Cancer which develops in specific organs of the human body, including the lungs, breast, or prostate, among others, can sometimes spread into the bone, causing what is known as�metastatic bone disease, or MBD. Approximately more than 1.2 million new cancer cases are diagnosed every year, where about 50 percent can spread,�or metastasize, to the bones.
Through medical advancements, patients diagnosed with several different types of cancers, especially lung, breast, and prostate cancer, can live longer. However, primary cancers in more patients go through bone metastases, where they disperse�to the bone. Meanwhile, other types of cancers do not disperse so easily to the�bone. The most common cancers which develop in the organs and spread to the bones include:
Breast
Lung
Thyroid
Kidney
Prostate
Metastatic bone disease,�or MBD, can damage�and weaken the affected bone, causing pain along the site of spread.�Moreover, patients with MBD are at higher risk of suffering fractures or broken bones. The painful symptoms associated with MBD can make it challenging for the patient to engage in regular physical activities. The main concern of patients with metastatic bone disease is the loss in quality of life.
The extent of the effects of metastatic bone disease on a patient can change and is associated with how cancer has spread, which bones are affected, and how severe the bone harm is. Furthermore, there is a range of treatment choices available to treat MBD. Treatment help patients deal with pain to maintain activity levels and preserve their independence.
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Metastatic Bone Disease Explained
The bones are the most common site of spread for cancers which begin in the organs, subsequent to the lung and the liver. Because many patients experience no painful symptoms of metastases to the liver and the lungs, these are often not discovered until the disease is in an advanced stage. In contrast, bone metastases are generally painful when they develop. Cancer most commonly spreads to these sites in the human skeleton:
Skull
Spine
Ribs
Upper arm
Pelvis
Long bones of the leg
Bone Damage
A tumor can completely destroy the bone at the site of spread, a process referred to as osteolytic bone destruction. Damage or weakened bones are most common in cancers which have spread from the lung, thyroid, kidney, and colon. New bone,�called osteoblastic, may also form due to the spread of cancer, more often seen in cancers from the stomach, bladder, and prostate.
Breast cancer often behaves in a combined osteolytic and osteoblastic method. Since the cancer cells secrete factors that interact with all the cells in the human skeleton, causing bone destruction, new bone formation, or both, osteolytic and osteoblastic metastatic bone disease happens. Also, breast cancer may commonly cause MBD in the hip and/or pelvis.
As a result of bone damage and weakness, patients with�metastatic bone disease are prone to fractures. Broken bones caused by MBD are termed “pathological fractures”.�Sometimes, the bone may be so weak that a fracture is imminent, termed “impending pathologic fractures”. Bedrest for lengthy intervals due to broken bones may result in chemical imbalances in the bloodstream, such as raised calcium levels, known as hypercalcemia. Patients with cancer that has spread to the spine can develop nerve damage which can result in paralysis or loss of using their arms and/or legs.
MBD Symptoms
A cancer patient who experiences any pain, especially in the back, arms, and legs should notify their doctor immediately. Pain which manifests without engaging in physical activities is especially concerning. The most common symptoms of�metastatic bone disease include:
Pain: MBD’s most prevalent symptom is pain. Patients may experience pain along their hip and/or pelvis, upper and lower extremities, and spine because the tumor may have damaged or weakened the bone.
Fractures: Broken bones, or fractures, can range from mild to severe and are generally a clear indication of the presence of MBD.
Anemia: The most common sites of spread, skull, spine, ribs, upper and lower extremities, and hip and/or pelvis, correspond to regions of bone marrow which produce high levels of red blood cells, responsible for carrying oxygen to cells. Anemia, or decreased red blood cell production, is a frequent blood abnormality with MBD.
MBD Diagnosis
Before following through with treatment for metastatic bone disease, it’s essential for the healthcare professional to understand the patient’s symptoms as well as their overall health and wellness. The doctor will ask for the patient’s medical history. After the medical history, the healthcare professional will perform a physical examination on the patient. The doctor may also utilize imaging diagnostics to help with the patient’s diagnosis.
Imaging Diagnostics
X-rays:�After the initial diagnosis, they may order x-rays. Because pain may often originate from other regions of the body, the healthcare professional will also order x-rays beyond the regions where the patient is experiencing discomfort. X-rays may tell an oncologist a great deal of information regarding how much bone is affected.
