老年股骨上段标本几何参数及骨密度与生物力学性能的相关性分析

目的 探讨股骨颈部几何因素及骨密度对髋部骨折的影响,通过生物力学试验研究髋部生物力学性能与二者的关系.方法 随机选取16例甲醛浸泡国人成年男性尸体股骨上段标本,测量其几何参数(包括股骨颈长、股骨颈直径、股骨头直径及颈干角)和骨密度,再通过生物力学试验,比较各因素对股骨颈生物力学特性的影响.结果 转子间骨密度、股骨颈骨密度及股骨头直径与股骨的生物力学特性有明显的相性(r=0.792,r2=0.628,P0.001;r=0.749,r2=0.560,P=0.001;r=0.706,r2=0.499,P=0.002);逐步线性回归分析结果显示转子间骨密度、股骨头直径和股骨颈直径相结合是预测髋部骨折的最好方法(r2=0.844,P＜0.001).结论 骨密度值结合股骨近端几何参数能提高对骨质疏松性髋部骨折的预测.     

骨密度结合股骨颈颈干角对各型髋部骨质疏松性骨折风险的预测

目的：探讨股骨近端骨密度和股骨颈颈干角与髋部骨质疏松性骨折的相关性。方法收集在我院住院的髋部骨折患者100例和健康老年对照组100例,采用美国GE公司生产的LUNAR-Bravo双能X线骨密度仪及其配置的高级骨科专用分析测量软件,分析股骨近端骨密度和股骨颈颈干角与骨质疏松的相关性。结果髋部骨折组与对照组比较,髋部骨折组BMD较对照组有明显下降,股骨外侧皮质骨厚度明显减小,股骨颈干角（ NSA）较对照组钝。结论髋部骨密度结合股骨颈颈干角变化特点可以提高对各型髋部骨质疏松骨折危险性的预测。     

老年人髋部骨折股骨近端骨质CT测量的意义

[目的]探讨老年人股骨近端松质骨CT值和皮质骨厚度值评估髋部骨折的意义。[方法]回顾性分析146例髋部CT检查患者,其中,73例髋部骨折,73例非髋部骨折。测量健侧股骨近端冠状位股骨头、股骨颈、转子间的松质骨CT值,以及股骨颈和转子间的皮质骨厚度值。[结果]骨折组股骨颈和转子间的CT值均显著低于非骨折组(P0.05),骨折组在股骨近端4个部位的皮质骨厚度值均显著低于非骨折组(P0.05)。ROC曲线下面积(area under curve, AUC)由大至小依次为:股骨颈外侧皮质厚度值转子间外侧皮质厚度值转子间CT值转子间内侧皮质厚度值股骨颈CT值股骨颈内侧皮质厚度值,P值均0.05。其中,股骨颈外侧皮质厚度及转子间外侧皮质骨厚度值的AUC分别为0.893及0.844。[结论]股骨颈和转子间的皮质骨厚度值及松质骨CT值可能具有预测骨质疏松髋部骨折的价值。     

老年髋部骨折类型与股骨近端骨密度的关系

目的探讨老年股骨颈骨折与转子间骨折患者在股骨近端骨密度(BMD)上的不同特点。方法回顾性研究520例60岁及60岁以上初次髋部骨折患者:股骨颈骨折237例,男67例,平均年龄80.0±8.5岁,女170例,平均年龄79.0±8.2岁;转子间骨折283例,男95例,平均年龄80.2±8.4岁,女188例,平均年龄82.4±6.7岁。比较两种髋部骨折患者健侧股骨近端五个区域(股骨颈、大转子、转子间、全髋部、Ward区)的BMD,并采用二分类logistic回归分析探讨股骨近端不同区域BMD与髋部骨折类型之间的关系。结果男性转子间骨折患者只有大转子BMD显著低于同性股骨颈骨折患者,差异有统计学意义(P0.01);而女性转子间骨折患者大转子、转子间、全髋部、Ward区的BMD显著低于同性股骨颈骨折患者,差异均有统计学意义(P0.01)。女性按年龄分层后,60~69岁转子间骨折患者只有Ward区BMD显著低于股骨颈骨折患者,差异有统计学意义(P0.05);70~79岁转子间骨折患者五个区域BMD均显著低于股骨颈骨折患者,差异有统计学意义(P0.05);大于79岁转子间骨折患者只有大转子BMD显著低于股骨颈骨折患者,差异有统计学意义(P0.01)。二分类Logistic回归分析发现:女性中增龄、大转子、转子间、全髋部以及Ward区的BMD与髋部骨折类型存在统计学关联(P0.01),而男性中只有大转子BMD与髋部骨折类型存在统计学关联(P0.01)。结论股骨颈骨折患者和转子间骨折患者存在不同的BMD水平,女性股骨近端BMD与髋部骨折类型的关系随着年龄的变化而变化。     

