钉棒系统与髋臼上外固定架在骨盆TileB1损伤模型中的生物力学比较

目的通过比较钉棒系统与髋臼上外固定架固定骨盆TileB1损伤模型的生物力学稳定性,为临床治疗选择更佳固定方式提供理论依据。方法取近期防腐的正常成人骨盆标本7具,保留从第5腰椎到股骨近端中上2／3的骨盆标本,保留双侧骶髂关节、双侧髋关节、双侧骶髂后韧带、双侧骶髂前韧带、双侧骶棘韧带、双侧骶结节韧带及完整的耻骨联合。将骨盆标本置于AGX生物力学实验机上,模拟人体正常双足站立中立位,由L5垂直向下加压至500N,依次测量下述4种情况下的耻骨联合位移：①完整骨盆;②耻骨联合切开,伴单侧骶棘韧带、骶结节韧带、骶髂前韧带切断,模拟骨盆水平旋转不稳定TileB1损伤：③钉棒系统固定骨盆TileB1损伤模型;,④髋臼上外固定架固定骨盆TileB1损伤模型。结果完整骨盆组的耻骨联合位移最小,为（0．125±0．024）mm。骨盆TileB1损伤模型无固定组的耻骨联合位移最大,为（4．589±0．366）mm。钉棒系统和髋臼上外固定架固定TileB1损伤模型,均可显著减少耻骨联合的分离,恢复部分骨盆环的力学稳定性。其中椎弓根钉棒系统固定的耻骨联合位移为（0．626±0．097）mm,髋臼上外固定架固定为（1．022±0．095）mm,两者之间存在统计学差异（P〈0．05）。结论钉棒系统在骨盆TileB1损伤模型中的生物力学稳定性优于髋臼上外固定架,能有效恢复骨盆环的力学稳定性。     

Osteoradionekrose nach Strahlentherapie gynäkologischer Tumoren

AIM: Insufficiency fractures of the pelvis are a well known but rare and frequently misinterpreted radiation sequela. The clinical features and possible risk factors were investigated. PATIENTS AND METHODS: 71 of living 82 patients, who were treated 1986-1994 for gynecologic tumors were clinically examined. 47 patients underwent also bone scan, CT of the pelvis and 13 patients had osteodensitometry. All patients had been treated with adjuvant (n = 29) or curative intent (n = 18) by d.v. fields with 18-MV photons, with 46 Gy in 23 fractions plus brachytherapy (15-39 Gy). Median follow-up was 36 months. RESULTS: Seven patients developed pelvic insufficiency fractures 11 months (median, minimum 2 months) after treatment. All patients complained of moderate to severe pelvic pain, which resolved after 5-28 months without specific therapy in five of seven patients. At first examination all but one bone scan showed extremely increased uptake in the os sacrum and/or iliosacral joints, correlating CT scans demonstrated small fractures and bony destruction. Four of the asymptomatic 40 patients with complete radiologic examinations had medium uptake in bone scan (CT normal). Three of four examined patients with insufficiency fractures and seven of nine patients without insufficiency fractures had osteoporosis. CONCLUSION: In women who present with pelvic pain after radiotherapy for gynecologic tumors bony destruction and fractures may be indicative of a late radiation effect rather than osseous metastasis, even after early onset of symptoms.     

Parasymphyseal and associated insufficiency fractures of the pelvis and sacrum

Eleven post-menopausal women presenting with a parasymphyseal insufficiency fracture of the pubis are reported. The plain radiographs showed delayed healing with a mixed lytic and sclerotic area developed at the fracture site simulating a malignant lesion. Aetiological factors included post-menopausal osteoporosis, rheumatoid arthritis and steroid therapy, previous hip replacement and pelvic radiotherapy. Ten patients had concomitant fractures of the pelvis, including nine with sacral fractures. These were all initially missed on presentation because of the subtle radiographic signs of a longitudinal band of sclerosis, usually bilaterally, in the sacral ala. Bone scanning was shown to be the most sensitive technique in detecting the sacral fractures by demonstrating increased uptake in the sacral ala as well as the other fractures of the pelvis. Computed tomography in three cases was helpful in confirming the presence of fractures and excluding the possibility of malignancy.     

