Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients

ObjectivesHistorically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients.MethodsA prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2–4 weeks, and 3, 6 and 12 months after fracture.Results102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2–4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0–8) vs. 5 (0–10), p = 0.19) and ADL scores (85 (25–100) vs. 78.6 (5–100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%.ConclusionsThe vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.     

人为提高儿童肱骨髁上骨折外侧克氏针出针点的可行性及置针经验分析

目的初步探讨人为提高儿童肱骨髁上骨折外侧克氏针出针点的可行性及其相应的置入方法。方法本研究分为两个阶段。第一阶段:收集2016年3月至2016年12月中国医科大学附属盛京医院161例儿童伸直型肱骨髁上骨折外侧针构型病例术中透视图像中最外侧针的出针点和入针点位置,测量最外侧针冠状面和矢状面钢针角度。第二阶段(2017年1月至2017年12月)基于第一阶段的研究结果,由中国医科大学附属盛京医院两名小儿骨科医生尝试人为提高最外侧针的出针位置(预期组),另外两名外科医生继续按照常规流程置针(对照组),对两组各项治疗参数进行比较。结果第一阶段参与回顾性研究的161例患者中,47例(29.2%)最外侧针出针点位于骨干-干骺端交界区(metaphyseal-diaphyseal junction,MDJ)上边界线以上,其中40例最外侧针(85.1%)由肱骨小头骨化中心(ossific nucleus of the capitellum,ONC)外侧或骨化中心外1/3置入(正位像),于骨化中心后1/3或骨化中心后方置入(侧位像)。冠状面和矢状面钢针平均角度分别为58.4°和90.5°。第二阶段,预期组中有47例(65.3%,47/72)患者的最外侧针出针点位于MDJ上边界线以上,而对照组中仅32例(36%,32/89)出针点位于MDJ上边界线以上。两组比较差异有统计学意义(χ2=16.134,P<0.05)结论在单纯外侧针构型中,人为提高最外侧针出针点可行。钢针路径位于正位像肱骨小头骨化中心外侧、外1/3及侧位像在肱骨小头后方或后1/3位置时更容易获得高位的出针点。     

Bone disorders associated with diabetes mellitus and its treatments

Both type 1 and type 2 diabetes mellitus are associated with bone disorders, albeit via different mechanisms. Early studies in patients with type 1 diabetes suggested a 10-fold increase in the hip fracture risk compared to non-diabetic controls. Meta-analyses published more recently indicate a somewhat smaller risk increase, with odds ratios of 6 to 7. Diminished bone mineral density is among the contributors to the increased fracture risk. Both types of diabetes are associated with decreased bone strength related to low bone turnover. The multiple and interconnected pathophysiological mechanisms underlying the bone disorders seen in type 1 diabetes include insulin deficiency, accumulation of advanced glycation end products, bone microarchitecture alterations, changes in bone marrow fat content, low-grade inflammation, and osteocyte dysfunction. The bone alterations are less severe in type 2 diabetes. Odds ratios for hip fractures have ranged across studies from 1.2 to 1.7, and bone mineral density is higher than in non-diabetic controls. The odds ratio is about 1.2 for all bone fragility fractures combined. The pathophysiological mechanisms are complex, particularly as obesity is very common in patients with type 2 diabetes and is itself associated with an increased risk of fractures at specific sites (humerus, tibia, and ankle). The main mechanisms underlying the bone fragility are an increase in the risk of falls, sarcopenia, disorders of carbohydrate metabolism, vitamin D deficiency, and alterations in cortical bone microarchitecture and bone matrix. The medications used to treat both types of diabetes do not seem to play a major role. Nevertheless, thiazolidinediones and, to a lesser extent, sodium-glucose cotransporter inhibitors may have adverse effects on bone, whereas metformin may have beneficial effects. For the most part, the standard management of bone fragility applies to patients with diabetes. However, emphasis should be placed on preventing falls, which are particularly common in this population. Finally, there is some evidence to suggest that anti-fracture treatments are similarly effective in patients with and without diabetes.     

不同干预措施治疗腕舟骨骨折的网状Meta分析

目的采用网状Meta分析系统评价石膏固定、空心螺钉、Herbert螺钉、克氏针固定四种干预措施治疗腕舟骨骨折的疗效。方法检索建库至2019年12月31日的PubMed、EMbase、Cochrane Library、Glinical Trial、中国学术期刊网络出版总库(CNKI)、中国生物医学文献数据库(CBMdisc)、维普科技期刊数据库(VIP)、万方医学网等数据库所收录的腕舟骨骨折治疗随机对照试验,采用Stata 16.0对符合纳入标准的文献数据进行网状Meta分析及作图。结果纳入16篇文献,参与研究患者1193例。经网状Meta分析结果表明,治疗有效率方面,空心螺钉、Herbert螺钉、克氏针三种干预措施疗效均优于石膏固定,愈合时间均短于石膏固定。结论治疗腕舟骨骨折有效率、愈合时间SUCRA排序均为空心螺钉>Herbert螺钉>克氏针>石膏固定,因此空心螺钉成为最佳治疗措施的可能性最大。