Author Archives: aenriquez

How To Use Crutches

By  aenriquez  published  September 20, 2019

A young man on crutches sprang past me at the dog park the other day. He was practically sprinting and it was a sight to see. He really knew how to use those things.


But sprinting on crutches is not only a bad idea for most of us, but it’s also a very dangerous idea. It is also rather difficult. This man was confident of his balance and the grip of the crutches and he was, well, in excellent shape – except for the fact that one knee was bandaged. Otherwise, he was iron-man fit. For most of us who aren’t track and field stars, crutches will get us places, but steadily, not at a sprint.


Even crutches at a reasonable pace require a bit of patience before you get the proper rhythm to make your way forward. But it all starts with the right fit for the crutches.

Crutches also have adjustable features that change the height and the distance to the grips

Fit the crutches properly


With very few exceptions, there is a standard way to fit crutches so that you can walk a modest amount without causing yourself further injury. The fitting standards are these:


  • Height of crutches should be two inches below your armpit
  • Height of the grips should be level with your hips.
  • You shoulders should lean forward when you are walking
  • The crutches should be close to your body to provide balance, but not splay out so much they slip as you move forward. Also, it’s more convenient to present a narrow profile while you use the crutches, so you don’t knock into people or things
  • Your elbows should be bent comfortably


Check Everything


Make sure you check the armpit padding, the grips, the rubber stoppers on the bottom that prevent slipping. All of these get worn out over time, especially the rubber stoppers. These can be easily replaced and they aren’t expensive. In contrast, using crutches that slip can be very dangerous, so check these items at least daily. Sometimes gum gets stuck on the bottom of your crutches and hardens there. The following day, the crutches start sliding on hard surfaces – so check the bottom of your crutches frequently.


Crutches also have adjustable features that change the height and the distance to the grips. Make sure all these items are secure. Check daily.


Normal use


Crutches are designed for you to take small steps. The further out you reach with the crutches, the higher the chance they will slip.


Small steps also allow you to put your weight on your hands as you walk. You should not be using your armpits to hold you up. Doing this quickly becomes quite painful from abrasion and from putting that much weight on your armpits. Your arms and hands, not your armpits, should be holding you up while you walk.




Crutches can be quite tiring. If crutches were an efficient way to walk, everyone would be using them. But, they are not. They will tire you out pretty quickly. When you get tired, stop and rest. Don’t overdo it, as this leads to another injury.


Standing, sitting


Getting in and out of a chair can be tricky. It is not recommended that you use the crutches to pull yourself up. That puts too much weight on one small spot, which could lead to a crutch going out from under you. Instead, use the chair or the table to pull yourself up. Then use the crutches to walk.




If the stairs have secure enough handrails, it is highly recommended that you use these to help you climb stairs with the crutches as added support. It is also highly recommended that you have a “spotter” climb stairs with you – someone who can stay close to you and correct your balance if you start to fall.


Climbing downstairs is also tricky. Again, use the handrails, rather than your crutches. For going downstairs safely, it is recommended that you hold yourself upright and hop on the healthy leg down one stair at a time while holding the handrail. It is very dangerous to lean forward over a set of crutches while going down a set of stairs. If your balance goes past the tipping point, your crutches will pole-vault you forward in a very dangerous fashion.


It is also highly recommended that you use a spotter to get downstairs when you are relying on crutches to keep weight off one of your legs.




Finally, you can save yourself many hassles and headaches if you prepare your home for someone using crutches Clear out the center of each room to provide a clear path for someone on crutches. Move items to the walls or put them in storage temporarily.


Seek Help


Staff at FXRX Orthopaedics and Bracing have lots of expertise in the use of crutches. Call 480-449-3979 to make an appointment.

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Bunions Aren’t Cute If You Have Them

By  aenriquez  published  September 11, 2019

A bunion sounds like something small and quaint – a bit like something extra someone in Victorian times would sneak into a picnic basket. Oh, you brought bunions! How delightful.


