Fractures after thyroidectomy in men: a population-based cohort study

Bone mass is purportedly reduced by an endogenous or exogenous excess of thyroid hormone or, perhaps, by calcitonin deficiency. Patients who have undergone thyroidectomy could be subject to all of these effects, yet their practical implications in terms of fracture risk are poorly defined. Interpretation is further hampered by the focus on women, where results may be influenced by involutional osteoporosis. Consequently, we assessed the potential for fractures among the 136 Rochester, Minnesota men who underwent thyroidectomy between 1935 and 1979, relative to a group of age-matched control men from the community. With 2194 person-years of follow-up in each group, survival free of any fracture of vertebra, proximal humerus, distal forearm, pelvis, or proximal femur was similar in the two groups (p = 0.23), and the relative risk of any of these fractures for thyroidectomized patients versus their controls was increased only 1.5-fold (95% CI, 0.7-3.2). The difference was entirely accounted for by a statistically significant excess of proximal femur fractures in the men with thyroidectomy. Risk factors for fractures among men with thyroidectomy included greater age at surgery, greater extent of surgery, and the presence of risk factors for secondary osteoporosis. Thus, thyroidectomy, performed mainly for adenoma or goiter, seems to have little overall influence on the risk of age-related fractures in men. However, the association with hip fractures requires further evaluation.     

Precision of dual energy x-ray absorptiometry in the upper extremities

Dual energy x-ray absorptiometry (DEXA) has been shown to be a precise method for measuring bone mineral density (BMD) and content (BMC) in lumbar spine and proximal femur, but it has not been widely used in other skeletal sites. The in vivo day-to-day precision of DEXA (Norland XR-26) for seven anatomic sites in the upper extremities was evaluated by twice measuring both the right and left sides in ten subjects. For consistently defined regions-of-interest, the following precision values (coefficient of variation) were obtained for BMD and BMC: 0.8% and 1.0% (proximal humerus); 0.5% and 0.5% (humeral shaft); 0.7% and 0.5% (radial shaft); 1.3% and 1.1% (ulnar shaft); 0.7% and 1.0% (distal radius); 0.7% and 1.2% (distal ulna); 0.4% and 0.6% (hand). The initially observed relative side-to-side differences did not change significantly in the repeated measurements. Our results indicate that DEXA is a precise method for assessment of BMD and BMC also in the upper extremities.     

Neuromyelitis optica

Compared with white women, Asian women have about a 40%-50% and blacks a 50%-60% lower risk of hip fracture, but the reason for this racial difference is not known. Women with a shorter hip axis have a lower risk of hip fracture. To test the hypothesis that a shorter hip axis length could account for the lower risk of hip fracture among Asian and black women, we measured hip axis length in 135 Caucasian, 74 Asian and 50 black women. The mean hip axis lengths of Asian and black women were significantly shorter (1.2 and 0.7 standard deviations, respectively) than that of the whites (p < 0.0001). We estimate that, compared with white women, Asians would have a 47% lower risk (95% confidence interval: 32%-63%) and blacks would have a 32% (15%-45%) lower risk of hip fracture because of their shorter hip axis. We conclude that a shorter hip axis length might be a major factor accounting for Asian women's lower risk of hip fracture and might contribute to the lower risk in black women.     

Nonmonotonous changes in erythrocyte sedimentation rate in whole blood

Scaphoid nonunion with avascular necrosis of the proximal pole remains a difficult problem. We have endeavoured to heal the fracture, restore scaphoid height and revascularize the proximal pole of the scaphoid by means of a vascularized dorsal interposition graft from the distal radius. The procedure has resulted in union of six of ten fractures. Fractures that healed had not been treated by a previous bone grafting procedure. Dissatisfaction was due to loss of motion in patients who had healed fractures, and pain in those patients with persistent non-unions.     