老年人骨质疏松与髋部骨折发病关系的分析

目的探讨骨质疏松与老年人髋部骨折的关系。方法采用随机分组设计测量了120名老年人股骨颈骨折及股骨粗隆间骨折患者与正常对照组的Singh指数、股骨颈皮质指数和股骨外侧皮质骨厚度。结果显示两组之间有非常显著（P〈0．01）的统计学差异。结论骨质疏松是老年人髋部骨折的主要致病因素之一。采用X线片评定股骨近端骨量改变对于预测髋部骨折的危险性具有一定价值。     

骨质疏松女性股骨颈骨折与股骨转子间骨折的髋部骨密度差异分析

目的明确骨质疏松女性股骨颈骨折与股骨转子间骨折的髋部骨密度差异,探讨骨质疏松患者发生髋部骨折(股骨颈骨折、股骨转子间骨折)与骨折部位骨密度的相关性。方法回顾性分析2015年1月1日至2016年12月31日期间于福建省某三级甲等医院的住院治疗的骨质疏松及髋部骨质疏松性骨折患者172例,其中无病史的原发骨质疏松患者109例、骨质疏松性股骨颈骨折患者39例、骨质疏松性转子间骨折24例。分别统计3组患者年龄、体质指数、糖尿病患病情况、骨折侧别、髋部各部位骨密度、血清Ⅰ型胶原交联C末端肽(C-terminal crosslinking telopeptide of type Ⅰ collagen,CTX)、Ⅰ型原胶原N-端前肽(procollagen type ⅠN propeptide,PINP)、25羟基维生素D(25-OH-D)。分别进行三组间及两两组间比较。结果三组间年龄、体质指数、糖尿病患病率差异无统计学意义(F=2.667,P=0.072; F=0.882,P=0.416;χ~2=3.216,P=0.232),股骨颈骨折组与股骨转子间骨折组组间骨折侧别差异无统计学意义(χ~2=0.958,P=0.328),三组间髋部Ward区骨密度差异无统计学意义(F=2.937,P=0.056),髋部骨密度比较,股骨颈、股骨大转子、股骨转子间、髋部整体差异有统计学意义(F=7.825,P=0.001; F=8.668,P0.001; F=9.657,P0.001)。股骨颈骨折组、转子间骨折组股骨颈、股骨大转子、股骨转子间、髋部整体骨密度均小于骨质疏松组,差异均有统计学意义(P0.05);股骨颈骨折组与转子间骨折组股骨颈、大转子、转子间、髋部整体骨密度差异均无统计学意义(P0.05)。三组间β-CTX、P1NP、维生素D差异均有统计学意义(P0.05)。股骨颈骨折组、转子间骨折组β-CTX、维生素D均小于骨质疏松组,差异均有统计学意义(P0.05);转子间骨折与骨质疏松组P1NP差异无统计学意义,股骨颈骨折组与转子间骨折组股骨颈、大转子、转子间、髋部整体骨密度差异均无统计学意义(P0.05)。结论女性骨质疏松患者发生髋部骨折的类型可能并不取决局部的骨密度,可能与骨微结构等因素相关,要得到明确、可靠的结果仍需进一步研究证实。     

老年股骨颈骨折骨密度、Singh指数的研究

目的研究骨密度和Singh指数在衡量股骨近端骨强度和预测股骨颈骨折中的意义.方法对21名60岁以上、因轻度创伤所致新鲜股骨颈骨折老年人进行股骨近端骨密度、Singh指数及Ward三角矿化骨体积进行测量.结果本组患者股骨近端骨密度减少规律,Ward三角>股骨颈>股骨粗隆,骨密度减少的下限(±s)是股骨颈1.14SD、粗隆部0.35SD、Ward三角2.04SD;Singh指数4级以下(含4级)20名(95.2%);Singh指数与MBV呈正相关(r=0.517P<0.05),与粗隆部骨密度及减少的标准差呈正相关(r=0.457,0.474P<0.05).结论骨密度较峰值骨量减少的标准差数在股骨颈大于1.14、粗隆部大于0.35、Ward三角大于2.04,加上Singh指数低于4级(含4级)提示股骨颈骨折的危险性明显增高.     

