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Journal of Bone and Mineral Research :... Nov 2023Bone fractures are among the most prevalent musculoskeletal injuries, and pain management is an essential part of fracture treatment. Fractures heal through an early...
Bone fractures are among the most prevalent musculoskeletal injuries, and pain management is an essential part of fracture treatment. Fractures heal through an early inflammatory phase, followed by repair and remodeling. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for fracture pain control as they potently inhibit the inflammatory phase and, thus, impair the healing. Opioids do not provide a better alternative for several reasons, including abuse potential. Accordingly, there is an unmet clinical need for analgesics that effectively ameliorate postfracture pain without impeding the healing. Here, we investigated the analgesic efficacy of two nonpsychotropic cannabinoids, cannabidiol (CBD) and cannabigerol (CBG), in a mouse model for tibial fracture. Mice with fractured tibiae exhibited increased sensitivity to mechanical, cold, and hot stimuli. Both CBD and CBG normalized pain sensitivity to all tested stimuli, and their analgesic effects were comparable to those of the NSAIDs. Interestingly, CBD and CBG promoted bone healing via multiple mechanisms during the early and late phases. During the early inflammatory phase, both cannabinoids increased the abundance of periosteal bone progenitors in the healing hematoma and promoted the osteogenic commitment of these progenitors. During the later phases of healing, CBD and CBG accelerated the fibrocartilaginous callus mineralization and enhanced the viability and proliferation of bone and bone-marrow cells. These effects culminated in higher bone volume fraction, higher bone mineral density, and improved mechanical quality of the newly formed bone. Together, our data suggest CBD and CBG as therapeutic agents that can replace NSAIDs in managing postfracture pain as both cannabinoids exert potent analgesic effects and, at the same time, promote bone healing. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Topics: Mice; Animals; Cannabidiol; Cannabinoids; Bony Callus; Pain; Anti-Inflammatory Agents, Non-Steroidal; Tibial Fractures; Minerals; Fracture Healing
PubMed: 37597163
DOI: 10.1002/jbmr.4902 -
Archives of Osteoporosis Aug 2023Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were... (Meta-Analysis)
Meta-Analysis Review
The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years.
UNLABELLED
Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline.
PURPOSE
After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines.
METHODS
PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance.
RESULTS
Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures.
CONCLUSIONS
Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.
Topics: Humans; Middle Aged; Clinical Governance; Fractures, Bone; Bone Density; Advisory Committees; Physical Functional Performance
PubMed: 37603196
DOI: 10.1007/s11657-023-01316-9 -
Current Osteoporosis Reports Dec 2023The integration of data from multiple genomic assays from humans and non-human model organisms is an effective approach to identify genes involved in skeletal fragility... (Review)
Review
PURPOSE OF REVIEW
The integration of data from multiple genomic assays from humans and non-human model organisms is an effective approach to identify genes involved in skeletal fragility and fracture risk due to osteoporosis and other conditions. This review summarizes genome-wide genetic variation and gene expression data resources relevant to the discovery of genes contributing to skeletal fragility and fracture risk.
RECENT FINDINGS
Genome-wide association studies (GWAS) of osteoporosis-related traits are summarized, in addition to gene expression in bone tissues in humans and non-human organisms, with a focus on rodent models related to skeletal fragility and fracture risk. Gene discovery approaches using these genomic data resources are described. We also describe the Musculoskeletal Knowledge Portal (MSKKP) that integrates much of the available genomic data relevant to fracture risk. The available genomic resources provide a wealth of knowledge and can be analyzed to identify genes related to fracture risk. Genomic resources that would fill particular scientific gaps are discussed.
Topics: Humans; Bone Density; Genome-Wide Association Study; Genetic Predisposition to Disease; Osteoporosis; Fractures, Bone; Bone and Bones; Gene Expression; Biology
PubMed: 37831357
DOI: 10.1007/s11914-023-00821-7 -
Clinical Practice and Cases in... Aug 2023Blowing the nose and sneezing are ubiquitous physiologic processes. While exceedingly rare, traumatic injuries have been described. We detail a case of spontaneous...
INTRODUCTION
Blowing the nose and sneezing are ubiquitous physiologic processes. While exceedingly rare, traumatic injuries have been described. We detail a case of spontaneous intracranial hemorrhage and orbital fractures sustained as a result of these two phenomena in an otherwise healthy adult without known risk factors for bleeding or intracranial hemorrhage.
CASE REPORT
A 79-year-old female presented to the emergency department after blowing her nose with an episode of sneezing following mild epistaxis. She denied any history of trauma, anticoagulation use, bleeding disorders, or pain associated with her symptoms. On examination, she had notable right periorbital swelling. Computed tomography revealed multiple areas of intracranial hemorrhage along with right-sided orbital and zygomatic fractures. After consulting trauma surgery and neurosurgery, we elected to pursue conservative management with repeat imaging. The patient had an uneventful course and was discharged with outpatient follow-up two days later.
