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< Back Mirels' Score for Upper Limb Metastatic Lesions: Do We Need a Different Cutoff for Recommending Prophylactic Fixation? Conclusions: This study demonstrates moderate to substantial agreement between and within raters using Mirels’ score on upper limb radiographs. However, Mirels’ score had a poor ensitivity and specifity in predicting upper extremity fractures. Until a more valid scoring system has been developed, based on our study, we recommend a Mirels’ threshold of 7/12 for considering prophylactic fixation of impending upper limb pathologic fractures. This contrasts with the current 9/12 cutoff, which is recommended for lower limb pathologic fractures. 🧠 Key Points: Mirels score was originally proposed for metastatic lesions in the lower extremities; its applicability to the upper extremity has been questioned. A score of ≥7 may be sufficient to consider prophylactic fixation in upper extremity metastases. This was a retrospective study analyzing 138 cases. JSES International (2022), Vol 6(4): 675–681 DOI:10.1016/j.jseint.2022.03.006 Previous Next

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Basic Science Musculoskeletal Science & Biomechanics Pharmacology, Systemic Disease & Toxicity Molecular, Cellular & Clinical Foundations • Bone and Joint Biology • Biologic Tissues • Skeletal Muscle • Tendons • Articular Cartilage • Skeletal Development • Peripheral Nerve Structure and Function • Articular Cartilage: Structure, Components, and Clinical Relevance Overview • Biomechanics • Cellular and Molecular Biology, Immunology and Genetics Terminology • Skeletal Medicine • Musculoskeletal Infections • Coaghulopathies • Anticoagulants • Clinical Research, Statistical Concepts, and Tests • Evidence-Based Medicine • Professionalism and Ethical Principles • Bone Grafts, BMP, and Bone Substitutes • Biomaterials • Bioabsorbable Materials • Imaging in Orthopaedics • Orthoses

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< Back Dr. Erhan OKAY Fibrous Dysplasia Fibrous dysplasia (FD) is a benign bone disorder characterized by the replacement of normal bone with fibro-osseous tissue, leading to pain, deformity, and fractures. It results from post-zygotic GNAS gene mutations that disrupt osteoblastic differentiation. FD may be monostotic (single bone) or polyostotic, the latter often occurring as part of McCune–Albright syndrome (MAS). Radiologically, it presents with a ground-glass appearance and possible deformities such as the “shepherd’s crook” in the proximal femur. Treatment is primarily symptomatic, involving bisphosphonates for pain control and surgery for deformity or fracture correction. Although benign, the disease may progress during growth and stabilize in adulthood, requiring periodic follow-up for skeletal deformity and functional assessment. Pathophysiology Caused by post-zygotic mutations in the GNAS gene . Leads to defective osteoblastic differentiation and formation of immature woven bone mixed with fibrous tissue. Two clinical forms: Monostotic FD: Involves a single bone. Polyostotic FD: Affects multiple bones and may be associated with McCune–Albright syndrome (endocrine abnormalities + café-au-lait spots). Clinical Presentation & Imaging Symptoms: Bone pain, deformity, limp, or pathological fracture. Typical signs: “Ground-glass” appearance on radiographs, cortical thinning, and possible cystic changes. Characteristic deformity: Shepherd’s crook in proximal femur due to repeated microfractures. CT scan: Useful for evaluating lesion extent and surgical planning. MRI: May show low-to-intermediate T1 and high T2 signal intensities. Differential Diagnosis Monostotic FD: Simple bone cyst, osteofibrous dysplasia, osteoblastoma, hemangioma, Paget’s disease. Polyostotic FD: Hyperparathyroidism, enchondromatosis, neurofibromatosis, eosinophilic granuloma.Fibrous dysplasia Treatment Medical Management Pain control: NSAIDs for symptomatic relief. Bisphosphonates (Pamidronate): 0.5–1 mg/kg/day IV for 2–3 days every 6–12 months. Reduces pain and bone turnover, but does not halt disease progression . Experimental therapies: Calcitonin and other bone-modulating agents under investigation. Surgical Management Indicated for: Structural deformity or pathological fractures. Progressive or symptomatic lesions. Procedures: Curettage, bone grafting, internal fixation (e.g., intramedullary nailing), corrective osteotomies. Risks: Recurrence and infection, though outcomes are generally favorable. Prognosis Usually benign and stabilizes after skeletal maturity. Polyostotic cases may require annual follow-up for deformity monitoring. Disease activity typically declines after adolescence. Functional disability may occur in cases with extensive skeletal involvement. References Hartley I, Zhadina M, Collins MT, Boyce AM. Fibrous Dysplasia of Bone and McCune-Albright Syndrome: A Bench to Bedside Review. Calcif Tissue Int. 2019;104(5):517–529. doi:10.1007/s00223-019-00550-z. Fitzpatrick KA, Taljanovic MS, Speer DP, et al. Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation. AJR Am J Roentgenol. 2004;182(6):1389–1398. doi:10.2214/ajr.182.6.1821389. Riddle ND, Bui MM. Fibrous Dysplasia. Arch Pathol Lab Med. 2013;137(1):134–138. doi:10.5858/arpa.2012.0013-RS. Lala R, Matarazzo P, Bertelloni S, et al. Pamidronate Treatment of Bone Fibrous Dysplasia in Children with McCune-Albright Syndrome. Acta Paediatr. 2000;89(2):188–193. doi:10.1080/080352500750028816. Hart ES, Kelly MH, Brillante B, et al. Onset, Progression, and Plateau of Skeletal Lesions in Fibrous Dysplasia and the Relationship to Functional Outcome. J Bone Miner Res. 2007;22(9):1468–1474. doi:10.1359/jbmr.070511. Plain radiograph and coronal CT image of the leg show a well-circumscribed intramedullary expansile lesion in the proximal fibula with a ground-glass matrix and smooth cortical thinning. No cortical breakthrough or periosteal reaction is present. The imaging features are consistent with monostotic fibrous dysplasia. Radiograph and coronal MRI images of the proximal femur demonstrate a well-defined intramedullary expansile lesion with a ground-glass matrix and cortical thinning without periosteal reaction or soft-tissue extension. On MRI, the lesion shows heterogeneous low-to-intermediate signal on T1-weighted and high signal on fat-suppressed proton-density images, consistent with a fibrous dysplasia involving the proximal femoral shaft. Aspect Details Nature Benign fibro-osseous lesion replacing normal bone with fibrous tissue Genetic Basis GNAS mutation causing defective osteoblastic differentiation Forms Monostotic (single bone) and Polyostotic (multiple bones, often with McCune–Albright syndrome) Common Sites Femur, tibia, ribs, craniofacial bones Characteristic Imaging “Ground-glass” matrix, cortical thinning, shepherd’s crook deformity (proximal femur) Symptoms Bone pain, deformity, limp, or pathologic fracture Treatment Pain control (NSAIDs), bisphosphonates for bone turnover reduction, surgery for deformity/fracture Prognosis Benign course; stabilizes after skeletal maturity; annual follow-up for polyostotic cases Previous Next

< Back Dr. Ozcan KAYA Subaxial Cervical Spine Fractures Subaxial cervical spine injuries (C3–C7) are common consequences of high- to moderate-energy trauma, though even low-energy mechanisms can cause significant damage in elderly or ankylosed spines. They result from flexion, extension, compression, or burst mechanisms, most frequently between C5 and C7. Diagnosis begins with ATLS evaluation and cervical immobilization, followed by neurologic assessment and imaging. Standard radiographs (AP, lateral, odontoid) are complemented by CT for fracture detail and MRI for disco-ligamentous complex (DLC) and cord evaluation. Classification systems such as AOSpine, SLIC, and Allen–Ferguson guide management. Stable compression fractures without posterior ligamentous involvement may be managed conservatively using a rigid orthosis, whereas unstable or displaced injuries—especially burst and flexion teardrop fractures—require surgical decompression and fixation. Prognosis depends on the initial neurological deficit, fragment displacement, and timing of surgery; patients with ankylosing spondylitis are at higher risk of neurological deterioration and often need long-segment stabilization. Overview Injury to bony and ligamentous anatomy of C3 to C7 levels Wide range of motion makes this region vulnerable to injury High energy -moderate energy injury mechanism; in elderly low energy trauma Anklylosis Spondylitis very low energy trauma may cause injury Compression,burst, flexion teardrop, extention tear drop mechanisms