CiteULike: Tag fractures

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

RA Kaye — 2005-05-09T22:49:27-00:00

Foot Ankle Int, Vol. 19, No. 4. (April 1998), pp. 221-224.

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

Insufficiency fractures in rheumatic patients: misdiagnosis and underlying characteristics.

O Elkayam — 2005-05-09T22:48:59-00:00

Clin Exp Rheumatol, Vol. 18, No. 3. (n 2000), pp. 369-374.

OBJECTIVE: To report 9 patients with rheumatic diseases referred to our observation due to presumed exacerbation of their rheumatic disease, subsequently diagnosed as stress insufficiency fractures, and to characterize the clinical profile of patients prone to this complication. METHODS: The medical history of the patients was reviewed with special emphasis on their rheumatic disease, its course, duration and management, their menopausal state, location and characteristics of the fracture, its presentation and the initial presumed diagnosis, the delay in diagnosis, imaging diagnostic tests performed and outcome. Three representative case reports are presented. RESULTS: All 9 patients were women, 8 of them aged 50 years old or more, 8 with rheumatoid arthritis and 1 with polymyalgia rheumatica. They were all treated with corticosteroids and had reduction in their bone mass density when evaluated. Three of the patients presented with subcapital fracture of the femur, 4 had fractures of metatarsal bones and 2 had fractures of the distal tibia. In only one patient was a stress fracture initially suspected. Diagnosis was delayed by a mean of 31 days. CONCLUSION: The diagnosis of stress fractures in patients with rheumatic diseases may often be delayed or missed, and thus improperly treated. Increased awareness of this entity is of importance for prompt diagnosis and correct management.

Insufficiency fractures in patients with chronic inflammatory joint diseases.

HM Mäenpää — 2005-05-09T22:48:34-00:00

Clin Exp Rheumatol, Vol. 20, No. 1. (b 2002), pp. 77-79.

OBJECTIVE: To describe the typical sites of stress fractures in the lower extremities and pelvis in rheumatoid patients (rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, ankylosing spondylitis). METHODS: Thirty-three patients with 52 stress fractures [mean age 44 years (range 11-73)] were studied at the authors' institution when they were being treated for their rheumatic diseases. Fourteen patients had RA, 9 JCA, 5 PsoA, and 5 SPA. Stress fractures were detected from patient documents and from series radiographs in suspected cases. In some cases magnetic resonance imaging was also performed. RESULTS: One patient presented with 5 fractures, 2 patients with 4 and 3 fractures, and 7 patients with 2 fractures each. Other patients (n = 19) had only one fracture each. The metatarsal (MT) bones were the most common site of involvement. Twenty-five of the 52 fractures were located on MT I-V. The second and third most common sites were thefibula (n = 13) and tibia (n = 6). All fractures of the lower tibia or fibula were associated with valgus malalignment of the ankle. CONCLUSION: If a patient with rheumatic disease experiences sudden and unexplained pain localised in the forefoot, above the ankle, below the knee, or in the pelvis, a stress fracture should be suspected. Patients with severe osteoporosis, high-load corticosteroid or methotrexate therapy, or marked joint deformity are at high risk of developing stress fracture.

Principles of stress fracture management. The whys and hows of an increasingly common injury.

AD Perron — 2005-05-04T21:01:10-00:00

Postgrad Med, Vol. 110, No. 3. (September 2001)

As the patient population becomes more involved with athletics, informally or in an organized fashion, risk of stress fracture increases. Rapid and safe recovery is best ensured with early diagnosis and expedient conservative therapy. A history of progressive pain, initially with exertion and ultimately at rest, suggests the diagnosis. Plain radiographs often do not reveal fractures, and specialized studies, such as bone scanning, SPECT, or MRI, may be necessary to confirm the diagnosis. Simple rest with progressive reintroduction of activity is the treatment of choice for most stress fractures.

Stress fractures. Current concepts of diagnosis and treatment.

MT Reeder — 2005-05-04T20:54:33-00:00

Sports Med, Vol. 22, No. 3. (September 1996), pp. 198-212.

