Awareness of fifth metatarsal stress fractures among soccer coaches in Japan: A cross-sectional study.

Although a fifth metatarsal stress fracture is the most frequent stress fracture in soccer players, awareness of fifth metatarsal stress fractures among soccer coaches is unclear. Therefore, we performed an online survey of soccer coaches affiliated with the Japan Football Association to assess their awareness of fifth metatarsal stress fractures. A total of 150 soccer coaches were invited for an original online survey. Data on participants' age, sex, types of coaching licence, coaching category, types of training surface, awareness of fifth metatarsal stress fractures, and measures employed to prevent fifth metatarsal stress fractures were collected using the survey. Data from 117 coaches were analysed. Eighty-seven of the 117 coaches were aware of fifth metatarsal stress fractures; however, only 30% reported awareness of preventive and treatment measures for fifth metatarsal stress fractures. Licensed coaches (i.e., licensed higher than level C) were also more likely to be aware of fifth metatarsal stress fractures than unlicensed coaches were. Furthermore, although playing on artificial turf is an established risk factor for numerous sports injuries, soccer coaches who usually trained on artificial turf were more likely to be unaware of the risks associated with fifth metatarsal stress fractures than coaches who trained on other surfaces were (e.g., clay fields). Soccer coaches in the study population were generally aware of fifth metatarsal stress fractures; however, most were unaware of specific treatment or preventive training strategies for fifth metatarsal stress fractures. Additionally, coaches who practised on artificial turf were not well educated on fifth metatarsal stress fractures. Our findings suggest the need for increased awareness of fifth metatarsal stress fractures and improved education of soccer coaches regarding injury prevention strategies.　.

A Scoping Review of the Epidemiology, Management, and Outcomes of Golf-Related Fractures.

ABSTRACT: Golf is a popular sport; however, there is a paucity of data in relation to golf-associated fractures, and the rate and timing of returning to golf. The aim of this review is to describe golf-associated fractures, including epidemiology, management, and timing of returning to golf following treatment. A literature search was performed using MEDLINE/PubMed, Embase, and Web of Science. Data were extracted and summarized in a narrative synthesis. A total of 436 articles were identified with an initial search of which 58 met the inclusion criteria. Twelve anatomical sites of golf swing-related fractures were identified, of which 10 sites were specific for stress fractures. The most common sites of golf swing-related stress fractures were the ribs followed by the hook of hamate. There was a common theme of delay to diagnosis, being initially assigned to a soft tissue injury. Most golfers with swing-related stress fractures were able to return to golf with the exception of osteoporotic associated vertebral stress fractures. Timing of returning to golf was between 4 and 12 months for most of the golfers with stress fractures following conservative management. Operative intervention was an option of hook of hamate nonunion, following a stress fracture, and tibial shaft stress fractures. Golf equipment-related fractures were not rare and were associated with major trauma and in some cases associated with significant persistent morbidity. Golf-related stress fractures commonly involve the ribs and hook of hamate; knowledge of this may aid in early diagnosis and appropriate treatment when symptomatic golfers are encountered. Although golf is a noncontact sport, fractures associated with golf equipment can be life changing, and safety training guidelines should be established.

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.

HWJMSC-EVs promote cartilage regeneration and repair via the ITGB1/TGF-ß/Smad2/3 axis mediated by microfractures.

The current first-line treatment for repairing cartilage defects in clinical practice is the creation of microfractures (MF) to stimulate the release of mesenchymal stem cells (MSCs); however, this method has many limitations. Recent studies have found that MSC-derived extracellular vesicles (MSC-EVs) play an important role in tissue regeneration. This study aimed to verify whether MSC-EVs promote cartilage damage repair mediated by MFs and to explore the repair mechanisms. In vitro experiments showed that human umbilical cord Wharton's jelly MSC-EVs (hWJMSC-EVs) promoted the vitality of chondrocytes and the proliferation and differentiation ability of bone marrow-derived MSCs. This was mainly because hWJMSC-EVs carry integrin beta-1 (ITGB1), and cartilage and bone marrow-derived MSCs overexpress ITGB1 after absorbing EVs, thereby activating the transforming growth factor-ß/Smad2/3 axis. In a rabbit knee joint model of osteochondral defect repair, the injection of different concentrations of hWJMSC-EVs into the joint cavity showed that a concentration of 50 µg/ml significantly improved the formation of transparent cartilage after MF surgery. Extraction of regenerated cartilage revealed that the changes in ITGB1, transforming growth factor-ß, and Smad2/3 were directly proportional to the repair of regenerated cartilage. In summary, this study showed that hWJMSC-EVs promoted cartilage repair after MF surgery.

