Fractura de odontoides en un paciente anciano con mala evolución final: a propósito de un caso y revisión de la bibliografía existente

Odontoid fractures are the most common cervical spine fracture in elderly patients, with falls being the most common mechanism of fracture in these patients. The clinical symptoms range from mild neck pain to quadriplegia, or even death. Treatment options include surgical and non surgical therapies, such as cervical collar or halo vest.     

Overview of osteoporosis.

Osteoporosis is a common age-related disorder manifested clinically by skeletal fractures, especially fractures of the vertebrae, hip, and distal forearm. The major cause of these fractures is low bone mass, although an increase in trauma due to falls in the elderly also contributes. There are multiple causes for the low bone mass which, in any given individual, may contribute differently to the development of the osteopenia. The most important groups of causes are failure to achieve adequate peak bone mass, slow bone loss due to processes relating to aging, the menopause in women, and a variety of sporadic behavioral, nutritional, and environmental factors that affect bone mass in some but not in other individuals. The most important approach is prevention. Drugs and behavioral factors known to cause bone loss should be eliminated and perimenopausal women should be evaluated for possible preventive administration of estrogen. For patients with fractures due to established osteoporosis, the only drugs approved by the Food and Drug Administration are the antiresorptive agents calcium, estrogen, and calcitonin. Formation-stimulating regimens, however, are being developed and may be available for clinical use in the foreseeable future. These regimens may be capable of increasing bone mass to above the fracture threshold, thereby resulting in a clinical cure of the osteoporosis.     

Management of osteoporosis

Osteoporosis or osteopenia occurs in about 44 million Americans, resulting in 1.5 million fragility fractures per year. The consequences of these fractures include pain, disability, depression, loss of independence, and increased mortality. The burden to the healthcare system, in terms of cost and resources, is tremendous, with an estimated direct annual USA healthcare expenditure of about $17 billion. With longer life expectancy and the aging of the baby-boomer generation, the number of men and women with osteoporosis or low bone density is expected to rise to over 61 million by 2020. Osteoporosis is a silent disease that causes no symptoms until a fracture occurs. Any fragility fracture greatly increases the risk of future fractures. Most patients with osteoporosis are not being diagnosed or treated. Even those with previous fractures, who are at extremely high risk of future fractures, are often not being treated. It is preferable to diagnose osteoporosis by bone density testing of high risk individuals before the first fracture occurs. If osteoporosis or low bone density is identified, evaluation for contributing factors should be considered. Patients on long-term glucocorticoid therapy are at especially high risk for developing osteoporosis, and may sustain fractures at a lower bone density than those not taking glucocorticoids. All patients should be counseled on the importance of regular weight-bearing exercise and adequate daily intake of calcium and vitamin D. Exposure to medications that cause drowsiness or hypotension should be minimized. Non-pharmacologic therapy to reduce the non-skeletal risk factors for fracture should be considered. These include fall prevention through balance training and muscle strengthening, removal of fall hazards at home, and wearing hip protectors if the risk of falling remains high. Pharmacologic therapy can stabilize or increase bone density in most patients, and reduce fracture risk by about 50%. By selecting high risk patients for bone density testing it is possible to diagnose this disease before the first fracture occurs, and initiate appropriate treatment to reduce the risk of future fractures.     

Orthopaedic and dental abnormalities in osteogenesis imperfecta: a review of the literature

Osteogenesis imperfecta is one of the most commonly recognized inheritable disorders of the connective tissue leading to bone fragility. Usually it is associated to a genetic mutation inducing a reduction in collagen quality and entity production. It involves either modification in dentin formation or multiple bone fractures. The authors reviewed the clinical aspects of these disorders, focusing on oral and orthopaedic concerns, especially related to the histological features of the fracture callus, with respect to new trends in pharmacological and surgical treatments of bone fractures. Surgical treatment varies, according to the age of the patient. In children, surgical orthopaedic procedures include multiple osteotomies and the use of telescopic rods. Medical therapy has always to be associated to surgery and is designed to reduce the incidence of fractures, to increase growth velocity and to ally pain in order to improve mobility and independence. Bisphosphonates (BP) are considered potent inhibitors of bone resorption decreasing the osteoclast population and its activity and bone turn over.     