The stress fracture is a common injury seen by healthcare professionals caring for athletes. They have been described in numerous areas of the skeletal system and in multiple sports. However, they are most commonly seen in the lower extremities, with running the reported cause in most cases. Stress fractures result from repetitive, cyclic loading of bone which overwhelms the reparative ability of the skeletal system. Mechanically, three events may lead to stress fractures. First, the applied load can be increased. Secondly, the number of applied stresses can increase. Finally, the surface area over which the load is applied can be decreased. Diagnosis requires thorough clinical evaluation with a high index of suspicion for stress fractures. History must focus on examining the athletes training regimen, especially any changes in distance, running surface and type of shoe. Physical examination varies depending on the location of the stress fracture. Ultrasound is a possible adjunct to the physical examination. Initial plain radiological evaluation may be normal, especially early in the course of a stress fracture. Further radiological evaluation may be necessary to make a definitive diagnosis. Repeating plain radiographs, bone scintigraphy, magnetic resonance imaging and computerised tomography are all possible options. Treatment options begin with rest and cessation of the precipitating activity. This should be 'active rest' in which the athlete continues to exercise depending on the site of the fracture. The athlete should be evaluated from a biomechanical point of view and any abnormalities dealt with prior to rehabilitation. Possible adjuncts to treatment include pneumatic braces and electromagnetic field therapy. There are specific stress fractures that must be considered at-risk for complications of healing. The treatment of these fractures begins with immobilisation and may require surgery pending response to therapy. Stress fractures occur more frequently in female athletes in relation to their male counterparts. There is a demonstrated relationship to eating disorders, amenorrhea and osteoporosis, or the female athlete triad. Thus, stress fractures in the female athlete requires additional investigation into those areas. The diagnosis and treatment of stress fractures is a challenge for the physician caring for the athlete. It requires a high index of suspicion combined with a strong knowledge of the at-risk stress fractures and their complications. Accurate and timely diagnosis is required to prevent possible costly and disabling complications.

Health-related quality of life following operative treatment of unstable ankle fractures: a prospective observational study.

M Bhandari — 2005-05-04T20:32:53-00:00

J Orthop Trauma, Vol. 18, No. 6. (July 2004), pp. 338-345.

BACKGROUND: Although Weber type B ankle fractures are often considered benign with a good prognosis, evidence from observational studies suggests that 17% to 24% of such patients may have less satisfactory outcomes. Although the explanation for variability in outcomes remains unclear, previous studies of other surgical procedures have suggested nonsurgery-related causes account for much of the variability in outcomes. METHODS: We conducted a prospective observational cohort study to evaluate health-related quality of life in 30 patients with unstable ankle fractures who were otherwise healthy. Only patients from 2 university-affiliated hospitals sustaining unstable type B Weber injury patterns requiring surgery were eligible. Patients provided detailed baseline information regarding alcohol consumption, smoking habits, and educational level. Patients completed the short form 36 questionnaire and a visual analogue pain scale at regular follow-up intervals. RESULTS: The average patient age was 51.6 years (SD 15.2 years), and 57% (17 out of 30) were male. The majority of fractures were the result of a fall (67%, 20 out of 30), and all were closed injuries. Almost half of all patients were smokers (47%, 14 out of 30), whereas 43% consumed alcohol on a weekly basis (13 out of 30). Forty-three percent of patients (13 out of 30) had obtained an elementary or high school level of education. Patients experienced significant improvements in all domains of the SF-36 questionnaire (P < 0.001), except general health, which remained essentially normal over the 24-month period. Study patients achieved scores similar to age-matched U.S. normative data across 6 of the 8 domains (Role Emotional, Social Function, Mental Health, Bodily Pain, Vitality, and General Health). However, patients' physical function and role physical scores remained significantly lower than US norms at 24 months (21.8 and 20.7 points lower on a 100-point scale, respectively; P < 0.001). Smoking history (P = 0.02), presence of a medial malleolar fracture (P = 0.02), and lower levels of education (P = 0.01) were significant independent predictors of lower physical function up to 3 months postoperation. Lower mental health domain scores were significantly associated with alcohol use (P = 0.02) and increasing age (P = 0.04). CONCLUSIONS: As is the case in many other areas, social factors may be important determinants of outcome in patients with traumatic fractures. Optimal orthopedic care may involve attention to modifiable risk factors, including smoking and alcohol consumption.

