Radiation-induced lumbosacral plexopathy and pelvic insufficiency fracture: A case report of unique coexistence of complications after radiotherapy for prostate cancer.

Case reports of plexopathy after prostate cancer are usually neoplastic. Radiation-induced lumbosacral plexopathy and insufficiency fractures have clinical significance due to the need to differentiate them from tumoral invasions, metastases, and spinal pathologies. Certain nuances, including clinical presentation and screening methods, help distinguish radiation-induced plexopathy from tumoral plexopathy. This case report highlights the coexistence of these two rare clinical conditions. Herein, we present a 78-year-old male with a history of radiotherapy for prostate cancer who developed right foot drop, severe lower back and right groin pain, difficulty in standing up and walking, and tingling in both legs over the past month during remission. The diagnosis of lumbosacral plexopathy and pelvic insufficiency fracture was made based on magnetic resonance imaging, positron emission tomography, and electroneuromyography. The patient received conservative symptomatic treatment and was discharged with the use of a cane for mobility. Radiation-induced lumbosacral plexopathy following prostate cancer should be kept in mind in patients with neurological disorders of the lower limbs. Pelvic insufficiency fracture should also be considered if the pain does not correspond to the clinical findings of plexopathy. These two pathologies, which can be challenging to diagnose, may require surgical or complex management approaches. However, in this patient, conservative therapies led to an improvement in quality of life and a reduction in the burden of illness.

Unusual Presentation of Hip Pain in a Pregnant Woman Due to Bilateral Cervical Neck Stress Fractures: A Case Report.

CASE: We present an unusual case of bilateral femoral neck fatigue fractures in a 28-year-old pregnant woman at the 18th week of gestation successfully treated through operative intervention involving consecutive total hip arthroplasty and internal fixation within the same procedure, resulting in favorable clinical outcomes. CONCLUSION: Current clinical practices suggest that a restricted use of plain radiographs, even those involving the pelvis in pregnant women carries a minimal risk to the fetus and is not contraindicated. Magnetic resonance imaging proved valuable for differential diagnosis, contrasting with sonography.

Multifocal stress fractures in a patient with rheumatoid arthritis.

Stress fractures are often associated to activities that requires repetitive stress such as running. However, insufficiency-type stress fractures can also occur in patients with risk factors such as rheumatoid arthritis. Diagnosis of stress fracture would require a thorough clinical evaluation along with radiological imaging. However, this may be difficult due to how it mimics other musculoskeletal problems. The case of a woman in her 60s presenting with 2 months of severe ipsilateral right knee and ankle pain is used as an example. Based on initial clinical assessment and plain radiograph, her provisional diagnosis was osteoarthritis or inflammatory arthritis secondary to rheumatoid disease. However, MRI scan revealed that she had multifocal stress fractures in her knee, ankle and foot. Hence, we hope that this case study can allow clinicians to consider multifocal stress fracture as a possible diagnosis in patients with risk factors and to have lower threshold in performing MRI scans.

The role of torsional stress in the development of subchondral insufficiency fracture of the femoral head: A finite element model analysis.

BACKGROUND: Subchondral insufficiency fracture of the femoral head generally occurs without evidence of trauma or with a history of minor trauma. Insufficient bone quality is considered one cause; however, the detailed mechanism of fracture development at the subchondral area (SA) is not understood. The aim of this study was to clarify the directions of force that cause subchondral fracture using finite element model analysis. METHODS: Two types of finite element models were generated from the CT data of femurs obtained from three individuals without osteoporosis (normal models) and another three with osteoporosis (osteoporosis models). Three directions of force, including compressive, shearing, and torsional, were applied to the femoral head. The distribution of von Mises stress (Mises stress) was evaluated at the SA, principal compressive trabeculae (PC), and principal tensile trabeculae. RESULTS: Under compressive force, the mean Mises stress value was greatest at the PC in both the normal and osteoporosis models. Under shearing force, the mean Mises stress value tended to be greatest at the SA in the normal model and at the PC in the osteoporosis model. Under torsional force, the mean Mises stress value was greatest at the SA in both types of models. CONCLUSIONS: The torsional force showed the greatest Mises stress at the SA in both the normal and osteoporosis models, suggesting the importance of torsion as a possible force responsible for subchondral insufficiency fracture development.

Sacral insufficiency fractures are a frequent and painful consequence of pubic symphysis osteomyelitis.