Fracture management of civilian gunshot wounds to the hand

Civilian gunshot wounds to the hand are typically caused by low-velocity weapons, which create a localized pattern of soft-tissue and bone injury that usually allows for early definitive treatment. A retrospective chart review of 72 patients treated for 98 gunshot wound fractures at an urban level I trauma center was conducted to evaluate the results of limited debridement and early definitive fracture fixation of urban gunshot wound fractures of the hand. The incidence of hand fractures, means of fracture fixation, number of operations, occurrence of infection, and level of patient compliance were determined. Twenty-nine fractures were managed definitively with reduction and splinting in the emergency department or intensive care unit. Sixty-eight fractures were treated surgically, at a mean of 2 days after injury. Eleven patients required more than one operation. The overall infection rate was 8 percent and was not influenced by the fracture fixation method. All infections were superficial and resolved with antibiotics alone. Thirty-nine percent of patients were lost to follow-up after hospital discharge and 85 percent of patients were lost to follow-up before documented fracture healing. Twenty-six percent of patients were lost to follow-up with a removable fixation device in place. Limited debridement and early definitive fracture fixation are associated with low rates of complications for typical civilian handgun wound fractures. Cases with extensive injury or contamination do require a staged approach to treatment. Poor patient compliance in the urban trauma setting should be expected and may affect the management plan.     

Septal fracture in simple nasal bone fracture

SUMMARY: Nasal bone fractures are the most common type of facial fractures. Previous studies have shown that most nasal fractures involve the septum, which can provide an obstacle to the successful reduction of nasal bone fractures. In particular, septal fractures in combination with simple nasal bone fractures are usually unrecognized and untreated at the time of injury. Furthermore, systemized treatment protocols and diagnostic tools for septal fractures in the case of simple nasal bone fracture have not previously been presented. In this study, the clinical findings of septal fractures in cases of simple nasal bone fracture were correlated with symptoms, signs, and computed tomography findings and assessed statistically. The patterns of septal fractures in simple nasal bone fractures were assessed by direct vision via hemitransfixion incision. Of the 52 patients with simple nasal bone fracture who presented over a 3-year period and were included in this study, 10 were female and 42 were male, with an average age of 33.8 years (age range, 18 to 61 years). Fifty of these patients (96.2 percent) showed septal fractures, and septoplasty or submucosal resection was performed on 41 patients (78.8 percent) who manifested severe septal fractures of perioperative septal grade 3 or higher. Closed reduction of the nasal bone fracture only was performed on the remaining 11 patients. Among the signs evident at physical examination, mucosal tearing was found to be statistically significant for septal fracture. Computed tomography was found to be very helpful in diagnosing septal fracture but could not predict its severity accurately (Spearman correlation coefficient between computed tomography septal grading and perioperative septal grading, 33.5 percent). Therefore, computed tomography could not be used as a definitive diagnostic modality for septal fractures in terms of deciding whether septoplasty or submucous resection was needed. It is evident that septal fractures are frequent in simple nasal bone fractures that are not combined with other facial bone fractures. This study confirms that there are differences between radiologic findings and perioperative findings. To reduce the incidence of posttraumatic nasal deformity, meticulous physical examinations with subsequent septoplasty or submucosal resection are needed in the treatment of simple nasal bone fracture.     

Relevance of bone mineral density, bone quality and falls in reduction of vertebral and non-vertebral fractures

All epidemiological studies conclude that without prompt, concerted and well-designed prevention programs, the increasing cost related to osteoporotic fractures will become an unbearable burden for the community within the next fifteen years. However, the most effective way of setting up such preventive strategies is not yet unequivocally defined. Low bone mass and microarchitectural damage of bone tissue may account for a large part of the epidemiology of vertebral fractures. Extraskeletal determinants, including low muscle strength, poor balance and gait, all resulting in an increased propensity to fall, also play a major role in the occurrence of hip fracture. Depending on the localization of the fractures, the relative importance of skeletal and extraskeletal risk factors can significantly differ. For prevention of vertebral fractures, drugs affecting bone mass and skeletal architecture may provide a substantial benefit while hip fracture prevention will be more successfully targeted by multi-faceted strategies concentrating not only on the skeletal dimension of the fracture but also aiming, either pharmacologically or through multi-intervention programs, at a reduction in the incidence and in the consequences of falls in the elderly.     

