Height loss in postmenopausal women predicts multiple fractures in 10-year follow-up: results from the RAC-OST-POL study.

INTRODUCTION: In daily practice the diagnostic process for osteoporosis in elderly patients should also include physical assessment. The aim of the study was to verify the hypothesis that height loss (HL) predicts fracture incidence. MATERIAL AND METHODS: The study was performed in an epidemiological sample of postmenopausal women recruited in the RAC-OST-POL study. At baseline, data were collected in 978 postmenopausal women at a mean age of 66.48±7.6 years, and at 10-year follow-up 640 patients remained, with a mean age of 75.04 ± 6.95 years. Current height and HL were established in regard to maximal life height. Data on fracture incidence were gathered throughout the period of observation. RESULTS: During the follow-up period 190 osteoporotic fractures were noted. Ninety-one women had one fracture, and in 38 women, multiple fractures occurred. In the fractured and unfractured subgroups, HL was 5.45 ± 3.28 and 4.8 ± 3.56 cm, respectively, and differed significantly (p < 0.05). HL in subjects without fracture did not differ from those with one fracture (HL 4.8 ± 3.56 vs. 4.8 ± 2.66 cm, respectively). For patients with more than one fracture HL was 7.03 ± 4.06 cm and was significantly higher than in subjects with one or without any fracture (p < 0.01). Based on receiver operating characteristic (ROC) analysis, HL of 6 cm was identified as the cut-off point for high risk of multiple fractures. CONCLUSION: HL of at least 6 cm is the predictor of multiple fractures in a prospective observation of a representative epidemiological female sample. Therefore, the measurement of HL should always be included in patients' assessments.

Not Just Small Adults: Operative Versus Nonoperative Treatment in Adolescent Tibial Shaft Fractures.

BACKGROUND: The standard of care for tibial shaft fractures in young children is nonoperative management, while in adults, operative treatment is considered the mainstay. There are no clear guidelines on preferred treatment for adolescents. PURPOSE: This paper aims to 1) identify clinical and radiographic characteristics predictive of malalignment and 2) determine if treatment type affects malalignment risk. METHODS: This retrospective cohort study identified patients aged 12 to 16 years old with a tibial shaft fracture at a Level 1 pediatric trauma center. The primary outcome of interest was malalignment, classified as meeting one or more of the following: >5° coronal angulation, >5° sagittal angulation, translation (cortical width or 100% displaced), and/or rotational deformity. Comparative analyses were done to identify risk factors for malalignment. RESULTS: A total of 162 patients were included-initial treatment was "planned nonoperative" for 102 patients and "planned operative" for 60 patients. The malalignment rate was 34% in the planned nonoperative group versus 32% in the planned operative group. In a multivariate regression, older patients [odds ratio (OR)=-0.07, 95% CI: -0.13 to -0.01; P =0.024] and those with 100% initial displacement (OR=-0.35, 95% CI: -0.64 to -0.05; P =0.021) had decreased odds of malalignment, and having increased sagittal angulation (OR=0.02, 95% CI: 0.01-0.04; P =0.002) and a fibula fracture (OR=0.22, 95% CI: 0.03-0.41; P =0.023) increased the odds of malalignment. There was no difference in the rate of malalignment by initial treatment ( P =0.289). Having a planned nonoperative treatment (OR=22.7, 95% CI: 14.0-31.5; P <0.001) and having a fibula fracture (OR=8.52, 95% CI: 0.59-16.45; P =0.035) increased the time immobilized. CONCLUSIONS: This study provides insight into factors affecting tibial shaft fracture alignment among patients aged 12 to 16 years. This study suggests that the risk of malalignment is higher among patients with increased initial sagittal angulation and concomitant fibula fractures, but the risk of malalignment is comparable in patients initially treated nonoperatively and operatively. Although healing parameters on average were similar, nonoperative treatment results in longer immobilization time and time for unrestricted weight bearing. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Development of AI-Based Diagnostic Algorithm for Nasal Bone Fracture Using Deep Learning.

