Dual energy X-ray absorptiometry (DXA): can it detect acute scaphoid fractures?

This prospective study investigated whether dual energy X-ray absorptiometry (DXA) could detect acute scaphoid fractures. We blindly compared 10 normal and 10 fractured scaphoid images produced with a new technique of DXA scan analysis. This measured and plotted the density of the scaphoid throughout its length, producing a linear graph of the scaphoids' density instead of a single area (g/cm2) measurement of bone density. These new plots only detected six of the 10 fractures and suggested that four of the normal controls were fractured. Thus, this technique of DXA scan analysis is neither sensitive nor specific for the detection of acute scaphoid fractures.

Clinical outcomes and treatment of hip fractures.

The worldwide prevalence of hip fracture is increasing as the mean age of the population increases. Despite advances in anesthesia, nursing care, and surgical techniques, however, the outcome of treatment is often poor, and hip fractures remain a significant source of morbidity and mortality for the elderly population. For these patients, operative treatment is considered to be optimal and most cost-effective for displaced intracapsular fractures and all extracapsular fractures. Undisplaced intracapsular fractures can be treated with bed rest and 6-8 weeks' delay of weight bearing in the "younger" elderly (< or = 70 years). The timing of surgery remains controversial, and evidence that a delay in operating leads to increased morbidity is inconclusive. In general, early surgery is indicated in premorbidly fit patients, whereas surgery should be delayed if correctable comorbidities are present. Methods of intracapsular fracture repair very geographically and according to surgeon preference. Prospective, randomized, case-controlled studies are needed to compare repair methods, including internal fixation versus hemiarthroplasty for intracapsular fractures and use of uncemented versus cemented hemiarthroplasty protheses. Extracapsular fractures are usually repaired using a dynamic hip screw or other variant of sliding nail fixation. The mortality rate after hip fracture appears to vary in association with poorly controlled systemic disease (particularly if multiple comorbidities are present); cognitive disorders; operative intervention before stabilization if > or = 3 comorbidities are present; and, in the absence of prophylaxis, deep vein thrombosis; the associations between mortality and male sex, advanced age, and anesthetic type are less clear. The factors associated with the recovery of walking ability include young age, male sex, absence of dementia, absence of postoperative confusional state, and use of a walking aid before the fracture. Many determinants of outcome are independent of the level of care given and are dependent on prefracture status. To maximize rehabilitation potential, a multidisciplinary approach using skilled medical, nursing, and paramedical care appears to be optimal. Prospective case-controlled studies are required to demonstrate the long-term effectiveness of specialist rehabilitation units. In today's cost-cutting environment, caution must be taken to prevent short-term cost-saving measures from compromising long-term outcome for elderly hip fracture patients.

Drugs used in the treatment of metabolic bone disease. Clinical pharmacology and therapeutic use.

Osteoporosis is the most important metabolic bone disease and places an increasing burden on the healthcare system. The condition can be prevented by the early introduction of hormone replacement therapy. The role of bisphosphonates in achieving the same result is being actively explored. The attraction of preventing bone loss is that it preserves the micro-architecture of bone, and therefore its mechanical integrity. The great problem of treating the established condition is that substantial bone loss is accompanied by architectural disintegration. Replacing lost bone may not necessarily restore mechanical integrity and protect against fractures. The management of Paget's disease has been quite revolutionised by the introduction of the bisphosphonates. The condition is a result of a primary increase in osteoclastic bone resorption which can be corrected by bisphosphonates, with considerable symptomatic improvement. The increasing potency and safety margin of the newer agents has meant that the threshold for treatment has fallen. There is now potential for long term control of bone turnover with the hope of preventing late complications. Hypercalcaemia of malignancy is usually the result of both increased bone destruction and decreased urinary calcium excretion. These two components of hypercalcaemia demand different approaches to management. The general availability of an ever-expanding range of increasingly potent bisphosphonates has resulted in a dramatic improvement in the treatment of increased bone resorption associated with malignancy. Many types of tumour, either directly or indirectly, compromise the ability of the kidney to eliminate a calcium load derived from increased bone destruction. Calcitonin is the only agent which is currently available to counter this process.

