Long-term changes in bone metabolism, bone mineral density, quantitative ultrasound parameters, and fracture incidence after spinal cord injury: a cross-sectional observational study in 100 paraplegic men

To study the time course of demineralization and fracture incidence after spinal cord injury (SCI), 100 paraplegic men with complete motor loss were investigated in a cross-sectional study 3 months to 30 years after their traumatic SCI. Fracture history was assessed and verified using patients' files and X-rays. BMD of the lumbar spine (LS), femoral neck (FN), distal forearm (ultradistal part = UDR, 1/3 distal part = 1/3R), distal tibial diaphysis (TDIA), and distal tibial epiphysis (TEPI) was measured using DXA. Stiffness of the calcaneus (QUI.CALC), speed of sound of the tibia (SOS.TIB), and amplitude-dependent SOS across the proximal phalanges (adSOS.PHAL) were measured using QUS. Z-Scores of BMD and quantitative ultrasound (QUS) were plotted against time-since-injury and compared among four groups of paraplegics stratified according to time-since-injury (<1 year, stratum I; 1-9 years, stratum II; 10-19 years, stratum III; 20-29 years, stratum IV). Biochemical markers of bone turnover (deoxypyridinoline/creatinine (D-pyr/Cr), osteocalcin, alkaline phosphatase) and the main parameters of calcium phosphate metabolism were measured. Fifteen out of 98 paraplegics had sustained a total of 39 fragility fractures within 1,010 years of observation. All recorded fractures were fractures of the lower limbs, mean time to first fracture being 8.9 +/- 1.4 years. Fracture incidence increased with time-after-SCI, from 1% in the first 12 months to 4.6%/year in paraplegics since >20 years ( p<.01). The overall fracture incidence was 2.2%/year. Compared with nonfractured paraplegics, those with a fracture history had been injured for a longer time ( p<.01). Furthermore, they had lower Z-scores at FN, TEPI, and TDIA ( p<.01 to <.0001), the largest difference being observed at TDIA, compared with the nonfractured. At the lower limbs, BMD decreased with time at all sites ( r=.49 to.78, all p<.0001). At FN and TEPI, bone loss followed a log curve which leveled off between 1 to 3 years after injury. In contrast, Z-scores of TDIA continuously decreased even beyond 10 years after injury. LS BMD Z-score increased with time-since-SCI ( p<.05). Similarly to DXA, QUS allowed differentiation of early and rapid trabecular bone loss (QUI.CALC) vs slow and continuous cortical bone loss (SOS.TIB). Biochemical markers reflected a disproportion between highly elevated bone resorption and almost normal bone formation early after injury. Turnover declined following a log curve with time-after-SCI, however, D-pyr/Cr remained elevated in 30% of paraplegics injured >10 years. In paraplegic men early (trabecular) and persistent (cortical) bone loss occurs at the lower limbs and leads to an increasing fracture incidence with time-after-SCI.

Postpartum osteoporosis associated with proximal tibial stress fracture

A 33-year-old woman presented with acute nonspecific knee pain, 6 months postpartum. MR imaging, computed tomography and radiography were performed and a proximal tibia plateau insufficiency fracture was detected. Bone densitometry demonstrated mild postpartum osteoporosis. To our knowledge these findings have not been described in this location and in this clinical setting. The etiology of the atraumatic fracture of the tibia is presumed to be due to a low bone mineral density. The bone loss was probably due to pregnancy, lactation and postpartum hormonal changes. There were no other inciting causes and the patient was normocalcemic. We discuss the presence of a postpartum stress fracture in a hitherto undescribed site in a patient who had lactated following an uncomplicated pregnancy and had no other identifiable cause for a stress fracture.

Quality controls for two heel bone ultrasounds used in the Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk Study

Because of the important morbidity and mortality associated with osteoporosis, it is essential to detect subjects at risk by screening methods, such as bone quantitative ultrasounds (QUSs). Several studies showed that QUS could predict fractures. None, however, compared prospectively different QUS devices, and few data of quality controls (QCs) have been published. The Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk is a prospective multicenter study that compared three QUSs for the assessment of hip fracture risk in a population of 7609 women age >/=70 yr. Because the inclusion phase lasted 20 mo, and because 10 centers participated in this study, QC became a major issue. We therefore developed a QC procedure to assess the stability and precision of the devices, and for their cross-calibration. Our study focuses on the two heel QUSs. The water bath system (Achilles+) had a higher precision than the dry system (Sahara). The QC results were highly dependent on temperature. QUS stability was acceptable, but Sahara must be calibrated regularly. A sufficient homogeneity among all the Sahara devices could be demonstrated, whereas significant differences were found among the Achilles+ devices. For speed of sound, 52% of the differences among the Achilles+ was explained by the water s temperature. However, for broadband ultrasound attenuation, a maximal difference of 23% persisted after adjustment for temperature. Because such differences could influence measurements in vivo, it is crucial to develop standardized phantoms to be used in prospective multicenter studies.