Facial bone fractures are relatively common, with the nasal bone the most frequently fractured facial bone. Computed tomography is the gold standard for diagnosing such fractures. Most nasal bone fractures can be treated using a closed reduction. However, delayed diagnosis may cause nasal deformity or other complications that are difficult and expensive to treat. In this study, the authors developed an algorithm for diagnosing nasal fractures by learning computed tomography images of facial bones with artificial intelligence through deep learning. A significant concordance with human doctors' reading results of 100% sensitivity and 77% specificity was achieved. Herein, the authors report the results of a pilot study on the first stage of developing an algorithm for analyzing fractures in the facial bone.

Depression, anxiety, and post-traumatic stress disorder following upper versus lower extremity fractures.

INTRODUCTION: Orthopaedic trauma has been linked to major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). Post-injury rates of psychiatric diagnoses and their relationship to various injury characteristics are not well characterized. We aimed to determine the association between orthopaedic trauma and MDD, GAD, and PTSD diagnoses at 5-year follow-up. METHODS: A national insurance claims database was used to create upper extremity fracture (UEF) and lower extremity fracture (LEF) cohorts, with further stratification by isolated versus multiple fractures. Patient undergoing elective upper or lower extremity orthopaedic procedures served as controls. Rates of post-injury psychiatric diagnoses were calculated. Univariate logistic regression was conducted after matching in a 1:1 ratio based on relevant comorbidities such as psychiatric history. All significant variables were included in multivariate analysis. RESULTS: A total of 308,578 UEF patients and 360,510 LEF patients were identified. Within the UEF cohort, the diagnosis rates following either isolated or multiple fractures were identified: MDD (25% to 30%), GAD (10% to 11%), and PTSD (4%). LEF cohort rates were as follows: MDD (30% to 38%), GAD (11% to 14%), and PTSD (4% to 7%). Compared to non-injured controls, both the UEF and LEF cohorts were associated with higher rates of all psychiatric diagnoses. In comparing UEF and LEF cohorts, isolated UEF was associated with MDD, GAD, and PTSD; however, multiple UEF was associated with MDD and GAD, whereas multiple LEF was associated with PTSD. CONCLUSION: Psychiatric pathology is prevalent following orthopaedic trauma. Even after controlling for psychiatric history, orthopaedic trauma is independently associated with post-injury psychiatric diagnoses and may be more predictive of PTSD and GAD than of MDD. Upper extremity fractures may portend higher psychiatric risk. With negative stigma surrounding mental health and the early role of orthopaedic surgeons in providing care, it is imperative to normalize psychiatric care with patients and discuss warning symptoms that may indicate the onset of psychiatric disorders. LEVEL OF EVIDENCE: Prognostic, Level III.

Physeal Fractures of the Distal Ulna: Incidence and Risk Factors for Premature Growth Arrest.

BACKGROUND: The aim of this study is to assess the rate of distal ulnar growth arrest following physeal fracture and to identify specific risk factors for premature physeal closure. METHODS: A retrospective review of patients with a distal ulnar physeal fracture was performed at a single United States children's hospital. Patients without 6-month follow-up were excluded. Patient demographics, injury characteristics, treatment, and outcomes were abstracted. Fractures were classified by the Salter-Harris (SH) system. All follow-up radiographs were reviewed for changes in ulnar variance or signs of premature physeal arrest. RESULTS: Fifty-six children with distal ulnar physeal fracture at a mean age of 10.7±3.3 years were included with a mean follow-up of 1.9 years. The most common fracture pattern was a SH II (52.7%), versus SH I (29.1%), SH III (9.1%), and SH IV (9.1%). Of displaced fractures (41.1%), the mean translation was 40.2±38.3% the and mean angulation was 24.8±20.9 degrees. Eleven fractures (19.6%) demonstrated radiographic signs of growth disturbance, including 3 patients (5.4%) with growth disturbance but continued longitudinal growth and 8 patients (14.3%) with complete growth arrest. The average ulnar variance was -3.4 mm. Three patients underwent subsequent surgical reconstruction including ulnar lengthening with an external fixator, distal ulna completion epiphysiodesis with distal radius epiphysiodesis, and ulnar corrective osteotomy. Patients with displaced fractures and SH III/IV fractures were more likely to develop a growth disturbance (34.8% vs. 3.2%, P =0.003; 50.0% vs. 11.1%, P =0.012, respectively). Children with less than 2 years of skeletal growth remaining at the time of injury had a higher risk of growth disturbance (46.2% vs. 9.5%, P =0.007). CONCLUSIONS: SH III and IV fractures are more common injury patterns in the distal ulna compared with the distal radius. Growth disturbance or growth arrest occurs in ~20% of distal ulnar physeal fractures. Displaced fractures, intra-articular fractures, fractures requiring open reduction, and older children are at increased risk of distal ulnar growth arrest and should be followed more closely. LEVEL OF EVIDENCE: Level IV--case series.

