Clinical evolution of sacral stress fractures: influence of additional pelvic fractures

To evaluate the clinical evolution of sacral stress fractures in relation to the scintigraphic pattern and the presence of additional pelvic fractures. METHODS--This was a retrospective study of 14 patients with sacral fractures. RESULTS--Six patients had additional pelvic fractures. Four bone scintigraphic patterns were found. The resolution of symptoms was longer in patients with associated pelvic fractures (30 weeks v three weeks). No relation was found between the bone scintigraphic pattern and the time of evolution. CONCLUSION--Associated pelvic fractures delay the resolution of symptoms in patients with sacral fractures, regardless of scintigraphic pattern.

Bone fractures among postmenopausal patients with endocrine-responsive early breast cancer treated with 5 years of letrozole or tamoxifen in the BIG 1-98 trial.

BACKGROUND: To compare the incidence and timing of bone fractures in postmenopausal women treated with 5 years of adjuvant tamoxifen or letrozole for endocrine-responsive early breast cancer in the Breast International Group (BIG) 1-98 trial. METHODS: We evaluated 4895 patients allocated to 5 years of letrozole or tamoxifen in the BIG 1-98 trial who received at least some study medication (median follow-up 60.3 months). Bone fracture information (grade, cause, site) was collected every 6 months during trial treatment. RESULTS: The incidence of bone fractures was higher among patients treated with letrozole [228 of 2448 women (9.3%)] versus tamoxifen [160 of 2447 women (6.5%)]. The wrist was the most common site of fracture in both treatment groups. Statistically significant risk factors for bone fractures during treatment included age, smoking history, osteoporosis at baseline, previous bone fracture, and previous hormone replacement therapy. CONCLUSIONS: Consistent with other trials comparing aromatase inhibitors to tamoxifen, letrozole was associated with an increase in bone fractures. Benefits of superior disease control associated with letrozole and lower incidence of fracture with tamoxifen should be considered with the risk profile for individual patients.

Clinical evolution of sacral stress fractures: influence of additional pelvic fractures

To evaluate the clinical evolution of sacral stress fractures in relation to the scintigraphic pattern and the presence of additional pelvic fractures. METHODS--This was a retrospective study of 14 patients with sacral fractures. RESULTS--Six patients had additional pelvic fractures. Four bone scintigraphic patterns were found. The resolution of symptoms was longer in patients with associated pelvic fractures (30 weeks v three weeks). No relation was found between the bone scintigraphic pattern and the time of evolution. CONCLUSION--Associated pelvic fractures delay the resolution of symptoms in patients with sacral fractures, regardless of scintigraphic pattern.

Immediate hip spica is as effective as, but more efficient than, flexible intramedullary nailing for femoral shaft fractures in pre-school children.

Flexible intramedullary nailing (FIN) is the gold standard treatment for femur fracture in school-aged children. It has been performed successfully in younger children, although Spica cast immobilisation (SCI) has been the most widely used strategy to date. METHOD: A retrospective analysis was performed between two comparable groups of children aged 1-4 years with a femoral shaft fracture. Two University hospitals, each using specific treatment guidelines, participated in the study: SCI in Group I (Basel, Switzerland) and FIN in Group II (Lausanne, Switzerland). RESULTS: Group I included 19 children with a median age of 26 months (range 12-46 months). Median hospital stay was 1 day (range 0-5 days) and casts were retained for a median duration of 21 days (range 12-29 days). General anaesthesia was used in six children and sedation in four. Skin breakdown secondary to cast irritation occurred in two children (10.5%). The median follow-up was 114 months (range 37-171 months). No significant malunion was noted. Group II included 27 children with a median age of 38.4 months (range 18.7-46.7 months). Median hospital stay was 4 days (range 1-13 days). All children required general anaesthesia for insertion and removal of the nails. Free mobilisation and full weight bearing were allowed at a median of 2 days (range 1-10 days) and 7 days (range 1-30 days), respectively, postoperatively. Nail exteriorisation was noted in three children (11%). The median follow-up was 16.5 months (range 8-172 months). No significant malunion was reported. CONCLUSIONS: Young children with a femoral shaft fracture treated by SCI or FIN had similarly favourable outcomes and complication rates. FIN allowed earlier mobilisation and full weight bearing. Compared to SCI, a greater number of children required general anaesthesia. In a pre-school child with a femoral shaft fracture, immediate SCI applied by a paediatric orthopaedic team following specific guidelines allowed early discharge from hospital with few complications.

