[Surgical Stabilization of Traumatic Multiple Rib Fractures Using Absorbable Osteosynthesis Agent(u-HA/PLLA Composite Material)].

In case that met several indication criteria with 4 or more rib fractures, we performed surgical stabilization of multiple fractured ribs using a plate and screw system( Super FIXORB MX) that was made of uncalcined hydroxyapatite (u-HA)/poly-L-lactic acid (PLLA) composite material with excellent bioactivity and absorbability. We report our clinical experience of 7 cases in which this device was used. Although there is still room for further consideration of the technique and the strength of the device itself, computed tomography( CT) images taken 9 months after surgery showed that the fixative device was almost assimilated with the bone at the fracture repair site in cases where fixation was successful.

[The Surgical Indication of Multiple Rib Fractures of Patients by Traumas and Timing of the Surgical Stabilization of Rib Fractures].

It's reported that 10% of the inpatients by traumas have fractured ribs. It's easy to judge if it's the case of flail chest, or respiratory failure due to airway injury or pulmonary contusion. There is no guideline for treatments of a patient who has multiple ribs fractures without respiratory failure. We did the surgical stabilization of rib fractures for 10 cases from 2020 to October 2023. As a result, we find out useful surgical indication for treatment of rib fractures.

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.

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.

Fracture gap and working length are important actionable factors affecting bone union after minimally invasive plate osteosynthesis for the treatment of simple diaphyseal or distal metaphyseal tibia fractures.

INTRODUCTION: Indirect reduction of minimally invasive plate osteosynthesis (MIPO) can often result in delayed union in tibia fractures. This study evaluated several factors in MIPO in relation to bone union. HYPOTHESIS: We hypothesized that the fracture gap, plate - tibia distance, or working length would have a substantial effect on the tibia union rate. MATERIALS AND METHODS: Forty-one patients with simple diaphyseal or distal metaphyseal tibia fractures who underwent internal fixation surgery using the MIPO technique were divided into two groups: patients with delayed union and patients without delayed union. Non-actionable factors involving AO/OTA classification, fibula fracture and actionable factors including postoperative fracture gap, plate - tibia distance, working length in relation to parameters of bone union were compared between the two groups. Also cumulative rates of bone union and risk factors of delayed union according to variables of interest were investigated. RESULTS: AO/OTA classification, site of fibula fracture, postoperative fracture gap, working length, and bone union rate of the two groups significantly differed (p<0.05). The cumulative rate of bone union during 1-year follow-up according to 43A tibia fracture, distal fibula fracture, fracture gap, and working length significantly differed between the two groups (p<0.05). By univariate Cox proportional hazards model, 43A tibia fracture, distal fibula fracture, facture gap, and short working length were risk factors for delayed union (p<0.05). DISCUSSION: Non-actionable factors involving AO/OTA classification, distal fibula fracture and actionable factors including postoperative fracture gap, working length were significant factors affecting bone union after MIPO. The present study indicated that small fracture gap and long working length during MIPO might facilitate bone healing in tibia fracture. LEVEL OF EVIDENCE: IV; single-center retrospective cohort study.

[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.

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.

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.

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.

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.

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.

A Simple and Minimal Invasive Method in Reduction of Depressed Nasal Bone Fracture by Using a Foley Catheter Ballooning Technique.

The nasal bone fracture is the most common type of facial bone fracture. Closed reduction with metal reduction instrument is commonly conducted for the treatment of a type II nasal bone fracture. The authors defined a new catheter dilation technique and used it in patients with type II depressed nasal bone fractures. Preoperative and postoperative nasal appearance and radiologic examination of the patients were compared. There was a statistically significant improvement in the nasal appearance of all patients. No recurrence or dorsal irregularity has been observed. This new, easily applicable catheter dilation method of closed reduction may be a simple and less invasive solution to treat type II nasal bone fractures.

Analysis of Nasal Bone Fractures: A 17-year Study of 3785 Patients.

In our previous study, we classified nasal bone fractures into 6 types based on computed tomography and the patterns of the nasal bone fractures (NBF) in 503 patients treated between 1998 and 2004. In the present study, we analyzed 3785 patients treated between 2005 and 2021. The age, sex, etiology, associated injuries, pattern of fractures, and treatments were reviewed, and radiographic studies were analyzed. The highest incidence was in the age group of 10 to 19 years (N=870, 23.0%), followed by 20 to 29 years (N=792, 20.9%) and 30 to 39 years (N=635, 16.8%). The most common causes of injury were slip or fall-down (42.3%), violence (24.3%), sports (19.2%), traffic accidents (8.9%), and work-related (5.3%). Most of the patients had tenderness (96.1%) and swelling (78.8%). Other findings were depression (27.1%) and nasal deviation (25.8%). Crepitus was heard in only 0.4% of the patients. The patterns of the NBFs classified by computed tomography findings were type IIA (unilateral simple fracture with displacement/without telescoping, 1283 cases, 33.9%), IIB (bilateral simple fracture with displacement/without telescoping, 786 cases, 20.8%), IIAs (unilateral simple fracture with septal fracture and displacement/without telescoping, 566 cases, 14.9%), IIBs (bilateral simple fracture with septal fracture and displacement/without telescoping 530 cases, 14.0%), I (simple fracture without displacement, 522 cases, 13.8%), and III (comminuted with telescoping or depression, 98 cases, 2.6%). In most of the cases (3,666, 96.9%), closed reduction was performed. The present analysis is one of the largest data sets on NBF in Korea, which could provide reference values for diagnosing and managing nasal bone fractures.