BACKGROUND: Pubic symphysis osteomyelitis can result from urosymphyseal fistula formation. High rates of sacropelvic insufficiency fractures have been reported in this population. The aim of this study was to describe the presentation and risk factors for sacral insufficiency fractures (SIF) associated with surgical treatment of pubic symphysis osteomyelitis. METHODS: A retrospective review was performed for 54 patients who underwent surgery for pubic symphysis osteomyelitis associated with a urosymphyseal fistula at a single institution from 2009 to 2022. Average age was 71 years and 53 patients (98%) were male. All patients underwent debridement or partial resection of the pubic symphysis at the time of fistula treatment. Average width of the symphyseal defect was 65 mm (range 9-122) after treatment. RESULTS: Twenty patients (37%) developed SIF at a mean time of 4 months from osteomyelitis diagnosis. Rate of sacral fracture on Kaplan-Meier analysis was 31% at 6 months, 39% at 12 months, and 41% at 2 years. Eleven patients developed SIF prior to pubic debridement and 12 patients developed new or worsening of pre-existing SIF following surgery. Width of pubic resection was higher in patients who developed SIF (76 mm vs. 62 mm), but this did not meet statistical significance (p = 0.18). CONCLUSION: Sacral insufficiency fracture is a common sequela of pubic symphysis osteomyelitis. These fractures are often multifocal within the pelvis and can occur even prior to pubic resection. Pubectomy further predisposes these patients to fracture. Clinicians should maintain a high index of suspicion for these injuries in patients with symphyseal osteomyelitis.

Stress fractures of the hand and wrist in athletes.

Stress fractures of the upper extremity are reported less often than their lower extremity counterpart. This review aims to provide a comprehensive overview of an important and often missed diagnosis in pediatric athletes: hand and wrist stress fractures.

Sacral insufficiency fracture: a single-center experience of 185 patients with a minimum 5-year follow-up.

PURPOSE: Sacral insufficiency fracture (SIF) is a commonly underdiagnosed etiology of back pain, especially in the geriatric and osteoporotic population. In this clinical study, we present our experience of 185 patients who were diagnosed with SIF and managed either with conservative or surgical treatment with a minimum 5-year follow-up. MATERIALS AND METHOD: Patients who were diagnosed with SIF, managed either conservatively or surgically, and had a minimum 5-year follow-up medical record were included in this study. CT scans and MR imaging including coronal STIR sequence were obtained from all. Bone densitometry (DEXA) was performed to detect accompanying osteopenia or osteoporosis. Patients were treated either conservatively or surgically. VAS and ODI scores were evaluated prior to the treatment and 1st day, 10th day, 3rd month, and 1st year postoperatively. RESULTS: The mean age of 185 patients was 69.2 and the mean follow-up period was 7.23 years (range: 5-11 years). 46 (24.9%) patients had a previous spinal or spinopelvic surgery and spinal instrumentation was implemented in 22(11.89%) of them. The time interval between the fusion surgery and the diagnosis of SIF was approximately 9.48 weeks. The fracture line could be detected with the MRI in 164 patients and with the CT in 177 patients. The fracture was bilateral in 120 (64.8%) patients. 102 patients were treated conservatively, and 83 received sacroplasty. VAS and ODI scores showed better improvement in pain and functionality in the surgical management group than in the conservative management group. CONCLUSION: SIF should be considered in the differential diagnosis of back and pelvic pain, especially in elderly and osteoporotic patients. MRI with coronal STIR imaging should be a standard protocol for patients with a risk of SIF. Our results show that sacroplasty provides better and faster pain relief and recovery than conservative management.

Operative Technique for Sacral Insufficiency Fractures Causing Spinopelvic Dissociation: A Case Report.

CASE: We present a case of a 54-year-old man with atraumatic, U-type sacral insufficiency and L5 compression fractures leading to spinopelvic dissociation, inability to ambulate, and bowel/bladder compromise. The patient underwent L3-4 percutaneous pedicle screw fixation with bilateral iliac bolts and percutaneous iliosacral screw fixation. Postoperatively, the patient had return of bowel/bladder function and independent ambulation at 2.5 years. CONCLUSION: Atraumatic spinopelvic dissociation is an underappreciated pathology in older patients. Here, we describe the result of our preferred treatment strategy, triangular osteosynthesis, to preserve function and independence. Despite optimal, prompt treatment, these injuries pose a difficult rehabilitation process for patients.

Weight-Bearing CT with Maximum Ankle Dorsiflexion to Identify Impingement and Tibial Plafond Stress Fracture: A Case Report.

CASE: A 25-year-old male pole vaulter presented with several months of right ankle pain. Radiographs showed an anterior tibial osteophyte with a small intra-articular body suggesting impingement. Weight-bearing computed tomography (CT) revealed an associated tibial plafond stress fracture. Subsequent arthroscopy with osteophyte resection and loose body removal significantly improved symptoms, and he gradually resumed training. CONCLUSION: Stress fractures should always be considered in athletes with ankle pain. A unique aspect of this case was the use of weight-bearing CT in diagnosis and surgical planning. To our knowledge, this is the first described case in which weight-bearing CT was used in this fashion.

Subchondral Insufficiency Fractures of the Knee: A Clinical Narrative Review.