CONCLUSION
To our knowledge, this is the first case described of this constellation of injuries after a relatively benign process. Despite not having increased risk factors for intracranial hemorrhage (anticoagulation use, history of trauma, history of coagulopathy), this patient had severe injuries that presented with few external symptoms. This case serves as a reminder that while physiologic processes are almost always benign, serious traumatic injuries can result. Clinicians should have a low threshold for advanced imaging when there is a high clinical suspicion of facial fractures or more ominous processes.
PubMed: 37595299
DOI: 10.5811/cpcem.1588 -
European Journal of Medical Genetics Nov 2023Osteogenesis imperfecta (OI) and hypophosphatasia (HPP) are rare skeletal disorders caused by mutations in the genes encoding collagen type I (COL1A, COL1A2) and...
Combination of osteogenesis imperfecta and hypophosphatasia in three children with multiple fractures, low bone mass and severe osteomalacia, a challenge for therapeutic management.
Osteogenesis imperfecta (OI) and hypophosphatasia (HPP) are rare skeletal disorders caused by mutations in the genes encoding collagen type I (COL1A, COL1A2) and tissue-non-specific isoenzyme of alkaline phosphatase (ALPL), respectively. Both conditions result in skeletal deformities and bone fragility although bone tissue abnormalities differ considerably. Children with OI have low bone mass and hypermineralized matrix, whereas HPP children develop rickets and osteomalacia. We report a family, father and three children, affected with growth retardation, low bone mass and recurrent fractures. None of them had rickets, blue sclera or dentinogenesis imperfecta. ALP serum levels were low and genetics revealed in the four probands heterozygous pathogenic mutations in COL1A2 c.838G > A (p.Gly280Ser) and in ALPL c.1333T > C (p.Ser445Pro). After multidisciplinary meeting, a diagnostic transiliac bone biopsy was indicated for each sibling for therapeutic decision. Bone histology and histomorphometry, as compared to reference values of children with OI type I as well as, to a control pediatric patient harboring the same COL1A2 mutation, revealed similarly decreased trabecular bone volume, increased osteocyte lacunae, but additionally severe osteomalacia. Quantitative backscattered electron imaging demonstrated that bone matrix mineralization was not as decreased as expected for osteomalacia. In summary, we observed within each biopsy samples classical features of OI and classical features of HPP. The apparent nearly normal bone mineralization density distribution results presumably from divergent effects of OI and HPP on matrix mineralization. A combination therapy was initiated with ALP enzyme-replacement and one month later with bisphosphonates. The ongoing treatment led to improved skeletal growth, increased BMD and markedly reduced fracture incidence.
Topics: Child; Humans; Osteogenesis Imperfecta; Hypophosphatasia; Osteomalacia; Fractures, Multiple; Mutation; Alkaline Phosphatase; Calcinosis; Rickets
PubMed: 37758163
DOI: 10.1016/j.ejmg.2023.104856 -
Journal of Clinical Medicine Sep 2023The management of pelvic fractures is a significant challenge. Surgical site infection can result in the need for revision surgery, cause functional impairment, and lead...
BACKGROUND
The management of pelvic fractures is a significant challenge. Surgical site infection can result in the need for revision surgery, cause functional impairment, and lead to a prolonged length of stay and increased treatment costs. Although reports on fracture-related infection (FRI) after pelvic fracture fixation are sparsely reported in the literature, it is a serious complication. This study analysed patients with FRIs after pelvic fracture regarding patient characteristics, treatment strategies, and an evaluation of risk factors for FRI.
METHODS
In this retrospective single-centre study, FRI was diagnosed based on clinical symptoms of infection and a positive culture of a bacterial infection. Depending on the severity and acuteness of the infection, osseous stabilization was restored either via implant retention (stable implant, no osteolysis), exchange (loose implant or bony defect), or external fixation (recurrence of infection after prior implant retaining revision). Healing of infection was defined as no sign of recurring infection upon clinical, radiological, and laboratory examination in the last follow-up visit.
RESULTS
The FRI rate in our patient population was 7.5% (24/316). In 8/24 patients, the FRI occurred within the first three weeks after initial surgery (early) and 16/24 presented with a late onset of symptoms of FRI. A strategy of debridement, antibiotics, and implant retention (DAIR) was successful in 9/24 patients with FRI after pelvic fracture. A total of 10 patients required an exchange of osteo-synthetic implants, whereof three were exchanged to an external fixator. In five patients, we removed the implant because the fracture had already consolidated at the time of revision for infection. A total of 17/24 patients had a poly-microbial infection after a pelvic fracture and 3/24 patients died from post-traumatic multi-organ failure within the first 6 months after trauma. There were no cases of persistent infection within the remaining 21 patients.
CONCLUSIONS
Although poly-microbial infection is common in FRI after pelvic fracture, the recurrence rate of infection is relatively low. A complex pelvic trauma with significant soft tissue injury is a risk factor for recurrent infection and multiple revisions. A strategy of DAIR can be successful in patients with a stable implant. In cases with recurrent infection or an unstable fracture site, the exchange of implants should be considered.