Other imaging tests: The doctor may also order a bone scan. This test can determine if other bones are involved with metastatic bone disease. In select situations, a computerized tomography, or�CT, scan and magnetic resonance imaging, or MRI, may be ordered, especially in scenarios where the spine or hip and/or pelvis are involved.
A variety of cancers can commonly cause metastatic bone disease, or MBD, throughout different regions of the human skeleton. Bone metastases can cause painful symptoms, ultimately affecting an individual’s quality of life. Research studies have demonstrated that metastatic bone disease in the hip and/or pelvis is a prevalent health issue associated with breast cancer. Treatment may vary on the progression of the problem.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Metastatic Bone Disease Treatment
Advances in surgical techniques, as well as radiation and medical treatment approaches, have significantly improved the quality of life of patients suffering from cancer that has spread to the bone from the site of origin. Treatment options for MBD are based upon how far the cancer has spread, which bones are affected, and how the bone was damaged or weakened.
In many cases of metastatic bone disease, cancer has progressed to multiple bony sites. As a result, treatment is concentrated on managing the symptoms of pain and bone weakness as it is not intended to be curative. The most common treatment option for MBD includes drugs and/or medications, and radiation to control pain and prevent additional spread of metastatic bone disease, and surgery to stabilize weak and broken bones.
Patients with metastatic bone disease require a team approach. A medical oncologist works closely with a radiation oncologist, and an orthopaedic surgeon. Diagnosis is essential in order to follow through with the best treatment approach. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Femoroacetabular impingement, or FAI, is a medical state where additional bone develops in a single or multiple of the bones which make up the hip joint, giving the bones an irregular form. As a result, the bones may rub against each other since they do not fit together properly. This friction can ultimately harm the joint, causing pain, discomfort and limiting movement.
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Anatomy
The hip is commonly characterized as a ball-and-socket joint. The acetabulum, which is part of the large pelvis bone, forms the socket of the joint. The ball of the joint is the femoral head, that is the upper end of the thighbone or femur. A type of soft tissue, known as articular cartilage, covers the surface of the ball-and-socket hip joint.
Articular cartilage makes a smooth, low friction surface which aids the bones to slide easily across each other through movement. The acetabulum is also lined by strong fibrocartilage, known as the labrum. The labrum shapes a gasket across the socket, forming a tight seal to provide stability as well as to help properly support the hip joint.
With femoroacetabular�impingement, bone spurs or bone overgrowth, surround the femoral head, across the acetabulum. The extra bone causes the hip joints to come into close contact and prevents them from gliding smoothly and without friction during movements. With age, this can cause labrum tears and osteoarthritis, or the breakdown of articular cartilage.
Types of Femoroacetabular Impingement
According to doctors, there are three types of femoroacetabular impingement, or FAI: pincer, cam,�and combined impingement.
Pincer:�This variety of impingement develops when bone extends outwards from the standard rim of the acetabulum. As a result, the labrum is crushed beneath the rim of the acetabulum.
Cam: In cam,�impingement of the femoral head causes the joint to be unable to rotate smoothly. A bump forms on the border of the femoral head which grinds the cartilage inside the acetabulum.
Combined: Combined impingement suggests that both pincer and cam types of femoroacetabular�impingement are found.
Causes of FAI
Abnormal development of the hip bones and joints throughout childhood is the most common cause of femoroacetabular impingement. However, it is the deformity of a pincer bone spur�or a cam bone spur which leads to joint damage and hip pain. If the hip bones and joints do not form normally, there’s little which can be done to prevent femoroacetabular�impingement.
Many people may have FAI and never�experience symptoms from the condition. When symptoms develop, however, it generally indicates that there is damage to the cartilage or labrum and the health issue may progress. Moreover, athletes are more likely to experience symptoms of femoroacetabular impingement, although exercise does not cause FAI.
Symptoms of FAI
The most common symptoms of femoroacetabular impingement include: pain and discomfort; stiffness; and limping.�Pain associated with FAI frequently occurs in the region of the groin, although it may also occur toward the exterior of the hip. Twisting, turning, and squatting may cause a sharp, stabbing pain while the pain is generally described as a dull ache.
Diagnosis of FAI
For the first consultation, the healthcare professional will discuss the patient’s hip symptoms and talk about their general health and wellness. They will also examine the patient’s hip. As part of the physical evaluation, the doctor will conduct an FAI impingement test by bringing up the patient’s knee then rotating it towards their opposite shoulder. If this recreates hip pain, the test is positive for femoroacetabular impingement.