¼ Subchondral insufficiency fractures of the knee (SIFKs) are subchondral plate fractures with a prevalence of 2% to 4% of all knee injuries.¼ Magnetic resonance imaging is the gold standard for evaluating SIFK, while plain radiographs have limited the use in the diagnosis of SIFK.¼ Among patients with SIFK, 50% to 100% have meniscal pathology.¼ Medical therapies and standard treatments traditionally used in the management of knee osteoarthritis differ from recommended management of SIFK patients.¼ Randomized controlled trials and cohort studies with long-term follow-up are needed to determine the optimal rehabilitation protocol, interventional therapy, and prognosis of SIFK patients.

Stress Fractures of the Distal Phalanx in Skeletally Immature Sport Climbers.

Stress fractures in the distal phalanx of skeletally immature patients are rare and previously unreported clinical occurrences. We report on 2 adolescent sport climbers with such fractures of the dorsal metaphysis of the distal phalanx at the point where parts of the extensor tendon insert. A conservative treatment approach alone was sufficient in healing this fracture type in both patients after 12 wk. Clinicians should be informed of the existence of this rare clinical phenomenon and counsel patients that a conservative treatment approach may result in complete healing without the need for an invasive procedure.

Bilateral femoral neck stress fractures in elderly individuals: A case report and literature review.

RATIONALE: Bilateral femoral neck stress fractures are relatively rare injuries that occur frequently in military recruits, athletes and patients with osteoporosis, renal bone disease, metabolic bone disease, and chronic steroid use. Herein, a case of an elderly patient with bilateral femoral neck stress fractures is reported. PATIENT CONCERNS: A 65-year-old man presented to the author's hospital with right hip pain for over a month. The patient was a farmer, had a long history of field labor before the onset of pain, denied any history of trauma. DIAGNOSIS: The patient was diagnosed with a right subcapital fracture of the femoral neck after examination. The patient complained of only right hip symptoms, and hip computed tomography showed no abnormalities in the left hip. A tension fracture of the left femoral neck was missed due to unawareness of the abnormal signal of the left femoral neck seen on right hip magnetic resonance imaging. INTERVENTIONS: During the first hospitalization, the patient underwent total hip arthroplasty (THA) on the right hip. Two months after the operation, the patient started to have pain in the left hip and underwent left THA again for a displaced left femoral neck fracture. OUTCOMES: The patient eventually underwent bilateral THA surgery and had a satisfactory functional recovery. But the oversight in the diagnostic process led to the patient undergoing left THA that could have been avoided. LESSONS: For patients who complain of hip pain but deny a history of trauma, we should be concerned about the presence of a hip fracture even if the patient's radiograph does not report a positive result. The most sensitive method is bilateral magnetic resonance imaging examination of the hip. Femoral neck stress fractures require early diagnosis and treatment to prevent complications.

Outcomes of conservative treatment of acromial and scapular spine stress fracture post reverse shoulder arthroplasty: a systematic review with meta-analysis.

INTRODUCTION: Acromial and scapular spine stress fractures are common complications post reverse shoulder arthroplasty. A systematic review with meta-analysis was conducted to evaluate the clinical outcomes of conservatively treated acromial and scapular spine stress fractures post reverse shoulder arthroplasty in comparison to nonfracture control. METHODS: Embase, MEDLINE, and Web of Science were searched on September 9, 2022, using various terms related to fracture, acromion, scapula, and reverse shoulder arthroplasty. Meta-analysis using a random effects model was performed on common outcome scores. Risk of bias was assessed using the Joanna Briggs Institute tools for case-controlled studies. Sensitivity analysis was performed for imputed standard deviations and studies with <20 participants. RESULTS: Thirteen studies with a total of 339 fracture and 3142 control patients were included in the systematic review. Meta-analysis was performed on 12 studies assessing active forward flexion, abduction, external rotation, Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, pain score, Simple Shoulder Test, and Single Assessment Numeric Evaluation. Fracture patients experienced significantly poorer functional outcome compared with control patients when the fractures were managed conservatively. Levy III fractures tend to experience worse outcomes. Pain score did not demonstrate a statistically significant difference between the fracture and nonfracture cohort. DISCUSSION: Currently, literature regarding surgical management is lacking, partially because of a dearth of high-quality literature but also hindered by a lack of standardized techniques. This review was limited by inclusion of studies of low evidence, small sample sizes, and inconsistency in outcome measurement and follow-up period. Overall, patients with acromial and scapular spine stress fractures treated conservatively are expected to have reduced shoulder function compared to nonfracture patients, with the spine of scapula fracture patients suffering the poorest outcomes. Future studies should aim to use the same sets of outcomes parameters to assess the patients at fixed time intervals and report outcomes stratified by Levy classification. This will enable interinstitutional collaboration and pooling of results.