Insufficiency fractures of the tibia and fibula.

P Alonso-Bartolomé — 2005-05-04T20:25:47-00:00

Semin Arthritis Rheum, Vol. 28, No. 6. (June 1999), pp. 413-420.

OBJECTIVE: Insufficiency fractures (IF) occur when normal or physiological muscular activity stresses a bone that is deficient in mineral or elastic resistance. IF of the tibia and fibula are probably less common than IF of the ribs, vertebrae, hip, pelvis, and distal ulna, and therefore they are frequently underrecognized and mistaken for other conditions. Our aim was to analyze the main features and outcome of IF of the tibia and fibula in patients attending our Rheumatology Service. METHODS: IF was considered when occurring spontaneously or with minimal trauma. Between January 1984 and July 1997, 25 patients were diagnosed as having IF of the tibia and fibula. The main predisposing factors, clinical features, therapy, and outcome were retrospectively reviewed. RESULTS: All the patients except four were women (mean age, 66+/-12 years). Three cases were diagnosed between 1984 and 1990 (0.42 cases/year) and 22 between 1991 and 1997 (three cases/year). Eighteen patients had an underlying CONDITION: rheumatoid arthritis (RA, 13 cases), psoriatic arthritis (2), systemic lupus erythematosus (SLE) (1), kidney transplant (1), and Crohn's disease (1). Eleven patients had osteoporotic fractures in other locations. Risk factors for osteoporosis were corticosteroids (13 cases), prolonged immobilization (10), early menopause (2), and methotrexate therapy (10). All patients had pain on weight bearing and marked functional impairment, 16 had local inflammatory signs, and 10 had deformity. In only five patients the diagnosis of IF was considered at the first examination. The diagnostic delay was 76+/-117 days (median, 21). The initial radiograph was diagnostic in 20 patients, and in the remaining the diagnosis was made by computed tomography (CT) scan (three cases), magnetic resonance imaging (MRI) (1), and bone scan (1). IF were located as follows: tibia (10 cases), fibula (seven), tibia and fibula (eight). Nineteen patients were treated with conservative management, four received no specific treatment, and two required surgery. Sixteen patients were hospitalized for a mean period of 12+/-8 days. Most patients had complete recovery. The high frequency of IF seen in RA patients is probably due to the severe disease in patients treated by our Service and that such patients have a higher risk for osteoporosis and its complications. CONCLUSIONS: IF of the tibia and fibula are probably more common than previously thought. They usually occur in patients with underlying rheumatic diseases, mainly RA, and are frequently mistaken for other joint and bone conditions. Despite a frequent delay in diagnosis, they have a good prognosis with conservative management. Nonetheless, a higher index of suspicion may avoid unnecessary investigations and treatments.

Fractures of the neck of the talus.

LG Hawkins — 2008-05-03T09:17:33-00:00

The Journal of bone and joint surgery. American volume, Vol. 52, No. 5. (July 1970), pp. 991-1002.

CURRENT CONCEPTS IN IMAGING OF THE PELVIS AND HIP

Curtis Hayes — 2008-04-19T12:17:57-00:00

Orthopedic Clinics of North America, Vol. 28, No. 4. (1 October 1997), pp. 617-642.

Radiography of the Hip: Lines, Signs, and Patterns of Disease

Scot Campbell — 2008-04-19T12:15:52-00:00

Seminars in Roentgenology, Vol. 40, No. 3. (July 2005), pp. 290-319.

Occult fractures of the femoral neck.

E Alba — 2008-04-19T12:07:04-00:00

The American journal of emergency medicine, Vol. 10, No. 1. (January 1992), pp. 64-68.

Occult fractures of the femoral neck can be subtle or even undetectable on plain radiographs. Yet, untreated, the morbidity of this fracture significantly increases. This report discusses the clinical and radiologic findings seen in occult fractures of the femoral neck. It also discusses the role of tomograms, bone scan, computed tomography, and magnetic resonance imaging in further delineating this entity.