Fracture patterns in adult onset type 1 diabetes and associated risk factors - A nationwide cohort study.

OBJECTIVE: This study aimed to determine the hazard ratios (HR) for various fracture sites and identify associated risk factors in a cohort of relatively healthy adult people with newly diagnosed type 1 diabetes (T1D). METHODS: The study utilized data from the UK Clinical Practice Research Datalink GOLD (1987-2017). Participants included people aged 20 and above with a T1D diagnosis code (n = 3281) and a new prescription for insulin. Controls without diabetes were matched based on sex, year of birth, and practice. Cox regression analysis was conducted to estimate HRs for any fracture, major osteoporotic fractures (MOFs), and peripheral fractures (lower-arm and lower-leg) in people with T1D compared to controls. Risk factors for T1D were examined and included sex, age, diabetic complications, medication usage, Charlson comorbidity index (CCI), hypoglycemia, previous fractures, falls, and alcohol consumption. Furthermore, T1D was stratified by duration of disease and presence of microvascular complications. RESULTS: The proportion of any fracture was higher in T1D (10.8 %) than controls (7.3). Fully adjusted HRs for any fracture (HR: 1.43, CI95%: 1.17-1.74), MOFs (HR: 1.46, CI95%: 1.04-2.05), and lower-leg fractures (HR: 1.37, CI95%: 1.01-1.85) were statistically significantly increased in people with T1D compared to controls. The primary risk factor across all fracture sites in T1D was a previous fracture. Additional risk factors at different sites included previous falls (HR: 1.64, CI95%: 1.17-2.31), antidepressant use (HR: 1.34, CI95%: 1.02-1.76), and anxiolytic use (HR: 1.54, CI95%: 1.08-2.29) for any fracture; being female (HR: 1.65, CI95%: 1.14-2.38) for MOFs; the presence of retinopathy (HR: 1.47, CI95%: 1.02-2.11) and previous falls (HR: 2.04, CI95%: 1.16-3.59) for lower-arm and lower-leg fractures, respectively. Lipid-lowering medication use decreased the risk of MOFs (HR: 0.66, CI95%: 0.44-0.99). Stratification of T1D by disease duration showed that the relative risk of any fracture in T1D did not increase with longer diabetes duration (0-4 years: HR: 1.52, CI95%: 1.23-1.87; 5-9 years: HR: 1.30, CI95%: 0.99-1.71; <10 years: HR: 1.07, CI95%: 0.74-1.55). Similar patterns were observed for other fracture sites. Moreover, the occurrence of microvascular complications in T1D was linked to a heightened risk of fractures in comparison to controls. However, when considering the T1D cohort independently, the association was not statistically significant. CONCLUSION: In a cohort of relatively healthy and newly diagnosed people with T1D HRs for any fracture, MOFs, and lower-leg fractures compared to controls were increased. A previous fracture was the most consistent risk factor for a subsequent fracture, whereas retinopathy was the only diabetes related one. We postulate a potential initial fracture risk, succeeded by a subsequent risk reduction, which might potentially increase in later years due to the accumulation of complications and other factors.

Do We Need a Strictly Lateral Radiograph for Fracture Management of Forearm Buckle Fractures in Children?

