Aberdeen, UK.
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18
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Borg-Stein J, Dugan SA. Musculoskeletal Disorders of Pregnancy, Delivery and Postpartum. Phys Med Rehabil Clin N Am 2007; 18:459-76, ix. [PMID: 17678762 DOI: 10.1016/j.pmr.2007.05.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Gender-specific care of musculoskeletal impairments is increasingly important in women's health. This is most relevant and of paramount importance as it relates to identification and management of musculoskeletal and peripheral neurologic disorders of pregnancy, delivery, and postpartum. The specific anatomic and physiologic changes of pregnancy predispose to a specific set of diagnoses. Virtually all women experience some degree of musculoskeletal discomfort during pregnancy. This article provides an overview of the more common pregnancy-related musculoskeletal conditions and includes a discussion of epidemiology, risk factors, diagnosis, prognosis, and management.
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Affiliation(s)
- Joanne Borg-Stein
- Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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19
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Lee P, van der Wall H, Seibel MJ. Looking beyond low bone mineral density: multiple insufficiency fractures in a woman with post-menopausal osteoporosis on alendronate therapy. J Endocrinol Invest 2007; 30:590-7. [PMID: 17848842 DOI: 10.1007/bf03346353] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Insufficiency fractures occur most commonly in the pelvic girdle and in the sacrum, followed by the tibia and the femoral neck. Insufficiency fractures of the femoral diaphyses are rare, with only few reported cases in the literature. The strongest associations exist with untreated osteoporosis. We describe an unusual case of multiple insufficiency fractures in a 73-yr-old Chinese woman who presented with a 10-month history of bilateral groin pain and difficulty with walking in the absence of trauma, diagnosed 18 months following the commencement of anti-resorptive therapy with alendronate. The pathogenesis of such insufficiency fractures is poorly understood, but next to low bone mineral density and micro-architectural damage likely involves other components such as changes in bone turnover and patient-related factors (e.g. non-compliance). This case report and review of the literature draws attention to some of the challenges in the diagnosis and management of such rare insufficiency fractures.
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Affiliation(s)
- P Lee
- Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, The University of Sydney, Sydney Concord, NSW 2139, Australia.
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Nakanishi T, Sakamoto A, Iwamoto Y, Ono H, Hidaka S. Insufficiency fractures in the medial tibial condyle with a special emphasis on the radiographic features and differential diagnosis. J Orthop Sci 2007; 12:296-9. [PMID: 17530383 DOI: 10.1007/s00776-007-1117-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Accepted: 01/26/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Tomonori Nakanishi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka, 812-8582, Japan
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Abstract
Research over the past 20 years has focused on the safety of physical activity during pregnancy. Guidelines for health care providers and pregnant/postpartum women have been developed from the results of these studies. The overwhelming results of most studies have shown few negative effects on the pregnancy of a healthy gravida, but rather, be beneficial to the maternal-fetal unit. Recently, researchers have begun to consider the role of maternal physical activity in a more traditional chronic disease prevention model, for both mother and offspring. To address the key issues related to the role of physical activity during pregnancy and postpartum on chronic disease risk, the American College of Sports Medicine convened a Scientific Roundtable at Michigan State University in East Lansing, MI. Topics included preeclampsia, gestational diabetes, breastfeeding and weight loss, musculoskeletal disorders, mental health, and offspring health and development.