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.

Spontaneous Repositioning of Significant Blow-out Orbital Roof Fracture Associated With Intracranial Hematoma.

Orbital roof fractures are relatively rare facial bone fractures that usually occur in conjunction with other facial bone fractures or intracranial hematoma during high-velocity facial trauma. This study reports a patient with a significant blow-out orbital roof fracture combined with a nondisplaced frontal bone fracture and epidural hematoma at the superior aspect of unilateral frontoparietal convexity. Despite the severe superiorly-displaced fracture segment, the follow-up computed tomography scans taken 4 days after the injury showed a spontaneous reduction of blow-out orbital roof fracture. At the 1-week follow-up, the coronal image of craniofacial magnetic resonance imaging was taken, showing spontaneous realignment of orbital roof fracture and physiological evolution of cerebral contusion. In conclusion, conservative treatment can acquire the best outcome regarding cosmesis and function unless the patient requires an emergent operation for other medical conditions. This is key for successfully returning the patient's form and function.

Nasotracheal intubation awake in a patient with multiple fractures of the maxilla and cervical spine: A case report.

RATIONALE: Nasotracheal intubation is an advanced airway modality used in specific contexts, such as limited mouth opening, macroglossia, cervical spine instability. In addition, it can be performed with the patient awake, especially when predictors a difficult airway are unknown. PATIENT CONCERNS: A 41-year-old male with a lesion in the C1 cervical vertebra, associated with a fracture of the right maxilla, was intubated through the nasopharyngeal route while awake. The forms of induction were discussed. DIAGNOSES: Based on the mechanism of trauma and on the report of pain, associated with imaging examination, fracture of the body of the right maxilla and a complex fracture of the anterior arch of the C1 cervical vertebra were diagnosed. INTERVENTIONS: In this case, we present a patient with trauma to the face and spine who was intubated through the nasopharyngeal route while awake and guided by video laryngoscopy and using a rigid cervical collar. The patient was operated on under total general anesthesia (propofol and remifentanil) and plates and screws were placed for maxillary osteosynthesis. The pain was alleviated with a peripheral block of the trigeminal nerve of the maxillary branch with 0.5% levobupivacaine. OUTCOMES: The patient woke up from surgery, was extubated uneventfully and without pain. Cervical spine injuries were followed up by the neurosurgery team for conservative treatment. LESSONS: Patients with neck injury and facial trauma may need a definitive airway either for emergencies or for elective procedures. Intubating the awake patient may be an option when the anatomy of the cavity is unknown, and inducing the anesthetic act without this knowledge may be a inappropriate option, due to the risk of intubation/ventilation difficulties.

Control of Mandibular Width With 3D Printed Occlusal Splint in Children With Multiple Mandibular Fractures.

BACKGROUND: The fracture of mandibular symphysis combined with bilateral condylar fractures often leads to changes in the width of the mandible, which significantly widens the face of the child. Therefore, it is necessary to reposition the mandible through accurate adduction. METHODS: To ensure that the mandible can be accurately repositioned, a 3D printed occlusal splint was used. Bilateral maxillomandibular fixation screws were implanted. The 3D printed occlusal splint was located on the maxillary dentition and fixed to the maxillomandibular fixation screws with wire loops. The reference basis for adduction is to make the mandibular dentition located in the occlusal splint. The absorbable plate was contoured according to the restored model and fixed at the fracture site. The 3D printed occlusal splint was retained in the maxillary dentition for two months. RESULTS AND DISCUSSION: Postoperative computed tomography showed that the mandible had been adducted according to the preoperative design. Two months of follow-up showed that the child's facial development, mouth opening type, occlusion, and range of motion were good. It is especially suitable for children with mandibular symphyseal fractures accompanied by bilateral condylar fractures.

Chronic Liver Disease Secondary to Chronic Budd Chiari Causing Osteomalacia Leading to Pathological Fractures.