比较不同类型骨质疏松性髋部骨折的特点

目的 比较骨质疏松性股骨颈骨折和转子间骨折患者在髋部骨密度及几何结构上的不同特点。方法 将137例50岁以上髋部骨折的患者分为两组:股骨颈骨折组69例,男20例,女49例,年龄50 -97岁（75.1 ±9.6),体重指数（BMI) ：21.6±4. 1 kg/m2 ;股骨转子间骨折组48例,男16例,女32例,年龄50-91岁（78. 1 ± 9. 1),体重指数（BMI )：21. 5 ± 4. 3 kg/m2。对所有患者的健侧股骨近端行双能X线骨密度仪（Dual energy X-ray absorptiometry,DXA)测定,并利用该仪器的HSA软件分析髋部几何结构参数。结果两组患者在男女构成比例、年龄、身高、体重、体重指数的比较上没有统计学差异（P <0. 05);两组 患者的骨密度在股骨颈区（Neck)、大转子区(Troch)、Ward区、转子间区（Inter)、全髋(Total hip)的比较上没有统计学差异(P <0. 05)。两组患者在股骨颈区及转子间区的横截面积(CSA)、横截面转动惯量(CSMI)、屈曲应力比（BR)的比较上均没有统计学差异(P <0. 05);两组患者在股骨颈区域的皮质骨厚度的比较上没有统计学差异(P <0. 05);两组患者在转子间区域的皮质骨厚度的比较上有统计学差异(P =0. 013)。结论 在脆性髋部骨折的不同骨折类型的发生机制上,皮质骨变薄是引起不同髋部骨折类型的一个主要因素,尤其是对于高龄的髋部骨折患者。     

骨密度结合Singh指数预测老年髋部骨折风险的意义

[目的]探讨骨密度值(BMD)结合Singh指数在预测髋部骨折风险的意义.[方法]观察组随机抽取老年髋部骨折50例,年龄60岁以上,其中男性13例,女性37例,股骨颈骨折29例,粗隆间骨折21例.对照组50例,年龄60岁以上,男11例,女39例.分别测量骨折组和对照组髋部骨密度(BMD),Singh指数,对比两组的测量结果.[结果]骨折组骨密度平均值(g/m2),股骨颈(0.64±0.13)、WardS三角(0.58±0.14)和转子处(0.69±0.11),对照组股骨颈(0.87±0.07)、WardS 三角(0.69±0.11)和转子处(0.75 ±0.14),组间差异显著.骨折组Sighn指数值3.34±1.05级,对照组Sighn指数值4.46±1.14级,组间差异显著.骨密度值与Sighn指数呈正相关.[结论]低骨密度值(BMD及Singh指数与骨质疏松髋部骨折有明显的相关性,二者结合应用可以更准确预测骨折.     

脆性股骨颈骨折的股骨颈皮质厚度和骨密度改变

目的 研究脆性股骨颈骨折的股骨颈皮质骨厚度和骨密度变化。方法 对76例病人行股骨近端CT扫描,骨质疏松性股骨颈骨折组42 例,非骨折组34 例。取对侧（正常侧）股骨小转子顶点上方20mm（T20）平面CT横截面影像,计算T20长径和股骨颈寛径皮质比率,作为评估皮质厚度的指标;用DXA测量股骨颈骨密度,了解骨质疏松程度。结果 T20长径皮质比率：骨质疏松性股骨颈骨折组：（17.57±3.54）% ;非骨折组：（21.64±3.75）%（P =0.000）;T20股骨颈宽径皮质比率：骨质疏松性股骨颈骨折组：（25.98±5.51）%;非骨折组：(32.89±5.74)%（P=0.000）。骨密度：骨折组：0.590±0.084 g/cm2 ;非骨折组：0.698±0.138g/cm2, , P <0.000。结论 股骨颈皮质变薄和骨密度降低是导致脆性股骨颈骨折重要因素,T20长径皮质比率和T20股骨颈宽径皮质比率是观察股骨颈皮质骨变化的有效指标。     

