Spontaneous femoral neck fracture resulting from osteonecrosis involving lateral femoral head-neck junction: a retrospective study.

BACKGROUND: Spontaneous femoral neck fracture is a rare condition that remains controversial due to limited reported cases. This retrospective study aims to provide further insights into the etiology and characteristics of the disease. METHOD: We conducted a retrospective review of data from 963 patients with femoral neck fractures. The data encompassed demographic information, medical histories, radiographic records, bone mineral density (BMD) measurements, and pathological examinations. Patients were categorized into two groups: spontaneous femoral neck fracture (SFF) group (30 cases) and control group (933 cases), based on their medical histories. Logistic regression analysis was employed to identify risk factors for SFF. Statistical analysis was performed to compare and elucidate the characteristics of SFF within each group. RESULTS: Logistic regression analysis revealed osteonecrosis of the femoral head, steroid use, and osteoporosis as three significant risk factors for SFF. Furthermore, a higher proportion of Garden type I and II fractures, as well as Pauwels type I fractures, were observed in the SFF group compared to the control group. Within the SFF group, a higher proportion of patients with osteonecrosis exhibited Garden type III and IV fractures compared to those with osteoporosis. Additionally, both magnetic resonance imaging (MRI) and pathological examinations demonstrated that osteonecrosis in the SFF group predominantly occurred at the lateral femoral head-neck junction. CONCLUSIONS: Osteonecrosis of the femoral head, particularly involving the lateral head-neck junction, was confirmed as a major risk factor for SFF. Furthermore, SFF exhibits internal heterogeneity based on its different causes.

Histological and micro Computed Tomography analysis of a femoral stress fracture associated with prolonged bisphosphonate use.

BACKGROUND: The origin of atypical femoral fractures (AFF) associated with bisphosphonate therapy remains to be elucidated. In this study, a biopsy of an AFF site is analyzed to determine whether microdamage and/or morphological changes are present in the area of the AFF. MATERIAL AND METHODS: Cortical bone from an AFF region was obtained during a preventive stabilization in a patient with a symptomatic AFF. This bone was scanned using microCT (resolution=0.01 mm), stained with basic fuchsin and analyzed histologically. RESULTS: The diameter of the Haversian canals was higher in the vicinity of the AFF compared to the bone further away from the AFF. The bone mineral density within the cortex ranged from 1020 to 1080 mg HA/cm3. We observed penetration of basic fuchsin into the matrix, which is a tell-tale sign of diffuse damage. DISCUSSION: The higher diameter of haversian canals is likely to result in higher local stresses and consequently increased microdamage. The diffuse microdamage in the biopsy may furthermore be directly related to bisphosphonate use, preventing repair of microdamage, and consequently the development of the AFF. CONCLUSION: Increased porosity of the cortex and accumulation of microdamage might have lead to a stress fracture and ultimately a complete AFF.

[Spontaneous fracture: a potential clinical concern].

Spontaneous fracture is an issue of increasing concern in clinical care. However, this topic has received only limited attention in nursing research. Gaps in understanding related to spontaneous fractures may increase medical-legal risks faced by frontline care nurses, exacerbate nursing pressures, and serve as a disincentive to remain in the already understaffed nursing profession. This article reviews previous research on spontaneous fractures to determine the epidemiological causes of clinical spontaneous fracture and identify effective prevention strategies. We hope this paper may increase clinical practitioner and expert awareness of spontaneous fractures; help establish a screening mechanism to identify high risk spontaneous fracture patients; and help nurses develop and implement proactive prevention / treatment strategies to strengthen awareness of this topic among patients and their families.

Axial Axis Metastasis.

Axial axis metastasis remains a challenge for surgical as well as other treatment modalities, like chemotherapy, immunotherapy, and radiotherapy. It is unequivocal that surgery provides pain improvements and preservation of neurological status, but this condition remains when associated with radiotherapy and other treatment modalities. In this review, we emphasize the current forms of surgical treatment in the different regions of the spine and pelvis. The evident possibility of percutaneous treatments is related to early or late cases, and in cases in which there are greater risks and instability to conventional surgeries associated with radiotherapy and have been shown to be the appropriate option for local control of metastatic disease.