8. Self-compressing implants in the management of fractures.

Internal fixation of fractures has become increasingly important since the introduction of self-compressing implants. Rigidity of fixation thus ensured permits primary bone healing. Two types of self-compressing implants are available--screws and plates. The former produces compression between fracture fragments, the latter, along the long axis of the bone. Two common types of plates are the dynamic compression plate and the Osteo self-compressing plate. Use of self-compressing implants requires familiarity with the technique, a definite plan of operation, and strict asepsis and lack of infection in the patient. Indications for the technique include failure or unsuitability of closed reduction of fractures, care of associated serious soft-tissue injuries, and displaced intra-articular fractures. Use of self-compressing plates hastens rehabilitation, lessens joint stiffness and reduces the duration of hospitalization. The incidence of nonunion with self-compression techniques is lower than with traditional methods of fracture management.     

Bone loss: Quantitative imaging techniques for assessing bone mass in rheumatoid arthritis

Osteoporosis is associated with low bone mass and microarchitectural deterioration of bone tissue with clinical manifestation of low trauma fractures. Rheumatoid arthritis (RA) is a risk factor due to generalized and articular bone loss. This minireview presents past and current bone mass measurement techniques in RA. These techniques include: plain radiographs, absorptiometry, quantitative computed tomography (QCT) and ultrasound. The most widely used technique is dual x-ray absorptiometry (DXA). RA patients have lower bone mass as compared with normals and substantial bone loss may occur early after the onset of disease. Measurement of bone mineral density (BMD) at the hand using either DXA or ultrasound maybe a useful tool in the management of RA patients.     

Bone loss. Quantitative imaging techniques for assessing bone mass in rheumatoid arthritis

Osteoporosis is associated with low bone mass and microarchitectural deterioration of bone tissue with clinical manifestation of low trauma fractures. Rheumatoid arthritis (RA) is a risk factor due to generalized and articular bone loss. This minireview presents past and current bone mass measurement techniques in RA. These techniques include: plain radiographs, absorptiometry, quantitative computed tomography (QCT) and ultrasound. The most widely used technique is dual x-ray absorptiometry (DXA). RA patients have lower bone mass as compared with normals and substantial bone loss may occur early after the onset of disease. Measurement of bone mineral density (BMD) at the hand using either DXA or ultrasound maybe a useful tool in the management of RA patients.     

The therapeutic effects of alfacalcidol on bone strength, muscle metabolism and prevention of falls and fractures

Established osteoporosis in older patients of both sexes is characterized by decoupled bone remodelling induced by sex hormone deficits and by somatopause, but also by lack of vitamin D and reduced synthesis of the D-Hormone (calcitriol; 1.25 (OH)2D) in the kidneys and bone, as well as from lack of receptors and/or receptor affinity for D-Hormone in the target organs. Parallel to the decreased bone strength a loss of muscle power occurs, together with an increase in balance disorders and an increasing risk of "intrinsic", nonsyncopal locomotoric falls. In alfacalcidol therapy, D-Hormone is provided to the body in circumvention of its own regulation, by means of which higher hormone concentrations can be achieved in the target tissues than by administration of plain vitamin D. In vitro and in vivo experiments have provided growing evidence that D-Hormone analogs tend to normalize PTH, lead to an increase in the number and activity of osteoblasts, reduce the activity of osteoclasts, and might thus normalize the "high bone turnover" in elderly osteoporotic patients ("supercoupling"). In addition, it has been shown that D-Hormone analogs are able to increase muscle power and walking distance in elderly D-Hormone deficient patients. Besides the known effect on the vertebral fracture rate, new clinical data confirm that D-Hormone analogs might reduce peripheral fractures by reducing falls. The expanded understanding of the pathogenesis of glucocorticoid- induced osteoporosis with its disturbed calcium homeostasis and the pharmacological effects of alfacalcidol, which counteract such iatrogenic bone loss, contribute to the understanding of its clinical efficacy in this most frequent form of secondary osteoporosis. Due to its recently discovered immunomodulating properties, alfacalcidol might find a slot in the management of bone loss caused by chronic inflammatory diseases or by organ transplantations. Alfacalcidol has multifactorial effects, among which the best known are its anti-bone loss and anti-fracture efficacies in postmenopausal osteoporosis. This demonstrated efficacy is related to its involvement in bone remodelling, leading to an improved bone strength. Its mode of action on muscle power, which reduces falls, is unique, differentiating this form of therapy from all other anti-osteoporotic drugs, none having demonstrated any influence on falls.     

