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Journal ArticleDOI

A Case Report of Abnormal Fracture Healing as Detected With High-Resolution Peripheral Quantitative Computed Tomography.

01 Oct 2017-Journal of Clinical Densitometry (Elsevier)-Vol. 20, Iss: 4, pp 486-489

TL;DR: The authors would like to thank Liesbeth Jutten and Margareth Winants from the Trial Bureau of the Department of Orthopedics for their efforts during this study.

AbstractThe authors would like to thank Liesbeth Jutten and Margareth Winants from the Trial Bureau of the Department of Orthopedics for their efforts during this study. This study was funded by the Weijerhorst Foundation (grant no. WH2).

Summary (1 min read)

Introduction

  • Fracture healing is a complex repair process with the primary objective of restoring the mechanical function of the fractured bone (1).
  • Quantifying outcome in clinical fracture healing trials remains challenging (2,3).
  • Using highresolution peripheral quantitative computed tomography (HR-pQCT) in combination with micro finite element analysis (µFEA), the authors previously described the typical healing of a distal radius fracture.
  • In the present case report, the authors describe a patient who deviated from this usually observed pattern of fracture healing.

Case Report

  • A 54-yr-old woman visited their emergency department with a displaced distal radius fracture of the left arm after a fall from standing height.
  • After a successful closed reduction at the emergency room, the patient was treated by cast immobilization.
  • Six weeks post fracture, the patient complained of increased pain, swelling, and stiff fingers.
  • At the 8-wk outpatient clinic visit, a decreased motor function of the extensor muscles of the left wrist and all digits without sensory disturbances was observed.

HR-pQCT Measurements

  • HR-pQCT is a low-dose radiographic imaging modality with an isotropic voxel size of 82 (XtremeCT-1; Scanco Medical AG, Brüttisellen, Switzerland).
  • Results Incongruent with the healing pattern observed with HRpQCT described earlier (4,5), a decrease in trabecular density was detected at 6 wk post fracture (−11.9 mgHA/ cm3), where the typical healing response showed an increase (median +35.4 mgHA/cm3).
  • This deviation was not restored even after 115 wk (Fig. 1A).
  • In contrast, the cortical region healed normally, following a similar pattern as the other patients in the study (Fig. 1C).
  • This is especially evident in the segmented 3-dimensional reconstructions.

Discussion

  • The present case report demonstrates the potential of HR-pQCT to distinguish different patterns of fracture healing in a clinical setting.
  • The relevance of CRPS in the present case report is uncertain.
  • Using HR-pQCT, the incidence and role of localized bone loss within the CRPS population could be further elucidated.
  • A limitation of the present case report is that it only presents a single affected patient to illustrate the detection of abnormal fracture healing using HR-pQCT.
  • Additionally, based on the current data available to us, the etiology of the observed bone loss is not certain and can only be speculated on.

Acknowledgments

  • The authors would like to thank Liesbeth Jutten and Margareth Winants from the Trial Bureau of the Department Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health Volume 20, 2017 of Orthopedics for their efforts during this study.
  • This study was funded by the Weijerhorst Foundation (grant no.WH2).

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Content maybe subject to copyright    Report