Ultrasound and dual X-ray absorptiometry densitometry in women with hip fracture

To assess the usefulness of the measurement of the os calcis by ultrasound, a method that probably reflects bone quality as well as density, we have studied 54 women with hip fracture of the proximal femur and a control group. Ultrasound evaluation of the os calcis [broadband ultrasound attenuation (BUA), speed of the sound (SOS), and a combined index (stiffness)], and bone mineral density (BMD) determination over the proximal femur by dual X-ray absorptiometry (DXA) were performed. Weight, BMD, and ultrasound values in the hip fracture patients were significantly lower than controls (P<0.001). The Z-scores for BUA and stiffness were not different than that for femoral neck. Ward's triangle or trochanteric BMD (between-1.7 and -1.5). The odds ratios determined by receiver-operating characteristics (ROC) analysis were greater at the femoral neck (25.1) and BUA (24.4). Intermediate values were found at stiffness (16.9), Ward's triangle (12.8), and trochanter (11.1), and lower values were obtained at SOS (4.2). In turn, patients with trochanteric hip fractures had a significantly lower femoral neck and Ward's triangle BMD, stiffness, and BUA than patients with cervical hip fractures. Comparing a subgroup of 30 women with hip fractures without vertebral fractures with an age-matched group of 87 women with osteoporotic vertebral fractures, both groups were of similar weight and BMD but all ultrasound values were significantly lower in the hip fractures compared with vertebral fracture patients (P<0.05-P<0.01). Our findings suggest that in women with hip fractures, ultrasound evaluation of the os calcis has diagnostic sensitivity comparable to DXA of the femur and could be useful to predict hip fracture risk. Ultrasound values are lower in hip fractures compared with vertebral fracture, age-matched women and in older compared with younger hip fracture patients.     

Risk for developing osteoporosis in untreated premature menopause

Summary The bone mineral density (BMD) of the lumbar spine and proximal femur was determined by dual photon absorptiometry in 32 women with untreated premature menopause (cessation of menses before 45 years of age). The BMD of the spine and proximal femur in four obese patients was not different from the BMD of the age-matched controls. On the contrary, the BMD of the nonobese females with premature menopause was significantly lower with respect to the average values found in healthy young women, in age-matched and menopause-matched controls. The BMD deficit was greater over the lumbar spine than in the proximal femur. Forty three percent of nonobese patients were already under the vertebral fracture threshold and 25% of nonobese patients were below the hip fracture threshold. The BMD deficit in the lumbar spine was correlated to the loss observed in the femoral neck (r=0.59, P<0.001), in the trochanter (r=0.65, P<0.001) and in the Ward's triangle (r=0.73, P<0.001). A negative correlation was observed between years of menopause and the BMD of the lumbar spine (r=-0.39, P<0.05). The results indicate the high individual risk for osteoporotic fractures in nonobese females with untreated premature menopause. The BMD loss was greater over the skeletal areas that are predominantly composed of trabecular bone compared with cortical bone.     

Proximal Femur Geometry To Detect and Distinguish Femoral Neck Fractures from Trochanteric Fractures in Postmenopausal Women