Evaluation of stress-controlled high-cycle fatigue characteristics in PLA-wood fused deposition modeling 3D-printed parts under bending loads.

PLA (Poly-lactic acid)-wood provides more biodegradability through natural fibers, a significant advantage of pure PLA. Nevertheless, these bio-composites may have inferior mechanical properties compared to non-degradable polymer composites, considering the lower strength of natural particles compared to synthetic fibers. This research examines the fatigue behavior of additive-manufactured biopolymer PLA-wood and assesses its comparability with pure PLA. Therefore, solid fatigue test samples were printed using the FDM (fused deposition modeling) method. Afterward, fully reversed rotary bending fatigue experiments were performed at 4 different stress levels (7.5 to 15 MPa) to extract the S-N curve of PLA-wood. Moreover, the fatigue fracture surfaces of the PLA-wood were investigated and compared at the highest and lowest stress levels using an FE-SEM (Field Emission Scanning Electron Microscopy), indicating more ductile fracture marks at higher stress levels. The fatigue lifetime of the PLA-wood decreased by 87.48% at the highest stress level (15 MPa), rather than the result at the lowest stress level (7.5 MPa). Additionally, the results demonstrated that the fatigue characteristics of the printed pure PLA and PLA-wood were comparable, suggesting that the 3D-printed PLA-wood with the used printing parameters can be an alternative choice.

Epidemiology of Stress Fracture in Police Trainees.

BACKGROUND: Military recruits and athletes have high occurrence of stress fractures, with very high incidence among military recruits. Symptomatic stress fractures can be disabling in some people. This study aims at identifying pattern and distribution of such fractures in Nepal Police trainee and assess the risk factors and demographics that may help to develop the local guidelines. METHODS: This study analysed 65 police trainees who presented to the orthopaedic Out Patient Department at Nepal Police and Province Police Hospital diagnosed as a case of stress fracture from 29 December, 2020 to 29 December, 2021. Ethical approval was obtained and different variables analysed were age, sex, Body Mass Index, location of fracture, duration of pain, method of treatment, time to heal the fracture and time to pain free mobilisation of patient. RESULTS: There were 65 trainees with 86 sites of fracture at different bones with 50.8% (33) of male population. The majority of fracture was located at tibia (58.1%) followed by pubic rami (33.7%) with potentially debilitating fracture neck of femur seen in 4.6% subjects. Mean duration of pain was 20.7±14.2 days with mean time for pain free mobilisation 42.2±17.7 days after presentation. 96.5% of those recovered with conservative treatment (activity restriction or cast). CONCLUSIONS: The location of stress fracture depends upon the type of training or activities. Modification of activities in early phase of training with early visit for medical care in case of trainees with increasing pain may decrease morbidities and complications requiring operative treatment.

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.

Ultrasound ability in early diagnosis of metatarsal stress fractures.

Stress fractures are common in young and active individuals, associated with aggressive or repetitive physical activity and their early detection is fundamental to optimise patient care, decrease complications and avoid unnecessary exams. Currently, magnetic resonance imaging is the standard of care for detecting these lesions. Recently, ultrasound has been getting an increasing interest for the detection of stress fractures. In this article, we describe a clinical case that involved a second metatarsal stress fracture diagnosed by ultrasound and review the literature regarding the use of ultrasound in the diagnosis of stress fractures, particularly of the metatarsals.

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment.

The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Safety and Early Results for Off-Label Use of Intranasal Calcitonin for Treatment of Nondisplaced Acromial and Scapular Spine Stress Fractures After Reverse Total Shoulder Arthroplasty.