A Case Report of Abnormal Fracture Healing as
Detected With High-Resolution Peripheral Quantitative
Computed Tomography
Citation for published version (APA):
Heyer, F. L., de Jong, J. J. A., Smeets, R. J. E. M., Arts, J. J., Poeze, M., Geusens's, P. E., van
Rietbergen, B., van den Bergh, J. P., & Willems, P. C. (2017). A Case Report of Abnormal Fracture
Healing as Detected With High-Resolution Peripheral Quantitative Computed Tomography. Journal of
Clinical Densitometry, 20(4), 486-489. https://doi.org/10.1016/j.jocd.2017.05.004
Document status and date:
Published: 01/01/2017
DOI:
10.1016/j.jocd.2017.05.004
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Case Report
A Case Report of Abnormal Fracture Healing as Detected With
High-Resolution Peripheral Quantitative Computed Tomography
Frans L. Heyer,*
,1,2,3
Joost J.A. de Jong,
1,4
Rob J.E.M. Smeets,
5,6
Jacobus J. Arts,
5,7
Martijn Poeze,
1,2
Piet P. Geusens,
4,5,8
Bert van Rietbergen,
9
Joop P. van den Bergh,
1,3,4,8
and Paul C. Willems
5,7
1
Research School NUTRIM, Maastricht University, The Netherlands;
2
Department of Surgery, Maastricht University
Medical Center, The Netherlands;
3
Department of Internal Medicine,VieCuri Medical Center Venlo, The Netherlands;
4
Department of Rheumatology, Maastricht University Medical Center, The Netherlands;
5
Research School CAPHRI,
Maastricht University, The Netherlands;
6
Department of Rehabilitation Medicine, Libra Rehabilitation and Audiology
location Eindhoven/Weert, The Netherlands;
7
Department of Orthopedic Surgery, Maastricht University Medical Center,
The Netherlands;
8
Faculty of Medicine and Life Sciences, Hasselt University, Belgium; and
9
Faculty of Biomedical
Engineering, Eindhoven University of Technology, The Netherlands
Key Words: Bone; case report; fracture healing; HR-pQCT.
Introduction
Fracture healing is a complex repair process with the
primary objective of restoring the mechanical function of
the fractured bone
(1). Quantifying outcome in clinical frac-
ture healing trials remains challenging
(2,3). Using high-
resolution peripheral quantitative computed tomography
(HR-pQCT) in combination with micro finite element
analysis (µFEA), we previously described the typical healing
of a distal radius fracture. This process consists of an in-
crease in bone density of the trabecular compartment
peaking at 6 wk post fracture, corresponding to the for-
mation of a mineralized fracture callus
(4,5). In the present
case report, we describe a patient who deviated from this
usually observed pattern of fracture healing.
Patient and Methods
Case Report
A 54-yr -old woman visited our emergenc y department with
a displaced distal radius fracture of the left arm after a fall
from standing height. After a successful closed reduction at
the emergency room, the patient was treated by cast immo-
bilization. Six weeks post fracture, the patient complained
of increased pain, swelling , and stiff fingers. Physical exami-
nation revealed no neurological or vascular impairment. Stan-
dard radiographs showed incomplete consolidation of the
fracture without secondary dislocation. Cast immobiliza-
tion was continued for 2 more weeks. At the 8-wk outpa-
tient clinic visit, a decreased motor function of the extensor
muscles of the left wrist and all digits without sensory dis-
turbances was observed.Radiographic examination showed
delayed but progressing consolidation (
Supplemental Fig .S1).
Physical therapy was started. Three months after the frac-
ture, the left lower arm was swollen and showed a purple
discoloration. Active flexion and extension of the left wrist
and digits were in all axes, and active and passive move-
ments of the left shoulder were limited. Electromyography
of the left arm revealed conduction abnormalities of the radial
nerve near the wrist, and ulnar and median nerve injuries at
elbow level.Three months post fracture,the patient met the
Budapest clinical and research criteria
(6) for complex re-
gional pain syndrome (CRPS) type 1. Subsequent multidis-
ciplinary treatment consisted of graded exposure therapy,
transcutaneous electrical nerve stimulation, amitriptyline,
Received 05/4/17; Accepted 05/8/17.
Disclosures: J.J. Arts is a board member of the workgroup Bio-
technology of the Dutch Orthopedic Association (NOV) and a
board member of the Dutch Society of Biomaterials and Tissue
Engineering (NBTE). B. van Rietbergen is a consultant for Scanco
Medical AG. P.C. Willems is a board member of the Dutch Spine
Society (association of spine surgeons). F.L. Heyer , J.J.A. de Jong,
R.J.E.M. Smeets, M. Poeze, P.P. Geusens, and J.P. van den Bergh
declare that they have no conflict of interest.
*Address correspondence to: Frans L. Heyer, MD, Depart-
ment of General Surgery, Maastricht University Medical Center,
P.O. Box 5800, 6202 AZ Maastricht, The Netherlands. E-mail:
f.heyer@maastrichtuniversity.nl
Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health, vol. 20, no. 4, 486–489, 2017
© 2017 The International Society for Clinical Densitometry.
1094-6950/20:486–489/$36.00
https://doi.org/10.1016/j.jocd.2017.05.004
486