Spontaneous fracture of a titanium mesh cranioplasty implant in a child: A case report.

BACKGROUND: Titanium mesh cranioplasty is often performed after decompressive craniectomy. Spontaneous fracture of the titanium prosthesis is an extremely rare postoperative complication. Here, we report a 10-year-old boy who presented with a spontaneous fracture of titanium mesh without antecedent head trauma. CASE SUMMARY: A 10-year-old boy presented with a 1-wk history of a tender bulge over the left temporo-parieto-occipital scalp. He had undergone a temporo-parieto-occipital titanium mesh cranioplasty 26 mo previously. He denied antecedent head trauma. Computerized tomography disclosed a perpendicular fissure in the titanium mesh, suggesting a diagnosis of spontaneous titanium mesh fracture. He underwent a second temporo-parieto-occipital cranioplasty and made an uneventful recovery. Three-dimensional modeling and finite element analyses were used to explore potential risk factors of titanium mesh fracture. CONCLUSION: We report a case of spontaneous fracture of a titanium mesh cranioplasty implant. The current case and literature review indicate that titanium mesh implants should be well-anchored to the base of bony defects to prevent fatigue-induced fractures.

Clinical and Radiological Aspects of Cough-induced Rib Fractures: A Case Report.

Cough-induced rib fracture is a very rare condition, with a few cases described in the medical literature. This case report describes the case of a 77-year-old male patient with a history of chronic obstructive pulmonary disease (COPD) who presented with left eighth and ninth rib fractures after severe cough secondary to upper respiratory tract infection. The patient had a good clinical outcome, followed by conservative management. Conservative treatment is the first-choice approach in cases of daily activities limiting symptoms or complications. Cough-induced rib fracture should be remembered as a possible diagnosis, as diagnostic delays increase the risk of complications.

"Noodle-like" deformity and spontaneous fracture of the lower limbs in uremia-a case report.

Renal osteopathy is common in patients with end-stage renal disease. For certain patients, treatment opportunities are lost due to extremely superstition and poor compliance. This article reports a rare case in which the patient developed "noodle-like" deformity of the bilateral lower limbs and spontaneous fracture of bilateral distal end of femur. The purpose of this article is to offer a warning to future patients.

Spontaneous intraoperative lumbar fracture leading to an unexpected correction in ankylosing spondylitis corrective surgery - a case report.

Severe kyphotic deformity in patients with ankylosing spondylitis can be corrected surgically to achieve a better spinal alignment and an improved visual axis. Different surgical techniques are used today depending on the extent of ossification and the degree of kyphosis. It is well known that the underlying disease leads to distinct biomechanical changes of the spinal column causing an increased fracture risk especially in case of minor trauma. This includes manipulations during surgical procedures as well as during the required perioperative measures. We present the case of a 45-year-old patient with severe global kyphotic deformity due to ankylosing spondylitis. During the elective corrective surgery (pedicle subtraction osteotomy at the level of L3) the patient sustained a spontaneous fracture at L2/3. This fortunately nondisplaced wedge-shaped fracture in the sense of a Smith-Peterson osteotomy led to a spontaneous correction of the kyphosis. The described unexpected event required a change in the surgical strategy. Correction could be achieved using a two-stage surgical procedure without further drawbacks for the patient. This case report stresses the need of particular attention regarding the increased susceptibility of the spinal column in case of ankylosing spondylitis.

A rare complication of ipsilateral femoral neck fracture after removal of the long Gamma nail in a healed intertrochanteric fracture.