Imaging Diagnostics
The healthcare professional may also order imaging diagnostics to help determine whether the patient has femoroacetabular impingement, or FAI. The following imaging diagnostics below can be used.
X-rays: These will show whether the hip has shaped bones of FAI, and provide images of the bone. X-rays may also reveal signs of arthritis.
Computed tomography (CT) scans: More comprehensive than a plain x-ray, CT scans help the healthcare professional determine the specific contour of the patient’s hips.
Magnetic resonance imaging (MRI) scans: These tests create pictures of soft tissue. They will help the doctor find harm to the labrum and articular cartilage. Injecting dye into the joint may make the damage or injury show up more clearly.
Local anesthetic: The doctor can also inject a numbing medication into the hip joint as a test. It affirms that FAI is the problem if temporary pain relief is provided by the local anesthetic.
�
Femoroacetabular impingement, or FAI, commonly affects the hip joint of many young and middle-aged adults. FAI occurs when the ball-and-socket joint of the hip causes abnormal friction and restricts range of movement. Furthermore, damage or injury to the articular cartilage or the labrum can affect the femoral head or the acetabular socket. Treatment options for FAI can range from alternative treatment options to surgery.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Treatment for Femoroacetabular Impingement
Non-Surgical Treatment
Lifestyle modifications:�The healthcare professional may recommend changes in physical activities that cause symptoms, simply altering the patient’s regular everyday routine.
Drugs and/or medications: The use of drugs and/or medications, such as ibuprofen, can be offered to help decrease painful symptoms and inflammation. The relief may only be temporary.
Alternative treatment options:�Treatment approaches like chiropractic care and physical therapy can help provide pain relief to patients with femoroacetabular impingement. Moreover, specific stretches and exercises can strengthen the muscles which support the joint and can boost range of movement. This can help relieve some stress and pressure on articular cartilage or the labrum.
Surgical Treatment
If imaging diagnostics and physical evaluations reveal additional hip joint damage and/or injury as well as the presence of other conditions and non-surgical treatment does not relieve the patient’s pain, the healthcare professional may recommend surgical interventions or surgery.
Arthroscopy
Femoroacetabular impingement can be treated with arthroscopic surgery. Arthroscopic surgical interventions are performed with thin instruments using little incisions. The surgeon then utilizes a small camera to look�inside the hip. The doctor can fix or clean out any damage to the labrum and articular cartilage by shaving the bulge on the femoral head and also trimming the bony rim of the acetabulum.
As the results of operation enhance, physicians will recommend surgery that is earlier for FAI. Surgical techniques continue to progress and at the future, computers may be utilized to guide the physician in reshaping and correcting the hip. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Chiropractic for Athletes with Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Macroscopic & Microscopic Appearance of Normal vs. Damaged Articular Hyaline Cartilage by DJD
Hip Osteoarthritis (OA) aka Osteoarthrosis
Symptomatic and potentially disabling DJD
Progressive damage and loss of the articular cartilage causing denudation and eburnation of articular bone
Cystic changes, osteophytes, and gradual joint destruction
Develops d/t repeated joint loading and microtrauma
Obesity, metabolic/genetic factors
Secondary Causes: trauma, FAI syndrome, osteonecrosis, pyrophosphate crystal deposition, previous inflammatory arthritis, Slipped Capital Femoral Epiphysis, Leg-Calves-Perthes disease in children, etc.
Hip OA, 2nd m/c after knee OA. Women>men
88-100 symptomatic cases per 100000
Radiography is the Modality of Choice for the Dx and Grading of DJD
Special imaging is not required unless other complicating factors exist
The acetabular-femoral joint is divided into superior, axial and medial compartments/spaces
Normal joint space at the superior compartment should be 3-4-mm on the AP hip/pelvis view
Understanding the pattern of hip joint narrowing/migration helps with the DDx of DJD vs. Inflammatory arthritis
In DJD, m/c hip narrowing is superior-lateral (non-uniform) vs. inflammatory axial (uniform)
AP Hip Radiograph Demonstrates DJD
With a non-uniform loss of joint space (superior migration), large subcortical cysts and subchondral sclerosis
Radiographic features:
Like with any DJD changes: radiography will reveal L.O.S.S.
L: loss of joint space (non-uniform or asymmetrical)
O: osteophytes aka bony proliferation/spurs
S: Subchondral sclerosis/thickening
S: Subcortical aka subchondral cysts “geodes.”
Hip migration is m/c superior resulting in a “tilt deformity.”