Vacuum phenomena in insufficiency fractures of the sacrum

Objective. Insufficiency fractures of the sacrum are found in women who have undergone radiation therapy to the lower abdomen as well as those suffering from osteoporosis of postmenopausal, steroid-induced, or primary biliary cirrhosis-related origin. Increased up-take in bone scintigraphy and osteolytic changes in these fractures can be misinterpreted as bone metastases, leading to unnecessary biopsies and other procedures in the ensuing search for non-existent primary tumor.Patients. In eight female patients averaging 69.4 years of age, insufficiency fracture of the sacrum was diagnosed by computed tomography (CT) and bone scintigraphy. Three underwent a total of five MRI examinations. Malignancy was excluded by histology in two patients and follow-up of at least 6 months in the remainder. Retrospective analysis of CT scans of 13 patients with metastases in the sacrum revealed no vacuum phenomena.Results. In seven of eight patients with insufficiency fracture of the sacrum, vacuum phenomena were shown on CT examination. The gas was localized centrally within the ventral part of the fracture in three patients; gas was located in ten adjacent sacro-iliac joints of six patients.Conclusions. The vacuum phenomenon may be an incidental finding in osteoarthritis of the sacro-iliac joint, but it has not been previously recognized in IFS. The presence of intra-articular vacuum phenomena in the sacro-iliac joints in combination with a sacral fracture and vacuum phenomena located within the sacral fracture supports a diagnosis of insufficiency fracture or may indeed be the clue by which this diagnosis is established. Insufficiency fractures of the sacrum are a well-known complication in women who have undergone radiation therapy of the pelvis or are suffering from postmenopausal, steroid-induced, or primary biliary cirrhosis-related osteoporosis [1–11]. These fractures are characterized by increased activity on radionuclide bone scans. The lateral masses of the sacrum contain large amounts of hematopoetic bone marrow and are therefore often the site of bone metastasis. Increased uptake in bone scintigraphy in lateral masses of the sacrum and osteolytic destructions on radiographs and computed tomography (CT), especially in patients with a history of a tumor elsewhere, are suggestive of skeletal metastasis, prompting biopsies and additional diagnostic procedures to find a primary tumor [2]. We present seven out of eight patients with insufficiency fractures of the sacrum, in whom we observed vacuum phenomena within the fracture or in the adjacent sacroiliac joints, indicating the benignity of the lesion. This phenomenon has not been recognized previously.     

CT-guided vertebroplasty in osteoprotic vertebral fractures: incidence of secondary fractures and impact of intradiscal cement leakages during follow-up

The purpose of this study was to analyse the number and types of secondary fractures, and to investigate the impact of intradiscal cement leaks for adjacent vertebral fractures. Patients with osteoporotic vertebral fractures were treated with vertebroplasty. Results were documented and prospectively followed by means of computed tomography (CT) and magnetic resonance imaging. The frequency and the types of cement leakages were analysed from multiplanar CT images and secondary fractures were characterised as follows: (1) adjacent fracture in the immediate vicinity of an augmented vertebra; (2) sandwich fracture, fracture of an untreated vertebra between two vertebrae that had been previously augmented, and (3) distant fractures not in the vicinity of augmented vertebrae. A total of 385 osteoporotic vertebral fractures were treated in 191 patients (61 men, 130 women, age 70.7 ± 9.7 years). The overall rate of cement leaks was 55.6%, including all leaks detectable by CT. Intradiscal leaks through the upper, the lower, and both endplates occurred in 18.2%, 6.8%, and 2.6%, respectively. In 39 patients (20.4%), a total of 72 secondary fractures occurred: 30 adjacent fractures in 23 patients (12.0%) with a time to fracture of 2 months [median; 1.0/4.0 months, first/third quartile (Q1/Q3)]; 11 secondary sandwich fractures in 11 patients (5.8%) after 1.5 months (median; 0.25/7.5 months, Q1/Q3); and 31 distant fractures in 20 patients (10.5%) after 5 months (median; 2.0/8.0 months, Q1/Q3). Ten of 30 adjacent fractures occurred in the presence of pre-existing intradiscal cement leaks and 20 where there was no leakage. Six of 11 sandwich fractures occurred in the presence of intradiscal leaks (five leaks in both adjacent disc spaces, one leak in the lower disc space) and five where there was no leakage. The rate of secondary adjacent and non-adjacent fractures is quite similar and there is no specific impact of intradiscal leakages on the occurrence of adjacent secondary fractures. Adjacent fractures occur sooner than distant secondary fractures. Sandwich fractures are associated with specific biomechanical conditions, with a 37.9% fracture rate in sandwich constellations.     