OBJECTIVES: Buckle fractures of the distal forearm are a common fracture entity in children treated conservatively. Diagnostics primarily include radiographs in 2 planes. Inadequate images may occur in the mostly very young patients. Therefore, additional lateral radiographs are often obtained to assess a possible angular tilt. The aim of this study is to investigate whether a strictly lateral x-ray image has an influence on fracture management. METHODS: Seventy-three children with buckle fractures of the distal forearm were included in this retrospective analysis. All cases were analyzed by quality of radiographs, necessity to obtain an additional lateral radiograph, and what influence on fracture management resulted. Follow-up was performed 2 to 4 weeks after immobilization. RESULTS: Thirty-five girls and 38 boys with a mean age of 7.16 years were included; 40 had fractured right and 33 had fractured left arms, respectively. Isolated distal radius fractures occurred in 48 cases, isolated distal ulna fractures in 6 cases, and both bones in 19 cases. Initial radiographic images were evaluated as inadequate in 25 cases. In each of those cases, an additional lateral image was obtained by fluoroscopy without resulting in an alternated fracture management protocol, which was chosen conservatively in each case and resulted in excellent clinical outcome at follow-up examination. CONCLUSIONS: Based on our results, the acquisition of additional lateral radiographs seems to be unnecessary in the diagnostic procedure of buckle fractures of the distal forearm, in case a possible palmar or dorsal angulation cannot be entirely assessed on the initial set of radiographs. An additional lateral image had no influence on fracture management, which was chosen conservatively in every case and led to excellent clinical results.Level of evidence: level III.

Do multiple fractures affect risk of fixation failure after surgical treatment of midshaft clavicle fracture? A retrospective cohort study.

BACKGROUND: Surgical treatment of midshaft clavicle fractures is associated with quick recovery and low risk of non-union. However, fixation failure may occur in case of severe comminution fractures. Moreover, clinical outcomes may be affected when clavicle fractures occur in combination with other injuries, particularly those involving the lower extremities, as the use of crutches or walkers may hinder the process of rehabilitation by adding strain on the acromioclavicular (AC) joint, resulting in possible fixation failure. This study aims to identify risk factors for fixation failure of midshaft clavicle fractures and elucidate the role of combined fractures in treatment outcomes. METHODS: This study included patients diagnosed with midshaft clavicle fractures who underwent initial surgery between January 2012 and November 2021 at a designated regional trauma center hospital. Retrospective evaluation of fixation failure was carried out in 352 patients with midshaft clavicle fractures using standard clinical evaluation protocols and conventional radiographs. The prevalence of fixation failure and the effects of several demographic variables on the risk of fixation failure and non-union were examined. Multivariate logistic regression analysis was carried out to identify independent risk factors for fixation failure. RESULTS: Fixation failure occurred in 40 patients (11.4%). Multivariate analysis identified comminution [odds ratio (OR) 3.532, p value = 0.003, 95% confidence interval (CI) 1.55-8.05)] and fewer number of screws (OR 0.223, p value = 0.022, 95% CI 0.06-0.80) as risk factors for fixation failure. Surgical techniques using wire cerclage reduced the chances of fixation failure in comminuted fractures (OR 0.63, p value = 0.033, 95% CI 0.05-0.80). Combined fractures that required rehabilitation using walkers or crutches increased the risk of non-union (OR 19.043, p value = 0.032, 95% CI 1.28-282.46). CONCLUSIONS: Additional fixation of comminuted fractures using cerclage can reduce the risk of treatment failure, while multiple fractures or rehabilitation for ambulation increases the risk of the same. LEVEL OF EVIDENCE: III.

Osteoporotic vertebral fractures localized in the lumbar area significantly impact sagittal alignment.