Radiographic Presentation of Hip OA May Vary Depending On Severity
Mild OA: mild reduction of joint space often w/o marked osteophytes and cystic changes
During further changes, collar osteophytes may affect femoral head-neck junction with more significant joint space loss and subchondral bone sclerosis (eburnation)
Cyst formation will often occur along the acetabular and femoral head subarticular/subchondral bone “geodes” and usually filled with joint fluid and some intra-articular gas
Subchondral cysts may occasionally be very large and DDx from neoplasms or infection or other pathology
Coronal Reconstructed CT Slices in Bone Window
Note moderate joint narrowing that appears non-uniform
Sub-chondral cysts formation (geodes) are noted along the acetabular and femoral head subchondral bone
Other features include collar osteophytes along head-neck junction
Dx: DJD of moderate intensity
Referral to the Orthopedic surgeon will be helpful for this patient
AP Pelvis (below the first image), AP Hip Spot (below the second image) CT Coronal Slice
Note multiple subchondral cysts, severe non-uniform joint narrowing (superior-lateral) and subchondral sclerosis with osteophytes
Advanced hip arthrosis
Severe DJD, Left Hip
When reading radiological reports pay particular attention to the grading of hip OA
Most severe (advanced) OA cases require total hip arthroplasty (THA)
Refer your patients to the Orthopedic surgeon for a consultation
Most mild cases are a good candidate for conservative care
Hip Arthroplasty aka Hip Replacement
Can be total or hemiarthroplasty
THA can be metal on metal, metal on polyethylene and ceramic on ceramic
A hybrid acetabular component with polyethylene and metal backing is also used (above right image)
THA can be cemented (above right image) and non-cemented (above-left image)
Non-cemented arthroplasty is used on younger patients utilizing porous metallic parts allowing good fusion and bone ingrowth into the prosthesis
Failed THA May Develop
Most develop within the first year and require revision
Femoral stem may fracture (above left)
Postsurgical infection (above right)
Fracture adjacent to the prosthesis (stress riser)
Particle disease
Femoroacetabular Impingement Syndrome
(FAI): abnormality of normal morphology of the hip leading to eventual� cartilage damage and premature DJD
Clinically:�hip/groin pain aggravated by sitting (e.g., hip flexed & externally rotated). Activity related pain on axial loading esp. with hip flexion (e.g., walking uphill)
Pincer-type�acetabulum: > in middle age women potentially� many causes
CAM-type deformity:�> in men in 20-50 m/c 30s
Mixed type (pincer-CAM) is most frequent
Up until the 90s, FAI was not well-recognized
FAI Syndrome
CAM-type FAI syndrome
Radiography can be a reliable Dx tool
X-radiography findings:�osseous bump on the lateral aspect of femoral head-neck junction. Pistol-grip deformity. Loss of normal head sphericity. Associated features: os acetabule, synovial herniation pit (Pit’s pit). Evidence of DJD in advanced cases
MRI and MR arthrography (most accurate Dx of labral tear) can aid the diagnosis of labral tear and other changes of FAI
Referral to the Orthopedic surgeon is necessary to prevent DJD progression and repair labral abnormalities. Late Dx may lead to irreversible changes of DJD
AP Pelvis: B/L CAM-type FAI syndrome
Pincer-Type FAI with Acetabula Over-Coverage
Key radiographic signs: “Cross-over sign” and abnormal center-edge and Alfa-angle evaluation methods
Dx of FAI
Center-edge angle (above the first image) and Alfa-angle (above the second image)
B/L CAM-type FAI with os acetabule�(above right image)
MR Arthrography
Labral tear and CAM-type FAI syndrome on axial (above left) and coronal T2 W (above right) MR arthrography
Note acetabula labral tear. Referral to an orthopedic surgeon is required. For more information:
Throbbing, dull and achy, sharp and excruciating. All of these words can be used to describe lower back pain.
Unfortunately, lower back pain is a common occurrence in adults. According to the American Chiropractic Association, low back pain is the single leading cause of disability worldwide, with millions of reported cases�every year.
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What Treatment Should You Seek If You Experience Pain in Your Lower Back?
The good news is that it often heals on its own. A few days of over-the-counter pain meds, ice,�and taking it easy, and you could be back to normal.
However, those who continue to deal with the pain after a few weeks’ time may choose to look for other solutions. This is also true for people who experience repeated flare-ups, or chronic lower back pain.
One of the best and most popular options is chiropractic care.