High Association of Posterior Malleolus Fractures with Spiral Distal Tibial Fractures

Sreevathsa Boraiah — 2008-05-18T15:34:42-00:00

Clinical Orthopaedics and Related Research

Abstract Associations between fracture patterns are important and can ensure proper diagnosis and guide treatment. Occult posterior malleolus fractures associated with distal spiral tibia fractures often are underrecognized and the morbidity of a missed posterior malleolus injury can be substantial. We determined the association between the two injuries and evaluated the ability of a new protocol to improve management of these associated fractures. Of 62 consecutive patients with fractures of the distal third of the tibia, we retrospectively evaluated the first 39 patients and prospectively used a diagnostic protocol including computed tomography of the ankle in the subsequent 23 patients. The minimum followup was 3 months (mean, 25 months; range, 3–68 months). Twenty-four patients (39%) had fractures of the posterior malleolus. Before initiation of the protocol, intraarticular fractures were recognized in 33% (with one delayed diagnosis and one missed diagnosis), and after institution of the protocol, the detection rate was 48% with no known missed injuries and complete followup; however, with the limited power the detection rates were similar without and with the protocol. A spiral distal tibial shaft fracture with a proximal fibula fracture should alert the surgeon to investigate an occult ankle injury, particularly of the posterior malleolus. A protocol including computed tomography of the ankle may detect more injuries in a larger study. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Safe Zone for the Placement of Medial Malleolar Screws

John Femino — 2008-04-19T15:48:52-00:00

J Bone Joint Surg Am, Vol. 89, No. 1. (1 January 2007), pp. 133-138.

Background: Hardware placement for fracture fixation can put soft-tissue structures at risk for injury or abutment. The prominence of the hardware is a frequent cause of pain after the fixation of ankle fractures. This study was designed to assess the risk of injury or abutment of the posterior tibial tendon with the placement of medial malleolar screws. Methods: Ten unmatched cadaveric limbs that had been disarticulated at the knee were used, and the medial malleolus was exposed by dissection of the skin. With use of fluoroscopy and direct visualization of the deep fascia, three Kirschner wires were placed through the tip of the medial malleolus and directed parallel to the medial articular surface. The first wire was placed in the center of the anterior colliculus. Two additional wires were placed parallel and posterior to the initial wire at 5-mm intervals. The wires were overdrilled, and 4.0-mm screws were inserted over the Kirschner wires. The specimens were dissected to inspect for trauma and the proximity of the screws to the posterior tibial tendon. The medial malleolus was divided into three zones on the basis of anatomic landmarks. Zone 1 is the anterior colliculus; Zone 2, the intercollicular groove; and Zone 3, the posterior colliculus. Results: Screws placed in Zone 1 (the anterior colliculus) did not contact the posterior tibial tendon in any specimens. Screws placed in Zone 2 (the intercollicular groove) were, on the average, 2 mm from the posterior tibial tendon. Screws placed in Zone 3 (the posterior colliculus) resulted in tendon abutment in all ten specimens and in tendon injury in five of the ten specimens. Conclusions: Screws inserted posterior to the anterior colliculus place the posterior tibial tendon at significant risk for injury or abutment. Clinical Relevance: On the basis of these results, we recommend direct visualization of the posterior tibial tendon prior to the placement of screws in the medial malleolus when they are inserted posterior to the anterior colliculus. 10.2106/JBJS.F.00689

Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. I. Anatomical studies.

AM Pankovich — 2008-04-19T15:45:22-00:00

Acta orthopaedica Scandinavica, Vol. 50, No. 2. (April 1979), pp. 217-223.

An anatomical study of the medial malleolus and the deltoid ligament of the ankle on fresh and formalin preserved legs of cadavera and amputation specimens has been carried out. The anterior and posterior colliculi, and the intercollicular groove of the medial malleolus were described. The deltoid ligament was found to have two layers: the superficial, attached primarily to the anterior colliculus, consisted of the naviculotibial, calcaneotibial, and superficial talotibial ligaments; the deep layer consisted of the deep anterior and posterior talotibial ligaments and was attached primarily to the posterior colliculus and the intercollicular groove. These findings are at variance with previous descriptions of the deltoid ligament.