Some proximal femur geometry (PFG) parameters, measured by dual-energy X-ray absorptiometry (DXA), have been reported to discriminate subjects with hip fracture. Relatively few studies have tested their ability to discriminate femoral neck fractures from those of the trochanter. To this end we performed a cross-sectional study in a population of 547 menopausal women over 69 years of age with femoral neck fractures (n= 88), trochanteric fractures (n= 93) or controls (n= 366). Hip axis length (HAL), neck–shaft angle (NSA), femoral neck diameter (FND) and femoral shaft diameter (FSD) were measured by DXA, as well as the bone mineral density (BMD) of the nonfractured hip at the femoral neck, trochanter and Ward’s triangle. In fractured subjects, BMD was lower at each measurement site. HAL was longer and NSA wider in those with femoral neck fractures. With logistic regression the age-adjusted odds ratio (OR) for a 1 standard deviation (SD) decrease in BMD was significantly associated at each measurement site with femoral neck fracture (femoral neck BMD: OR 1.9, 95% confidence interval (95% CI): 1.4–2.5; trochanter BMD: OR 1.6, 95% CI 1.2–2.0; Ward’s triangle BMD: OR 1.7, 95% CI 1.3–2.2) and trochanteric fracture (femoral neck BMD: OR 2.6, 95% CI 1.9–3.6; trochanter BMD: OR 3.0, 95% CI 2.2–4.1; Ward’s triangle BMD: OR 1.8, 95% CI 1.4–2.3). Age-adjusted OR for 1 SD increases in NSA (OR 2.2, 95% CI 1.7–2.8) and HAL (OR 1.3, 95% CI 1.1–1.6) was significantly associated with the fracture risk only for femoral neck fracture. In the best predictive model the strongest predictors were site-matched BMD for both fracture types and NSA for neck fracture. Trochanteric BMD had the greatest area (0.78, standard error (SE) 0.02) under the receiver operating characteristic curve in trochanteric fractures, whereas for NSA (0.72, SE 0.03) this area was greatest in femoral neck fractures. These results confirm the association of BMD with proximal femur fracture and support the evidence that PFG plays a significant role only in neck fracture prediction, since NSA is the best predictive parameter among those tested. Received: 24 April 2001 / Accepted: 1 August 2001     

How Hip and Whole-Body Bone Mineral Density Predict Hip Fracture in Elderly Women: The EPIDOS Prospective Study

We conducted a population-based cohort study in 7598 white healthy women, aged 75 years and over, recruited from the voting lists. We measured at baseline bone mineral density (BMD g/cm²) of the proximal femur (neck, trochanter and Ward's triangle) and the whole body, as well as fat and lean body mass, by dual-energy X-ray absorptiometry (DXA). One hundred and fifty-four women underwent a hip fracture during an average 2 years follow-up. Each standard deviation decrease in BMD increased the risk of hip fracture adjusted for age, weight and centre by 1.9 (95% CL 1.5, 2.3) for the femoral neck, 2.6 times (2.0, 3.3) for the trochanter, 1.8 times (1.4, 2.2) for Ward's triangle, 1.6 times (1.2, 2.0) for the whole body, and 1.3 times (1.0, 1.5) for the fat mass. The areas under the receiver operating characteristic (ROC) curves were not significantly different between trochanter and femoral neck BMD, whereas ROC curves of femoral neck and trochanter BMD were significantly better than those for Ward's triangle and whole-body BMD. emsp;Women who sustained an intertrochanteric fracture were older (84 ± 4.5 years) than women who had a cervical fracture (81 ± 4.5 years) and trochanter BMD seemed to be a stronger predictor of intertrochanteric ([RR = 4.5 (3.1, 6.5)] than cervical fractures ([RR = 1.8 (1.5, 2.3]). emsp;In very elderly women aged 80 years and more, hip BMD was still a significant predictor of hip fracture but the relative risk was significantly lower than in women younger than 80 years. emsp;In the 48% of women who had a femoral neck BMD T-score less than –2.5, the relative risk of hip fracture was increased by 3, and the unadjusted incidence of hip fracture was 16.4 per 1000 woman-years compared with 1.1 in the population with a femoral neck BMD T-score 5–1. Received: 19 May 1997 / Accepted: 16 October 1997     

Combination of bone mineral density and upper femur geometry improves the prediction of hip fracture

Bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) is the main determinant of the clinical evaluation of hip fracture risk. However, it has been shown that BMD is not the only predictive factor for hip fracture, but that bone geometry is also important. We studied whether the combination of bone geometry and BMD could further improve the determination of hip fracture risk and fracture type. Seventy-four postmenopausal females (mean age 74 years) with a non-pathologic cervical or trochanteric hip fracture without previous hip fracture or hip surgery constituted the study group. Forty-nine had a cervical fracture (mean age 73 years) and 25 had a trochanteric fracture (mean age 76 years). The control group consisted of 40 age-matched females (mean age 74 years). The geometrical parameters were defined from plain anteroposterior radiographs, and the potential sources of inaccuracy were eliminated as far as possible by using a standardized patient position and calibrated dimension measurements with digital image analysis. BMD was measured at the femoral neck (FEBMD), Wards triangle (WABMD), and the trochanter (TRBMD). Stepwise linear regression analysis showed that the best predictor of hip fracture was the combination of medial calcar femoral cortex width (CFC), TRBMD, neck/shaft angle (NSA), and WABMD (r=0.72, r²=0.52, P<0.001). The area under the receiver operating characteristic curve (ROC) for this model was 0.93, while the area under ROC for TRBMD alone was 0.81. At a specificity of 80%, sensitivity improved from 52.5% to 92.5% with this combination compared with TRBMD alone. The combined predictors of cervical and trochanteric fracture differed, being NSA, CFC, TRBMD, and WABMD for cervical and TRBMD and femoral shaft cortical thickness for trochanteric fracture. In addition, we found a statistically significant correlation between FEBMD and femoral shaft and femoral neck cortex width (r=0.40, P<0.01 and r=0.30, P<0.01, respectively). The results confirm that the combination of BMD and radiological measures of upper femur geometry improve the assessment of the risk of hip fracture and fracture type compared to BMD alone, and that bone geometry plays an important role in the evaluation of bone strength.     