Reduced bone formation in UK Gulf War veterans: a bone histomorphometric study.

AIMS: Gulf War veterans report a high prevalence of musculoskeletal symptoms. The aim of this study was to establish whether there were abnormalities in bone turnover and remodelling in a group of symptomatic subjects who had served in the Gulf War. METHODS: Iliac crest bone biopsies were obtained from 17 Gulf War veterans who were seeking litigation and compared with those of 13 age and sex matched healthy controls. Bone histomorphometry was performed using image analysis. RESULTS: Cancellous bone area was significantly lower in Gulf War veterans than in control subjects (p = 0.027) and this was associated with a significantly reduced mineral apposition rate (p = 0.002), mean wall width (p < 0.0001), and bone formation rate at the tissue level (p < 0.0001). CONCLUSIONS: These results demonstrate that in this group of Gulf War veterans there was a significant reduction in bone formation at both the cellular and tissue level and this was associated with a reduction in cancellous bone area. The cause of these abnormalities is unknown but might be related to potentially harmful exposures during service in the Gulf War or to changes in life style as a result of chronic ill health. The clinical relevance of the observed reduction in bone formation remains to be established.

Clinical diagnosis of tears of the rotator cuff.

We have studied the reported clinical assessment of the presence and extent of a rotator cuff tear in 42 patients presenting to a special shoulder clinic. This pre-operative diagnosis was compared with the findings at operation. The clinical tests had a sensitivity of 91% and a specificity of 75%. It is important to exploit clinical examination before resorting to costly and sometimes harmful special investigations.

A prospective study of two conservative treatments for ganglia of the wrist.

This randomized prospective study assessed whether multiple puncture of the ganglion wall improves the results of simple ganglion aspiration. We found that 32% of ganglia resolved after aspiration alone in comparison with 22% after aspiration and multiple puncture. This difference was not significant. However, only 18% of patients requested formal surgical excision, suggesting that aspiration allays fears of malignancy and allows the patient to accept a minor cosmetic embarrassment.

Is occupation an aetiological factor in the development of trigger finger?

We investigated the occupation histories of 178 patients with idiopathic trigger finger. When compared with the 1991 Census data, the distribution of their occupations was not significantly different from the local general population. It is concluded that the vast majority of trigger fingers develop for reasons other than occupation.

[Post-traumatic synovial chondromatosis of the elbow in an 8-year-old child]. / Chondromatose synoviale post-traumatique du coude chez un enfant de 8 ans.

The authors present a case of synovial chondromatosis occurring in an eight year old child's elbow. A clear post traumatic aetiology was demonstrated. This is the youngest patient in whom this condition has been reported.

Ascertainment and natural history of treated acromegaly in Northern Ireland.

The prevalence of known cases of acromegaly in Northern Ireland in 1984 was 6.3 per 100,000 population. The incidence of newly-diagnosed cases over the preceding 25 years was 5.5 patients per year, or 0.4 patients per 100,000 population per year. This rate would be equivalent to about 200 new cases per year in the United Kingdom. Four options have been available to most of these patients--surgical hypophysectomy (transfrontal or transsphenoidal), pituitary radiotherapy (usually external cobalt beam), drug treatment with bromocriptine, or no treatment. Choice of treatment has been mainly influenced by tumour size, with the larger pituitary adenomas having surgery initially. No single form of treatment has been successful in achieving a clinical remission or cure in more than a minority of cases. The most successful outcome has been where total pituitary ablation has been achieved. Life-table analysis for the whole group shows life expectancy which is not markedly different for that of an age-matched population from Northern Ireland. Morbidity related to long term osteoarthritis and treatment complications remain a major problem. The incidence of malignant tumours is higher than would be expected.

Aortic rupture as a result of a sporting injury.