Human evolution and osteoporosis-related spinal fractures

The field of evolutionary medicine examines the possibility that some diseases are the result of trade-offs made in human evolution. Spinal fractures are the most common osteoporosis-related fracture in humans, but are not observed in apes, even in cases of severe osteopenia. In humans, the development of osteoporosis is influenced by peak bone mass and strength in early adulthood as well as age-related bone loss. Here, we examine the structural differences in the vertebral bodies (the portion of the vertebra most commonly involved in osteoporosis-related fractures) between humans and apes before age-related bone loss occurs. Vertebrae from young adult humans and chimpanzees, gorillas, orangutans, and gibbons (T8 vertebrae, n = 8–14 per species, male and female, humans: 20–40 years of age) were examined to determine bone strength (using finite element models), bone morphology (external shape), and trabecular microarchitecture (micro-computed tomography). The vertebrae of young adult humans are not as strong as those from apes after accounting for body mass (p<0.01). Human vertebrae are larger in size (volume, cross-sectional area, height) than in apes with a similar body mass. Young adult human vertebrae have significantly lower trabecular bone volume fraction (0.26±0.04 in humans and 0.37±0.07 in apes, mean ± SD, p<0.01) and thinner vertebral shells than apes (after accounting for body mass, p<0.01). Since human vertebrae are more porous and weaker than those in apes in young adulthood (after accounting for bone mass), even modest amounts of age-related bone loss may lead to vertebral fracture in humans, while in apes, larger amounts of bone loss would be required before a vertebral fracture becomes likely. We present arguments that differences in vertebral bone size and shape associated with reduced bone strength in humans is linked to evolutionary adaptations associated with bipedalism.     

Long-term effects of aromatase inhibitors on bone

The risk of fracture in the postmenopausal woman given aromatase inhibitors may be increased by up to 60%. This is likely to be true for all third generation drugs, but the clinical trials did not include sufficient fracture events for certainty on this issue. It would appear that most of the excess fracture risk relates to vertebral fracture and in future studies, more effort should be given to ascertaining these fractures. The likely mechanism for the increase in fracture risk is an increase in bone turnover (of about 20%) and an acceleration of bone loss. There is evidence to suggest that the residual levels of oestradiol present in the postmenopausal woman are important for bone health, and thus, the effect of these drugs is to remove this protective effect. Current clinical practice should include the measurement of bone mineral density in postmenopausal women taking these drugs and commencement of antiresorptive therapy if osteoporosis is already present.     

Accurate,firm stabilization using external pins: a proposal for closed reduction of unfavorable nasal bone fractures and their simple classification

Nasal bone fractures are the most common among facial fractures and are the third most common fractures in the human frame. Although many forms of treatment have been introduced, controversy regarding the optimal treatment still remains. Nasal bone fractures are complex, with significantly varying types that are often undermanaged in closed reduction procedures. The authors' experiences with nasal bone fractures have shown that the baseline for surgical intervention depends on the type of fracture and the method of maintenance after reduction, both of which have considerable impact on the final result. Therefore, it is very important and challenging to determine the proper method of reduction and maintenance. The periosteal covering plays an important role in the splinting action after closed reduction, but sagging, depression, and instability remain major complications in some cases. The authors devised a new method of accurate, firm stabilization of the fractured nasal bone by using external pins in those unfavorable fractures determined radiologically to gain optimal reduction and fixation. In the present study, fractures were grouped into favorable and unfavorable fractures, the latter being those that remained unstable or impacted even after reduction and thus needed open reduction. Unfavorable fractures were divided into four subclasses according to radiologic findings: (1) type I (frontal), including chip or tip fractures, which often depress the upper lateral cartilage and tend to sag after reduction; (2) type II (lateral), or laterally depressed segmental fractures with a lateral shift of the arch in fragments or as a unit; (3) type III (mixed), or type II with septal involvement; and (4) type IV (complex), including open or multiple comminuted fractures. After an initial evaluation to determine the fracture type, closed reduction and external fixation were performed for types I, II, and III fractures and open reduction was performed for type IV fractures 5 to 7 days after the fracture. Closed reduction with the use of external pins was done in eight cases: type I (two), type II (four), and type III (two). The mean age of the patients was 27.8 years, and the average follow-up period was 11.7 months. Functional and aesthetic results were satisfactory. This new method for support and fixation is an alternative to the conventional closed reduction and a promising way to prevent secondary deformity.     