The epidemiology of osteoporotic fractures in a Mediterranean country

A population study was carried out over a period of 3 years (1987-1989) to determine the incidence of osteoporotic fractures. Fractures diagnosed in the two acute hospitals of the Maltese Islands were collected and classified according to the fracture site, age, sex, and patient's residence. Fractures in the Maltese Islands can only be diagnosed and adequately treated in these two general hospitals. A total of 8780 fractures were examined. Fracture of the neck of the femur was the most common fracture for which patients were admitted to the hospital. There were twice (1.96) as many females as males hospitalized for this fracture, giving an annual incidence of 262/100,000 females to 134/100,000 males over the age of 45. The fracture incidence was 2-3 times less than that found in North European countries, but was similar to the fracture rates obtained in Mediterranean studies. Fracture radius was the most frequent fracture treated on an outpatients basis. In over 45-year-olds, the female predominance persisted, giving a ratio of 3.65:1. This gave an annual incidence of 452/100,000 females to 150/100,000 males. Again, the fracture incidence obtained was significantly lower than that of Northern European countries. Other long bones showed a similar female to male (F:M) ratio in the cohort over 45 years of age. The bones showing this F:M ratio were the humerus (3.9:1), fibula (1.89:1), and tibia (1.6:1). Below 45 years of age males had more fractures than females for any bone studied.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of the Gamma nail in the treatment of fractures of the proximal femur

Fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. The Gamma nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. A series of 224 fractures of the proximal femur in which this nail was used is reported. The average age of the patients was 79.2 years. The mean healing time was 68.2 days in 99.4% of the cases. The incidence of perioperative complications was 10.3% showing that, in most of the cases, the complications occurred because of poor technique. Postoperative complications occurred with an incidence of 14.1%. Seven cases of migration of a proximal screw, six shaft fractures, and one broken nail were the most important complications. The device allowed for early mobilization and full weightbearing of the affected hip regardless of the type of fracture. With adequate surgical technique and experience, the advantages of the Gamma nail increases as the complication rate diminishes.     

Heparin, low molecular weight heparin, heparinoid, and antithrombin III therapy of disseminated intravascular coagulation

OBJECTIVE: To determine features of fractures in young children that would be helpful in distinguishing child abuse from unintentional injuries. DESIGN: Case series. SETTING: Pediatric Services of Yale-New Haven (Conn) Hospital (a tertiary care center). PATIENTS: Consecutive children who were less than 3 years of age and who were examined for a fracture from January 1979 through December 1983 were identified from the daily logs of the emergency department or the hospital's child abuse registry. OUTCOME MEASURE: Each case was rated, by means of predefined criteria and a consensus of two clinicians and two pediatric radiologists, on a seven-point scale from "definite child abuse" to "definite unintentional injury." A middle rating of "unknown" was used if there was not enough information to reach a consensus. RESULTS: Of the 253 fractures in 215 children that were identified, we categorized 24.2% as abuse, 8.4% as unknown, and 67.4% as unintentional injuries. Fractures that were considered likely due to abuse were (1) fractures in children whose caretakers reported either a change in the child's behavior, but no accidental event, or a minor fall, but the injury was more severe than expected; (2) fractures of the radius/ulna, tibia/fibula, or femur in children less than 1 year of age; or (3) midshaft or metaphyseal fractures of the humerus. Linear fractures of the parietal bone were the most common skull fractures, whether due to abuse or unintentional injuries. CONCLUSION: In young children with fractures, child abuse is common. By comparing fractures due to abuse and those due to unintentional injuries, we obtained empiric evidence to help clinicians and radiologists correctly examine children with such serious injuries.     

Giant cell tumor of bone

Giant cell tumor is a locally aggressive tumor with a high recurrence rate if not completely excised. The condition is more common among Asians than whites. During a 10-year period 44 patients, ranging in age from 12 to 51 years, were treated. The most common sites were the proximal femur and the distal radius. The aim of treatment was to excise the tumor completely. Because the tumor usually occurred at the juxtaarticular region of the bone, difficult reconstruction was expected. The authors' method of choice for filling large defects resulting from resection was to use a large vascularized bone graft from the iliac crest to enhance bone to bone corporation. The recurrence rate was low (4.5%), with only 2 recurrences: 1 at the proximal femur and the other at the proximal tibia. The functional results were highly satisfactory, with excellent stability of the joint, although in the case of the distal radius there was some degree of subluxation of the wrist joint. By applying microsurgical technique for the reconstruction, one was able to be more aggressive with excision of this locally aggressive tumor while maintaining excellent functional results. In the case of the knee, as long as 1 tibial condyle was intact, reconstruction of the other condyle using a vascularized iliac crest block maintained the joint integrity perfectly or created a pseudojoint component that was perfectly stable.     