Immobilization for acromial and scapular spine stress AU4fractures (AF/SSF) after reverse total shoulder arthroplasty (RSA) is associated with patient dissatisfaction. Our study reports the effects and safety of intranasal calcitonin alongside sling immobilization on pain and function in the treatment of AF/SSF after RSA. The treatment was regimented calcitonin (salmon) 200 unit/actuation nasal spray (1 spray/day) for 6 weeks with sling immobilization for 4 weeks. Each patient was monitored through blood work. Visual analog scale, American Shoulder and Elbow Surgeons score, and active range of motion were collected preoperatively, postoperatively, at presentation of AF/SSF, and after completion of calcitonin treatment. Two hundred eighty-two RSAs were performed by two board-certified orthopaedic surgeons, of which 18 patients sustained AF/SSF (6.4%). Ten patients met inclusion criteria (nine AFs and one SSF). After calcitonin treatment, patients demonstrated an average improvement of visual analog scale of 5.8 points, active range of motion of 46_, and American Shoulder and Elbow Surgeons score of 43.6 points at average 7.53 months after RSA. No medical complications were reported at 6-month follow-up after calcitonin treatment. The use of intranasal calcitonin was not associated withadverse events including no aberrations/signs of cancer at 6-month follow-up after administration. Calcitonin with sling immobilization markedly improved clinical and functional outcomes of patients with nondisplaced AF/SSF and may be considered by orthopaedic surgeons for symptom management.

Magnetic resonance imaging combined with histological evaluation of repair process using the microfracture technique in an association of osteocartilaginous and meniscal surgically induced lesions of the knee. In vivo experiment on a rabbit model.

The present research study aimed to assess magnetic resonance imaging (MRI) changes and histological findings in the therapeutic effects of microfractures in the treatment of complex animal knee lesions resulting from osteochondral and meniscal defects resulting from non-total meniscectomies. The anterior cruciate ligament lesions are also proven to facilitate the development of osteoarthritis in the knee and worsen the prognosis. Surgery was performed on the right knee joint of 22 male rabbits in order to partially remove the anterior horn of the internal meniscus and to induce an osteochondral defect at the level of the internal femoral condyle. The induced lesion complex was aimed to simulate a clinical situation that occurs frequently in orthopedic practice when young adults undergo partial meniscectomy and at the time of surgery, an osteochondral defect is diagnosed. Rabbits were separated into two study groups: the control (C1) group and the microfractures (MF2) group. After the induced cartilage defect and partial meniscectomy, both groups were followed-up for six months using detailed MRI. Also, anatomical specimens were histologically analyzed to show modifications and signs of healing process, along with complications, in the study group. The results showed that the microfracture group had better results concerning articular surface defect healing in comparison to the control group. Our results suggest that microfractures do improve results concerning surface contact healing and serial MRI studies can be useful in observing the remodeling process in dynamics.

Refracture-related bone transport of tibia: technical notes and preliminary clinical results in nineteen cases.

PURPOSE: Refracture is one of the main complications of bone transport, which brings additional physical and mental burden to surgeries and patients. We aimed to raise a new classification system of refracture-related bone transport based on the Simpson classification and to present our experience on treatment. METHODS: This retrospective analysis included 19 patients with refracture-related bone transport (average age of 37.7 years; 18 men). We developed a modified Simpson classification system to assist decision-making (conservative versus surgical). The ASAMI criteria were used to assess the outcomes at last follow-up. RESULTS: The mean follow-up was 12.3 ± 3.2 months. Complete union was achieved in all patients, with no reinfection. Based on the modified Simpson classification, refracture was Ia type (within regeneration area) in three cases, Ib (collapsed fracture at the regeneration area) in one case, Ic (stress fracture) in three cases, II (at the junction between the regenerate and original bone) in one case, III (at the docking site) in nine cases, and V (at distant site) in two cases. Refracture was managed conservatively in six cases and surgically in 13 cases. Average time to bone union was 2.8 ± 1.2 months in the conservative group versus 4.4 ± 1.4 months in the surgery group. Assessment at the final follow-up using the ASAMI criteria revealed excellent bone result in all patients, excellent functional results in six patients (31.6%), and good functional results in 13 patients. CONCLUSIONS: The modified Simpson classification could include refracture at the docking site and stress fracture in the regeneration zone and provide some guidance in determining the appropriate treatment strategy.

Bone health and the masters runner.

Masters runners are often defined as those ages 35 years and older who train and compete in running events. These runners represent a growing population of the overall running community and experience running-related injuries including bone stress injuries (BSIs). Similar to younger runners, health considerations in masters runners include the goal to optimize bone health with focus on mitigating age-associated loss of bone strength and preventing BSIs through a combination of ensuring appropriate physical activity, optimizing nutrition, and correcting faulty biomechanics. Importantly, BSIs in masters runners may include characteristics of both overuse injury from insufficient recovery and failure of bone weakened by age-related loss of bone (insufficiency fractures). This narrative review covers the limited available research on strategies to optimize bone health in masters runners. Applying knowledge on masters athletes and extrapolating from other populations, we propose strategies on treatment and prevention of BSIs. Finally, the review highlights gaps in knowledge that require further age-specific discoveries to advance treatment and prevention.