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Ofluoglu D, Ofluoglu O, Akyuz G. Bilateral tibial stress fracture in a young man due to hypercalciuric osteoporosis: a case report. Rheumatol Int 2006; 26:469-72. [PMID: 16096792 DOI: 10.1007/s00296-005-0026-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 06/22/2005] [Indexed: 11/30/2022]
Abstract
Osteoporosis is commonly thought of as a disease of postmenopausal women, and older men have a lower risk of fracture than women. A stress fracture is an overuse injury and an important cause of disability in the athletic population. Presented here is a 30-year-old healthy man with pain on the anterior surface of the bilateral tibia. He did not communicate any trauma or overuse activity. The neurologic and locomotor system examinations were normal. Radiological examinations revealed tibial stress fractures in both left and right tibia and he had low bone mineral density. Routine hematological tests, bone resorption and formation markers were normal, except for hypercalciuria. After analyzing the results of these tests, the patient was diagnosed with bilateral tibial stress fractures due to hypercalciuric secondary osteoporosis. Osteoporosis should be considered in the differential diagnosis of atraumatic insufficiency fractures, especially in young healthy adults.
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Affiliation(s)
- Demet Ofluoglu
- Department of Physical Medicine and Rehabilitation, Physiatrist, Marmara University School of Medicine, Istanbul, Turkey.
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23
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Abstract
Stress fractures of the lower extremities are common, especially in the younger athletic population. The current literature consists mainly a variety of case reports but is devoid of any sizeable series of knee stress fracture investigations. Diagnosing a stress fracture around the knee can be a challenge. The proximity of the stress fracture to the knee joint may lead the clinician to investigate intra-articular or other periarticular pathology. The differential diagnosis can be large, including bursitis, tendonitis, mechanical causes, insufficiency fracture, and tumor. A high index of suspicion is necessary to confirm the underlying diagnosis. A patient's medical history combined with a physical examination and imaging modalities will aid the physician in arriving at the diagnosis of stress fracture.
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O'Sullivan SM, Grey AB, Singh R, Reid IR. Bisphosphonates in pregnancy and lactation-associated osteoporosis. Osteoporos Int 2006; 17:1008-12. [PMID: 16758139 DOI: 10.1007/s00198-006-0112-3] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 03/15/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Pregnancy and lactation-associated osteoporosis (PLO) is an uncommon condition characterized by the occurrence of fracture(s) during late pregnancy or the puerperium. The aetiology is uncertain, and its management and natural history poorly defined. METHODS We report a series of 11 women with PLO seen at our institution over the past 20 years, with follow-up ranging from 1 to 19 years. RESULTS Ten women presented with painful low-trauma vertebral fractures, at a median of 1 month postpartum. In nine cases the fractures were multiple (median: 3, range: 2-5). At least one recognised risk factor for osteoporosis (low body weight, smoking history, family history of osteoporosis/fracture, vitamin D insufficiency) was present in nine patients. Bone density was in the osteoporotic range at the spine (mean T score: -2.8), with less marked reduction at the proximal femur (mean T score: -1.9). Nine patients received bisphosphonate treatment, for a median duration of 24 months. In the five women who received a bisphosphonate within 1 year of presentation, spinal bone density increased by 23% over baseline values after 2 years of treatment (p=0.0014). Of the 5 women who had subsequent pregnancies, one, who had declined bisphosphonate therapy after the initial presentation, sustained a fracture in the postpartum period. Two patients (both of whom were followed for at least 10 years) sustained fractures outside of pregnancy. CONCLUSIONS PLO is therefore associated with significant morbidity, a high prevalence of recognized risk factors for osteoporosis and a risk of recurrence in subsequent pregnancies. Bisphosphonate therapy administered soon after presentation substantially increases spinal bone density in patients with PLO.
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Affiliation(s)
- S M O'Sullivan
- Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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26
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Abstract
Sex-specific care of musculoskeletal impairments is an increasingly important topic in women's health. This is clinically relevant and of paramount importance as it pertains to diagnosis and treatment of musculoskeletal and peripheral neurologic disorders of pregnancy and the puerperium. It is estimated that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms. This review provides information on common pregnancy-related musculoskeletal conditions, including a discussion of anatomy and physiology, diagnosis, prognosis, and treatment of these disorders.
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Affiliation(s)
- Joanne Borg-Stein
- Rehabilitation Center, Spaulding and Newton-Wellesley Hospital, Wellesley, MA 02481, USA
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