PubMed: 37834865
DOI: 10.3390/jcm12196221 -
Cureus Apr 2024Artificial intelligence (AI) simulates intelligent behavior using computers with minimum human intervention. Recent advances in AI, especially deep learning, have made... (Review)
Review
Artificial intelligence (AI) simulates intelligent behavior using computers with minimum human intervention. Recent advances in AI, especially deep learning, have made significant progress in perceptual operations, enabling computers to convey and comprehend complicated input more accurately. Worldwide, fractures affect people of all ages and in all regions of the planet. One of the most prevalent causes of inaccurate diagnosis and medical lawsuits is overlooked fractures on radiographs taken in the emergency room, which can range from 2% to 9%. The workforce will soon be under a great deal of strain due to the growing demand for fracture detection on multiple imaging modalities. A dearth of radiologists worsens this rise in demand as a result of a delay in hiring and a significant percentage of radiologists close to retirement. Additionally, the process of interpreting diagnostic images can sometimes be challenging and tedious. Integrating orthopedic radio-diagnosis with AI presents a promising solution to these problems. There has recently been a noticeable rise in the application of deep learning techniques, namely convolutional neural networks (CNNs), in medical imaging. In the field of orthopedic trauma, CNNs are being documented to operate at the proficiency of expert orthopedic surgeons and radiologists in the identification and categorization of fractures. CNNs can analyze vast amounts of data at a rate that surpasses that of human observations. In this review, we discuss the use of deep learning methods in fracture detection and classification, the integration of AI with various imaging modalities, and the benefits and disadvantages of integrating AI with radio-diagnostics.
PubMed: 38756254
DOI: 10.7759/cureus.58364 -
Trauma Surgery & Acute Care Open 2024Concomitant chest wall fractures (sternal and/or rib fractures) with unstable thoracolumbar fractures that require surgical fixation are rare but highly morbid injuries...
Concomitant chest wall fractures (sternal and/or rib fractures) with unstable thoracolumbar fractures that require surgical fixation are rare but highly morbid injuries that mandate a multidisciplinary approach to treatment. There is limited evidence in the literature regarding optimal timing and order of surgical fixation of these patients with multiple injuries. Here, we present our experience with two patients at a single institution that demonstrates the challenges that present with this patient population. We advocate for earlier fixation of the chest wall fractures in the appropriately indicated patients, prior to prone positioning for spinal fixation.
PubMed: 38529315
DOI: 10.1136/tsaco-2023-001196 -
Journal of Personalized Medicine Aug 2023The patellofemoral joint (PFJ) is a complex articulation between the patella and the femur which is involved in the extensor mechanism of the knee. Patellofemoral...
The patellofemoral joint (PFJ) is a complex articulation between the patella and the femur which is involved in the extensor mechanism of the knee. Patellofemoral disorders can be classified into objective patellar instability, potential patellar instability, and patellofemoral pain syndrome. Anatomical factors such as trochlear dysplasia, patella alta, and the tibial tuberosity-trochlear groove (TT-TG) distance contribute to instability. Patellofemoral instability can result in various types of dislocations, and the frequency of dislocation can be categorized as recurrent, habitual, or permanent. Primary patellar dislocation requires diagnostic framing, including physical examination and imaging. Magnetic resonance imaging (MRI) is essential for assessing the extent of damage, such as bone bruises, osteochondral fractures, and medial patellofemoral ligament (MPFL) rupture. Treatment options for primary dislocation include urgent surgery for osteochondral fragments or conservative treatment for cases without lesions. Follow-up after treatment involves imaging screening and assessing principal and secondary factors of instability. Detecting and addressing these factors is crucial for preventing recurrent dislocations and optimizing patient outcomes.
PubMed: 37623475
DOI: 10.3390/jpm13081225 -
Cureus Jul 2023Testicular rupture is a surgical emergency necessitating prompt diagnosis and intervention to prevent irreversible damage. Blunt trauma, including motorcycle collisions,...
Testicular rupture is a surgical emergency necessitating prompt diagnosis and intervention to prevent irreversible damage. Blunt trauma, including motorcycle collisions, is a common cause of testicular rupture. In the case of multi-trauma, the diagnosis of testicular rupture may be missed in the rush to surgical intervention of more grossly obvious injuries. We present a case of a 24-year-old male who suffered a motorcycle accident and subsequently presented with diffuse abdominal and hip pain. Physical exam and imaging at the emergency department showed multiple pelvic bone fractures, along with a small scrotal injury which was triaged below his pelvic injuries. His pelvic fractures were immediately operated on. Nearly 18 hours after his initial presentation, the patient received a scrotal ultrasound which demonstrated a rupture of the right testicle. Due to this long delay in diagnosis, his urological team opted for non-surgical management and instead employed a more conservative treatment regimen involving pain control, scrotal support, rest, and serial scrotal ultrasounds. This case highlights the importance of timely ultrasound examination for testicular pathology in the setting of multi-trauma and known scrotal injury. Another highlight of this case is the showcase of an uncommon treatment regimen utilizing conservative tactics as opposed to opting for surgical intervention.
PubMed: 37565108
DOI: 10.7759/cureus.41609