Lumbar fractures and/or multiple fractures at the lumbar or thoracolumbar regions are risk factors for sagittal malalignment in patients older than 70 years old. Although patients with OVF show a huge capacity to compensate after the fractures, lumbar and TL lumbar fractures require closer monitoring. PURPOSE: To assess the impact of osteoporotic vertebral fractures on the sagittal alignment of the elderly and identify risk factors for sagittal malalignment. METHODS: We performed a retrospective study on a cohort of 249 patients older than 70 years old and diagnosed with osteoporosis who suffered chronic vertebral fractures. Demographic and radiological data were collected. Full-spine lateral X-rays were obtained to analyze the sagittal plane. Patients were classified according to the number and location of the fractures. Pearson's correlation coefficient was used to assess the relationships between the type of fractures and sagittal alignment. RESULTS: A total of 673 chronic fractures were detected in 249 patients with a mean number of vertebral fractures per patient of 2.7 ± 1.9. Patients were divided into 9 subgroups according to the location and the number of fractures. Surprisingly, any of the aggregated parameters used to assess sagittal alignment exceeded the threshold defined for malalignment. In the second part of the analysis, 41 patients with sagittal malalignment were identified. In this subpopulation, an overrepresentation of patients with lumbar fractures (34% vs. 11%) and an under-representation of thoracic fractures (9% vs. 34%) were reported. We also observed that patients with 3 or more lumbar or thoracolumbar fractures had an increased risk of sagittal malalignment. CONCLUSIONS: Lumbar fractures and/or multiple fractures at the lumbar or thoracolumbar regions are risk factors for sagittal malalignment in patients older than 70 years old. Although patients show a remarkable capacity to compensate, fractures at the lumbar and thoracolumbar regions need closer monitoring.

Finite element analysis and a pilot study of different fixation constructs for Danis-Weber A and B lateral malleolus fractures.

BACKGROUND: Displaced lateral malleolus fractures are typically stabilised through open reduction and internal fixation. The biomechanically and clinically efficacy of locking plates and lag screws, particularly in Weber A and B distal fibular fractures remains a subject of contention. This study examines two locking plate designs for lateral malleolus fractures, evaluating their performance with and without interfragmentary screws using finite element models. METHODS: Utilising CT images of a healthy adult male volunteer, a three-dimensional finite element model was constructed. The Fibula-specific Flank Multiaxial Locking Anatomic Plate (FMLP) and the Conventional Locking Plate (CLP) were subjected to stabilisation, both with and without an interfragmentary screw, mimicking the Danis-Weber A and B lateral malleolus oblique fracture fixation. Loads of 140 N and 70 N, equivalent to 20% of the body weight, were applied to simulate the single-leg and two-leg standing conditions in the axial direction. The von Mises stress (VMS) distributions and element displacements were subsequently analyzed. RESULTS: In the Danis-Weber A fracture model group, the FMLP with an interfragmentary screw fixation exhibited the lowest peak VMS values: 51.9 MPa in the fibula, 89.0 MPa in the plate, and 61.3 MPa in the screws for simulating single-leg conditions. Under two-leg standing conditions, these peak VMS values decreased to 25.9 MPa in the fibula, 44.5 MPa in the plate, and 30.6 MPa in the screws, respectively. Furthermore, the overall structural peak displacements during single-leg standing for both Weber-A and B fractures with different implants ranged from 1.61 to 2.54 mm. While standing on two feet, the ranged was from 0.80 to 1.27 mm. An interfragmentary screw at the oblique fracture site resulted in reduced the peak value of VMS in the fibula, plate, screws, consequently decreased the overall structural displacement for FMLP and CLP fixation in lateral malleolus fractures. CONCLUSIONS: The current finite element analysis (FEA) demonstrates that FMLP exhibits superior mechanical characteristics in Danis-Weber A and B lateral malleolus fractures compared to CLP. The inclusion of an interfragmentary screw, combined with locking plate design, enhances stability for simple oblique distal fibular fractures. The FMLP presents itself as potential as an alternative for lateral malleolus fractures from a biomechanical perspective. Nevertheless, further verification of these results is imperative through subsequent clinical studies.

[Comparative study of the effects of intramedullary nail fixation and minimally invasive percutaneous plate internal fixation technique on platelet activation and serum transforming growth factor-ß1(TGF-ß) 1 and bone morphogenetic protein-2 (BMP-2) in patients with tibial and fibular fracture].