New developments in stabilization of dia- and metaphyseal fractures of long tubular bones

Nail, plate and external fixator are since decades the most frequently and stabilizers for the surgical treatment of dia- and metaphyseal fractures. These elements are still present today. However, there were important changes in recent years. Together with better knowledge and understanding of fracture healing, fracture biology, implant metallurgy and mechanics and a more and more specified application of these techniques, this resulted in improved possibilities for the treatment of injured patients. Beside an overview about the current discussion of unreamed and reamed nail insertion new trends, techniques and nails are presented for the different long bones (retrograde nails, spiral blade, flex-nail humerus and a distal aiming device (DAD) for interlocking screws). In addition, new approach techniques for nailing (stab incision) and minimally invasive percutaneous plate osteosynthesis (MIPO) for metaphyseal fractures of the proximal and distal femur and proximal tibia are described including the necessary techniques for control of axes and rotation.     

Effect of stimulation and blockade of muscarinic receptors on L-arginine-stimulated glucagon secretion in healthy persons and patients with insulin-independent diabetes

This paper describes an attempt that was made to confirm the suggestion that limb bone length may be a good indicator of perinatal age. Gestational (menstrual) age was regressed on: (i) the lengths of the ossified shafts of the femur, humerus and radius of 17 subjects of mixed sex aged between 27 and 46 weeks; and (ii) the femur, tibia, humerus, radius and ulna of a second, larger, sample of 65 subjects (29 male; 36 female) aged between 24 and 40 weeks. Age was regressed on single bones and combinations thereof, e.g. humerus, radius and ulna. The data were analyzed both in their raw form and as logarithms, the latter yielding very slightly, but not significantly, better results than the former in the case of sample (ii) but not in (i).     

Contraindications to the repositioning of fractured or dislocated limbs in the fields

Supracondylar fractures of the femor or humerus and fractures of the radius, ulna, tibia or fibula, plus crush injuries of the limbs, most likely should not be manipulated in the field because of the potential for traumatizing adjacent nerves, veins and arteries. An emergency splinting system that allows immobilization without repositioning has been developed. Furthermore, fractures in or about the elbow, wrist, knee, or ankle should not be subjected to reduction in the field, unless there are compelling reasons to justify the risk of producing significant additional trauma. Conservative immobilization without repositioning may yield a more positive prognosis for the patient.     

Aerobic workout and bone mass in females

This cross-sectional study aimed to investigate bone mass in females participating in aerobic workout. Twenty-three females (age 24.1 +/- 2.7 years), participating in aerobic workout for about 3 hours/week, were compared with 23 age-, weight- and height-matched non-active females. Areal bone mineral density (BMD) was measured in total body, head, whole dominant humerus, lumbar spine, right femoral neck, Ward's triangle, trochanter femoris, in specific sites in right femur diaphysis, distal femur, proximal tibia and tibial diaphysis, and bone mineral content (BMC) was measured in the whole dominant arm and right leg, using dual energy X-ray absorptiometry. The aerobic workout group had significantly (P < 0.05-0.01) higher BMD in total body (3.7%), lumbar spine (7.8%), femoral neck (11.6%), Ward's triangle (11.7%), trochanter femoris (9.6%), proximal tibia (6.8%) and tibia diaphysis (5.9%) compared to the non-active controls. There were no differences between the groups concerning BMD of the whole dominant humerus, femoral diaphysis, distal femur and BMC and lean mass of the whole dominant arm and right leg. Leaness of the whole dominant arm and leg was correlated to BMC of the whole dominant arm and right leg in both groups. In young females, aerobic workout containing alternating high and low impact movements for the lower body is associated with a higher bone mass in clinically important sites like the lumbar spine and hip, but muscle strengthening exercises like push-ups and soft-glove boxing are not associated with a higher bone mass in the dominant humerus. It appears that there is a skeletal adaptation to the loads of the activity.     