Competence of the Deltoid Ligament in Bimalleolar Ankle Fractures After Medial Malleolar Fixation

Paul Tornetta — 2008-04-19T15:43:37-00:00

J Bone Joint Surg Am, Vol. 82, No. 6. (1 June 2000), 843.

Background: The stability of the ankle joint is provided by the medial and lateral malleoli and ligaments. Recent studies of cadaveric ankles have demonstrated that injury to the medial structures of the ankle is necessary to allow lateral subluxation of the talus after fracture. However, cadaveric models are limited by the fracture pattern chosen for the model. We sought to investigate the competency of the deltoid ligament in vivo in patients with an operatively treated bimalleolar ankle fracture. Methods: Twenty-seven patients with a bimalleolar ankle fracture were evaluated. In each patient, the medial malleolus was anatomically reduced and fixed. A radiograph of the ankle was then made with application of an external rotation load to the joint. All lateral malleolar injuries were then reduced and fixed. The radiographs were evaluated for restoration of the competence of the deltoid ligament according to established criteria. Results: Seven (26 percent) of the twenty-seven patients had radiographically evident incompetence of the deltoid ligament after medial malleolar fixation. This finding was associated with a small medial malleolar fragment. Conclusions: In bimalleolar fractures, the medial injury may be an osseous avulsion, leaving the deltoid intact on the displaced fragment, or it may be a combination of ligamentous and osseous injury with disruption of the deep portion of the deltoid ligament.

Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations.

N LAUGE-HANSEN — 2008-04-19T15:41:02-00:00

Archives of surgery, Vol. 60, No. 5. (May 1950), pp. 957-985.

Does thoracic or lumbar spine bone architecture predict vertebral failure strength more accurately than density?

EM Lochmüller — 2008-03-24T21:21:13-00:00

Osteoporosis International, Vol. 19, No. 4. (14 April 2008), pp. 537-545.

Abstract Summary Trabecular bone microstructure was studied in 6 mm bone biopsies taken from the 10th thoracic and 2nd lumbar vertebra of 165 human donors and shown to not differ significantly between these sites. Microstructural parameters at the locations examined provided only marginal additional information to quantitative computed tomography in predicting experimental failure strength. Introduction It is unknown whether trabecular microstructure differs between thoracic and lumbar vertebrae and whether it adds significant information in predicting the mechanical strength of vertebrae in combination with QCT-based bone density. Methods Six mm cylindrical biopsies taken at mid-vertebral level, anterior to the center of the thoracic vertebra (T) 10 and the lumbar vertebra (L) 2 were studied with micro-computed tomography (μCT) in 165 donors (age 52 to 99 years). The segment T11-L1 was examined with QCT and tested to failure using a testing machine. Results The correlation of microstructural properties was moderate between T10 and L2 (r ≤ 0.5). No significant differences were observed in the microstructural properties between the thoracic and lumbar spine, nor were sex differences at T10 or L2 observed. Cortical/subcortical density of T12 (r 2 = 48%) was more strongly correlated with vertebral failure stress than trabecular density (r 2 = 32%). BV/TV (of T10) improved the prediction by 52% (adjusted r 2) in a multiple regression model. Conclusion Microstructural properties of trabecular bone biopsies displayed a high degree of heterogeneity between vertebrae but did not differ significantly between the thoracic and lumbar spine. At the locations examined, bone microstructure only marginally improved the prediction of structural vertebral strength beyond QCT-based bone density.

Zoledronic acid and clinical fractures and mortality after hip fracture.

KW Lyles — 2008-01-09T04:24:55-00:00

N Engl J Med, Vol. 357, No. 18. (1 November 2007), pp. 1799-1809.