OBJECTIVE: To investigate the effect of intramedullary nail fixation (IMN) and minimally invasive percutaneous plate internal fixation (MIPPO) techniques on tibiofibular fractures and their effect on platelet activation and serum transforming growth factor-ß1 (TGF-ß1) and bone morphogenetic protein-2 (BMP-2). METHODS: Total of 105 patients with tibiofibular fractures from February 2019 to February 2020 were selected and divided into 53 cases in the MIPPO group and 52 cases in the IMN group. There were 29 males and 24 females with an average age of (41.74±6.05) years old in MIPPO group;in IMN group, 31 males and 21 females with an average age of (40.59±5.26) years old. The perioperative surgical indexes, postoperative complications, ankle function recovery at 12 months postoperatively, platelet activation indexes at 3 and 7 days preoperatively and postoperatively, and serum TGF-ß1 and BMP-2 levels at 4 and 8 weeks preoperatively and postoperatively were compared between the two groups. RESULTS: The operating time and fracture healing time in the MIPPO group were shorter than those in the IMN group(P<0.05); Compared with the preoperative period, the levels of GMP-140, PAC-1, CD63, and CD61 increased in both groups at 3 and 7 days after surgery, but were lower in the MIPPO group than in the IMN group(P<0.05);the levels of serum TGF-ß1 and BMP-2 increased in both groups at 4 and 8 weeks after surgery compared with the preoperative period, and the postoperative complication rate in the MIPPO group was lower than that in the IMN group(P<0.05);the difference was not statistically significant in the excellent rate of ankle function recovery at 12 months follow-up after surgery between two groups(P>0.05). CONCLUSION: Both intramedullary nail fixation and MIPO technique for treatment of tibia and fibula fractures can improve ankle joint function, but the latter has the advantages of short operation time, fast fracture healing, fewer complications, and light platelet activation. Serum TGF-ß1, BMP-2 level improves quickly.

The safe zone of distal fibula was determined based on the classification of lateral malleolus fossa.

BACKGROUND: Lateral malleolus fractures are very common, and the distal fibular geometry is complex. This study aimed to classify the lateral malleolus fossa (MF) into different types by characterizing the lateral MF imaging morphology and exploring the relationship between the lateral MF and internal fixation position after distal fibula fractures. METHODS: Anteroposterior CT reconstruction was performed on 248 subjects. After reconstruction, the deepest point of the lateral MF was located, and then, the cross-sectional shape of the lateral MF was observed and classified. RESULTS: According to the morphology of the CT cross section, the lateral MF was divided into three types: type C (43.1%), type V (32.2%), and type Flat (24.7%). Type V (3.98 ± 0.82) was significantly longer than type C(2.83 ± 0.54) and type Flat (1.84 ± 0.42) in cd. Similarly, in ∠α, Type Flat(136.31 ± 9.63) was the largest, followed by type C (116.51 ± 8.79), and type V (89.31 ± 9.07) was the smallest. Other measurements were not found any significant differences between the above. CONCLUSION: According to the morphology of the CT cross section, the lateral MF was divided into three types: type C, type V and type Flat. Type V is most likely to be invaded when fixing the distal fibula. Screws less than 9 mm should be selected when fixing, and screws no more than 10 mm should be selected when there are type C and type Flat of MF.

Perfecting the Outcome of Nasal Bone Fracture in the Pediatric Population With a Navigation System.

BACKGROUND: The trend of using navigation systems for treating facial bone fractures is increasing. Nevertheless, any detailed recommendation on using a navigation system to treat nasal bone fracture has never been discussed. Plastic surgeons are prone to do closed reduction of nasal bone fractures with remnant posttraumatic edema in the pediatric population. This study hypothesized that the navigation system benefits this population's treatment of nasal bone fractures. METHODS: The authors evaluated the medical records, plain x-ray, and facial computed tomography scans of 44 pediatric patients (below the age of 18) with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and postoperative computed tomography scan were used to assess the outcome. RESULTS: The average age for 44 pediatric nasal bone fracture patients was 10. Fifteen were female, while males were 29. All cases were successfully corrected clinically and radiologically without noticeable complications. CONCLUSIONS: Using navigation systems to correct nasal bone fractures provides additional benefits for the pediatric population. This technique is especially useful if the fracture is located at the junction between the nasal bone and nasal process of the maxilla and is combined with concurrent old nasal bone fractures.

Combination of osteogenesis imperfecta and hypophosphatasia in three children with multiple fractures, low bone mass and severe osteomalacia, a challenge for therapeutic management.