Why?�
First of all, chiropractic care doesn’t focus solely on the pain but helps the body heal itself. Chiropractors understand the bones,�muscles, discs, and nerves�in the back, and can figure out the reason for the pain.
From there, they can create a customized treatment plan from compresses to spinal manipulation to exercises that help heal the area and reduces the pain.
Second, It’s A Drug-Free Solution.
Because of its healing, therapeutic approach, chiropractic treatment tends to the source of the pain, instead of simply dulling it. Spine Universe estimates 6 to 12 treatments are typically needed to treat low back pain, but each person’s requirement may vary.
Throughout these�treatments, spinal alignment begins�to balance the other parts of a person’s back and helps correct the issue causing the pain. Also, spinal manipulation helps improve mobility and function in many cases, whereas drugs alone do not.
Finally, Chiropractic Care for Lower Back Pain Also Helps Minimize Relapses
Patients who experience lower back pain never want to deal with it again, but�it can flare up periodically. According to the National Institute of Neurological Disorders and Stroke, roughly 20% of those who suffer from low back pain will eventually deal with it chronically. This can cause frustration, primarily when it affects mobility.
Before you run screaming in horror to the medicine cabinet, one of the best reasons to participate in chiropractic treatment is that it helps reduce the chance of a recurrence. By working on the total body and getting it in the best shape possible, the patient is stronger and more balanced to handle their workload and other strenuous activities. Chiropractors also impart advice on how to minimize the chances of re-aggravating the lower back.
Millions of people suffer from back pain each year, and some never visit a chiropractor. Those who do choose chiropractic treatment are privy to treatment that reduces their pain, increases healing, shortens their downtime and lessens their chances of a recurrence. If over the counter medication and ice packs haven’t worked within a few days, it’s time to make an appointment for a consultation with a licensed chiropractor. You will be happy you did.
With the increase of osteoporosis in older adults, the diagnosis and treatment�of abnormal hip fractures, such as�bisphosphonate-related proximal femoral fractures,�has become more important. According to Dr. Edward J. Fox, MD, obesity is often managed through the long-term�use of bisphosphonate treatment, which can inhibit�osteoclast-mediated bone regeneration. Over the prolonged utilization of bisphosphonate, patients� may develop atypical proximal femoral fractures.
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Understanding Atypical Femur Fractures
Atypical femur fractures are characterized as stress fractures which commonly occur in the proximal one-third of the diaphyseal bone, although they might also occur more distally, developing in the lateral cortex and slowly progressing medially. “With irregular fractures, a small ‘beak’ of bone can form on the lateral surface of the femur and that is where the fracture generally begins,” explains Dr. Fox. This contrasts with stress fractures which occur laterally in the medial portion of the bone.
As a result, when a patient with osteoporosis reports feeling hip and knee pain without previous damage or injury, healthcare professionals will ask about bisphosphonate treatment. It is essential for the�doctor to request x-rays of the hip and femur shaft for proper diagnosis.�It is also important to request x-rays of the opposite femur, as atypical bisphosphonate-related proximal femoral fractures frequently occur bilaterally. Dr. Edward J. Fox urges patients to discontinue bisphosphonate use in the case of hip fractures,�followed by the subsequent use of crutches or a walker. Patients will eventually be able to resume regular physical activities.
Approximately more than 250,000 hip fractures occur in the United States, causing significant patient disability. The variety of hip fractures in older adults, including bisphosphonate-related proximal femoral fractures, often need several treatment approaches which depend on different considerations, such as the mechanism of injury, location and degree of the fracture, as well as the patient’s age and overall health and wellness.
Dr. Alex Jimenez D.C., C.C.S.T.
