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1/43. A case of sternal insufficiency fracture.

    We report a case of insufficiency fracture of the sternum in a 70-year-old female patient with a review of the literature. She complained of sudden onset chest pain and aggravating dyspnea. She has been managed with corticosteroid due to chronic obstructive pulmonary disease for 15 years. diagnosis of sternal insufficiency fracture presented with thoracic kyphosis was made on the basis of absence of trauma history, radiologic findings of lateral chest radiograph, bone scintigraphy and chest computed tomography. Thoracic kyphosis and osteoporosis secondary to menopause, corticosteroid therapy and limited mobility due to chronic obstructive pulmonary disease were considered as predisposing factors of the sternal insufficiency fracture in this patient.
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2/43. osteoporosis. An overview of the National osteoporosis Foundation clinical practice guide.

    During the past decade, numerous organizations and associations have published recommendations for the prevention and treatment of osteoporosis. For the primary care physician, the most applicable of these--due to its reliance on clinical trial data and its scope--is the clinical guide published by the National osteoporosis Foundation. The guide addresses risk assessment, bone mineral density testing, diagnosis, nutritional supplementation, and pharmacologic therapy, including consideration of the newer agents used to slow or manage osteoporosis progression. Reflecting one of the key deficiencies in the clinical trial data, the guide applies predominantly to a patient population of postmenopausal white females. The refined design of new osteoporosis studies will in time allow for recommendations that apply to a more diverse patient population.
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3/43. Insufficiency fractures in rheumatic patients: misdiagnosis and underlying characteristics.

    OBJECTIVE: To report 9 patients with rheumatic diseases referred to our observation due to presumed exacerbation of their rheumatic disease, subsequently diagnosed as stress insufficiency fractures, and to characterize the clinical profile of patients prone to this complication. methods: The medical history of the patients was reviewed with special emphasis on their rheumatic disease, its course, duration and management, their menopausal state, location and characteristics of the fracture, its presentation and the initial presumed diagnosis, the delay in diagnosis, imaging diagnostic tests performed and outcome. Three representative case reports are presented. RESULTS: All 9 patients were women, 8 of them aged 50 years old or more, 8 with rheumatoid arthritis and 1 with polymyalgia rheumatica. They were all treated with corticosteroids and had reduction in their bone mass density when evaluated. Three of the patients presented with subcapital fracture of the femur, 4 had fractures of metatarsal bones and 2 had fractures of the distal tibia. In only one patient was a stress fracture initially suspected. diagnosis was delayed by a mean of 31 days. CONCLUSION: The diagnosis of stress fractures in patients with rheumatic diseases may often be delayed or missed, and thus improperly treated. Increased awareness of this entity is of importance for prompt diagnosis and correct management.
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4/43. osteoporosis overview.

    osteoporosis, a disease characterized by low bone mass, microarchitectural deterioration of bone, and susceptibility to bone fractures, can lead to debilitating pain and deformity. The disease represents a major health problem, particularly in older women. Approximately 1.5 million people in the united states suffer osteoporosis-related fractures annually, and many never gain full recovery. The direct annual health expenditures related to osteoporosis fractures were estimated at $13.3 billion in 1994, but quality of life costs related to osteoporosis are even more profound. Identifying people at risk for osteoporosis and early treatment can minimize its destructive effects. nurses play an important role in the development of strategies to reduce the incidence of osteoporosis and osteoporosis-related fractures, pain, and deformity to help older adults lead healthy, productive lives in their later years.
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5/43. Prevention for the older woman. A practical guide to prevention and treatment of osteoporosis.

    osteoporosis causes approximately 1.5 million low-trauma fracture per year, and at all ages the incidence of fracture is higher in women than in men. risk factors for osteoporotic fractures in postmenopausal women include family history of bone fracture, ethnicity, and weight < 127 pounds. densitometry is used to diagnose osteoporosis and can be performed at intervals to monitor bone density during treatment. The older woman's diet should, in general, include 1,200 to 1,500 mg of calcium and 400 to 800 IU of vitamin d. estrogens, bisphosphonates, selective estrogen receptor modulators, calcitonin, and exogenous parathyroid hormone are pharmacologic therapy options that can preserve and increase bone mass and reduce the risk of fracture.
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6/43. Synchrotron radiation microtomography allows the analysis of three-dimensional microarchitecture and degree of mineralization of human iliac crest biopsy specimens: effects of etidronate treatment.