Ipsilateral femoral neck fracture after hardware removal in healed trochanteric fracture is a rare complication. We reported a case of a 79-year-old woman who had undergone open reduction and internal fixation for her left intertrochanteric fracture with a long Gamma nail about 1 year ago. She asked for implants removal due to local irritation. However, 5 days after implants removal, left subcapital femoral neck fracture occurred. Removal of implants under elective indications could lead to high complication rate. Orthopedic surgeons should perform the removal of hardware in healed intertrochanteric fracture for very selected cases.

Fulminant Skeletal Failure in a Centenarian: The Impact of Nutrition and Immobility.

This case describes a 103-year-old lady who presented from home with an incidental diagnosis of a left femoral fracture. She had no history of trauma and denied pain. She had a known diagnosis of osteoporosis, and sustained a fracture of the contralateral femur aged 93 which was managed conservatively. She was bed-bound with fixed contractures, poor oral intake and was non-compliant with prescribed calcium/vitamin D supplementation. Clinical biochemical measurements showed severe vitamin D deficiency and mild hypocalcaemia. Secondary hyperparathyroidism in the setting of an inappropriately normal phosphate suggested concurrent renal bone disease. Biomarkers of bone turnover were also consistent with bone remodelling. The history of prior fragility fractures, severe vitamin D deficiency and immobility supports a diagnosis of osteoporotic fracture, however other causes of spontaneous fracture were also considered. This case highlights the complexity of interpreting clinical biochemistry results in the setting of multi-morbidity and addresses the challenges of bone health management in the frail older person.

Mesenchymal Cell-Derived Juxtacrine Wnt1 Signaling Regulates Osteoblast Activity and Osteoclast Differentiation.

Human genetic evidence demonstrates that WNT1 mutations cause osteogenesis imperfecta (OI) and early-onset osteoporosis, implicating WNT1 as a major regulator of bone metabolism. However, its main cellular source and mechanisms of action in bone remain elusive. We generated global and limb bud mesenchymal cell-targeted deletion of Wnt1 in mice. Heterozygous deletion of Wnt1 resulted in mild trabecular osteopenia due to decreased osteoblast function. Targeted deletion of Wnt1 in mesenchymal progenitors led to spontaneous fractures due to impaired osteoblast function and increased bone resorption, mimicking the severe OI phenotype in humans with homozygous WNT1 mutations. Importantly, we showed for the first time that Wnt1 signals strictly in a juxtacrine manner to induce osteoblast differentiation and to suppress osteoclastogenesis, in part via canonical Wnt signaling. In conclusion, mesenchymal cell-derived Wnt1, acting in short range, is an essential regulator of bone homeostasis and an intriguing target for therapeutic interventions for bone diseases. © 2019 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.

CT bone density analysis of low-impact proximal femur fractures using Hounsfield units.

AIM: To quantify and compare changes in bone mineral density (BMD) via CT analysis in patients with and without spontaneous femoral fractures. MATERIALS AND METHODS: Consecutive series of patients with CT imaging for spontaneous femoral fractures were compared to the age and gender matched controls. Bone density fixed region of interest measurements were obtained at the site of the fracture, proximally at the femoral head, and distally at the lesser trochanter in fracture patients and controls. Inter- and intrapatient comparisons were performed, including Chi-square and t-test analyses. RESULTS: 24 spontaneous fractures and 25 controls were analyzed with no significant differences in mean age, gender, or body mass index. There were differences in the bone density between the fracture and contralateral non-fracture sides at (p = 0.0001) and distal (p < 0.0001) to the fracture. Proximal and distal bone density differences existed between case fracture and control non-fracture sites (p < 0.0001, p = 0.0001), and between the case non-fracture and control non-fracture sites (p < 0.0001, p < 0.0001). The reliability for measurements was good to excellent proximally (ICC = 0.63-0.87), moderate to excellent at the fracture site (ICC = 0.43-0.78), and fair to good distal (ICC = 0.24-0.68) to the fracture site. CONCLUSION: Patients with spontaneous femoral fractures exhibit lower bone density than the asymptomatic controls. Bone insufficiency is best demonstrated proximal or distal to, rather than at the fracture site.