Change in pelvic incidence due to sacral stress fracture following multilevel instrumented fusion.

Multilevel-instrumented fusion is a common surgical technique used to treat adult spinal deformity (ASD), but it can occasionally lead to rare complications such as sacral insufficiency fractures. The impact of sacral fractures on spinopelvic parameters, particularly pelvic incidence (PI), has not been thoroughly investigated even though they have been documented in the literature. Here, we present a case of a patient who underwent a Th11-sacrum instrumented fusion for ASD. She underwent a revision surgery 18 months after the first procedure to treat proximal junctional pain brought on by a localised kyphosis of the rods. An asymptomatic sacral fracture was discovered during the radiological evaluation: the PI had increased from 71° to 103° between the 2 surgical procedures.

Distal Femoral Stress Fractures Has High Operation Rates in Adolescent and Young Adult Athletes.

BACKGROUND: Although stress fractures of the distal femur are rare, symptoms can overlap with other peri-articular knee pathology, delaying diagnosis. Untreated stress fractures have the potential to progress into completed fractures with a higher likelihood for requiring surgery and longer recovery times in otherwise healthy adolescents and young adults. This case series represents the largest cohort of adolescent athletes with distal femoral stress fractures who presented with activity-related knee pain. METHODS: Patients treated nonoperatively and operatively for metaphyseal distal femur stress fractures at a tertiary referral center over a four-year period were retrospectively identified from the medical record. RESULTS: Eight patients (mean age 16.8 y; range 14 to 22 y; 87.5% male; mean body mass index [BMI] 20.9) with a total of 10 distal femur stress fractures were identified. All patients were involved in competitive sports or military training. There was an average of 3.8 encounters with a medical provider between presentation with activity-related knee pain and diagnosis with distal femur stress fracture. All except 1 patient (87.5%) were initially incorrectly diagnosed with another type of peri-articular knee pathology. Six stress fractures (60%) were treated conservatively with protected weight bearing, activity modification, and gradual return to activity. Four completed stress fractures (40%) required operative fixation-3 healed uneventfully, while 1 had an asymptomatic delayed union. Vitamin D insufficiency (<30 ng/mL) was identified in 7 of 8 patients (87.5%) and 3 patients (37.5%) had an underweight BMI (<18.5). The mean clinical follow-up was 13.1 weeks (range, 2.8 to 32.0 wk). CONCLUSIONS: High clinical suspicion for distal femoral stress fractures is needed to avoid misdiagnosis or delayed diagnosis in young, active individuals with activity-related knee pain refractory to conservative management. In this patient population, activity-related knee pain recalcitrant to activity modification, rest, and physical therapy warrants further workup with magnetic resonance imaging and orthopaedic evaluation. Though rare, misdiagnosis can result in catastrophic fractures with prolonged rehabilitation needs. An open line of communication and streamlined access for referral between primary care providers and orthopaedic surgeons is critical in preventing misdiagnosis and delayed treatment. Furthermore, the treatment of concomitant metabolic disorders and nutritional deficiency should not be neglected when treating distal femoral stress fractures. LEVEL OF EVIDENCE: Level-IV (case series).

Injury incidence and prevalence in elite short-course triathletes: a 4-year prospective study.

OBJECTIVE: To characterise the prevalence, incidence rate (IR) and burden of injuries in elite short-course triathletes over a 4-year training and competition period. METHODS: Fifty elite Australian triathletes were prospectively monitored for injury during four consecutive seasons (2018-2021). Injuries requiring medical attention were prospectively recorded and further subcategorised according to time loss. The IR and burden (injury IR×mean injury severity) were calculated per 365 athlete days, with sex differences in IR compared using IR ratios (IRR) from negative binomial regression models. RESULTS: Two hundred and sixty-six injuries were reported in 46 (92.0%) athletes, of which 67.3% resulted in time loss. The injury IR was 1.87 injuries per 365 athlete days (95% CI 1.70 to 2.80), and comparable between sexes (IRR 0.82, 95% CI 0.64 to 1.04, p=0.109). Most injuries (70.7%) were training related. The most frequently injured body sites were the ankle (15.8%), foot (12.4%) and lower leg (12.0%). Bone stress injuries (BSIs) were the most burdensome injury type with 31.38 days of time loss per 365 days (95% CI 24.42 to 38.34). Twenty athletes (40.0%) reported at least one bone stress injury (BSI) (range 0-3). The rate of BSIs in female athletes was three times greater compared with male athletes (IRR 2.99, 95% CI 1.26 to 7.07, p=0.013). CONCLUSION: Two-thirds of injuries reported in elite short-course triathletes resulted in time loss, with the majority occurring during training activities. Foot, ankle and other lower leg injuries had the highest incidence, with BSIs carrying the highest injury burden. The considerably higher rate of BSI observed in female athletes warrants consideration for future prevention strategies in female triathletes.