Observation of a distinct humeral spur formation

A 23 year old male with a mirror right hand, duplicated ulna and aplasia of the radius is presented. A large deformity of the distal and anterior surface of the humerus was also noted. Based on clinical documentation and X-rays it was felt that this unusual bony formation probably represented a minimal rudiment of the radius and that the bone deformity at the distal end of the humerus did not represent a supracondylar humeral spur which is occasionally seen in humerus without any concommittent congenital deformities, as is nearly always seen in mammals.     

Na+,K(+)-ATPase activity is selectively increased in thalamus in thiamine deficiency prior to the appearance of neurological symptoms

OBJECTIVES: We analyzed the relationship between menstrual and reproductive history and risk of hip fractures in post-menopausal women using data from an Italian case-control study. METHODS: Cases were 206 post-menopausal women admitted for fractures of the hip proximal femur to a network of teaching and general hospitals in Milan, Italy. The comparison group consisted of 590 post-menopausal women admitted to the same network of hospitals for acute, non-neoplastic, non-hormone-related conditions, other than traumatic or orthopedic disorders. Odds ratios (OR) of hip fracture were derived from unconditional multiple logistic regression. RESULTS: No relation emerged between risk of hip fractures and age at menarche, lifelong menstrual cycle pattern and age at menopause. In comparison with women with age at menopause > or = 53 years, the multivariate OR of hip fractures were 1.2, 1.1, 1.2 and 0.5 in women with menopause at 50-52, 45-49, 40-44 and before 40 years (X2(1) trend 0.21). In comparison with nulliparae, the estimated age-adjusted OR was 0.6 (95% confidence interval, CI, 0.4-0.9) for parous women, but the multivariate estimate was not significant (OR 0.8, 95% CI 0.6-1.3) and the multivariate trend in risk with number of births was not significant either. No relation emerged between hip fractures and age at first and last birth, and history of abortions. CONCLUSIONS: This study found no relevant influence of menstrual and reproductive factors on the risk of hip fractures in post-menopausal women. However, this is not in contrast with the observation of a short-term effect of menopause and more in general. female hormone levels on osteoporosis and hence on hip fractures.     

Ultrasound in the evaluation of bone fragility caused by osteoporosis: a comparison between different sites of measurement

The authors compare two different measurement sites of ultrasound transmission velocity (UTV) in discriminating between subjects with or without vertebral fracture caused by osteoporosis. To this purpose a total of 150 women in menopause, of which 50 with vertebral fracture documented radiologically, for whom UTV was measured in the distal radius and in the patella, were examined. In both sites measurement of UTV in fractured women (1531.9 m/sec in the distal radius, and 1825.1 m/sec in the patella) was significantly less than for healthy women (1557.4 m/sec in the distal radius and 1874.5 m/sec in the patella) and there was a significant inverse linear correlation with age. The logistic regression shows that in both sites ultrasound examination is capable of significantly discriminating between osteoporotic women with fracture and those without fracture (odds ratio of the distal radius = 38.857, odds ratio of the patella = 7.822). A comparison of the discriminating capacity of the two measurement sites shows that the ORC curves for the distal radius (area = 0.773) is significantly greater than that of the patella (area = 0.684). Our study confirms that UTV can discriminate healthy subjects from osteoporotic ones, and it shows that the method in question has greater diagnostic sensitivity in the distal radius than in the patella.     

Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.     