Spontaneous fracture of indwelling pleural catheter.

Indwelling pleural catheters (IPCs) are increasingly used for the management of symptomatic malignant pleural effusion worldwide. IPCs have been documented to reduce the number of hospital bed days in patients with malignant pleural effusion and thus are often used as the preferred mode of management in fit healthy patients with good performance status. Complications related to IPCs, mainly in the form of pleural infection and needle tract metastasis, are well reported in the literature. Similarly, fracture of IPCs is a recognized complication during the process of IPC removal. We report the first ever case of spontaneous fracture of IPC in a patient with Stage IV lung cancer with malignant pleural effusion who was undergoing active chemotherapy and symptomatic management of the pleural effusion with an IPC.

Lethal fat embolism complicating Sotos syndrome.

Sotos syndrome is a rare congenital syndrome caused by deletions or mutations in the NSD1 gene (chromosome 5q35) which results in overgrowth. A wide range of manifestations may result in unexpected and/or early death, including congenital cardiac malformations and tumours, epilepsy, intra-tumoural haemorrhage or embolism and bleeding diatheses. A case of lethal pulmonary fat embolism complicating revision of a left total hip replacement following spontaneous fracture is reported in a 39-year-old man with Sotos syndrome. This case demonstrates that orthopaedic problems later in life may be added to potential causes of premature death in this syndrome.

Axial Axis Metastasis / Metástase do eixo axial

Abstract Axial axis metastasis remains a challenge for surgical as well as other treatment modalities, like chemotherapy, immunotherapy, and radiotherapy. It is unequivocal that surgery provides pain improvements and preservation of neurological status, but this condition remains when associated with radiotherapy and other treatment modalities. In this review, we emphasize the current forms of surgical treatment in the different regions of the spine and pelvis. The evident possibility of percutaneous treatments is related to early or late cases, and in cases in which there are greater risks and instability to conventional surgeries associated with radiotherapy and have been shown to be the appropriate option for local control of metastatic disease.

Resumo As metástases no eixo axial permanecem um desafio para o tratamento cirúrgico bem como para outras modalidades, como quimioterapia, imunoterapia e radioterapia. É inequívoco que a cirurgia proporciona melhorias na dor e na preservação do status neurológico; porém, há permanência desta condição quando associada à radioterapia e a outras modalidades de tratamento. Nesta revisão damos ênfase às formas de tratamento cirúrgico atuais nas diferentes regiões da coluna vertebral e pelve. A evidente possibilidade de tratamentos percutâneos está relacionada a casos iniciais ou tardios, bem como a casos em que há maiores riscos e instabilidade às cirurgias convencionais associadas à radioterapia, e tem se mostrado a opção adequada para o controle local da doença metastática.

A Case Report of an Unusual Case of Tuberculous Osteomyelitis Causing Spontaneous Pathological Fracture of Humerus in a Middle Aged Female.