Osteogenesis imperfecta (OI) and hypophosphatasia (HPP) are rare skeletal disorders caused by mutations in the genes encoding collagen type I (COL1A, COL1A2) and tissue-non-specific isoenzyme of alkaline phosphatase (ALPL), respectively. Both conditions result in skeletal deformities and bone fragility although bone tissue abnormalities differ considerably. Children with OI have low bone mass and hypermineralized matrix, whereas HPP children develop rickets and osteomalacia. We report a family, father and three children, affected with growth retardation, low bone mass and recurrent fractures. None of them had rickets, blue sclera or dentinogenesis imperfecta. ALP serum levels were low and genetics revealed in the four probands heterozygous pathogenic mutations in COL1A2 c.838G > A (p.Gly280Ser) and in ALPL c.1333T > C (p.Ser445Pro). After multidisciplinary meeting, a diagnostic transiliac bone biopsy was indicated for each sibling for therapeutic decision. Bone histology and histomorphometry, as compared to reference values of children with OI type I as well as, to a control pediatric patient harboring the same COL1A2 mutation, revealed similarly decreased trabecular bone volume, increased osteocyte lacunae, but additionally severe osteomalacia. Quantitative backscattered electron imaging demonstrated that bone matrix mineralization was not as decreased as expected for osteomalacia. In summary, we observed within each biopsy samples classical features of OI and classical features of HPP. The apparent nearly normal bone mineralization density distribution results presumably from divergent effects of OI and HPP on matrix mineralization. A combination therapy was initiated with ALP enzyme-replacement and one month later with bisphosphonates. The ongoing treatment led to improved skeletal growth, increased BMD and markedly reduced fracture incidence.

Low-Intensity Pulsed Ultrasound for Symptomatic Pseudarthrosis After Toe Fracture with Symphalangism: A Report of 2 Cases.

CASE: Distal phalangeal fractures are often treated conservatively. However, some patients experience residual pain. We report 2 cases of patients who underwent low-intensity pulsed ultrasound (LIPUS) therapy for pseudarthrosis after fracture of the distal phalanx of the fifth toe with symphalangism. Both patients (female, 63 and 33-year-old, respectively) underwent conservative treatment with buddy-taping fixation; however, bone union failed, and LIPUS therapy was initiated. In both cases, bone union was achieved and pain resolved after 3 months. CONCLUSION: Bone union occasionally fails after conservative treatment of distal phalangeal fractures. LIPUS is a useful treatment of symptomatic pseudarthrosis after such fractures.

Long-Term Aesthetic Cicatrization Analysis of Lower Eyelid Incision for Orbital Floor Fracture Approach.

Orbital fractures are among the most frequent facial injuries. Of the 3 most widely described approaches in the literature, the lower eyelid approach is the authors' preference. This study retrospectively analyzed the patients treated at the Trauma Center of the Umberto I Hospital, Sapienza University of Rome from January 2010 to December 2020. Inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological documentation, and a minimum of 12 months follow-up. Sex, age, etiology, treatment, and associated complications were analyzed using IBM SPSS Statistics. Two internationally validated scales were used for the functional and esthetic long-term evaluation: the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver one. The scales were compiled by the patient himself and by 3 independent expert observers. Of the 543 patients who underwent surgery in the specified period, 208 fully met the inclusion criteria. One hundred forty-two (68.2%) were males and 66 (31.8%) were females, with a mean age of 40.68 years. The main cause was represented by assaults (33.1%). One hundred seventy-nine patients had a pure orbital fracture (83.8%) and 29 an impure one (16.2%). The most frequent symptoms at the time of diagnosis were diplopia (31.2%), followed by anesthesia of the second trigeminal branch (24.3%). Open reduction with internal fixation was the preferred treatment and proved to be effective in reducing the main signs and symptoms of the fracture in a statistically significant way ( P < 0.05). Long-term esthetic results of the lower eyelid, using the Vancouver and POSASs, were respectively as follows: Vancouver Scar Scale mean total score was 2.41 (range: 0-8), observer POSAS mean total score was 1.83 (range: 1.2-3.9), observer general opinion mean score was 1.66, patient POSAS mean total score was 2.23 (range: 1.33-3.7), and patient general opinion mean score was 2.87. The lower eyelid approach has proven to be reproducible, with a fast-learning curve and a low complication rate. The analysis conducted highlighted an excellent long-term esthetic-functional result. Further studies will be needed to statistically compare the results obtained with other orbital floor surgical approaches.