Sellar fracture followed by sudden death: an autopsy case

The authors describe a case of sellar fracture followed by sudden death. The victim was involved in a wrangle. The autopsy revealed facial damage and sellar fracture and no evidence of cerebral damage, except for a mild subarachnoid hemorrhage in the left parietotemporal regions and undersurface of both frontal lobes. Sellar fracture is a rare and severe entity, associated with serious complications, which is frequently diagnosed postmortem. In any case, death is rarely a direct consequence of the sellar fracture itself and is usually considered to be the result of associated cerebral trauma. This case prompted us to screen the literature on sellar fracture to gain a better understanding of the mechanism of death.

High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate

INTRODUCTION Stable reconstruction of proximal femoral (PF) fractures is especially challenging due to the peculiarity of the injury patterns and the high load-bearing requirement. Since its introduction in 2007, the PF-locking compression plate (LCP) 4.5/5.0 has improved osteosynthesis for intertrochanteric and subtrochanteric fractures of the femur. This study reports our early results with this implant. METHODS Between January 2008 and June 2010, 19 of 52 patients (12 males, 7 females; mean age 59 years, range 19-96 years) presenting with fractures of the trochanteric region were treated at the authors' level 1 trauma centre with open reduction and internal fixation using PF-LCP. Postoperatively, partial weight bearing was allowed for all 19 patients. Follow-up included a thorough clinical and radiological evaluation at 1.5, 3, 6, 12, 24, 36 and 48 months. Failure analysis was based on conventional radiological and clinical assessment regarding the type of fracture, postoperative repositioning, secondary fracture dislocation in relation to the fracture constellation and postoperative clinical function (Merle d'Aubigné score). RESULTS In 18 patients surgery achieved adequate reduction and stable fixation without intra-operative complications. In one patient an ad latus displacement was observed on postoperative X-rays. At the third month follow-up four patients presented with secondary varus collapse and at the sixth month follow-up two patients had 'cut-outs' of the proximal fragment, with one patient having implant failure due to a broken proximal screw. Revision surgeries were performed in eight patients, one patient receiving a change of one screw, three patients undergoing reosteosynthesis with implantation of a condylar plate and one patient undergoing hardware removal with secondary implantation of a total hip prosthesis. Eight patients suffered from persistent trochanteric pain and three patients underwent hardware removal. CONCLUSIONS Early results for PF-LCP osteosynthesis show major complications in 7 of 19 patients requiring reosteosynthesis or prosthesis implantation due to secondary loss of reduction or hardware removal. Further studies are required to evaluate the limitations of this device.

High resolution quantitative computed tomography-based assessment of trabecular microstructure and strength estimates by finite-element analysis of the spine, but not DXA, reflects vertebral fracture status in men with glucocorticoid-induced osteoporosis

High-resolution quantitative computed tomography (HRQCT)-based analysis of spinal bone density and microstructure, finite element analysis (FEA), and DXA were used to investigate the vertebral bone status of men with glucocorticoid-induced osteoporosis (GIO). DXA of L1–L3 and total hip, QCT of L1–L3, and HRQCT of T12 were available for 73 men (54.6±14.0years) with GIO. Prevalent vertebral fracture status was evaluated on radiographs using a semi-quantitative (SQ) score (normal=0 to severe fracture=3), and the spinal deformity index (SDI) score (sum of SQ scores of T4 to L4 vertebrae). Thirty-one (42.4%) subjects had prevalent vertebral fractures. Cortical BMD (Ct.BMD) and thickness (Ct.Th), trabecular BMD (Tb.BMD), apparent trabecular bone volume fraction (app.BV/TV), and apparent trabecular separation (app.Tb.Sp) were analyzed by HRQCT. Stiffness and strength of T12 were computed by HRQCT-based nonlinear FEA for axial compression, anterior bending and axial torsion. In logistic regressions adjusted for age, glucocorticoid dose and osteoporosis treatment, Tb.BMD was most closely associated with vertebral fracture status (standardized odds ratio [sOR]: Tb.BMD T12: 4.05 [95% CI: 1.8–9.0], Tb.BMD L1–L3: 3.95 [1.8–8.9]). Strength divided by cross-sectional area for axial compression showed the most significant association with spine fracture status among FEA variables (2.56 [1.29–5.07]). SDI was best predicted by a microstructural model using Ct.Th and app.Tb.Sp (r2=0.57, p<0.001). Spinal or hip DXA measurements did not show significant associations with fracture status or severity. In this cross-sectional study of males with GIO, QCT, HRQCT-based measurements and FEA variables were superior to DXA in discriminating between patients of differing prevalent vertebral fracture status. A microstructural model combining aspects of cortical and trabecular bone reflected fracture severity most accurately.