Spinal compression fractures in osteoporotic women: patterns and relationship to hyperkyphosis

A prospective study of thoracic and lumbar spinal fracture distribution and its relationship to thoracic kyphosis was performed in 87 women with osteoporosis. Anterior wedge fractures were most commonly seen in the midthoracic spine and about the thoracolumbar junction, whereas central compression fractures were most common from the first to the fourth lumbar levels. Solitary wedge fractures did not occur above the seventh thoracic vertebra, suggesting that a cause other than osteoporosis must be suspected in any patient with an isolated high thoracic fracture. Analysis of the spinal radiographs obtained in an additional 16 women without osteoporosis revealed that both forms of fracture were unusual in this small group with normal spinal mineralization. The number of anterior wedge fractures in the thoracic spine correlated (r = .546) with the degree of thoracic kyphosis. However, 19% of the women with no thoracic fractures still had thoracic hyperkyphosis. The authors conclude that the hyperkyphosis of osteoporotic women is related to anterior compression fractures but also has contributing nonskeletal factors.     

MR imaging of supra-acetabular insufficiency fractures

 Objective. Diagnosis of insufficiency fractures in the pelvis is difficult, especially in patients with prior malignancy, irradiation, steroid therapy or osteoporosis. This report shows the MR imaging appearance of supra-acetabular insufficiency fractures and how they can be differentiated from metastatic disease. Design and patients. Twelve patients (four men, eight women, average age 72.8 years) at risk for pelvic insufficiency fractures and who had pelvic or hip pain were studied with MR imaging. Indications were possible recurrent tumor or previous radiation to the pelvis (7 patients); osteoporosis from steroid use in rheumatoid arthritis (two patients); to exclude osteonecrosis of the hip (two patients); or to rule out a hip fracture (one patient). Results. A characteristic linear region of low signal intensity on both T1- and T2-weighted sequences was found in the supra-acetabular region paralleling the superior acetabulum in a curvilinear arc in 92% (11/12) of cases, and oblique in origin in 8% (1/11). Diffuse bands of high signal on T2-weighted images indicated surrounding edema. In two cases, MR findings obviated biopsy. One patient underwent a biopsy prior to the imaging studies being reviewed. All patients were treated conservatively and did well. Discussion. Attention to insufficiency fractures has previously focused on characteristic locations in the sacrum and pubic bones. Supra-acetabular insufficiency fractures also occur and are difficult to diagnose without a high degree of suspicion. MR imaging is a useful tool for diagnosing supra-acetabular insufficiency fractures. The characteristic MR imag-ing appearance of these fractures can preclude additional diagnostic studies and therapy in most instances.     