Bunions, however, are not particularly delightful. In fact, they are painful, bony protrusions that form at the base of the joint of your big toe or your little toe, where they are referred to as “tailor’s bunions,” or “bunionettes.” These also sound quaint, but are, in fact, painful.


A bunion is an abnormal growth that is fairly common. About 18 million women in the United States over 21 years of age (about 8 percent) have bunions, while about 4 million men suffer from the same condition. The difference between genders is explained due to the shoes men and women choose to wear. But the condition is the same and it can hurt.

The bunion shows as a swollen, usually red, inflamed looking bump protruding outward

A growth at the base of the outer toes has nowhere to go if not outward. The middle toes block the protrusion from going inward, so the growth goes outward. While doing so, it forms an exposed outer nub that will be the first thing your foot collides with when it bangs up against something. It is, in effect, an exposed, readily accessible growth that is even visible. It forms a bump at the base of the large or the small toe that then turns the toe inward. The affected toes then start to crowd the middle toes, overlapping them or pushing them inward.




The symptoms of a bunion include pain in the first joint of the largest or smallest toes (the first and fifth metatarsophalangeal joints). The bunion shows as a swollen, usually red, inflamed looking bump protruding outward.


The skin around the bunion tends to become calloused over time, so the skin is likely to be thickened around a bunion. In addition, bunions usually present a dull pain and are vulnerable to bumping. The toes may become misaligned and bunions can make it difficult to find proper footwear that is not painful to wear.


What causes bunions?


There are a variety of causes for bunions. Genetics can be a contributing factor. Poorly fitting shoes or foot injuries can also lead to bunions. Other causes include:


  • Flat feet
  • Poorly fitting shoes especially shoes that squeeze toes together
  • Congenital defects
  • Arthritis and other joint diseases that cause inflammation
  • Foot injuries
  • Occupational issues that require specialized footwear. Dancers are specifically prone to bunions.




Bunions and bunionettes will often retreat if the patient begins to wear the correct shoes, although orthopedic padding or shoe insteps could help the symptoms retreat even faster.


Padded socks can also be worn to protect the patient’s foot and help turn toes back to their proper alignment. Inflammation can be brought down with non-steroidal anti-inflammatory drugs. Heat is sometimes used to reduce swelling and alleviate pain.


In more serious cases, cortisone injections are used to reduce swelling and pain. Surgery is also a possibility for the most severe cases.


See a specialist


Bunions only sound cute. In reality, medical intervention is frequently required. See a specialist as soon as possible. Progressive conditions like bunions are best treated by starting a course of treatment as early as you can.


In Tempe, call FXRX Orthopaedics & Bracing at 480-449-3979 for an appointment.

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Joint Stiffness

By  aenriquez  published  July 11, 2019

Are you suffering from stiff joints? If you are, many people will say “Welcome to the club.” This is because stiff joints is a common symptom for many conditions from a cold or the flu to specific joint diseases.  It is also extremely common for the elderly to complain of stiff joints, which are almost as predictable as needing bifocals when you turn 45. If you see an elderly person having trouble bending over, then having more trouble picking up an object from the floor, give them a hand. Those aches and pains are real.

There are two general observations about growing old that contribute to those aches and pains, including stiff joints. One is simple wear and tear on cartilage, bursa, vertebral discs and other mechanisms that help joints move. These structures allow for easy movement by providing a fluid-like cushion or a smooth surface for bones to move without having them grind together. Bursa, for example, acts like very tiny water balloons that are wedged into joints, allowing for smoother motion. Cartilage, meanwhile, covers the ends of bones where they terminate at joints, providing a smooth, resilient surface for the bones to slide on. When the cartilage wears out, it is extremely slow to heal, partly because cartilage does not have a blood supply.