dimethyl sulfoxide 50%, pregabalin, calcitonin, paracetamol,
and tramadol.At the last follow-up, 3 yr post fracture, active
motion of the left wrist was in all axes and both sponta-
neous pain and allodynia were present, although the patient
was able to use her affected hand to a greater extent during
normal daily activities than before treatment.
Routine screening on osteoporosis with dual-energy
X-ray absorptiometry and laboratory examination showed
osteopenia at the lumbar spine and proximal femur, and
secondary hyperparathyroidism (parathyroid hormone
8.0 pmol/L, ref. 1.3–6.8), due to vitamin D deficiency
(25(OH) vitamin D: 33 nmol/L, ref. >75 nmol/L).W ith cho-
lecalciferol supplementation, the latter was resolved by
12 wk post fracture (25(OH) vitamin D: 67 nmol/L, para-
thyroid hormone 4.5 pmol/L).
HR-pQCT Measurements
HR-pQCT is a low-dose radiographic imaging modal-
ity with an isotropic voxel size of 82 (XtremeCT-1; Scanco
Medical AG, Brüttisellen, Switzerland). The high resolu-
tion enables the assessment of bone microarchitecture in
vivo
(7) and estimation of bone strength µFEA (8).
HR-pQCT scans (XtremeCT-1) were performed at 1, 3,
6, 12, and 115 wk post fracture using the manufacturer’s
clinical in vivo settings (effective energy of 60 kVp, tube
current of 900 µA, and 100-ms integration time), in accor-
dance with the approved study protocol (NTR3821). From
these images, bone density, geometry, and microarchitectural
and µFEA parameters were derived
(4,5).
Results
Incongruent with the healing pattern observed with HR-
pQCT described earlier (4,5), a decrease in trabecular
density was detected at 6 wk post fracture (−11.9 mgHA/
cm
3
), where the typical healing response showed an in-
crease (median +35.4 mgHA/cm
3
). This deviation was not
restored even after 115 wk (Fig. 1A). Simultaneously, the
Fig. 1. High-resolution peripheral quantitative computed tomography-derived bone parameters of the presented case
of abnormal fracture healing (black circles) compared to the other subjects of the study cohort (white squares, N = 14).
In the case patient, the trabecular density is seen to decrease early in the healing process, persisting up to 115 wk (A),
along with the trabecular number (B). In contrast to trabecular density, cortical density during fracture healing follows
a normal pattern (C), which explains the restored compression stiffness (D). Data are presented as median with interquartile
range. Scans were performed (on average) at 1, 3, 6, 12, and 115 wk post fracture.
Fracture Healing as Detected with HR-pQCT 487
Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health Volume 20, 2017

trabecular number declined significantly more from 6 wk
post fracture onward (−0.7 vs median −0.2 mm
−1
), a dif-
ference persisting up to 115 wk (−1.5 vs median −0.5 mm
−1
,
Fig. 1B).
In contrast, the cortical region healed normally, follow-
ing a similar pattern as the other patients in the study
(
Fig. 1C). As a result, calculated compression stiffness using
µFEA was comparable to the other patients (Fig. 1D).
Visual inspection of the HR-pQCT reconstructions con-
firmed cortical healing. The axial and coronal reconstruc-
tions show that the trabecular bone loss in the deviating
patient (case) was more extensive than the generally ob-
served decline in trabecular density and structure (
Fig. 2
and Supplemental Video S1). This is especially evident in
the segmented 3-dimensional reconstructions. Remark-
ably, these images also indicate that the trabecular bone
loss occurred predominantly in the region proximal to the
fracture line (
Fig. 2).
Discussion
The present case report demonstrates the potential of
HR-pQCT to distinguish different patterns of fracture
healing in a clinical setting. In a single patient, we de-
tected a remarkable resorption of trabecular bone proxi-
mal to the fracture line, whereas the cortical bone healed
normally. These regional discrepancies were not detected
to this extent in the other patients with a fracture of the
distal radius.
The relevance of CRPS in the present case report is un-
certain. Although regional osteoporosis was part of the
CRPS spectrum when it was first described by Paul Sudeck
in 1900
(9), current clinical imaging techniques are unable
to discriminate normal posttraumatic bone loss as a result
of immobilization and disuse from bone loss concurring with
CRPS development
(10). However , the data presented here
are in accordance with the recent suggestion that HR-
pQCT could be a solution to this challenge
(11): the tra-
becular bone loss discriminated the patient with CRPS from
the other study participants
(4) as early as 6 wk post frac-
ture, a period characterized by cast immobilization for all
subjects. Nonetheless, CRPS remains an elusive clinical syn-
drome subject to much debate
(12–14). Using HR-pQCT,
the incidence and role of localized bone loss within the
CRPS population could be further elucidated.
A limitation of the present case report is that it only pres-
ents a single affected patient to illustrate the detection of
abnormal fracture healing using HR-pQCT. Additionally,
based on the current data available to us, the etiology of
the observed bone loss is not certain and can only be specu-
lated on. However, this case report indicates that HR-
pQCT offers a new way of looking at abnormal fracture
healing even before the presentation of clinical symptoms.
Acknowledgments
The authors would like to thank Liesbeth Jutten and
Margareth Winants from the Trial Bureau of the Department
Fig. 2. Representative slices from the presented case showing abnormal fracture healing, as compared to a patient
representative of the observed healing pattern in the study group. After 115 wk, the trabecular structure is resorbed to
a greater extent in the affected patient. The contrast between the region proximal and distal from the fracture line can
be observed in particular in the segmented 3D reconstructions. 3D, 3-dimensional.
Heyer et al.488
Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health Volume 20, 2017