Development of an ex vivo protocol to model bone fracture in laying hens resulting from collisions.

Fractures of the keel bone, a bone extending ventrally from the sternum, are a serious health and welfare problem in free range laying hens. Recent findings suggest that a major cause of keel damage within extensive systems is collisions with internal housing structures, though investigative efforts have been hindered by difficulties in examining mechanisms and likely influencing factors at the moment of fracture. The objectives of this study were to develop an ex vivo impact protocol to model bone fracture in hens caused by collision, to assess impact and bird-related factors influencing fracture occurrence and severity, and to identify correlations of mechanical and structural properties between different skeletal sites. We induced keel bone fractures in euthanized hens using a drop-weight impact tester able to generate a range of impact energies, producing fractures that replicate those commonly found in commercial settings. The results demonstrated that impact energies of a similar order to those expected in normal housing were able to produce fractures, and that greater collision energies resulted in an increased likelihood of fractures and of greater severity. Relationships were also seen with keel's lateral surface bone mineral density, and the peak reactive force (strength) at the base of the manubrial spine. Correlations were also identified between the keel and long bones with respect to both strength and bone mineral density. This is the first study able to relate impact and bone characteristics with keel bone fracture at the moment of collision. Greater understanding of these relationships will provide means to reduce levels of breakage and severity in commercial systems.

Fracture and Back Stress Along the Byrd Glacier Flowband on the Ross Ice Shelf

East Antarctic ice discharged by Byrd Glacier continues as a flowband to the calving front of the Ross Ice Shelf. Flow across the grounding line changes from compressive to extensive as it leaves the fjord through the Transantarctic Mountains occupied by Byrd Glacier. Magnitudes of the longitudinal compressive stress that suppress opening of transverse tensile cracks are calculated for the flowband. As compressive back stresses diminish, initial depths and subsequent growth of these cracks, and their spacing, are calculated using theories of elastic and ductile fracture mechanics. Cracks are initially about one millimeter wide, with approximately 30 in depths and 20 in spacings for a back stress of 83 kPa at a distance of 50 kin beyond the fjord, where floating ice is 600 in thick. When these crevasses penetrate the whole ice thickness, they release tabular icebergs 20 kin to 100 kin wide, spaced parallel to the calving front of the Ross Ice Shelf

Magma-Driven Multiple Dike Propagation and Fracture Toughness of Crustal Rocks

Dike swarms consisting of tens to thousands of subparallel dikes are commonly observed at Earth's surface, raising the possibility of simultaneous propagation of two or more dikes at various stages of a swarm's development. The behavior of multiple propagating dikes differs from that of a single dike owing to the interacting stress fields associated with each dike. We analyze an array of parallel, periodically spaced dikes that grow simultaneously from an overpressured source into a semi-infinite, linear elastic host rock. To simplify the analysis, we assume steady state (constant velocity) magma flow and dike propagation. We use a perturbation method to analyze the coupled, nonlinear problem of multiple dike propagation and magma transport. The stress intensity factor at the dike tips and the opening displacements of the dike surfaces are calculated. The numerical results show that dike spacing has a profound effect on the behavior of dike propagation. The stress intensity factors at the tips of parallel dikes decrease with a decrease in dike spacing and are significantly smaller than that for a single dike with the same length. The reduced stress intensity factor indicates that, compared to a single dike, propagation of parallel dikes is more likely to be arrested under otherwise the same conditions. It also implies that fracture toughness of the host rock in a high confining pressure environment may not be as high as inferred from the propagation of a single dike. Our numerical results suggest fracture toughness values on the order of 100 MPa root m. The opening displacements for parallel dikes are smaller than that for a single dike, which results in higher magma pressure gradients in parallel dikes and lower flux of magma transport.

Primary Oil Migration Through Buoyancy-Driven Multiple Fracture Propagation: Oil Velocity and Flux

We present a fracture-mechanics-based formulation to investigate primary oil migration through the propagation of an array of periodic, parallel fractures in a sedimentary rock with elevated pore fluid pressure. The rock is assumed to be a linearly elastic medium. The fracture propagation and hence oil migration velocity are determined using a fracture mechanics criterion together with the lubrication theory of fluid mechanics. We find that fracture interactions have profound effects on the primary oil migration behavior. For a given fracture length, the mass flux of oil migration decreases dramatically with an increase in fracture density. The reduced oil flux is due to the decreased fracture propagation velocity as well as the narrowed fracture opening that result from the fracture interactions.