When cartilage wears out, it is extremely slow to heal, partly because cartilage does not have a blood supply

The second reason behind stiff joints as you age is the lack of fluids. As we age, we become drier. While water content in our bodies is also dependent on age and weight (thinner people have less water than heavier people when we are infants, our average water content is 75 percent to 78 percent. As adults, this drops to 50 percent to 65 percent. This loss of water affects mechanisms like your vertebral discs. These compact spongy cushions become less spongy as we age. Part of the reason: They become drier.

Here are just some of the diagnosable conditions that can result in a stiff joint.

  • Rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disorder characterized by pain in the wrists, fingers, hands, and feet. The immune system in this disease attacks the lining of your joints, which often creates painful swelling and stiffness.

  • Osteoarthritis

As opposed to rheumatoid arthritis, which is an autoimmune disorder, osteoarthritis is a wear and tear condition. As we age, the cartilage that protects the ends of our bones begins to wear out, resulting in bone against bone movement.

  • Bursitis

Bursitis is another wear and tear condition. Bursae are tiny sacks that give joints cushioned movement. However, when these become inflamed, the result is a painful condition called bursitis.

  • Lupus

Lupus is an autoimmune disorder that can result in painful joints, especially in the knees, wrists, and fingers. People who suffer from lupus have good days and bad days, as the pain is intermittent.

  • Gout

Gout, which generally starts in the joints of the big toe, is a painful condition that is grouped together with arthritis, which it resembles.

  • Fibromyalgia

This chronic pain condition is usually associated with muscle pain, but many patients experience stiff joints, as well.

  • Polymyalgia Rheumatica

This is a joint disease that is rarely seen in people under 50. It results in stiff joints, mostly in the shoulders, neck, hips, fingers, and wrists.

Make a call

Are you or anyone you know suffering from joint stiffness? Let us help you return to an active lifestyle with minimum pain. Call FXRX Orthopaedics and Bracing in Phoenix, Az., at 480-449-FXRX.

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Decompression Laminectomy

By  aenriquez  published  July 2, 2019

The decompression laminectomy operation is a common back surgery in which the doctor removes vertebral bone that is putting pressure on nerves. The back part of the vertebral bone is the part that is removed and the operation could entail removal of that portion of vertebral bone from more than one vertebra. Other painful conditions, like bone spurs, can also be addressed during decompression laminectomy surgery.

The surgery is considered a major operation that requires the use of general anesthesia delivered through a facial mask. Patients are also given a sedative to help them remain calm and to increase the general anesthesia’s effectiveness. During the operation, the patient lies on his or her stomach to allow access to the back. Patients are frequently intubated, which involves putting a plastic tube through the patient’s mouth, past the vocal cords to the windpipe. This allows doctors to have air pumped in and out of the patient’s lungs during the surgery. This is done with a mechanical ventilator.

Spinal surgery can be done from the front or the back, but a decompression laminectomy is done from the back

The Surgery Itself

Spinal surgery can be done from the front or the back, but a decompression laminectomy is done from the back. It starts with the surgeon making an incision above the area where the pain originates. After the incision is made, the surgeon then moves the muscle and soft tissue in order to have a view of the patient’s spine.

After the correct area of the spine is exposed, surgeons then cut away bone spurs and any ligaments that are pressing on nerves. The surgeon could also cut away substantial portions of vertebrae that have been causing the patient pain or discomfort or limiting flexibility.

Spinal Fusion

Along with the decompression laminectomy, the patient may have to undergo spinal fusion. This entails “welding” two vertebrae together by use of bone grafts – one or several – that allow the adjacent vertebrae to heal together as one bone. Sometimes, the surgeon elects to use metal plates, screws and rods to ensure that the vertebrae are stabilized.

A spinal fusion restricts flexibility the patient had before surgery, but the movement is often the source of the pain. The patient sacrifices some movement while finding relief from the pain presented by a herniated disc or other conditions.

When the surgery is complete, the surgeon sews the wound back together and the patient wakes up as the mask is removed and the intubations tube is taken out.