The effect of age and menopause on bone mineral density of the proximal femur

Although the menopause has been associated with increased bone loss at several skeletal sites, it has not previously been noted in the hip, yet estrogen therapy has been reported to reduce the incidence of hip fractures. We investigated the effect of age and menopause on bone loss in the proximal femur by measuring bone mineral density (BMD) of the femoral neck, Ward's triangle, and trochanter by dual-photon absorptiometry in 263 normal women aged 20-84. Multiple regression analyses revealed a significant decrease in BMD of the femoral neck and Ward's triangle with age in both pre- and postmenopausal women (p less than 0.001). In the trochanter the decrease with age was significant only in postmenopausal women (p less than 0.001). Further analysis revealed that BMD decreased faster at all sites in the early postmenopausal years. During the first 6 years postmenopause, the decrease in BMD of the femoral neck and trochanter was 3-10 times higher than the change in the decade prior to menopause. About 20% of the lifetime femoral neck loss and 30% of the trochanteric loss occurred in the early postmenopausal period. It is concluded that both age and menopause are major determinants of BMD in the proximal femur. These findings could explain why estrogen therapy has been reported to prevent hip fracture. The rapid early postmenopausal loss in BMD of the proximal femur demonstrates the importance of starting estrogen replacement therapy immediately after menopause for maximum effect.     

Bone diminution of osteoporotic females at different skeletal sites

Summary The bone mineral density (BMD) of the radius and spine was determined by photo absorptiometry in a large number of controls (radius: n=111; spine: n=85; age range: 50–79 years) and osteoporotic women (radius: n=98; spine n=140; age range: 50–79 years) with at least one “atraumatic” vertebral compression fracture. Compared to age-matched controls, the BMD of the osteoporotic women showed the following diminutions: sixth decade: radius:−9.1%; spine:−25%; femur: −33%; seventh decade: radius:−16%; spine: −19%; femur:−23%; eighth decade: radius: −21%; spine:−20%; femur:−24%. The BMD was significantly diminished at all sites in all decades but in contrast to the radius, the difference from controls was bigger in the spine and femur in the sixth decade than in the seventh and eighth decade. In the osteoporotic women there was a significant correlation between radius BMD and age (4=−0.56;P<0.01) but not between spine or femoral BMD and age. The femoral neck BMD was also determined in a subset group of female controls (n=68), patients with crush fractures of the spine without a fracture of the hip (n=46), and in patients with fractures of the proximal femur (n=21). There was no difference among these groups in mean age (64±7, range: 50–79 years). Patients with hip fracture and spine fracture showed bone diminution in all three regions that was significantly below controls (P<0.001). The Ward's triangle region was specially diminished (−35%) and as a consequence the neck BMD was low (−26%). Trochanteric density was lower (−25%) in spine fracture cases than in hip fracture (−16%). The difference between the two groups of osteoporotic women was significant (P<0.05). In the hip fractures cases, spine BMD was reduced only moderately compared to controls (−14%,P<0.01) and slightly elevated compared to spinal osteoporosis where the diminution was greater (−24%,P<0.001). Again, the difference between the two osteoporotic groups was significant (P<0.05). It appeared that spinal osteoporosis involved loss of bone from both the spine and hip, whereas femoral osteoporosis showed a preferential loss of bone from the femur neck region, and a lesser loss from the trochanter or the spine.