On the Disintegration of Ice Shelves: The Role of Fracture

Crevasses can be ignored in studying the dynamics of most glaciers because they are only about 20 m deep, a small fraction of ice thickness. In ice shelves, however, s urface crevasses 20 m deep often reach sealevel and bottom crevasses can move upward to sea-level (Clough, 1974; Weertman, 1980). The ice shelf is fractured completely through if surface and basal crevasses meet (Barrett, 1975; Hughes, 1979). This is especially likely if surface melt water fills surface crevasses (Weertman, 1973; Pfeffer, 1982; Fastook and Schmidt, 1982). Fracture may therefore play an important role i n the disintegration of ice shelves. Two fracture criteria which can be evaluated experimentally and applied to ice shelves, are presented. Fracture is then examined for the general strain field of an ice shelf and for local strain fields caused by shear rupture alongside ice streams entering the ice shelf, fatigue rupture along ice shelf grounding lines, and buckling up-stream from ice rises. The effect of these fracture patterns on the stability of Antarctic ice shelves and the West Antarctic ice sheet is then discussed.

Urethral entrapment following pelvic fracture fixation in a dog

An 18-month-old female crossbred dog was presented with a unilateral sacroiliac luxation and separation of the pelvic symphysis. Surgical correction of the luxation with screw fixation led to entrapment of the urethra between the symphyseal parts of the two hemipelves.

Surgical anatomy of the feline sacroiliac joint for lag screw fixation of sacroiliac fracture-luxation

Twenty-eight feline pelves (56 hemipelves) were examined in order to identify the location for optimal sacroiliac screw placement in sacroiliac fracture-luxation repair. A drill hole was started on the median plane of the hemipelvis in the centre of the body of the first sacral segment until it penetrated the lateral cortex of the ilial wing, thus providing optimal drill hole placement. The position of the drill hole on the articular surface of the sacral wing and on the lateral surface of the ilial wing was measured. The distance of the drill hole from the cranial margin of the sacral wing was 51% of sacral wing length, just cranial to the crescent shaped hyaline cartilage. The distance from the dorsal margin was 47% of sacral wing height. The drill bit direction has to be adjusted to the cranio-caudal inclination (range 10° to 29°) and dorso-ventral inclination (range 2° to 25°) of the sacral wing. A notch in the cranial edge of the sacral wing was present, with variable position, in 34% of the specimens and is consequently not a useful landmark for sacroiliac screw placement. The drill hole on the lateral surface of the ilium was located in craniocaudal direction at a distance of 69% of sacral tuber length, measured from the cranial dorsal iliac spine. The dorso-ventral position of the drill hole was at a distance of 52% of ilial wing height measured from the sacral tuber. The ventral gluteal line, present in 93% of the cases, is a useful landmark to locate optimal screw hole position on the ilial wing.

The Effect of 6 versus 9 Years of Zoledronic Acid Treatment in Osteoporosis: A Randomized Second Extension to the HORIZON-Pivotal Fracture Trial (PFT).

While bisphosphonates reduce fracture risk over 3 to 5 years, the optimal duration of treatment is uncertain. In a randomized extension study (E1) of the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly - Pivotal Fracture Trial (HORIZON-PFT), zoledronic acid (ZOL) 5 mg annually for 6 years showed maintenance of bone mineral density (BMD), decrease in morphometric vertebral fractures, and a modest reduction in bone turnover markers (BTMs) compared with discontinuation after 3 years. To investigate the longer-term efficacy and safety of ZOL, a second extension (E2) was conducted to 9 years in which women on ZOL for 6 years in E1 were randomized to either ZOL (Z9) or placebo (Z6P3) for 3 additional years. In this multicenter, randomized, double-blind study, 190 women were randomized to Z9 (n=95) and Z6P3 (n=95). The primary endpoint was change in total hip BMD at year 9 vs. year 6 in Z9 compared with Z6P3. Other secondary endpoints included fractures, BTMs, and safety. From year 6 to 9, the mean change in total hip BMD was -0.54% in Z9 vs. -1.31% in Z6P3 (difference 0.78%; 95% confidence interval [CI]: -0.37%, 1.93%; p=0.183). BTMs showed small, non-significant increases in those who discontinued after 6 years compared with those who continued for 9 years. The number of fractures was low and did not significantly differ by treatment. While generally safe, there was a small increase in cardiac arrhythmias (combined serious and non-serious) in the Z9 group but no significant imbalance in other safety parameters. The results suggest almost all patients who have received six annual ZOL infusions can stop medication for up to 3 years with apparent maintenance of benefits. This article is protected by copyright. All rights reserved.