绝经后妇女腰椎骨密度测量的研究

作者对患有或未患腰椎骨折的绝经后妇女的骨密度测量进行了研究分析，旨在比较L－DXA和mL－DXA对骨折诊断的敏感性。材料和方法：共240例绝经后妇女。根据各胸腰椎（胸4至腰4）倒位X线平片所见，并采用目视半定量法判断椎体的骨折或其程度，腰椎骨密度值分别选用L－DXA和mL－DXA所测数据。结果：骨折组的年龄高于非骨折组，而其BMD值则低于非骨折组。分析比较L－DXA和mL—DXA的结果表明其下降百分数和Z分数相似，ROC曲线下面积也无显著性差异，logistic回归分析中，两者年龄调整后的优势比无显著性差异。进一步将正常与轻度骨折组比较，两者的ROC面积仍无显著性差异。结论：在区分正常与骨折以及正常与轻度骨折时，mL－DXA并不优于L－DXA。因轻度骨折的L－DXA和mL－DXA所测骨密度值均低于非骨折组，故应视其为骨折。     

Radiation-induced insufficiency fractures of the pelvis: evaluation with 99mTc-methylene diphosphonate scintigraphy.

99mTc-methylene diphosphonate (99mTc-MDP) bone scans in 80 patients, 30-80 years old (average, 62 years old) with uterine cancer who received high doses of radiation (10-60 Gy; average, 46 Gy) were reviewed retrospectively to evaluate the frequency of pelvic insufficiency fractures caused by radiotherapy and to study the appearance of the fractures on bone scans. Bone scans in 29 of 80 patients showed abnormalities in the pelvis: insufficiency fractures were identified in 27 patients (34%) and osseous metastases were found in two patients (3%). The fractures and metastases were diagnosed by CT and were confirmed by observing the patients' clinical courses. Fractures were identified in 27 (39%) of 69 postmenopausal women and in none of 11 premenopausal patients (p greater than .05). Fractures were found in 21 (84%) of 25 patients who had pelvic pain and in six (11%) of 55 patients who were asymptomatic (p greater than .001). Scintigrams in patients with fractures showed more than one fracture in most patients (85%), and fractures were often symmetric (67%). Scintigrams in two patients with osseous metastases showed increased activity in an iliac wing that was outside the radiation field. Our results suggest that a marked increase in insufficiency fractures occurs after radiation therapy, especially in postmenopausal patients. A symmetric area of increased uptake of radionuclide is a characteristic scintigraphic appearance of an insufficiency fracture.     

Risk factors for recurrent stress fractures in athletes

Our aim was to identify factors predisposing athletes to multiple stress fractures, with the emphasis on biomechanical factors. Our hypothesis was that certain anatomic factors of the ankle are associated with risk of multiple stress fractures of the lower extremities in athletes. Thirty-one athletes (19 men and 12 women) with at least three separate stress fractures each, and a control group of 15 athletes without fractures completed a questionnaire focusing on putative risk factors for stress fractures, such as nutrition, training history, and hormonal history in women. Bone mineral density was measured by dual-energy x-ray absorptiometry in the lumbar spine and proximal femur. Biomechanical features such as foot structure, pronation and supination of the ankle, dorsiflexion of the ankle, forefoot varus and valgus, leg-length inequality, range of hip rotation, simple and choice reaction times, and balance in standing were measured. There was an average of 3.7 (range, 3 to 6) fractures in each athlete, totaling 114 fractures. The fracture site was the tibia or fibula in 70% of the fractures in men and the foot and ankle in 50% of the fractures in women. Most of the patients were runners (61%); the mean weekly running mileage was 117 km. Biomechanical factors associated with multiple stress fractures were high longitudinal arch of the foot, leg-length inequality, and excessive forefoot varus. Nearly half of the female patients (40%) reported menstrual irregularities. Runners with high weekly training mileage were found to be at risk of recurrent stress fractures of the lower extremities.     