The precise mechanism of injury by which bisphosphonates cause atypical femur fractures is unknown. Research studies have demonstrated that the suppression of osteoclast activity prevents the clearance of bone fragments which build up on the bone surface during regular daily tasks; decreasing the strength of the bones which lead to fracture. “We all know that the threat of those fractures increases with the extended duration of bisphosphonate exposure, particularly after five decades. Bisphosphonates are stored with a half-life of at least eight decades in bone matrix. To reduce over-exposure and risk of atypical fracture, passing medication discontinuance has been speculated to be beneficial,” explained Dr. Fox
Dr. Edward J. Fox, MD, stated that until research studies find the exact mechanism of injury and treatment for bisphosphonate-related proximal femoral fractures, healthcare professionals should continue to determine the best treatment option for each patient, carefully weighing the benefits and risks of individual patients. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
X-radiography pitfalls: some undisplaced Garden 1 & 2 Fxs may be missed d/t pre-existing DJD and osteophytes along the femoral head-neck junction that may overly the Fx line
Fx line is incomplete and too small/subtle especially if the study is read by non-radiologists
Incomplete Fxs if left untreated will not heal and likely to progress to complete Fxs
AP hip spot view: note valgus deformity of the head (above yellow arrow) with a small/subtle line of sclerosis in the sub-capital region representing Garden 1 Fx. MRI may help with Dx of subtle radiographic Fxs. If MRI contraindicated, Tc 99 radionuclide bone scan may help demonstrate high uptake of the radiopharmaceutical in Fx (below image)
Above – Tc99 Radionuclide Bone Scan Reveals Left Subcapital Femoral Neck Fx
Garden 2 complete undisplaced (above green arrows) Fx
AP hip: Garden 3 complete partially displaced Fx (above the first image)
AP pelvis: complete displaced Garden 4 Fx (above the second image)
Clinical pearls: in some cases of Garden 4 Fx, DDx may be difficult to differentiate from OSP vs. pathologic fx d/t to bone Mets of Multiple myeloma (MM)
Management: depends on patients age and activity level
Garden 3 & 4� require total hip arthroplasty in patients <85-y.o.
Garden 1 & 2 may be treated with closed reduction of fx and open capsule and 3-cannulated fixating screws
Pre-existing DJD may require total arthroplasty
Occasionally observation may be performed on patients who are not active and significant risks of surgery and depends on surgical centers
m/c Rx of Garden 1 & 2 undisplaced Fx with 3-screws. Screws proximity depends on the bone quality and Fx type
THA aka hip replacement: cemented THA with bone cement (above the first image) vs. non-cemented (biologic) that is used mostly in younger patients
2-types: metal on metal vs. metal on polyethylene
The femoral angle of the prosthesis should have slight valgus but never >140 degrees
The non-cemented component uses porous metal allowing the bone to integrate sometimes coating in bone cement from osteoconduction
THA has good outcome and prognosis
Occasionally cement failure, fractures, and infections may complicate this procedure
Hip fractures are characterized as any type of break in the upper region of the femur or thigh bone. The variety of broken bones generally depends on the circumstances and the force applied to the bone, where some can be more common than others. Impacted femoral neck fractures are common hip fractures which occur in many older adults in the United States.
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Anatomy of Impacted Femoral Neck Fractures
The hip is a ball-and-socket joint which provides the femur the ability to bend and rotate at the pelvis. While any form of broken bones in the thigh bone or femur is considered a hip fracture, damage or injury to the socket, or acetabulum, itself is not considered a hip fracture. Below we will discuss hip fractures, particularly impacted femoral neck fractures, among others.
Causes, Symptoms and Diagnosis
Hip fractures frequently�occur due to a slip-and-fall accident or due�to a direct blow to the hip. Various health issues, including osteoporosis and stress injuries, as well as cancer, can sometimes weaken the bones and make the pelvis more vulnerable to fractures.�The neck of the femur is located under the ball of the hip joint. Impacted femoral neck fractures occur when a force presses against both ends of the femur at the femoral neck, pushing the broken ends of the bone together.
Patients with hip fractures experience symptoms of pain on the upper thigh or in the groin. They may also experience considerable discomfort with any attempt to flex or rotate the hip. In comparison to impacted femoral neck fractures, if the bone is completely broken, the leg may appear to be shorter than the non-injured leg. Also, the patient will hold the injured leg in a still position with the foot and knee turned outward in external rotation.
Diagnosis�for hip fractures commonly involves the use of x-rays of the hip, pelvis and/or femur. In several instances, if the patient experiences a slip-and-fall accident or a direct blow to the hip resulting in impacted femoral neck fractures, they may not be seen on a regular x-ray. Magnetic resonance imaging, or MRI, may be recommended to view some cases of hip fractures. The MRI scan will typically demonstrate any hidden hip fractures. Computed tomography, or CT, scans may also be utilized instead.
Impacted femoral neck fractures are hip injuries which occur just below the femoral head, or the ball-and-socket hip joint, where the broken ends of the bone are jammed together by the force of the injury. This area of the thigh bone, or femur, is known as the femoral neck. Treatment for impacted femoral neck fractures may include rest and physical rehabilitation. Diagnosis for impacted femoral neck fractures is important for treatment.