Die Behandlung von Acetabulumfrakturen bei geriatrischen Patienten mittels modifizierter Kabelcerclage und primärer Hüfttotalprothese. Erste Ergebnisse [Treatment of acetabular fractures in the elderly with primary total hip arthroplasty and modified cerclage. Early results]

This prospective study addresses early results of the treatment of acute acetabular fractures in elderly patients by total hip arthroplasty and cerclage wiring.Fifteen patients with an average age of 81 years were treated at our institution between February 1998 and December 2000. There were two transverse fractures, eight T-shaped fractures, two transverse fractures with associated posterior wall fracture, two posterior column fractures with associated posterior wall fracture, and one fracture of both columns. Treatment consisted of cerclage wiring of the fracture and primary non-cemented total hip replacement.All of the patients were followed for a mean of 36 months. Although there was one patient with three hip dislocations during the first 10 months after the operation, we found an excellent or good result for the entire group. During this relatively short follow-up period, we have not found a radiological loss of fracture reduction of more than 1 mm or a cup migration of more than 3.2 mm. All of the fractures healed and no loosening of the implant was evident.Primary total hip arthroplasty combined with internal fixation is a valid treatment option for acetabular fractures in the elderly. Preliminary results are convincing, but a bigger patient population and a longer follow-up time are necessary before we are able to draw final conclusions.

Outcome of long-axis percutaneous sacroplasty for the treatment of sacral insufficiency fractures.

Our aim was to assess the clinical outcome of patients who were subjected to long-axis sacroplasty for the treatment of sacral insufficiency fractures. Nineteen patients with unilateral (n = 3) or bilateral (n = 16) sacral fractures were involved. Under local anaesthesia, each patient was subjected to CT-guided sacroplasty using the long-axis approach through a single entry point. An average of 6 ml of polymethylmethacrylate (PMMA) was delivered along the path of each sacral fracture. For each individual patient, the Visual Analogue pain Scale (VAS) before sacroplasty and at 1, 4, 24 and 48 weeks after the procedure was obtained. Furthermore, the use of analgesics (narcotic/non-narcotic) along with the evolution of post-interventional patient mobility before and after sacroplasty was also recorded. The mean pre-procedure VAS was 8 +/- 1.9 (range, 2 to 10). This rapidly and significantly (P < 0.001) declined in the first week after the procedure (mean 4 +/- 1.4; range, 1 to 7) followed by a gradual and significant (P < 0.001) decrease along the rest of the follow-up period at 4 weeks (mean 3 +/- 1.1; range, 1 to 5), 24 weeks (mean 2.2 +/- 1.1; range, 1 to 5) and 48 weeks (mean 1.6 +/- 1.1; range, 1 to 5). Eleven (58%) patients were under narcotic analgesia before sacroplasty, whereas 8 (42%) patients were using non-narcotics. Corresponding values after the procedure were 2/19 (10%; narcotic, one of them was on reserve) and 10/19 (53%; non-narcotic). The remaining 7 (37%) patients did not address post-procedure analgesic use. The evolution of post-interventional mobility was favourable in the study group as they revealed a significant improvement in their mobility point scale (P < 0.001). Long-axis percutaneous sacroplasty is a suitable, minimally invasive treatment option for patients who present with sacral insufficiency fractures. More studies with larger patient numbers are needed to explore any unrecognised limitations of this therapeutic approach.

Suplementação mineral e mobilização de cálcio nos ossos de eqüinos em pastagem de Brachiaria humidicola

Durante 150 dias, 12 potras Quarto-de-Milha de 1 ano de idade permaneceram exclusivamente em pastagem de Brachiaria humidicola, num experimento inteiramente casualizado, com três tratamentos, nível 0 (recomendação do NRC, 1989); nível 50 (50% a mais do NRC); nível 100 (100% a mais do NRC), e quatro repetições. Como palatabilizante foram empregadas 270 g de açúcar. Realizaram-se biópsias na asa do osso do ílio de cada potra, no início e final do experimento, para avaliar a mobilização de Ca e a relação Ca:P. As amostras da gramínea, foram coletadas mensalmente para verificação do teor de oxalato e composição químico-bromatológica. Houve efeito de tempo na mobilização de Ca, P e da relação Ca:P (p<0,05), independentemente dos tratamentos. As médias dos três tratamentos, no início e final do período experimental foram, quanto aos teores de Ca, P e da relação Ca:P, respectivamente: 10,05, 5,22, 1,93:1 e 6,24, 4,06, 1,54:1. O teor do oxalato na gramínea variou de 1,18 a 2,00%. A utilização do nível de cálcio suplementar duas vezes superior ao recomendado pelo National Research Council não foi suficiente para impedir a mobilização deste mineral nos ossos de eqüinos pastejando Brachiaria humidicola por longos períodos.