Differences in proximal femur geometry distinguish vertebral from femoral neck fractures in osteoporotic women

Bone mineral density (BMD) is generally used to predict the risk of fracture in osteoporotic subjects. However, femoral neck BMD and spine BMD have been reported not to be significantly different among patients with hip or vertebral fractures, suggesting that other risk factors are needed to determine the different fracture types. Proximal femur geometry (PFG) parameters, such as hip axis length (HAL), femoral neck-shaft angle (NSA) and femoral neck diameter (FND) have also been shown to predict the risk of hip fracture. These parameters are statistically different in spine fractures compared with both types of hip fractures (trochanteric and femoral neck) when considered together. We wanted to assess the difference in these parameters by comparing spine fractures with a homogeneous group of hip fractures, i.e. femoral neck fractures. 807 post-menopausal women were divided into three groups; those with vertebral fractures (182), those with femoral neck fractures (134) and a control group without fractures (491). Dual X-ray absorptiometry (DXA) scans of the spine and hip were carried out to measure BMD and define the PFG parameters of the hip. Data were statistically analysed. In agreement with other authors, we found that women with femoral neck fractures had longer HAL, wider FND and larger NSA than controls, whereas there were no statistically significant differences in PFG between women with spine fractures and controls. Logistic regression showed HAL and NSA could predict the risk of femoral neck but not vertebral fracture. These data indicate specificity of some PFG parameters for hip fracture risk.     

Stress fractures of the distal tibia and calcaneus subsequent to acute fractures of the tibia and fibula

Stress fractures (two in the calcaneus and four in the distal tibia) occurring distal to the site of a healing fracture of the tibia or fibula were discovered in five patients. Three of these fractures were identified radiographically at the time of their occurrence, and three were identified only after retrospective review of the radiographs of 74 patients with previous tibial or fibular fractures. Three of the patients were less than 10 years old. All five patients had disuse osteopenia and recently had begun weight-bearing. Four patients had healing of their acute fractures with angulation or displacement. Stress fractures can easily be overlooked on radiographic studies in this setting and may be a source of pain that mistakenly can be attributed to malunion or nonunion. Stress fractures should be considered in patients with fractures of the lower extremity, particularly those who experience new or persistent pain or discomfort.     

Detection of incidental vertebral fractures on routine lateral chest radiographs

Purpose

This study sought to assess the usefulness of routine lateral chest radiographs for detecting unrecognised vertebral compression fractures.

Materials and methods

We prospectively selected outpatients without symptoms or risk factors for osteoporosis who underwent chest radiography for different clinical indications. Two independent reviewers with different levels of experience assessed the radiographs for vertebral deformities and graded them as mild, moderate and severe according to the semiquantitative Genant Index. The kappa statistic was used to evaluate interobserver agreement and verify the reproducibility of this method. The prevalence of vertebral fractures observed was compared with that recorded in the official radiology reports.

Results

Our study involved 145 patients (73 men, 72 women; age range 50–86 years, mean age 67.5). Clinically relevant vertebral fractures were seen in 18/145 patients (12.4%). These were moderate in 13 patients and severe in five, and single in 12 patients and multiple in six. Interobserver agreement was very high (κ=0.9). Only 11% of these fractures were recorded in the official reports.

Conclusions

Lateral chest radiographs could be effective for assessing previously unknown vertebral compression fractures in individuals without clinical evidence or risk factors for osteoporosis.     