INTRODUCTION: Tuberculosis is a major health problem worldwide. Extrapulmonary tuberculosis is often secondary to some primary foci in lungs. There are reports of tuberculous osteomyelitis involving maxilla, ulna, femur, and shoulder joint but none have reported pathological fracture in humeral diaphysis due to tuberculosis osteomyelitis without shoulder joint involvement. We report a case of pathological fracture of humerus diaphysis due to tuberculous osteomyelitis with normal articular space. We noticed favorable outcome following surgery and antitubercular drugs. CASE REPORT: A 62-year-old female diabetic patient presented with complaints of pain in the right shoulder of 2 weeks duration and inability to raise right arm. Initial clinical evaluation revealed local rise of temperature, tenderness over the right shoulder and proximal arm and restricted range of movements in all plane. Neurologically, the patient was normal. Erythrocyte sedimentation rate was raised. Computed tomography chest showed small area of consolidation in the left upper lobe. Plain radiograph of the right shoulder with humerus showed transverse fracture of proximal shaft of the right humerus. J-needle biopsy was done from proximal humerus fracture site. Histopathological examination of biopsy tissue from fracture site confirmed granuloma with epithelioid and Langhan's giant cells. Mantoux test and culture for acid-fast bacilli were non-conclusive. Based on histopathology report, we concluded this to be tuberculous osteomyelitis of humerus and the patient was started on category 1 antitubercular drugs, under Revised National Tuberculosis Control Programme as per revised WHO guidelines. We performed open debridement and fixation of fracture with rush nail. Initial follow-up 4 months, post-operative and plain radiograph showed overall improvement in general condition of the patient, weight gain, and good fracture healing. One year following index surgery, rush nails were removed due to pain at insertion site. Fracture healed completely. Shoulder abduction and forward flexion were restricted in terminal 30°, internal and external rotation, and adduction was full compared to opposite shoulder. CONCLUSION: Tuberculosis is very common in India, but its presentation as spontaneous fracture of humerus is unusual. It is highly likely that most orthopedician will encounter and treat tuberculosis and our case highlights the high degree of suspicion one must have in diagnosing pathological fracture of long bones. Error in diagnosis and treatment burdens the medical resources and overall morbidity.

Immunoglobulin D Multiple Myeloma Presenting as Spontaneous Fracture.

Immunoglobulin D multiple myeloma is a rare type of multiple myeloma that usually presents as bone pain, fatigue, or weight loss. We report a case of immunoglobulin D multiple myeloma in a 53-year-old Caucasian male patient with previous medical history of anaplastic oligodendroglioma status post-surgical resection who was evaluated for back pain while mowing the lawn. His physical examination showed tenderness over the lower thoracic vertebrae with no sensory or motor impairment. Initial lab investigations showed normocytic anemia and hypercalcemia with low parathyroid hormone. Magnetic resonance imaging of thoracic spine with and without contrast showed acute pathological fracture of the T12 vertebral body with enhancing soft tissue which extended into the left ventral epidural space and left T11-T12 neural foramen. Serum protein electrophoresis showed abnormal protein band in the gamma globulin. Free light chain assay showed serum free kappa which was elevated at 3,090.0 mg/L (reference range 3.3-19.4 mg/L). Immunoglobulin D was elevated at 566.0 mg/dL (reference range <15.3 mg/dL). The patient was successfully treated with standard chemotherapy and autologous peripheral blood stem cell transplant with complete remission 3 years after starting treatment. Advancement in the treatment of immunoglobulin D multiple myeloma urge clinicians to offer their patients new treatment options especially as of the earlier presentation of this subtype of multiple myeloma and the previous reports of worse prognosis.

Femoral neck fractures after removal of hardware in healed trochanteric fractures.