of Orthopedics for their efforts during this study.T his study
was funded by the Weijerhorst F oundation (grant no .WH2).
Appendix
Supplementary material
Supplementary data to this article can be found online
at
doi:10.1016/j.jocd.2017.05.004.
References
1. Einhorn TA. 1998 The cell and molecular biology of frac-
ture healing. Clin Orthop Relat Res 355(Suppl):S7–S21.
2. Bottlang M, Augat P. 2014 The bottleneck of evidence-
based fracture care. Injury 45(Suppl 2):S1–S2.
3. Einhorn TA. 2014 Invited commentary. J Orthop Trauma
28(1):62.
4. de Jong JJA, Willems PC, Arts JJ, et al. 2014 Assessment of
the healing process in distal radius fractures by high resolu-
tion peripheral quantitative computed tomography. Bone
64:65–74.
5. de Jong JJ, Heyer FL, Arts JJ, et al. 2016 Fracture repair in
the distal radius in postmenopausal women: a follow-up 2
years postfracture using HRpQCT. J Bone Miner Res
31(5):1114–1122.
6. Harden RN, Oaklander AL, Burton AW, et al. 2013 Complex
regional pain syndrome: practical diagnostic and treatment
guidelines, 4th edition. Pain Med 14:180–229.
7. Boutroy S, Bouxsein ML, Munoz F, Delmas PD. 2005 In vivo
assessment of trabecular bone microarchitecture by high-
resolution peripheral quantitative computed tomography. J
Clin Endocrinol Metab 90(12):6508–6515.
8. MacNeil JA, Boyd SK. 2008 Bone strength at the distal radius
can be estimated from high-resolution peripheral quantita-
tive computed tomography and the finite element method.
Bone 42(6):1203–1213.
9. Sudeck P. 2005 On acute inflammatory bone atrophy. J Hand
Surg [Br] 30(5):477–481.
10. Schürmann M, Zaspel J, Löhr P, et al. 2007 Imaging in early
posttraumatic complex regional pain syndrome: a compari-
son of diagnostic methods. Clin J Pain 23(5):449–457.
11. Lascombes P, Mamie C. 2016 Complex regional pain syn-
drome type I in children: what is new? Orthop Traumatol Surg
Res 103(1):S135–S142.
12. Borchers AT, Gershwin ME. 2014 Complex regional pain syn-
drome: a comprehensive and critical review. Autoimmun Rev
13(3):242–265.
13. Borchers AT, Gershwin ME. 2017 The clinical relevance of
complex regional pain syndrome type I: the emperor’s new
clothes. Autoimmun Rev 16(1):22–33.
14. F rölke JPM, van Dongen RT, van de Meent H. 2015 Complex
regional pain syndrome type 1: negating the myth. Ned Tijdschr
Geneeskd 159:A8370.
Fracture Healing as Detected with HR-pQCT 489
Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health Volume 20, 2017
Citations
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Journal ArticleDOI
01 Oct 2019-Bone
TL;DR: This exploratory study indicates that HR-pQCT with μFEA performed within four weeks after a distal radius fracture captures biomechanical fracture characteristics that are associated with long-term functional outcome and therefore could be a valuable early outcome measure in clinical trials and clinical practice.
Abstract: Identifying determinants of long-term functional outcome after a distal radius fracture is challenging. Previously, we reported on the association between early HR-pQCT measurements and clinical outcome 12 weeks after a conservatively treated distal radius fracture. We extended the follow-up and assessed functional outcome after two years in relation to early HR-pQCT derived bone parameters. HR-pQCT scans of the fracture region were performed in 15 postmenopausal women with a distal radius fracture at 1-2 (baseline), 3-4 weeks and 26 months post-fracture. Additionally, the contralateral distal radius was scanned at baseline. Bone density, micro-architecture parameters and bone stiffness using micro-finite element analysis (μFEA) were evaluated. During all visits, wrist pain and function were assessed using the patient-rated wrist evaluation questionnaire (PRWE), quantifying functional outcome with a score between 0 and 100. Two-year PRWE was associated with torsional and bending stiffness 3-4 weeks post-fracture (R2: 0.49, p = 0.006 and R2: 0.54, p = 0.003, respectively). In contrast, early micro-architecture parameters of the fracture region or contralateral bone parameters did not show any association with long-term outcome. This exploratory study indicates that HR-pQCT with μFEA performed within four weeks after a distal radius fracture captures biomechanical fracture characteristics that are associated with long-term functional outcome and therefore could be a valuable early outcome measure in clinical trials and clinical practice.