Morphological analysis and classification of posterior malleolar fractures based on CT scans.

OBJECTIVES: The aim of the study was to propose a classification system of posterior malleolar fractures by fracture lines with the use of CT scans, including 3D CT reconstruction, which can better understand morphological characteristics, analyze the mechanism and guide the surgeon to choose the optimal approach and fixation. METHODS: Patients with OTA/AO type 44 fractures involving the posterior malleolus and preoperative CT scans were included. We retrospectively analyzed 128 consecutive patients with posterior malleolar fractures from January 2013 to December 2019 at our institution. CT data were loaded into Mimics software (V20.0, Materialize), in which 3D CT reconstruction, morphological analysis and data measurements were made. RESULTS: Based on the number of fracture lines in 128 consecutive patients, posterior malleolar fractures were classified into three types: type 1 with a single fracture line, type 2 with double fracture lines and type 3 with multiple fracture lines. According to the distribution of the fracture line, type 1 was divided into types 1A, 1B and 1C, and type 2 was divided into types 2A, 2B and 2C. The fracture line from the fibular notch to the posterior rim of the distal tibia was defined as type 1A, and the fracture line to the medial malleolus was defined as type 1B. Type 1C was a small fragment in the posterior rim of the distal tibia. Type 2A was regarded as type 1A with type 1C. It was considered type 2B because another fracture line started from the fracture line of type 1A and extended to the medial malleolus. In type 2C, we could see that the double fracture lines were all from the fibular notch to the posterior rim of the distal tibia and did not cross. Type 3 fractures were comminuted fractures with multiple fracture lines. CONCLUSION: The morphology of posterior malleolar fractures, involvement of the fibular notch, or the medial malleolus can be obviously assessed by our classification system. We found the relation of the injury mechanism between type 1 and type 2 by comparing the area of the fragment. We have indicated that each type of fracture corresponds to its associated injury mechanism and which surgical approach and fixation can be chosen.

Osteogenesis imperfecta type VIII: highlighting the need for genetic testing.

We report a severe form of osteogenesis imperfecta (OI) type VIII from a lower-middle income country. This is the first case report of this type in Tanzania. The term neonate was delivered normally via spontaneous vaginal delivery and presented at the neonatal unit with features of shortened limb girdles and macrocephaly. The long bones had multiple fractures. He was diagnosed clinically to have OI or a type of metaphysial dysplasia. A plain X-ray showed multiple fractures of the long bones. The eyes did not have blue sclerae. Clinically, the generic diagnosis of OI was made.Genetic testing revealed typical prolyl 3-hydroxylase 1 (P3HI) gene mutations and a variant coordinate NM_001243246.1:c.1095C>G p, indicating a severe, fatal form of autosomal-recessive OI type VIII which presents with white sclerae. This rare variant is described here for the first time in our setting. This case highlights the need for genetic testing.

Pediatric Nasoorbitoethmoid Fractures: A Single Institution's 15-Year Experience.

BACKGROUND: Nasoorbitoethmoid (NOE) fractures impact growth of the craniofacial skeleton in children, which may necessitate differentiated management from adult injuries. This study describes characteristics, management, and outcomes of NOE fractures in children seen at a single institution. METHODS: A retrospective review of patients under 18 years who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Data collected included demographics, mechanism of injury, fracture type, management, and outcomes. RESULTS: Fifty-eight patients met inclusion criteria; 77.6% presented with Manson-Marcowitz Type I fractures, 17.2% with Type II, and 5.2% with Type III. The most common cause of injury was motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Scale and injury mechanism were not predictive of injury severity in the pediatric population ( P =0.353, P =0.493). Orbital fractures were the most common associated fractures (n=55, 94.8%); parietal bone fractures were more likely in Type III fractures ( P =0.047). LeFort III fractures were more likely in type II fractures ( P =0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). There was no significant difference in type of operative management or in the rates of adverse outcomes between types of NOE fractures. CONCLUSIONS: These findings suggest that pediatric NOE fractures, although rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population.