INTRODUCTION: Hardware removal in healed trochanteric fractures (TF) in the absence of infection or significant mechanical complications is rarely indicated. However, in patients with persistent pain, prominent material and discomfort in the activities of daily living, the implant is eventually removed. Publications of ipsilateral femoral neck fracture after removal of implants from healed trochanteric fractures (FNFARIHTF) just because of pain or discomfort are rare. The purpose of this systematic review of the literature is to report on the eventual risk factors, the mechanisms, the clinical presentation, and frequency, and to pay special emphasis in their prevention. MATERIALS AND METHODS: A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of FNFARIHTF and series of TF with cases of FNFARIHTF due to pain or discomfort published between inception of journals to December 2016 were eligible for inclusion. Relevant information was divided in two parts. Part I included the analysis of cases of FNFARIHTF, with the objective of establishing the eventual risk factors, mechanisms and pathoanatomy, clinical presentation and diagnosis, treatment and prevention. Part II analyzed series of TF which included cases of FNFARIHTF for assessing the incidence of femoral neck fractures in this condition. RESULTS: Overall 24 publications with 45 cases of FNFARIHTF met the inclusion criteria. We found that the only prevalent factors for FNFARIHTF were: 1) preexisisting systemic osteoporosis, as most patients were older and elder females, with lower bone mineral density and bone mass; 2) local osteoporosis as a result of preloading by the fixation device in the femoral neck, leading to stress protection, reducing the strain at the neck, and increasing bone loss and weakness; and 3) the removal of hardware from the femoral neck, with reduction of the failure strength of the neck. The femoral neck fractures were spontaneous, i.e. not related to trauma or fall, in 87.5% of the cases, mostly subcapital, and with no prevalence between displaced and undisplaced fractures. The clinical presentation was that of a spontaneous fracture, and most of the patients consulted because of hip pain and presented in the emergency room walking by themselves which led to delayed diagnosis in several instances. Radiological diagnosis was mostly with radiographs, though in some cases CT scans or MRI were necessary. The overall median incidence of this complication was 14.5% after hardware removal because of pain or discomfort in healed trochanteric fractures. CONCLUSION: The risk factors for FNFARIHTF seem to be preexisisting systemic osteoporosis, local osteoporosis as a result of preloading by the fixation device in the femoral neck, and the removal of hardware from the femoral neck, with reduction of the strength of the neck. The clinical presentation may be obscure as most of the patients complain of hip pain of some days or weeks, and arrive in the hospital walking. Therefore, the attending physician should be alert in order to request the appropriate radiological investigation and if this is not clear CT scan or MRI should be done in order to diagnose promptly these "spontaneous" fractures. Treatment should be replacement surgery in most cases; however, there is some place for internal fixation especially in undisplaced fractures or younger patients. The occurrence of the femoral neck fracture after hardware removal may be prevented with re-osteosynthesis and the use of bone chips or bone substitutes. Finally, the relatively high incidence of this complication should alert orthopaedic surgeons to reduce the removal of hardware in healed trochanteric fractures to very selected cases.

A man with a fracture from minor trauma.

BACKGROUND: We commonly encounter fractures secondary to trauma on and off in our daily practice. While it is not uncommon to see fractures due to underlying pathology, we need to be on the alert when patients present atypically because the treatment for pathological fractures is far different from that for simple fractures. METHODS: We presented a case of left clavicle fracture secondary to minor trauma, in which the initial X-ray shows suspicious lesion around the fracture site and further investigation reveals multiple myeloma. The patient received treatment at the clinical oncology department upon diagnosis. Since he was relatively young and fit, he was started on the induction therapy of VTD, which was followed by high dose melphalan and autologous stem cell transplant. RESULTS: He is currently free from symptoms and on maintenance thalidomide. CONCLUSIONS: Though multiple myeloma is not commonly encountered in emergency practice, earlier identification of relatively subtle symptoms can allow early treatment. Missing this diagnosis will delay treatment and produce severe outcome to the patient. We should be on the alert for such important condition.

Spontaneous Fracture of the Humerus 18 Months after a High Voltage Electrical Injury: A Case Report.

Electrical burn occurs when a current passes through the body, interfering with the function of internal organs or sometimes burning tissue. Four major mechanisms of electricity-induced injuries are presently known. In this case report, a 29-year-old farmer sustained electrical trauma to extremities from a high voltage transformer, followed by a major, deep burn wound on upper lateral aspect of his left arm, and a deep burn wound over the left medial ankle. After a few months, the patient developed left arm fracture with complete separation of two segments, and plantar wound with purulent discharge accompanied by complete destruction of the head of 4th metatarsal bone which was in favor of chronic osteomyelitis. In this case, passage of the high voltage current and direct trauma could destroy metaphyseal, medullary and periosteal blood supply. Patients with high voltage electrical-induced bone injuries who underwent reconstructive surgery seem to be susceptible to osteonecrosis and pathologic fractures; therefor, these patients should be under close follow-up and periodic radiologic evaluations may be recommended.