Blunt abdominal aortic rupture is a rare and almost invariably fatal injury that usually occurs as a consequence of motor vehicle accidents. The case of a patient who sustained a nonfatal abdominal aortic rupture while playing soccer is reported. This is the third nonfatal case to be described and the first as the result of a sporting injury.

Development of pseudarthrosis in a dysplastic clavicle: A variant of congenital pseudarthrosis?

The development of a pseudarthrosis is reported in a child's right clavicle, which was previously noted to have been morphologically abnormal. Such pseudarthroses are uncommon, but they usually appear on the right side and may rarely be bilateral. The differential diagnosis is of a postpartum fracture, a posttraumatic pseudarthrosis, cleidocranial dysostosis, or neurofibromatosis. A review of the development of the clavicle and the hypotheses for such anomalous development are given.

The contribution of bone densitometry to the diagnosis and treatment of osteoporosis.

OBJECTIVE: It has recently been proposed that a specialist osteoporosis service, including bone densitometry, should be made available to those most at risk in the UK population. The aim of this study was to evaluate such a service, and in particular the role of bone densitometry, in terms of its effect on the diagnosis of osteoporosis and clinical management of the disease. METHODS: A retrospective data abstraction study was performed to investigate the diagnosis and management of patients referred to the Metabolic Clinic, City Hospital Nottingham, with a potential diagnosis of osteoporosis. Hospital records were available for 117 patients, aged between 45 and 59, who had attended the Clinic in a given time period and undergone bone mineral density measurement. RESULTS: Forty-eight patients (41.0%) had osteoporosis of the lumbar spine. The final diagnosis of osteoporosis after attending the clinic was different from that on referral in a substantial proportion (62.6%) of cases. Only 48.9% of patients with spinal osteoporosis were identified by their referring doctor. The percentage of patients receiving treatment for osteoporosis increased from 34.2% to 72.6% after attending the clinic. CONCLUSIONS: Measurement of bone mineral density identifies cases of osteoporosis who would not otherwise be detected and as a consequence contributes to the proportion of patients receiving treatment after referral. The osteoporosis service provided by the Metabolic Clinic including measurement of bone mineral density was thus found to have a considerable impact on the diagnosis and treatment of patients with osteoporosis.

Long-term survival following cancer of the male breast in Northern Ireland. A report of 81 cases.

Eighty-one patients with cancer of the male breast were studied. The majority (79) presented with a mass in the breast and in 8 patients the tumor was found by chance. Two patients presented with serosanguinous discharge. Average duration of symptoms was 11.9 months. Thirty patients had Stage I, 25 had Stage II, 16 had Stage III, and 8 had Stage IV disease. Fifty-three patients had simple mastectomy, nine had lumpectomy, six had radical mastectomy, and five had biopsy only. Eight had no local surgery. Overall 5- and 10-year survival allowing for all causes of death was 38% and 17%, respectively. Cox's (1972) proportional hazard regression model was used to assess the contribution of various factors to survival. Age at presentation, postoperative hormone therapy, postoperative radiotherapy, site of the primary tumor within the breast, and type of local surgery did not contribute to survival. Only the stage of disease contributed to survival and did so in the expected direction.

Reduced bone formation after exposure to organophosphates.

Bone histomorphometric analysis in 24 agricultural workers with chronic organophosphate exposure showed significantly lower bone formation at tissue and cellular level than in healthy controls.

Progressive visual failure in acromegaly following external pituitary irradiation.

Four out of twenty-three acromegalic patients selected for treatment with external megavoltage pituitary irradiation between 1961 and 1975 developed progressive visual failure. They had received megavoltage external irradiation through multiple portals from a cobalt-60 unit over a period of 3 weeks. Visual deterioration began 2 months to 6 years after irradiation. In two patients the optic nerves were explored. In both, post-mortem later confirmed radiation damage to the optic nerves and hypothalamus. In one case there was also necrosis of the right frontal lobe with necrosis and inflammation of the bone surrounding the pituitary fossa. In the two other patients, extensive clinical and neuroradiological investigation excluded the presence of a suprasellar mass as a cause for this visual failure and a clinical diagnosis of radiation necrosis was made.