BACKGROUND: Mortality is increased after a hip fracture, and strategies that improve outcomes are needed. METHODS: In this randomized, double-blind, placebo-controlled trial, 1065 patients were assigned to receive yearly intravenous zoledronic acid (at a dose of 5 mg), and 1062 patients were assigned to receive placebo. The infusions were first administered within 90 days after surgical repair of a hip fracture. All patients (mean age, 74.5 years) received supplemental vitamin D and calcium. The median follow-up was 1.9 years. The primary end point was a new clinical fracture. RESULTS: The rates of any new clinical fracture were 8.6% in the zoledronic acid group and 13.9% in the placebo group, a 35% risk reduction with zoledronic acid (P=0.001); the respective rates of a new clinical vertebral fracture were 1.7% and 3.8% (P=0.02), and the respective rates of new nonvertebral fractures were 7.6% and 10.7% (P=0.03). In the safety analysis, 101 of 1054 patients in the zoledronic acid group (9.6%) and 141 of 1057 patients in the placebo group (13.3%) died, a reduction of 28% in deaths from any cause in the zoledronic acid group (P=0.01). The most frequent adverse events in patients receiving zoledronic acid were pyrexia, myalgia, and bone and musculoskeletal pain. No cases of osteonecrosis of the jaw were reported, and no adverse effects on the healing of fractures were noted. The rates of renal and cardiovascular adverse events, including atrial fibrillation and stroke, were similar in the two groups. CONCLUSIONS: An annual infusion of zoledronic acid within 90 days after repair of a low-trauma hip fracture was associated with a reduction in the rate of new clinical fractures and with improved survival. (ClinicalTrials.gov number, NCT00046254 [ClinicalTrials.gov].).

Clinical and economic burden of fractures in patients with renal osteodystrophy.

GT Schumock — 2007-07-17T16:22:51-00:00

Clin Nephrol, Vol. 67, No. 4. (April 2007), pp. 201-208.

Renal osteodystrophy is a key cause of fractures in patients with chronic kidney disease (CKD). AIMS: This article reviews the clinical and economic burden of fractures and explores the types of studies that need to be conducted in order to fully understand the impact of fractures in renal osteodystrophy. We also discuss the role that active vitamin D compounds and calcimimetics play in treating secondary hyperparathyroidism. MATERIALS AND METHODS: Medline was searched for relevant articles on renal osteodystrophy and fractures. RESULTS: CKD-related fractures are the source of significant morbidity and costs. Extensive osteoporosis research has been utilized to guide fracture prevention and improve disease management, but further costs and outcomes analyses are needed for renal osteodystrophy. Recent research regarding newer, present-day treatment paradigms has suggested that distinct cost savings and improved patient outcomes are possible. CONCLUSIONS: In order to realize such economic and human benefits, the medical community must first have sufficient pathologic, pharmacoeconomic and epidemiologic data to properly understand, manage and prevent renal osteodystrophy and fractures.

Computer-Aided Image-Guided Bone Fracture Surgery: Modeling, Visualization, and Preoperative Planning

L Tockus — 2008-07-02T12:49:20-00:00

(1998), pp. 29-38.

The epidemiology of peripheral fractures

JA Baron — 2008-07-02T07:28:29-00:00

Bone, Vol. 18, No. 3, Supplement 1. (March 1996), pp. S209-S213.

Although much is known about hip fracture epidemiology, there are relatively little data regarding fractures at other peripheral sites. Epidemiological differences between fractures are important, since they imply that an understanding of the consequences and clinical expression of osteoporosis requires the study of many different fracture types. Recent data regarding the basic epidemiology of limb fractures among the elderly in industrialized countries have made some patterns clear. Fractures outside the hip are relatively common events, and before age 70 to 75, ankle and distal forearm fractures occur more commonly than fractures of the hip. Among the elderly, fractures at the most proximal and most distal ends of the limbs have the highest incidence. Thus, in the upper extremity, fractures of the proximal humerus and distal forearm are the most common, while in the lower extremity, those at the hip and ankle predominate. Outside the axial skeleton, females have higher rates for most fracture types, and at most fracture sites whites have higher rates than blacks. In each limb, the most proximal fractures tend to have the most pronounced age-related increases in risk.