PKP治疗骨质疏松性椎体压缩骨折的预后评价及继发危险因素分析

目的:分析椎弓根入路行椎体后凸成形术(PKP)治疗骨质疏松性椎体压缩骨折的预后评价及继发危险因素分析。方法:选择2016年2月-2018年2月我院收治的骨质疏松性椎体压缩骨折患者85例纳入本次研究,采用随机数表法分为观察组(n=43)和对照组(n=42)。对照组使用经皮椎体成形术进行治疗,观察组采用PKP进行治疗。比较两组患者手术情况、术后情况、椎体前缘高度丢失率、Cobb角、继发性骨折发生情况及分析骨质疏松性椎体压缩骨折患者术后继发骨折的危险因素。结果:观察组手术时间、透视次数、骨水泥注入量、术中出血量均显著低于对照组,差异显著(P0.05);观察组疼痛缓解时间、下地时间及住院时间均显著低于对照组,差异显著(P0.05);治疗前,两组椎体前缘高度丢失率、Cobb角比较,无显著差异;治疗后,两组患者的椎体高度丢失率明显下降,但两组术后7 d、术后6月两组椎体前缘高度丢失率、Cobb角比较无显著差异;观察组术后12月椎体前缘高度丢失率、Cobb角低于对照组,差异显著(P0.05);所有患者均随访12月,其中22例(25.88%)发生继发性椎体骨折,进行单因素分析,结果发现,两组患者性别、骨折部位、局部矢状面后凸角度、骨水泥量、椎体高度恢复、术后抗骨质疏松治疗差异无统计学意义(P0.05);骨质疏松原因、骨水泥椎间隙渗漏、术后支具佩戴、原发骨折类型与骨质疏松性椎体压缩骨折患者术后发生继发骨折相关(P0.05)。多因素Logistic分析显示,骨质疏松原因、骨水泥椎间隙渗漏、术后支具佩戴、原发骨折类型均是骨质疏松性椎体压缩骨折患者术后发生继发骨折的独立危险因素(P0.05)。结论:在骨质疏松性椎体压缩骨折患者中应用PKP可有效改善手术情况,随着时间的延长,PKP更有利于维持患者椎体高度;骨质疏松原因、骨水泥椎间隙渗漏、术后支具佩戴、原发骨折类型是骨质疏松性椎体压缩骨折患者术后发生继发骨折的危险因素,临床上对于具有危险因素的患者引起重视,并采取干预措施。     

Glucocorticoid-induced osteoporosis

Osteoporosis is a common and serious complication of glucocorticoid therapy, resulting in increased risk of fragility fractures. Recent studies indicate that fracture risk is increased even at low doses of glucocorticoids and that this increased risk is seen soon after the commencement of glucocorticoid therapy. Both increased bone resorption and reduced bone formation contribute to bone loss, which affects cortical and cancellous sites. A number of interventions have been shown to prevent glucocorticoid-induced bone loss, although the strongest evidence exists for the bisphosphonates etidronate, alendronate and risedronate. Primary prevention of bone loss should be considered in all high-risk individuals taking oral glucocorticoids for 3 months or more, for example those aged 65 years or over or those with a previous fragility fracture. In other glucocorticoid-treated individuals, the decision to treat should be based on bone densitometry.     