etc. Cervical spine injury 3% due to blunt trauma ;50% between C5 and C7 Clinical Presentation Focal neurologic deficit, neck pain, torticollis, Reporting diving as the mechanism of injury 1st evaluation is ATLS and suspicion of cervical spine injury requires spinal immobilization Posterior midline tenderness and step off Patient transport with spine board log roll technique *Cervical alignment: In children head size is larger so Alignment of the external auditory meatus with the shoulders, even if this involves a relative extension of the neck, will align the cervical spine in neutral and avoid forward flexion in young children *Standard sensory and motor exam, with reflexes of the upper and lower extremities, should be documented. *Findings of upper motor neuron signs ( muscle weakness, spasticity, hyperreflexia, and clonus) may indicate cord compression *Compromised root may indicate injury level; In cervical spine roots exit above corresponding vertebral body (Figure ROOT MUSCLE TABLOSU) Imaging * An anteroposterior, lateral, and open-mouth odontoid xray views are standard *Normal cervical spine should be 15 to 30 degrees of lordosis from C1 through C7 *NEXUS criterias for radiologic evaluation of cervical spine injury *Multiplanar CT scans *Suspicion of neurologic injury and age over 60, polytrauma patients, cervical spondylosi, and a patient that cannot undergo evaluation due to a low GCS or other altered mental status needs MRI Classification 1-AOSpine Subaxial Cervical Spine Injury Classification (LINK) fracture type, facet injury, neurological status, and the presence of specific modifiers 2-Subaxial Injury Classification System (SLIC) (LINK+ FIGURE) the type of fracture, the competency of the DLC, and the patient’s neurologic status 3-Allen and Ferguson Classification (FIGURE) *Subaxial cervical spine injuries are the result of compression or distraction forces that cause flexion or extension moments. Treatment Conservative treatment: *Rigid cervical/cervicothoracic orthosis for 6 to 12 weeks and follow-up with interval radiographs to evaluate alignment ( compression fractures; no posterior ligamentous or capsular involvement-stable fracture pattern) *High risk of posttraumatic kyphosis with conservative treatment if the fracture is a C7 Surgery: *Unstable fracture w/wo neurologic compromise needs decompression and fixation *Burst fractures mostly unstable w/wo neurologic deficits and usually require surgical decompression and fixation( displacement to the canal, flexion-type teardrop fractures often treated anterior approach (effected number of levels/intact DLC+ posterior fixation support) * Awake and alert patient; facet dislocations may be reduced with controlled cervical traction (Unilateral dislocations may be locked and inappropriate for closed reduction) *Unconscious and incoorperate patient evaluate with MRI before reduction attempt *Ankylosing spondylitis patient check neuro with intervals; may require long instrumentation Prognosis *Larger fragments compressing cord and advanced injury classification scores are related with poor prognosis also increased time to surgery from injury may cause poor prognosis *60% limits neurologic deficit and 30% improves somewhat *A flexion moment injury and known AS may be associated with late onset neurologic deterioration *AS pts tend to have higher incidence of neurologic complications. References Fehlings MG, Tetreault LA, Riew KD, Middleton JW. Cervical Spine Trauma: Principles of Evaluation and Management. In: Orthopaedic Knowledge Update: Spine 6. AAOS; 2018. Vaccaro AR, Hulbert RJ, Patel AA, et al. The Subaxial Cervical Spine Injury Classification System and Case Examples. Spine (Phila Pa 1976). 2007;32(21):2365–2374. Joaquim AF, Patel AA. Subaxial Cervical Spine Trauma: Evaluation and Surgical Decision-Making. Global Spine J. 2014;4(1):63–70. AOSpine Knowledge Forum Trauma. AOSpine Subaxial Cervical Spine Injury Classification. Eur Spine J. 2015;24(10):2244–2257. Allen BL, Ferguson RL, Lehmann TR, O'Brien RP. A Mechanistic Classification of Closed, Indirect Fractures and Dislocations of the Lower Cervical Spine. Spine (Phila Pa 1976). 1982;7(1):1–27. Mendenhall SK, Mroz TE, Benzel EC. Subaxial Cervical Spine Trauma. Neurosurgery. 2017;80(3S):S139–S145. Previous Next

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