    Quantitative microcomputed tomography using synchrotron radiation (SR microCT) was used to assess the effects of a sequential etidronate therapy on both three-dimensional (3D) microarchitecture and degree of mineralization of bone (DMB) in postmenopausal osteoporosis. Thirty-two iliac crest biopsy specimens were taken from 14 patients with osteoporosis (aged 64 /- 1.8 years) before (baseline) and after 1 year of etidronate treatment, and after 2 years of treatment for four of the patients. The samples were imaged at high spatial resolution (voxel size = 10 microm) using the microtomography system developed at the European Synchrotron radiation Facility (ESRF), Grenoble, france. Three-dimensional microarchitecture parameters were calculated and compared with those obtained from conventional histomorphometry. In addition, the DMB was evaluated also in 3D. No significant statistical changes regarding bone mass and structural parameters were observed in histomorphometry or 3D analyses. The distribution of the DMB in cortical and trabecular bone showed a trend to a shift toward highest mineralization values after 1 year of etidronate treatment (3.88% and 1.24% in cortical and trabecular bone, respectively). This trend was more evident after 2 years. The study also showed that SR microCT is an accurate technique and the only one for quantifying both the mineralization and the microarchitecture of bone samples at the same time in 3D.
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7/43. Insufficiency fracture of the femoral neck during osteoporosis treatment: a case report.

    Acase of insufficiency fracture of the femoral neck that occurred during treatment for osteoporosis is reported. A 77-year-old woman (height 150 cm, body weight 43 kg) with osteoporosis associated with high bone turnover was treated with oral cyclical etidronate (400 mg/day for 2 weeks every 3 months). Three months after the treatment was started the patient experienced pain in the right hip joint while walking despite no evidence of trauma. Although radiographs were normal, weight-bearing was not possible because of pain. T2-weighted magnetic resonance (MR) imaging was used to detect a fracture line localized on the inferior aspect of the femoral neck. Because on bone marker measurement bone resorption was increased and bone formation was decreased from baseline, treatment was switched to oral alendronate (5 mg/day, daily). Pain resolved 3 weeks after the fracture was evident, and free gait was possible during the following 3 weeks. Follow-up radiographs, obtained 3 and 6 months after the fracture was evident, showed bony sclerosis on the aspect in which the fracture line was observed on the T2-weighted MR image. The dissociation (imbalance) of bone formation and resorption was also alleviated. A possibility of increased bone fragility should be kept in mind when oral cyclical etidronate is applied to elderly Japanese, small-physique women with osteoporosis at a daily dose of 400 mg (higher dose).
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8/43. Aggressive systemic mastocytosis.

    Systemic mastocytosis is a rare and occasionally aggressive condition that raises major diagnostic challenges. We report a case in a 72-year-old patient in whom the diagnosis of malignant mastocytosis required two bone marrow smears and three bone marrow biopsies examined using specific staining techniques. Despite interferon therapy, a mast-cell sarcoma of the sternum developed 1 year after symptom onset, followed 1 year later by acute myeloblastic leukemia, which was rapidly fatal.
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9/43. Bundle nailing in nonunion of the distal radius: case report.

    A previously unreported technique for dealing with severe distal radial nonunion in the presence of marked osteoporosis and deformity in a 65-year-old female is presented. The technique involves temporary ankylosis of the wrist with bundle nails connecting the second and third metacarpal with the distal and proximal fragment of the radius, dorsal to the carpal bones and joints. Union was achieved radiographically after nine months. When the bundle nails were removed, there was some recovery of wrist movement and useful function.
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10/43. An unconventional indication for open kyphoplasty.

    BACKGROUND CONTEXT: kyphoplasty is a means of treatment for painful osteoporotic vertebral body compression fractures. Its efficacy has not yet been totally proven. Even though the conventional percutaneous kyphoplasty is a relatively safe procedure, it is not routinely recommended for use in vertebral body fractures that involve posterior cortical compromise/retropulsion or in fractures associated with neurological deficit. PURPOSE: To see whether the open kyphoplasty procedure can be used in patients with painful vertebral body compression fractures who also have bony retropulsion into the spinal canal. STUDY DESIGN/SETTING: This technical report is based on the experience of one patient. methods: A 79-year-old woman with a history of osteoporosis presented with a painful vertebral body compression fracture at T12. magnetic resonance imaging of her lumbar spine demonstrated an acute compression fracture at T12 with significant decrease in vertebral body height and retropulsion of bone resulting in one-third reduction in canal width. She was not considered a candidate for percutaneous kyphoplasty. Three months after the injury, an open kyphoplasty was performed after a decompression laminectomy at T12. RESULTS: The fractured vertebral body was successfully reduced, and there was no leakage of polymethylmethacrylate into the spinal canal through the fractured posterior cortex using the open kyphoplasty procedure. One month after the operation, the patient was free from mid-back pain and was again able to walk. CONCLUSION: Open kyphoplasty procedure allows direct visualization to the spinal canal. It can be performed safely and effectively in selected vertebral body compression fractures with retropulsed bone associated with neurological deficit.
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