Vertebral morphometry: evaluation of osteoporosis-caused fractures

PURPOSE: To compare visual reading of spine radiographs and quantitative morphometric approach for assessing the prevalence of vertebral fractures in postmenopausal osteoporosis. MATERIAL AND METHODS: In 473 postmenopausal women afferent to our Centre of Osteoporosis under-went lateral thoracic and lumbar spine radiograph to identify vertebral fractures and dual energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD) of the lumbar spine (L1-L4). Osteoporosis was defined according to the World Health Organization (WHO) guidelines. To identify vertebral fractures the radiographs were visually analyzed by two radiologists; a woman was judged as fractured only if both readers independently found at least one vertebral fracture on her films. Then the spine radiographs were digitized by means of a scanner to perform quantitative vertebral morphometry (QVM) using specific software. An expert operator manually located the calipers on the vertebral bodies from T4 to L5 and the computer automatically calculated the anterior, middle and posterior vertebral heights and their ratios. A vertebral fracture was defined by morphometry as a reduction by at least 20%, with an absolute decrease of at least 4 mm, in one of three height ratios of any vertebral body compared to the corresponding reference ratio for fertile women. RESULTS: Visual reading by radiologists detected 9.5% (45/473) women with vertebral fractures and QVM detected 13.7% (65/473) with statistical significance (p < 0.001). In the 75-80 years age group the prevalence of vertebral fractures reaches the maximum value, 26.3% by visual reading and 36.8% by QVM. Among fractured women, 34 were osteoporotic by DXA; 11 women found fractured by visual reading and 21 by QVM were osteopenic women, with bone mineral densities between -1 and -2.5 SD of the T-score. CONCLUSION: This study showed that quantitative assessment of spine radiographs by vertebral morphometry is an objective method that allows to identify a larger number of vertebral fractures compared to visual inspection. This is very important not only for epidemiological studies, but also for clinical use because a previous vertebral fracture increases the risk of subsequent fractures significantly. Therefore, to improve the risk assessment of vertebral fractures for osteoporotic patients it is necessary to combine the use of QVM and BMD.     

Fractures of the nasolacrimal fossa and canal: a CT study of appearance, associated injuries, and significance in 25 patients.

The bony nasolacrimal fossa and canal, which protect the more distal excretory portion of the lacrimal apparatus, the nasolacrimal sac and duct, are contained within the medial portion of the orbit and lateral aspect of the nose, sites that are commonly injured in facial trauma. The CT scans of 25 patients who sustained fractures of the nasolacrimal fossa and/or canal as a result of motor vehicle accidents were reviewed to determine the appearance of the fractures and to determine types of facial fractures also present. The patients' clinical records were reviewed to determine the frequency of associated complications. Thirty-six fractures of the nasolacrimal fossa and canal were found in the 25 patients. In 20 patients these were associated with complex fractures of the midportion of the face; the other five patients had simple unilateral facial fractures. Three kinds of nasolacrimal fractures were identified: avulsion of the fossa, comminution of the fossa or canal, and linear fractures of the canal. Of the 19 fractures involving the nasolacrimal fossa, 15 consisted of an avulsed fragment of bone containing the nasolacrimal sac and four had comminution of the nasolacrimal fossa. The majority of the fractures of the nasolacrimal canal (15 patients) were comminuted. Our results show that nasolacrimal fractures occur in association with simple unilateral facial fractures and with more complex fractures of the midface and that the fractures follow certain patterns. Complications related to injury to the nasolacrimal sac and duct were documented in five patients. Although this number is significant, it is fewer than we expected, considering the severity of the injuries.     

Clinical results and prognostic factors of radiotherapy for bone metastases from breast cancer

The purpose of this study was to analyze the results of initial radiotherapy for bone metastases (BM) from breast cancer and to investigate the prognostic factors. Between 1981 and 1995, 65 women (109 lesions) received initial radiotherapy for BM, aiming at a total dose of 50 Gy/25 Fr. Significant relief of pain was obtained in 61 (88.4%) of 69 estimable lesions according to the RTOG score. The control rates of pain including the prevention of pathological fractures or myelopathy were 80.4% at 5 years and 64.3% at 10 years. The median survival time of all patients was 11 months, and the survival rates were 56% at 1 year, 31.6% at 3 years, 17.9% at 5 years and 10.7% at 10 years, with five long-term survivors. Univariate analysis showed that a normal state of LDH, no other metastatic organs, a disease-free interval longer than two years, good performance status (0 or 1), BM limited to the axial bones, maintenance chemo-hormonal therapy and an age of more than 55 years were good prognostic factors. Multivariate analysis showed that LDH, age and performance status were significant predictors of prognosis. It is important to note the prognostic factors at the initial treatment of BM from breast cancer. We consider that further prospective studies are needed to determine the optimal treatment schedule, including radiotherapy and its combination with chemohormonal therapy, for BM.     

