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1/52. Type I osteogenesis imperfecta: diagnostic difficulties.

    A 65-year-old woman presented with vertebral fractures of the lumbar spine and a history of pathological fractures following minor trauma, which had occurred before the onset of menopause. Her past medical history was significant for intermittent low back pain since childhood, which was attributed to thoracolumbar scoliosis. A diagnosis of unclassifiable osteoporosis was made until invasive diagnostic procedures suggested a mild form of type I osteogenesis imperfecta (OI). In unclear or atypical perimenopausal osteoporosis and diagnosis of OI should be considered.
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ranking = 1
keywords = fracture
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2/52. Insufficiency fracture of the femoral neck after intramedullary nailing.

    We report a patient with insufficiency fracture that occurred after intramedullary nailing for a subtrochanteric fracture. Intramedullary nailing is speculated to have increased the stress in the already osteoporotic subcapital region. It therefore should be recognized as a causative factor in insufficiency fracture of the femoral neck. Careful follow-up is needed for patients with this condition.
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ranking = 3.5
keywords = fracture
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3/52. Intrathecal infusion of bupivacaine with or without buprenorphine relieved intractable pain in three patients with vertebral compression fractures caused by osteoporosis.

    BACKGROUND AND OBJECTIVES: At present, there is no reliable method of relieving "refractory" pain in patients with compression fractures of the vertebral bodies caused by osteoporosis. We explored the possibility of relieving this type of pain by intrathecal (i.t.) infusion of bupivacaine with or without buprenorphine. methods: An 18-g nylon i.t. catheter was inserted via a lumbar interspace with its tip positioned at the level of the fractured vertebra from which the maximal pain originated. bupivacaine (2.375-5.0 mg/mL) with (n = 1) or without (n = 2) buprenorphine (0.015 mg/mL) was infused through the i.t. catheter from an external electronic pump. The infusion began in the operating room at a basic rate of 0.1-0.2 mL/h, with optional bolus doses (0.1 mL, 1-4 times/h) via patient controlled analgesia. The daily dose of i.t. bupivacaine was adjusted to provide satisfactory pain relief [visual analogue scores (VAS) = 0-2 on a scale of 0-10]. RESULTS: Satisfactory pain relief was obtained with daily doses of i.t. bupivacaine ranging from 10 to 70 (mean approximately 25) mg and buprenorphine from 0.02 to 0.2 (mean = 0.15) mg. The duration of i.t. treatment was 37, 387, and 407 days, respectively. Two patients terminated the i.t. treatment when it was no longer needed. Treatment was discontinued in the third patient because of death caused by irreversible heart failure. The 2 surviving patients were still free of pain 1,074 and 1,476 days after termination of the i.t. treatment. No severe complications occurred. CONCLUSIONS: Continuous intrathecal infusion of bupivacaine, with or without buprenorphine, appeared to be an effective method for the long-term treatment (months to > 1 year) of "refractory" pain from vertebral compression fractures, in this small group of patients.
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ranking = 3.5
keywords = fracture
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4/52. 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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ranking = 3.5
keywords = fracture
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5/52. Cardiac cause of hypoxaemia in a kyphoscoliotic patient.

    This report presents the case of a 73 yr-old female in whom kyphoscoliosis, osteoporotic vertebra compression fractures and sternal injury resulted in severe respiratory failure and hypoxaemia. Pulmonary function testing showed moderate restrictive pattern and rare mismatches were found on lung ventilation/perfusion scanning. Transoesophageal echocardiography with contrast studies showed abnormal anatomic mediastinal interactions which led to right-to-left interatrial shunt, through patent foremen ovale. First-intention treatment, because of orthopaedic and respiratory surgical restraints, was to close the shunt using transcatheter devices. Follow-up after 6 months demonstrated that these interauricular umbrella devices corrected arterial hypoxaemia. True right-to-left interatrial shunts can be found in kyphoscoliotic patients, as a result of thoracic deformation, and can be safely treated with percutaneous trancatheter closure.
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ranking = 0.5
keywords = fracture
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6/52. 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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ranking = 5.5
keywords = fracture
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7/52. 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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ranking = 2
keywords = fracture
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8/52. Sacral insufficiency fractures: a report of two cases and a review of the literature.

    Sacral insufficiency fractures (SIF) are a type of stress fracture that occur primarily in postmenopausal women. They were first described in 1982 by Lourie and have since been frequently overlooked as a cause of low back, buttock, or groin pain. We present two cases of SIF to demonstrate the clinical presentation, diagnosis, and treatment of patients with SIF. Both patients were elderly women with complaints of pelvic and low back pain in the absence of significant trauma. physical examination was significant for marked sacral tenderness. diagnostic imaging supported the diagnosis of SIF. Both patients underwent early rehabilitation, including early ambulation, and had good functional outcomes. These patients serve to illustrate how conservative treatment yields excellent clinical results in the majority of patients, with most reporting improvement within 1-2 weeks after fracture and complete resolution of symptoms after 6-12 months of treatment.
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ranking = 3.5
keywords = fracture
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9/52. tibia fracture after fibula resection for distal peroneal bypass.

    The lateral approach to the distal peroneal artery has been used by vascular surgeons for 25 years. No complications specifically related to this approach have previously been reported. We reviewed 18 cases of peroneal bypass for limb salvage using the lateral approach with fibula resection and found that two of these cases had ipsilateral tibia fractures within 1 year of the bypass. Eight out of 18 cases were women, and two of these eight had tibia fracture. Both women suffered from osteoporosis. We conclude that tibia fracture is a possible complication of this approach, especially in elderly women with osteoporosis.
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ranking = 3.5
keywords = fracture
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10/52. 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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ranking = 2.5
keywords = fracture
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