Open fractures of the arm in children

We describe the results of treatment of open fractures of the humerus, radius and ulna in 61 children. Most were due to low-energy trauma and were rarely associated with head or other injuries; 72% were Gustilo type I, 15% type II and 13% type III. Fifteen children (25%) had open diaphyseal, supracondylar or T-shaped fractures of the humerus. Arterial injuries occurred in two (13%) and nerve injuries in 7 (47%). All nerve injuries recovered spontaneously. The long-term results in 13 children were excellent or good in 11 (85%) and fair in two (15%). Forty-six children (75%) had open forearm fractures. Arterial injuries occurred in one (2%), nerve injuries in five (11%) and a compartment syndrome in five (11%). Ruptured radial and ulnar arteries and median and ulnar nerves were repaired in one child. All other nerve injuries resolved spontaneously. Early compartment release in five children prevented Volkmann's ischaemic contracture. Normal union occurred in only 36 children (78%). Delayed union, nonunion, malunion and refracture frequently complicated type-II and type-III fractures of the shafts of the radius and ulna. The long-term results in 38 children were excellent or good in 33 (87%), fair in 4 (11%) and poor in one (2%). The short-term results for open fractures of the humerus were better than for open fractures of the forearm, but the long-term results were similar being excellent or good in 86% of the children.     

Osteoporosis in rheumatoid arthritis

In cases of rheumatoid arthritis, osteoporosis may be local or general. The aetiology is multifactorial. Reduced bodily function, synovial inflammation, steroids and menopause are important risk factors. Studies have shown that, in cases of primary osteoporosis, bone mineral density measurements in the distal radius may predict risk of fracture at other sites, such as the neck of the femur and the dorsal vertebrae. Such a connection is not found for rheumatoid arthritis. Bone density measurements in the distal radius may overestimate the risk of fractures due to localised periarticular osteoporosis. Overall bone quality is assumed to be poorer, however, in patients with rheumatoid arthritis, leading to higher risk of fracture than the bone mineral density measurements seem to show. Data are lacking on the effect of antiresorptive drugs on this condition. Treatment with oestrogen and the bisphosphonate pamidronate has been shown to increase bone mineral density. Data are lacking on fractures. As shown in the case of primary osteoporosis, decreased risk of fracture is to be expected also in patients with secondary osteoporosis.     

Fractures of the humerus in children

Fractures of the humerus above the distal epiphysis are not common fractures in children. Treatment should be directed toward maintenance of alignment with healing expected without fail. Contrary to experience with adults with the same fractures, children seldom have residual functional or cosmetic problems if one aligns the fractures and protects the healing process.     

Type of physical activity, muscle strength, and pubertal stage as determinants of bone mineral density and bone area in adolescent boys

The present study was conducted to evaluate the influence of different types of weight-bearing physical activity, muscle strength, and puberty on bone mineral density (BMD, g/cm2) and bone area in adolescent boys. Three different groups were investigated. The first group consisted of 12 adolescent badminton players (age 17.0 +/- 0.8 years) training for 5.2 +/- 1.9 h/week. The second group consisted of 28 ice hockey players (age 16.9 +/- 0.3 years) training for 8.5 +/- 2.2 h/week. The third group consisted of 24 controls (age 16.8 +/- 0.3 years) training for 1.4 +/- 1.4h/week. The groups were matched for age, height, and pubertal stage. BMD, bone mineral content (BMC, g), and the bone area of the total body, lumbar spine, hip, femur and tibia diaphyses, distal femur, proximal tibia, and humerus were measured using dual-energy X-absorptiometry. When adjusting for the difference in body weight between the groups, the badminton players were found to have significantly higher BMD (p < 0.05) of the trochanter and distal femur compared with the ice hockey players despite a significantly lower weekly average training. The badminton players had higher BMD compared with the control with the control group at all weight-bearing BMD sites, except at the diaphyses of the femur and tibia and lumbar spine. The independent predictors of bone density were estimated by adjusting BMC for the bone area in a multivariate analysis among all subjects (n = 64). Accordingly, the bone density of all sites except the spine was significantly related to muscle strength and height, and the bone density of the total body, neck, trochanter, distal femur, and proximal tibia was significantly related to type of physical activity (beta = 0.09-0.33, p < 0.05). The bone area values at different sites were strongly related to muscle strength and height and less strongly related to the type of physical activity and pubertal stage. In conclusion, it seems that during late puberty in adolescent boys the type of weight-bearing physical activity is an important determinant of bone density, while the bone area is largely determined by parameters related to body size. The higher BMD at weight-bearing sites in badminton players compared with ice hockey players, despite significantly less average weekly training, indicates that physical activity including jumps in unusual directions has a great osteogenic potential.