Hamann-Todd Collection aging studies: osteoporosis fracture syndrome

The study presents a retrospective analysis of distal radius, proximal femur, vertebral, and sacral fractures that occurred in 938 Hamann-Todd Collection skeletons. Individuals included in the investigation were retrieved from dissecting room cadavers in Cleveland, Ohio, between the years 1910 and 1940. Demographic analysis showed that the mean ages at death for blacks and whites included in the study were 41.9 and 53.8 years, respectively. Evaluations of fracture repair status were made for all fractures that were identified. Observations that document side of involvement and unilateral/bilateral distribution were made for distal radius and hip fractures. It was found that the age-, sex-, and race-related fracture patterns which characterize the early 20th century Hamann-Todd sample strongly correspond in distribution and magnitude to those seen in modern American and European urban industrial communities. The distal radius, hip, vertebral, and sacral fractures which were identified in individuals over 60 years of age appear to be a primary result of skeletal fragility due to age progressive bone loss. However, it is suggested that the early onset and high frequency of distal radius fractures seen in climacteric Caucasian women may be more directly due to accidental falls initiated by a greater frequency, intensity, and duration of vasomotor disturbances which are known to accompanay estrogen withdrawal in perimenopausal white females.     

The Risk of Bone Fractures in Post-Poliomyelitis Patients Transitioning to Middle Adulthood

ObjectiveWhile osteoporotic fractures are reported in up to 40% of adults with post-poliomyelitis syndrome (PPS), clinical guidelines regarding bone mineral density (BMD) and indications for treatment are scarce. We investigated the characteristics of PPS patients, focusing on fractures and osteoporosis as the primary outcomes.MethodsA cross-sectional retrospective data analysis from medical records of 204 PPS patients regarding their clinical characteristics and long-term outcome, with emphasis on bone metabolism status.ResultsOur cohort included 53% women; mean age was 65 years at study entry and 1.7 years at the diagnosis of acute poliomyelitis. The lower limb was involved in 97.5% of patients, and the BMD in the affected limb tended to be lower than the unaffected, with a mean T-score of -1.64 vs. -1.19, respectively (P = .06). Recurrent falls were documented in 39.2% of patients, and osteoporosis in 20.6%, being more frequent in women (P = .003) and patients with fractures (P = .002). At least one fracture occurred in 52.2% of patients, and more than one in 40.3%. The median age for the first fracture was 57.5 years (range, 30 to 83 years), and most fractures occurred in the affected limb (73.2%).ConclusionsUnderdiagnosis and delayed treatment of osteoporosis in late-adulthood post-poliomyelitis patients underlie the need for comprehensive clinical guidelines to manage these patients, including recommendations on bone health assessment, medical treatment, and their inclusion as a high-risk group for bone fractures.     

Off-axis loads cause failure of the distal radius at lower magnitudes than axial loads: a finite element analysis

Distal radius (Colles') fractures are a common fall-related injury in older adults and frequently result in long-term pain and reduced ability to perform activities of daily living. Because the occurrence of a fracture during a fall depends on both the strength of the bone and upon the kinematics and kinetics of the impact itself, we sought to understand how changes in bone mineral density (BMD) and loading direction affect the fracture strength and fracture initiation location in the distal radius. A three-dimensional finite element model of the radius, scaphoid, and lunate was used to examine changes of +/-2% and +/-4% BMD, and both axial and physiologically relevant off-axis loads on the radius. Changes in BMD resulted in similar percent changes in fracture strength. However, modifying the applied load to include dorsal and lateral components (assuming a dorsal view of the wrist, rather than an anatomic view) resulted in a 47% decrease in fracture strength (axial failure load: 2752N, off-axis: 1448N). Loading direction also influenced the fracture initiation site. Axially loaded radii failed on the medial surface immediately proximal to the styloid process. In contrast, off-axis loads, containing dorsal and lateral components, caused failure on the dorsal-lateral surface. Because the radius appears to be very sensitive to loading direction, the results suggest that much of the variability in fracture strength seen in cadaver studies may be attributed to varying boundary conditions. The results further suggest that interventions focused on reducing the incidence of Colles' fractures when falls onto the upper extremities are unavoidable may benefit from increasing the extent to which the radius is loaded along its axis.