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TL;DR: Using a reproducible model of experimental fracture healing in the rat, the integrated cellular responses that signal the pathways and the role of the extracellular matrix components in orchestrating the events of fracture healing are elucidated.
Abstract: Fracture healing is a complex physiologic process that involves the coordinated participation of several cell types. By using a reproducible model of experimental fracture healing in the rat, it is possible to elucidate the integrated cellular responses that signal the pathways and the role of the extracellular matrix components in orchestrating the events of fracture healing. Histologic characterization of fracture healing shows that intramembranous ossification occurs under the periosteum within a few days after an injury. Events of endochondral ossification occur adjacent to the fracture site and span a period of up to 28 days. Remodeling of the woven bone formed by intramembranous and endochondral ossification proceeds for several weeks. Spatial and temporal expression of genes for major collagens (Types I and II), minor fibrillar collagens (Types IV and XI), and several extracellular matrix components (osteocalcin, osteonectin, osteopontin, fibronectin and CD44) are detected by in situ hybridization. Immunohistochemical studies show that expression of proliferating cell nuclear antigen is both time and space dependent and differentially expressed in the callus tissues formed by the intramembranous and endochondral processes. Chondrocytes involved in endochondral ossification undergo apoptosis (programmed cell death), and early events in fracture healing may be initiated by the expression of early response genes such as c-fos. Additional characterization and elucidation of fracture healing will lay the foundation for subsequent studies aimed at identifying mechanisms for enhancing skeletal repair.

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"A Case Report of Abnormal Fracture ..." refers background in this paper

  • ...Fracture healing is a complex repair process with the primary objective of restoring the mechanical function of the fractured bone (1)....

    [...]


Journal ArticleDOI
TL;DR: HR-pQCT appears promising to assess bone density and microarchitecture at peripheral sites in terms of reproducibility and ability to detect age- and disease-related changes.
Abstract: Context: Assessment of trabecular microarchitecture may enhance the prediction of fracture risk and improve monitoring of treatment response. A new high-resolution peripheral quantitative computed tomography (HR-pQCT) system permits in vivo assessment of trabecular architecture and volumetric bone mineral density (BMD) at the distal radius and tibia with a voxel size of 82 μm3. Objective and Patients: We determined the short-term reproducibility of this device by measuring 15 healthy volunteers three times each. We compared HR-pQCT measurements in 108 healthy premenopausal, 113 postmenopausal osteopenic, and 35 postmenopausal osteoporotic women. Furthermore, we compared values in postmenopausal osteopenic women with (n = 35) and without previous fracture history (n = 78). Design and Setting: We conducted a cross-sectional study in a private clinical research center. Intervention and Main Outcome Measure: We took HR-pQCT measurements of the radius and tibia. Femoral neck and spine BMD were measured in post...

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"A Case Report of Abnormal Fracture ..." refers background in this paper

  • ...The high resolution enables the assessment of bone microarchitecture in vivo (7) and estimation of bone strength μFEA (8)....

    [...]