INTRODUCTION: Metabolic disturbances of bone are common in patients of CLD manifesting as osteoporosis and osteopenia while osteomalacia is rare. MATERIALS: 34 years old lady with history of portal vein thrombosis and CLD since 2008 presented with complaints of anorexia, early satiety, nausea, vomiting weight loss for 8 months and syncopal attack followed by fall on ground leading to multiple fractures in both lower limbs and left upper limb. Investigations including hemogram, metabolic profile, X-rays, anemia workup, Vitamin D3, parathyroid hormone (PTH), hormone profile, CA-125, 24-hour urinary calcium, USG were planned. RESULT: On presentation her BP=106/64 mm Hg, PR = 98, RBS = 104. GPE showed cachexia, severe pallor, bipedal edema, deformed elbow joint, thoracic kyphosis with cervical lordosis. Hemogram and metabolic panel were suggestive of severe anemia, thrombocytopenia, deranged LFT, increased ALP, anemia of chronic disease (AOCD), X-rays suggestive of multiple fractures. Possiblity of metabolic bone disease (hepatic osteodystrophy) was kept. Further investigations showed Vitamin D deficiency, raised PTH, low 24-hour urinary calcium and FSH was raised for age. Diagnosis of osteomalacia was made and patient was started vitamin D and calcium supplementation, normocalcemia achieved and PTH and ALP settled in months. CONCLUSION: Patients with liver disease should be investigated for the presence of hepatic osteodystrophy, to allow the identification and the correction of risk factors and start of the therapeutic program. Niranjan Gangoor, Sanjay Neeralagi, Gayathri Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India Introduction: Liver plays an important role in the metabolism of thyroid hormones, as it is the most important organ in the peripheral conversion of tetraiodothyronine (T4) to triiodothyronine (T3) by Type 1 deiodinase. MATERIALS: This Prospective observational study included 100 liver cirrhosis patients Serum FT3, FT4, and thyroid-stimulating hormone (TSH) levels were measured using electrochemiluminescence immunoassay. Results were also analyzed for severity of liver disease according to Child-Turcotte-Pugh (CTP) (Class A, B, and C), model for end-stage liver disease (MELD) score, and HE grades. RESULT: Most common etiology was alcohol (58%) and presentation was gross ascites (77%). Cirrhosis patients had statistically significant lower level of FT3 and FT4 but had higher level of TSH. Cirrhosis with HE (n = 38) had significantly lower lever of FT3 compared with cirrhosis without HE (n = 62). In all cirrhotic patients, FT3 and FT4 were negatively correlated, but TSH level was positively correlated with total leukocyte counts, serum total bilirubin, aspartate transaminase, alanine transaminase, globulin, prothrombin time blood urea, serum creatinine, CTP, and MELD score. CONCLUSION: The mean FT3 and FT4 levels were significantly decrease and mean TSH levels were significantly increase in liver cirrhosis patients. Level of FT3, FT4, and TSH also correlate with the severity of liver disease, level of FT3 can be used as prognostic marker for liver cirrhosis patients. References Patira NK, Salgiya N, Agrawal D. Correlation of thyroid function test with severity of liver dysfunction in cirrhosis of liver. J Assoc Physicians India 2019;67(3):51-54. Kumar A, Ahuja V, Kaur I, et al. Prevalence of thyroid dysfunction in patients of cirrhosis of liver and its correlation with severity of cirrhosis. Int J Adv Res 2020;8:91-95.

Multiple rib and vertebral fractures associated with Bordetella pertussis infection: a case report.

BACKGROUND: Pertussis is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis, characterized by paroxysms of severe coughing, and predominantly affects children. We report the first case of multiple fractures in the ribs, lumbar spine, and sacrum associated with severe coughing caused by Bordetella pertussis infection in an adult. CASE PRESENTATION: A 49-year-old female presented with acute-onset chest wall pain for 3 weeks. Imaging results revealed multiple fractures in the ribs and vertebrae, as well as bilateral pleural effusion, pericardial effusion, right pneumothorax, and enlargement of the left parapharyngeal and subclavian lymph nodes. The patient's bone density scan, autoimmune antibodies, bone marrow biopsy, and sacral bone biopsy all came back normal. Imaging test results found no evidence of solid tumors or active TB infection. The patient later recalled having violent coughing prior to the onset of chest pain and several family members having similar symptoms. Her blood sample was sent to the CDC, revealing Bordetella pertussis toxin (PT) IgG titer of 110.68 IU/mL. The patient was diagnosed with pertussis and multiple stress fractures from violent coughing. Symptomatic treatments were administered, and the patient's symptoms improved. The patient was followed up 8 weeks later, she reported no more coughing or chest pain. CONCLUSIONS: Pertussis is not just a pediatric disease, but diagnosis in adults is challenging as patients may present with a myriad of confusing symptoms, such as multiple stress fractures due to violent coughing. Medical and epidemiological histories are key to reaching the correct diagnosis, which is essential for appropriate treatments to avoid further complications. Adult immunization should be suggested both for the protection of the adult population and to prevent transmission to children.