Secondary prevention of osteoporotic fractures : room for improvement

Résumé : Introduction : l'ostéoporose est une maladie fréquente, invalidante, sous-diagnostiquée et sous-traitée, alors qu'il existe des évidences cliniques, densitométriques et biologiques de l'efficacité de la prévention secondaire. Matériel et méthode : dans cette étude, nous décrivons les habitudes de prescription de traitements en prévention secondaire dans les 6 mois qui suivent une fracture de fragilité et définissons les catégories de femmes recevant ou non un traitement, selon le type de fractures, les antécédents fracturaires et les données socio-démographiques. Il s'agit d'une étude suisse de cohorte, prospective de 7609 femmes de 70 ans et plus, suivies de 1998 à 2000. Deux groupes de patientes ont été analysés : celles avec un événement fracturaire durant le suivi (3 sous-groupes de fractures ont été considérés fractures vertébrales, fractures du radius distal et fractures de l'humérus proximal) et celles sans fractures durant le suivi (groupe contrôle). La détermination des événements fracturaires et l'instauration d'un traitement s'est faite par l'envoi aux patientes et à leurs médecins traitants d'un questionnaire structuré. Dans cette étude, le but primaire est de décrire les attitudes médicales de prévention secondaire, le but secondaire d'analyser les motifs dé décision thérapeutique (type de fracture, antécédents de fractures), alors que le but tertiaire cherche à caractériser les femmes non traitées. Résultats, discussion : 7354 femmes ont été incluses dans cette étude, 183 dans le groupe fracture et 7171 dans le groupe contrôle. Le suivi moyen a été de 21 mois. L'introduction d'un traitement est restée rare dans chaque catégorie de fracture et a été plus importante pour le sous-groupe avec fracture vertébrale (p<0.001). La seule donnée associée à l'adjonction d'un traitement a été la présence d'un antécédent anamnestique de fracture vertébrale. La description des attitudes thérapeutiques après une fracture de fragilité, a montré que. 44 % des femmes ne reçoivent aucun traitement en prévention secondaire. Seule la fracture vertébrale et les antécédents de fracture vertébrale entraînent une modification de l'attitude thérapeutique des médecins traitants mais de façon encore insuffisante puisque plus de 50 % des femmes avec une fracture de vertèbre n'ont aucun changement dans leur prise en charge. Les femmes non traitées ne différaient pas des autres sur un plan socio-démographique. Le nombre de patientes dans chaque sous-groupe est relativement faible ce qui limite !a puissance statistique de l'analyse. Les données consistent essentiellement en du « selfreporting » ce qui peut limiter la signification de celles-ci. Les résultats sont cependant suffisamment inquiétants pour que de nouvelles campagnes d'information soient lancées auprès des médecins de .premiers recours quant à la nécessité d'instaurer un traitement efficace lors de la survenue d'une fracture clinique ou radiologique chez une femme en post-ménopause.

Immediate hip spica is as effective as but more efficient than flexible intramedullary nailing for femoral shaft fractures in preschool children

Résumé¦L'Embrochage Centro-Médullaire Elastique Stable (ECMES) est le traitement de choix des fractures du fémur chez l'enfant en âge scolaire. Il est pratiqué avec succès chez le jeune enfant, alors que l'Immobilisation par Plâtre (IP) était la technique la plus largement utilisée jusque-là.¦Méthode : Une analyse rétrospective comparant deux groupes d'enfants âgés de 1 à 4 ans avec des fractures diaphysaires du fémur a été effectuée. Deux hôpitaux universitaires, utilisant chacun une méthode de traitement spécifique, ont participé à cette étude : l'IP dans le groupe I (Bâle, Suisse) et l'ECMES dans le groupe II (Lausanne, Suisse).¦Résultats : Le groupe I inclue 19 enfants avec un âge médian de 26 mois (12-46 mois). La médiane du séjour hospitalier est de 1 jour (0-5 jours) et le plâtre est laissé en place pour une durée médiane de 21 jours (12-29 jours). Une anesthésie générale a été nécessaire chez 6 enfants et une sédation chez 4. Des lésions cutanées secondaires au plâtre sont apparues chez 2 enfants (10.5%). La médiane de la durée du suivi est de 114 mois (37-171 mois). Aucun défaut de consolidation n'est à déplorer. Le groupe II inclue 27 enfants avec un âge médian de 38.4 mois (18.7-46.7 mois). La médiane du séjour hospitalier est de 4 jours (1-13 jours). Tous les enfants ont nécessité une anesthésie générale pour la mise en place et pour le retrait des broches. La mobilisation et la mise en charge complète du membre ont été permises respectivement à une médiane de 2 jours (1-10 jours) et 7 jours (1-30 jours) postopératoires. Une complication sous la forme d'une extériorisation à la peau d'une broche a été notée chez 3 enfants (11%). La médiane de la durée du suivi et de 16.5 mois (8-172 mois). Aucun défaut de consolidation n'est à déplorer.¦Conclusion : Les jeunes enfants présentant une fracture diaphysaire du fémur, traité pas IP ou ECMES, ont des résultats favorables et des taux de complications similaires. L'ECMES permet une mobilisation et une charge complète sur le membre fracturé plus rapide. Mais comparé à l'IP, l'ECMES requiert un plus grand nombre d'anesthésies générales. Chez un enfant d'âge préscolaire présentant une fracture diaphysaire du fémur, l'application immédiate d'un plâtre par une équipe orthopédique pédiatrique entraînée à la mise en place de plâtre chez l'enfant, permet un retour à domicile rapide et un taux de complication bas.