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01 Jun 2008-Bone
TL;DR: The combined numerical-experimental procedure for FE model validation on the patient micro-CT technology demonstrated that bone strength can be estimated non-invasively, and this may provide important insight into fracture risk in patient populations.
Abstract: Bone strength is a fundamental contributor to fracture risk, and with the recent development of in vivo 3D bone micro-architecture measurements by high-resolution peripheral quantitative computed tomography, the finite element (FE) analysis may provide a means to assess patient bone strength in the distal radius. The purpose of this study was to determine an appropriate FE procedure to estimate bone strength by comparison with experimental data. Models based on a homogeneous tissue modulus or a modulus scaled according to computed tomography attenuation were assessed, and these were solved by linear and non-linear FE analyses to estimate strength. The distal radius from fresh, human cadaver forearms (5 male/5 female, ages 55 to 93) was dissected free and four 9.1 mm sections were cut beginning at the subchondral plate to provide 40 test specimens. The sections were scanned using an in vivo protocol providing 3D image data with an 82 μm voxel size. All specimens were mechanically tested in uniaxial compression, and elastic and yield properties were determined. Linear FE analyses were performed on all specimens (N = 40), and non-linear analyses using an asymmetric, bilinear yield strain criteria were performed on a sub-sample (N = 10) corresponding to the normal clinical measurement site. Experimentally determined apparent elastic properties correlated highly with ultimate stress (R2 = 0.977, p < 0.05, N = 31) for the 31 specimens tested to failure. Subsequently, a linear FE analysis estimating apparent elastic properties also correlated highly with failure, and the correlation was higher when moduli were determined from scaled CT-attenuation values than a homogeneous modulus (R2 = 0.983 vs. R2 = 0.972, p < 0.05, N = 31). A non-linear analysis based on tensile and compressive yield strains of 0.0295 and 0.0493 for homogeneous models, and 0.0127 and 0.0212 for scaled models directly estimated ultimate stress, and correlated highly (R2 = 0.951 vs. R2 = 0.937, p < 0.05, N = 5). The linear relation between stiffness and strength may be unique to radius compressive loading. It supports the use of a linear FE analysis to determine bone strength by regression equations established here. Scaled tissue modulus models performed better than homogeneous modulus models, and the advantage of a scaled model is its potential to account for mineralization changes. The combined numerical–experimental procedure for FE model validation on the patient micro-CT technology demonstrated that bone strength can be estimated non-invasively, and this may provide important insight into fracture risk in patient populations.

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  • ...Using highresolution peripheral quantitative computed tomography (HR-pQCT) in combination with micro finite element analysis (µFEA), we previously described the typical healing of a distal radius fracture....

    [...]

  • ...The high resolution enables the assessment of bone microarchitecture in vivo (7) and estimation of bone strength µFEA (8)....

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  • ...As a result, calculated compression stiffness using µFEA was comparable to the other patients (Fig....

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  • ...The high resolution enables the assessment of bone microarchitecture in vivo (7) and estimation of bone strength μFEA (8)....

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Abstract: Objective This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy). Methods Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking. Results The research quality, clinical relevance, and “state of the art” of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature. Conclusions In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these “practical” guidelines.

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TL;DR: A detailed critical overview of not only the history of CRPS, but also the epidemiology, the clinical features, the pathophysiological studies, the proposed criteria, the therapy and an emphasis that future research should apply more rigorous standards to allow a better understanding ofCRPS are provided.
Abstract: Complex regional pain syndrome (CRPS) is a term used to describe a variety of disorders characterized by spontaneous or stimulus-induced pain that is disproportional to the inciting event and accompanied by a myriad of autonomic and motor disturbances in highly variable combinations. There are no standards which can be applied to the diagnosis and would fulfill definitions of evidence-based medicine. Indeed, there are almost as many diagnostic criteria as there are names to this disorder. The umbrella term CRPS has been subdivided into type I and type II. CRPS I is intended to encompass reflex sympathetic dystrophy and similar disorders without a nerve injury; while CRPS II occurs after damage to a peripheral nerve. There are numerous etiological pathophysiological events that have been incriminated in development of CRPS, including inflammation, autoimmune responses, abnormal cytokine production, sympathetic-sensory disorders, altered blood flow and central cortical reorganization. However, the number of studies that have included appropriate controls and have sufficient numbers of patients to allow statistical analysis with appropriate power calculations is vanishingly small. This has led to over-diagnosis and often excessive pharmacotherapy and even unnecessary surgical interventions. In this review we provide a detailed critical overview of not only the history of CRPS, but also the epidemiology, the clinical features, the pathophysiological studies, the proposed criteria, the therapy and, in particular, an emphasis that future research should apply more rigorous standards to allow a better understanding of CRPS, i.e. what it is, if it is, and when it is.

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Q1. What are the contributions mentioned in the paper "A case report of abnormal fracture healing as detected with high-resolution peripheral quantitative computed tomography" ?

• A submitted manuscript is the version of the article upon submission and before peer-review. People interested in the research are advised to contact the author for the final version of the publication, or visit the DOI to the publisher 's website. The final author version and the galley proof are versions of the publication after peer review. The final published version features the final layout of the paper including the volume, issue and page numbers.