Early experience with computer-assisted shoulder hemiarthroplasty for fractures of the proximal humerus: Development of a novel technique and an in vitro comparison with traditional methods

Ryan Bicknell — 2008-07-02T13:58:28-00:00

Journal of Shoulder and Elbow Surgery, Vol. 16, No. 3, Supplement 1. ( 2007), pp. S117-S125.

A computer-assisted technique was developed for treatment of 4-part proximal humeral fractures via a hemiarthroplasty and tuberosity fixation. This was compared with a standard traditional method in 7 pairs of cadaveric shoulders. The computer-assisted technique used preoperative computed tomography data and computer simulations of anatomic characteristics of the contralateral humerus. This allowed accurate anatomic reconstruction by use of an electromagnetic tracking system and real-time intraoperative feedback. Various anatomic measurements were used to quantify the accuracy of the reconstruction. The differences between the intact and reconstructed values were improved with the computer-assisted technique for 5 of 7 characteristics. However, this was statistically significant only for humeral head offset (P < .05). With further investigation and refinement, this technique should allow for a more anatomic reconstruction of the proximal humerus, potentially resulting in improved patient outcomes. The technique may also prove to be a valuable resource for the laboratory training of inexperienced surgical trainees.

Biomechanical Evaluation of Periprosthetic Femoral Fracture Fixation

Rad Zdero — 2008-05-03T21:28:18-00:00

J Bone Joint Surg Am, Vol. 90, No. 5. (1 May 2008), pp. 1068-1077.

Background: A variety of methods are available for the fixation of femoral shaft fractures after total hip arthroplasty. However, few studies in the literature have quantified the performance of such repair constructs. The aim of this study was to evaluate biomechanically four different constructs for the fixation of periprosthetic femoral shaft fractures following total hip arthroplasty. Methods: Twenty synthetic femora were tested in axial compression, lateral bending, and torsion to determine initial stiffness, as well as stiffness following fixation of a simulated femoral midshaft fracture with and without a bone gap. Four fracture fixation constructs (five specimens per group) were assessed: construct A was a Synthes locked plate (a twelve-hole broad dynamic compression plate) with locked screws; construct B, a Synthes locked plate (a twelve-hole broad dynamic compression plate) with cables and locked screws; construct C, a Zimmer nonlocking (eight-hole) cable plate with cables and nonlocked screws; and construct D, a Zimmer nonlocking (eight-hole) cable plate with allograft strut, cables, and nonlocked screws. Axial stiffness, lateral bending stiffness, and torsional stiffness were assessed with respect to baseline intact specimen values. Axial load to failure was also measured for the specimens. Results: Construct D demonstrated either equivalent or superior stiffness in all testing modes compared with the other constructs in femora with both a midshaft fracture and a bone gap. A comparison of constructs A, B, and C demonstrated equivalent stiffness in all test modes (with one exception) in femora with a midshaft fracture and a bone gap. Conclusions: A combination of a nonlocking plate with an allograft strut (construct D) resulted in the highest stiffness of the constructs examined for treating a periprosthetic fracture around a stable femoral component of a total hip replacement. Clinical Relevance: A locked plate (constructs A and B) should be used with caution as a stand-alone treatment for the fixation of a periprosthetic femoral shaft fracture following total hip arthroplasty, particularly with good bone stock. 10.2106/JBJS.F.01561

Diagnosis of Osteoporotic Vertebral Fractures: Importance of Recognition and Description by Radiologists

Leon Lenchik — 2007-01-26T15:33:07-00:00

Am. J. Roentgenol., Vol. 183, No. 4. (1 October 2004), pp. 949-958.

How to Simplify the CT Diagnosis of Le Fort Fractures

James Rhea — 2007-05-14T20:42:51-00:00

Am. J. Roentgenol., Vol. 184, No. 5. (1 May 2005), pp. 1700-1705.

OBJECTIVE. The numerous components seen in the Le Fort fractures make classification difficult. Our objective is to simplify the task of classifying Le Fort fractures. CONCLUSION. Each of the Le Fort fractures has at least one unique component that is easily recognizable: I, the anterolateral margin of the nasal fossa; II, the inferior orbital rim; and III, the zygomatic arch. Classification of the Le Fort fractures is simplified by using these unique components to establish a tentative classification that is then confirmed.