Apport du CT-3D dans le diagnostic et le traitement des fractures des plateaux tibiaux [Value of 3D CT in diagnosis and treatment of fractures of the tibial plateau]

A precise classification and an optimal understanding of tibial plateau fractures are the basis of a conservative treatment or adequate surgery. The aim of this prospective study is to determine the contribution of 3D CT to the classification of fractures (comparison with standard X-rays) and as an aid to the surgeon in preoperative planning and surgical reconstruction. Between November 1994 and July 1996, 20 patients presenting 22 tibial plateau fractures were considered in this study. They all underwent surgical treatment. The fractures were classified according to the Müller AO classification. They were all investigated by means of standard X-rays (AP, profile, oblique) and the 3D CT. Analysis of the results has shown the superiority of 3D CT in the planning (easier and more acute), in the classification (more precise), and in the exact assessment of the lesions (quantity of fragments); thereby proving to be of undeniable value of the surgeon.

Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy

To evaluate the sensitivity of postmortem computed tomography (PMCT) in rib fracture detection validated against autopsy. Fifty-one forensic cases underwent a postmortem CT prior to forensic autopsy. Two image readers (radiologist and forensic pathologist) assessed high resolution CT data sets for rib fractures. Correct recognition rates (CRR), sensitivity and specificity values were calculated over all observations as well as individually for every rib and region. Additionally, for partial rib fractures the sensitivity of autopsy was calculated vice versa. 3876 entries in each study protocol (autopsy, PMCT radiologist and PMCT forensic pathologist) were investigated. A total of 690 fractures (autopsy), 491 (PMCT and radiologist) and 559 (PMCT and forensic pathologist) were detected. The CRR was 0.85. Sensitivity and specificity of PMCT for rib fracture detection were 0.63 (0.58 radiologist, 0.68 forensic pathologist) and 0.97 (both readers 0.97), respectively. Low CRR and sensitivity values were obtained for antero-lateral fractures. Partial rib fractures were better detected by PMCT. PMCT has a rather low sensitivity for rib fracture detection when validated against autopsy and indicates that clinical CT may also demonstrate a reasonable number of false negatives. Partial rib fractures often remain undetected at autopsy.

Diagnostic algorithm for a validated displacement grading of pediatric supracondylar fractures.

Background: The first AO comprehensive pediatric long bone fracture classification system has been established following a structured path of development and validation with experienced pediatric surgeons. Methods: A follow-up series of agreement studies was applied to specify and evaluate a grading system for displacement of pediatric supracondylar fractures. An iterative process comprising an international group of 5 experienced pediatric surgeons (Phase 1) followed by a pragmatic multicenter agreement study involving 26 raters (Phase 2) was used. The last evaluations were conducted on a consecutive collection of 154 supracondylar fractures documented by standard anteroposterior and lateral radiographs. Results: Fractures were classified according to 1 of 4 grades: I = incomplete fracture with no or minimal displacement; II = Incomplete fracture with continuity of the posterior (extension fracture) or anterior cortex (flexion fracture); III = lack of bone continuity (broken cortex), but still some contact between the fracture planes; IV = complete fracture with no bone continuity (broken cortex), and no contact between the fracture planes. A diagnostic algorithm to support the practical application of the grading system in a clinical setting, as well as an aid using a circle placed over the capitellum was proposed. The overall kappa coefficients were 0.68 and 0.61 in the Phase 1 and Phase 2 studies, respectively. In the Phase 1 study, fracture grades I, II, III, and IV were classified with median accuracies of 91%, 82%, 83%, and 99.5%, respectively. Similar median accuracies of 86% (Grade I), 73% (Grade II), 83%(Grade III), and 92% were reported for the Phase 2 study. Reliability was high in distinguishing complete, unstable fractures from stable injuries [ie, kappa coefficients of 0.84 (Phase 1) and 0.83 (Phase 2) were calculated]; in Phase 2, surgeons' accuracies in classifying complete fractures were all above 85%. Conclusions: With clear and unambiguous definition, this new grading system for supracondylar fracture displacement has proved to be sufficiently reliable and accurate when applied by pediatric surgeons in the framework of clinical routine as well as research.