Dr. Alex Jimenez D.C., C.C.S.T.
Treatment of Impacted Femoral Neck Fractures
Once a healthcare professional has diagnosed the patient’s hip fracture, their overall health and wellness will also be evaluated.�Treatment for femoral neck stress fractures depends on the patient’s age and on the extent of the broken bone. Treatment for femoral neck stress fractures�include bed rest for several days followed by a physical rehabilitation program.
Many femoral neck stress fractures are treated with surgery. It’s essential for the patient to talk to their doctor to discuss the best treatment option.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topics: Chiropractic for Athletes with Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Grateful for the treatment they have received for their injuries and conditions, many patients highly recommend Dr. Alex Jimenez, doctor of chiropractic, for a variety of health issues. Chiropractic care is an alternative treatment option which focuses on the diagnosis, treatment, and prevention of injuries and conditions associated with the musculoskeletal and nervous system. Dr. Alex Jimenez’s patients describe how much chiropractic care has improved their overall health and wellness, changing their quality of life for the best. Dr. Alex Jimenez is the recommended non-surgical treatment choice for a variety of health issues, including neck and back pain, among others.
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Back pain can be debilitating, causing immobility, inflexibility, and have a significant impact on a person�s quality of life. It can make even the most mundane daily activities extremely difficult � and even excruciating. Building the muscles that make up your core (abdominals and back) can help support your spine and reduce back pain. In many cases, strengthening these muscles can assist a patient to avoid medication with its unpleasant side effects and even avoid surgery. With just a few smart moves you can significantly decrease your back pain, increase your mobility, and take back your life.
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The Role of Abs and Back Muscles
The spine is the supporting structure for the back, but it also is a vital infrastructure for the entire body. It houses the central nervous system, and neural impulses are transferred along what is�a spinal superhighway.
The arms, legs, neck, and head are all connected and stabilized by the spine through an intricate network of ligaments and muscles. The back muscles and abs, or abdominal muscles, are at the center, or core, of this muscle network. They keep the body upright and facilitate movement. When these core muscles are not in good condition, it puts stress on the spine, impacting its ability to support the body. This often results in back pain and even injury in some cases.
Postural Alignment
Postural alignment is a frequent contributor to back pain. This is often due to weak core muscles.
As the muscles fail to do their job to stabilize the spine, the body adjusts structurally to accommodate the weakness. This can result in postures that cause joint pain as well as muscular pain and even headaches.
For instance, stooped or hunched shoulders can cause back pain, but it can also create tension in the shoulders and neck. This, in turn, can cause tension headaches and migraines in patients.
A sway back, where the lower back bows, causing the pelvis to tilt up, can cause severe lower back pain, especially after standing for long periods of time. Swayback can be the result of weakened core muscles or a combination of a weak core, combined with obesity or pregnancy.
The weight in the abdominal area pulls the spine forward so that it curves. A pregnancy sling can sometimes help with the pain, but it is just a band-aid. The real cure is to strengthen the core muscles so that they are better able to support the spine and body adequately.
Foundation Training
Eric Goodman, a chiropractor, developed Foundation Training as a way to help his patients who suffer from lower back pain but are not physically able to do Pilates or yoga. It is also designed to help those who sit for long periods of time to counteract the associated adverse health effects.
Foundation training incorporates powerful yet straightforward movements that work to integrate the body�s muscular chains, increasing strength and realigning the core and spine. It does not require any equipment so the actions can be performed anywhere. The muscles are trained how to move correctly and work together so that you the body learns to move how it is designed to move. The critical, essential exercise can be viewed in this video.
Creating a strong core can help relieve back pain but also have added benefits such as increasing energy, better mobility, and an improved mood. By allowing the body to support itself, it can naturally relieve pain and heal certain conditions without invasive surgery or medication which can have unpleasant or even harmful side effects. When you take good care of your body, it will take good care of you.