Improving osteoporosis management in at-risk fracture clinic patients.

MC Ashe — 2005-04-11T22:45:30-00:00

J Am Geriatr Soc, Vol. 53, No. 4. (April 2005), pp. 727-728.

Redesigning the care of fragility fracture patients to improve osteoporosis management: A health care improvement project.

J Timothy Harrington — 2005-04-11T22:40:22-00:00

Arthritis Rheum, Vol. 53, No. 2. (7 April 2005), pp. 198-204.

OBJECTIVE: To develop new processes that assure more reliable, population-based care of fragility fracture patients. METHODS: A 4-year clinical improvement project was performed in a multispecialty, community practice health system using evidence-based guidelines and rapid cycle process improvement methods (plan-do-study-act cycles). RESULTS: Prior to this project, appropriate osteoporosis care was provided to only 5% of our 1999 hip fracture patients. In 2001, primary physicians were provided prompts about appropriate care (cycle 1), which resulted in improved care for only 20% of patients. A process improvement pilot in 2002 (cycle 2) and full program implementation in 2003 (cycle 3) have assured osteoporosis care for all willing and able patients with any fragility fracture. Altogether, 58% of 2003 fragility fracture patients, including 46% of those with hip fracture, have had a bone measurement, have been assigned to osteoporosis care with their primary physician or a consultant, and are being monitored regularly. Only 19% refused osteoporosis care. Key process improvements have included using orthopedic billings to identify patients, referring patients directly from orthopedics to an osteoporosis care program, organizing care with a nurse manager and process management computer software, assigning patients to primary or consultative physician care based on disease severity, and monitoring adherence to therapy by telephone. CONCLUSION: Reliable osteoporosis care is achievable by redesigning clinical processes. Performance data motivate physicians to reconsider traditional approaches. Improving the care of osteoporosis and other chronic diseases requires coordinated care across specialty boundaries and health system support.

Calcium plus vitamin D supplementation and the risk of fractures.

RD Jackson — 2006-02-21T21:36:06-00:00

N Engl J Med, Vol. 354, No. 7. (16 February 2006), pp. 669-683.

BACKGROUND: The efficacy of calcium with vitamin D supplementation for preventing hip and other fractures in healthy postmenopausal women remains equivocal. METHODS: We recruited 36,282 postmenopausal women, 50 to 79 years of age, who were already enrolled in a Women's Health Initiative (WHI) clinical trial. We randomly assigned participants to receive 1000 mg of elemental calcium as calcium carbonate with 400 IU of vitamin D3 daily or placebo. Fractures were ascertained for an average follow-up period of 7.0 years. Bone density was measured at three WHI centers. RESULTS: Hip bone density was 1.06 percent higher in the calcium plus vitamin D group than in the placebo group (P<0.01). Intention-to-treat analysis indicated that participants receiving calcium plus vitamin D supplementation had a hazard ratio of 0.88 for hip fracture (95 percent confidence interval, 0.72 to 1.08), 0.90 for clinical spine fracture (0.74 to 1.10), and 0.96 for total fractures (0.91 to 1.02). The risk of renal calculi increased with calcium plus vitamin D (hazard ratio, 1.17; 95 percent confidence interval, 1.02 to 1.34). Censoring data from women when they ceased to adhere to the study medication reduced the hazard ratio for hip fracture to 0.71 (95 percent confidence interval, 0.52 to 0.97). Effects did not vary significantly according to prerandomization serum vitamin D levels. CONCLUSIONS: Among healthy postmenopausal women, calcium with vitamin D supplementation resulted in a small but significant improvement in hip bone density, did not significantly reduce hip fracture, and increased the risk of kidney stones. (ClinicalTrials.gov number, NCT00000611.).

Geometric modelling and object-oriented software concepts applied to a heterogeneous fractured network from the Grimsel rock laboratory

Kalbacher — 2007-03-24T18:19:11-00:00

Computational Geosciences, Vol. 11, No. 1. (March 2007), pp. 9-26.