[Diagnostics and treatment of insufficiency fractures of the pelvis]. / Diagnostik und Therapie von Beckeninsuffizienzfrakturen.

Insufficiency fractures of the pelvis have increased in recent years, primarily due to the demographic change and the incidence will continue to rise. In addition to conventional X­rays, the diagnostics always require slice imaging. Unlike high-energy trauma magnetic resonance imaging (MRI) plays an important role in insufficiency fractures. Once the fracture has been diagnosed, in addition to the extent of instability in the anterior and posterior pelvic rings, the pain symptoms are crucial for the decision on surgical treatment. The basic principle is to stabilize as little as possible but as much as necessary. There are currently a variety of procedures that can be applied as a minimally invasive procedure, especially for the often slightly or displaced insufficiency fractures. The decisive factor for treatment is that it enables early mobilization of the patients. All of these measures must be accompanied by thorough diagnostics of osteoporosis and the appropriate treatment.

Arthroscopic microfracture and associated techniques in the treatment of osteochondral lesions of the talus: A systematic review and metanalysis.

BACKGROUND: Osteochondral lesions of the talus are common in patients suffering even minor trauma; timely diagnosis and treatment can prevent the development of early osteoarthritis. The objectives of this systematic review and meta-analysis were to evaluate the effects of additional procedures on arthroscopic ankle microperforations for osteochondral lesions. METHODS: A systematic literature search was conducted using PubMed-Medline, Cochrane Central, and Google Scholar to select clinical studies analyzing the efficacy of platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow concentrate (BMC) procedures. Ten articles following PRISMA guidelines with a total of 464 patients were included in this review. Quality assessment using MINORS was performed, and all studies demonstrated high quality. RESULTS: The results of the systematic review showed benefits in all patients undergoing infiltrative therapy with PRP, hyaluronic acid, and BMC. The best results in terms of AOFAS score and VAS scale were found in patients undergoing PRP injection. The meta-analysis showed improvements in pain relief and return to daily activities in patients undergoing arthroscopic microperforations and PRP, although not reporting statistically significant results (p = 0.42). CONCLUSION: All treatment strategies reported better scores compared to the control groups. Among the various treatments analyzed, the addition of PRP appears to be the most valuable probably for the larger population receiving this treatment, showing excellent outcomes in pain reduction, clinical outcomes, and return to daily activities. LEVEL OF EVIDENCE: II.

Epidemiology of bone injuries in elite athletics: A prospective 9-year cohort study.

OBJECTIVES: To describe bone injury patterns in elite track and field athletes. To investigate relationships between bone injury and athlete characteristics to inform future injury prevention strategies. DESIGN: Descriptive epidemiology study. SETTING: Elite athletics training centres across the United Kingdom and internationally, observed between 2012 and 2020. PARTICIPANTS: 207 Olympic programme senior track and field athletes. MAIN OUTCOME MEASURES: Injury number, Incidence, Severity, Burden, Time Loss. RESULTS: There were 78 fractures during the study period. Gradual repetitive bone injuries were the most common type of injury mode. The foot, pelvis and the lumbar spine were the regions with the highest number of bone stress injuries. Stress fractures had a higher burden overall compared to stress reactions. Average return to full training was 67.4 days (±73.1) for stress reactions and 199 (±205.2) days for stress fractures. There was no relationship between bone injury type and age, sex, ethnicity, side dominance or event group. CONCLUSION: Bone stress injuries in athletics have a high severity and burden warranting continued efforts to prevent their occurrence and optimize management. Age, sex, ethnicity, side dominance and event region do not have any relationship with bone injury occurrence and are therefore unlikely to increase risk in this cohort.