Unstable Fx: a result of high energy trauma with >50% d/t MVA
20% closed Fx and 50% of open Fx result in mortality
Mortality is associated with vascular and internal organs injuries
Vascular injury: 20% arterial 80% venous
Chronic morbidity/disability and prolonged pain
Unstable Fx are rarely seen in the outpatient setting and typically and present to the ED
Stable pelvic Fx are usually caused by muscles/tendons avulsions and more often seen in pediatric cases
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Understanding Pelvic Anatomy Is The Key To Successful Imaging Dx
The bony pelvis is a continuous ring of bone held by strong ligaments
During significant impact, pelvic fractures may occur in more than one location because forces applied to one region of the ring will also correspond to injury on the other, usually the opposite side of the ring (above image)
Thus the majority of unstable pelvic Fx will typically demonstrate more than one break
Pelvic is seen as a ring of� bone connected by some of the strongest ligaments in the body
The pelvic ring comprises 2-semirings: anterior to the acetabulum and posterior to the acetabulum
The bony pelvis is in close proximity to major vessels carrying a greater chance of vascular injury
Anatomical Differences of The Female and Male Pelvis
Post-Traumatic Pelvic Views May Vary and Include:
Standard AP Pelvis (above images)
Judet views evaluating the acetabulo-pelvic region
Inlet/Outlet views helping with the symphysis and SIJ regions
Rad survey of the pelvis should include evaluation of the continuity of pelvic rings:
Inlet/outlet, obturator rings (above the first image)
Symphysis pubis and SIJ for diastasis and post-trauma separation (above the second image)
Lumbosacral spine and hips should also be carefully examined
Pelvic inlet (above top left) and Outlet (above bottom left)
Judet views: left and right posterior oblique views
Additional Survey:
Iliopectineal, ilioischial, Shenton and Sacral arcuate lines will help detection of sacral, acetabular and hip fracture/dislocations
Stable Pelvic Fractures aka Avulsion Injury
Appreciating anatomical sites of pelvic origin/insertion of different muscles will help Dx of pelvic avulsion Fx
Avulsion Fx of the AllS (origin of the direct head of Rectus femoris M)
Pelvic avulsions occur by sudden eccentric contraction especially during kicking or jumping
Imaging: x-radiography will suffice
Clinically: sudden snap or pop followed by local pain. Pt can weight bear
Care: non-operative with rest for 4-weeks. Non-union is rare. No major complications
DDx: key rad DDx feature is not to mistake an avulsion from an aggressive pediatric bone tumor-like osteosarcoma that may show some exuberant new bone formation d/t healing and bone callus
Commonly Encountered Unstable Pelvic Fractures
Malgaigne Fx: d/t vertical shear injury to the ipsilateral pelvis
Rad Dx: ipsilateral superior and inferior pubic rami Fx (anterior ring) with ipsilateral SIJ separation/Fx of the sacrum and adjacent ilium (posterior ring). Symphysis pubis diastasis can be seen. An additional clue is an avulsion of L4 and/or L5 TP that often signifies serious pelvic injury
Clinically: marked leg shortening, shock, inability to weight bear.
Damage to Superior Gluteal Artery can occur
Imaging: x-radiography followed by CT scanning w/o and with IV contrast esp. if visceral injury present
Care: surgical in most cases d/t significant instability. ORIF. Hemostasis, Pelvic stabilization
Prognosis: depends on the complexity, rate of visceral complications and stability. 10% Superior glut artery bleed requiring rapid hemostasis
Open Book Pelvis (major instability)
Mechanism: AP compression of different force magnitude (picture depiction)
Rad Dx: diastasis of symphysis pubis with diastasis of SIJ with and w/o adjacent Fx of the ala
Imaging steps: x-radiographic, CT scanning with and w/o contrast for vascular injury, cystography for acute urinary bladder rupture
Immediate and delayed complications may occur: vascular injury, urethral/bladder injury
Straddle Injury: Unstable Fx
Mechanism: direct impact/collision
High risk of urinary bladder/urethral injury
Imaging: bilateral superior and inferior pubic rami Fx with or w/o diastasis and Fx of SIJ
CT with and w/o contrast for vascular injury
Cystourethrogram additionally evaluates a urogenital injury
2) Osteoporotic patients with low impact, trivial or no trauma (i.e., insufficiency Fx)
X-radiography is crucial to early Dx and prevention of complications which include:
Dx: intra-capsular vs. extra-capsular Fx
Ischemic osteonecrosis aka avascular necrosis (AVN) of the femoral head and rapid disabling DJD
Epidemiology: USA has some of the highest rates of OSP hip Fx worldwide. Highest healthcare cost Fx to treat overall
Women>men, Caucasians>African-Americans
25-30% mortality within the 1st year. Mortality depends on co-morbidities and stat of activity prior Fx
Pathophys: the femoral neck is intra-capsular and transmits arterial flow to the head. The neck is uncovered by the periosteum and unable to develop a good callus. The neck transmits maximum tensile forces through the proximal femur and prone to Fx and non-union
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