Stress fractures in young athletic women: case reports of unsuspected cortisol-induced osteoporosis.

Stress fractures in the female athlete are common events, usually occurring in the lower limb and less often in the pelvic girdle. Two cases are presented of young women athletes who presented with initial lower limb stress fractures, but subsequently fractures of the pelvis and hip thought to be associated with their athletic activity. After careful medical evaluation, they were diagnosed with Cushing's syndrome. One patient had a microadenoma of the pituitary gland secreting excessive amounts of ACTH, and the other had a benign adenoma of the left adrenal gland. Both women had significant decreases in their spinal mineral density. After treatment, partial reversal of these spinal losses occurred. Although stress fractures in the female athlete might be common and thought to be associated with problems of amenorrhea, presentation of unusual anatomical sites for these fractures necessitates a more thorough evaluation for correctable secondary causes.     

13例骨盆骨折大出血的急诊介入治疗

目的:探讨经导管选择性血管栓塞术治疗不稳定性骨盆骨折所致大出血的临床价值。方法:对13例骨盆骨折所致大出血合并失血性休克的患者进行选择性动脉造影,均发现髂内动脉或其分支出血,并对出血动脉进行栓塞。结果:13例失血性休克患者栓塞成功,手术均在1～2h完成,复查DSA,动脉出血停止,血压稳步上升并保持稳定。结论:急诊经导管选择性栓塞髂内动脉是治疗骨盆骨折所致大出血的首选方法,具有安全、迅速、准确、疗效高的优点。     

Iliac insufficiency fractures

Twenty-five post-menopausal women with one or more insufficiency fractures of the pelvic ring are reported. In 80% of cases the fractures were multiple and a total of 79 insufficiency fractures was identified. Twelve iliac insufficiency fractures were present in 11 patients located at one of three sites: above and parallel to the acetabular roof ("supra-acetabular"), extending diagonally across the iliac ala from the greater sciatic notch ("oblique iliac"), and adjacent to the sacro-iliac joint ("superomedial iliac"). The plain radiographic appearances of these iliac fractures were typically subtle with ill defined medullary sclerosis, due to trabecular compression, the cardinal sign. Scintigraphy revealed the fractures as foci of increased activity which, in the presence of multiple pelvic insufficiency fractures, may be mistaken for metastatic disease. Computed tomography can be helpful in confirming the presence of suspected fractures, revealing further occult fractures and also excluding the likelihood of malignancy.     

The menopause

Symptoms due to estrogen deficiency begin in the perimenopausal years and progress as serum levels of this hormone decrease Vasomotor instability, manifested by hot flushes or night sweats, may persist for several months to a few years. Psychologic symptoms include anxiety, tension, depression, insomnia, palpitations, and headaches. Atrophy of the genital epithelium may result in senile vaginitis with symptoms of irritation, burning, pruritus, dyspareunia, and even vaginal bleeding. Even the lower urinary tract mucosa is dependent upon estrogen. Postmenopausal osteoporosis affects 25 to 50% of older women and increases the risk for vertebral, hip, and other fractures. Estrogen therapy for menopausal complaints has received adverse publicity because several reports have indicated that unopposed estrogens increase the risk of endometrial cancer. Added progestogen not only negates this risk but reduces the incidence of endometrial adenocarcinoma in estrogen-progestogen users to less than that observed in untreated women. Estrogen replacement therapy does not increase the risk of breast cancer; the incidence of this malignancy, however, was also less in the estrogen-progestogen users when compared with either the untreated women or from that expected from the national cancer surveys. In evaluating postmenopausal women for hormone replacement, the benefits of estrogen-progestogen therapy must be weighed against possible risks.