Recovery Time

Recovering from a decompression laminectomy can take a while, although many patients, with their doctor’s approval, find they can go home the same day the surgery is performed.  You will be instructed on how much activity you can take on until healing is complete.

Others are not so lucky. According to Spine-Health, 70 percent to 80 percent of patients who undergo this operation feel immediate relief, while others find relief is slower to arrive.


There are also risks with this surgery, just as there is with other major operations. In the case of decompression laminectomy, the risks include:

  • Nerve root damage – the odds are 1 in 1,000 of this occurring
  • Cerebrospinal fluid leak – odds are 1 percent to 3 percent, but recovery from this is usually under 24 hours if the patient remains lying down
  • Infections – 1 percent of cases, although usually this can be dealt with by the use of IV antibiotics.


Make A Call

Are you or anyone you know suffering from back pain? Let us help you return to an active lifestyle. Call FXRX Orthopaedics and Bracing in Phoenix, Az., at 480-449-FXRX.

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By  aenriquez  published  June 18, 2019

Osteoporosis is a naturally occurring condition that becomes a health concern once people reach 50 years of age. It becomes potentially more serious the older they get. In fact, since bone mass peaks in your mid-20s, it can be said that the process of osteoporosis begins at that point. After that, as you age, your bones become less dense and weaker. The less dense your bones become, the higher your risk of a fracture.

Bones Are Living Tissue

Many people don’t realize that bones are living tissues that are undergoing constant change. Older cells reabsorb into the body, while new cells are created. At first, of course, your bones grow from the time you are born until you reach your late teenage years. After density peaks in your late 20s, bone strength is maintained through a process called remodeling. During this phase, your bones are still living tissue with old bone matrix reabsorbed into the body, while new formation is taking place.

Depending on your age, your general health and the severity of the injury, the time it takes to heal from a hip fracture can vary

As we age, bone formation continues, but at a pace, that is too slow to keep up with bone loss. This is the process of osteoporosis, which means “porous bone.” Certainly, porous bone is weaker and more prone to fractures and breaking.

Major Concerns

According to the International Osteoporosis Foundation, one in three women and one in five men over fifty years of age are at significant risk for an osteoporosis-related bone fracture. These commonly occur in the hip, the spine and the wrist with more serious consequences depending on the location. All fractures are serious, but the weight-bearing responsibilities of the hips and the spine make a fracture in those locations potentially life-altering.

Depending on your age, your general health and the severity of the injury, the time it takes to heal from a hip fracture can vary. Meanwhile, osteoporosis of the spine can lead to a compression fracture of vertebrae, which can be extremely painful. Left untreated, a vertebral compression fracture results in a condition called Dowager’s Hump, which is a characteristic posture that includes a rounded upper back and a neck tilted too far forward. In addition, a vertebral fracture often results in a lower height.


While everyone past a certain age experiences osteoporosis – just as everyone past 40 years of age is a candidate for bifocals – when the condition becomes acute, you can be diagnosed with osteoporosis.

This is usually done with a physical at your doctor’s office. If need be, the doctor will then order a bone mineral density test (BMD). This is done with specialized imaging called a DXA, which stands for dual-energy X-ray absorptiometry. This is a low radiation X-ray that can identify small changes in bone density.

Your doctor will recommend one or more specialized DXA tests that focus on the forearm, finger and heel, the spine, the hip or your whole body.

Osteoporosis – essentially, acute osteoporosis – is diagnosed when someone has a T-score lower than minus 2.5. A score of minus 1 to minus 2.5 is labeled osteopenia, while a score lower than minus 2.5 is considered severe osteoporosis.




While diet, exercise and the avoidance of tobacco and heavy alcohol use are recommended for preventing osteoporosis, there are medications available for people diagnosed with osteoporosis. These are:


  • Bisphosphonates
  • Denosumab
  • Selective Estrogen Receptor Modulators
  • Calcitonin
  • Strontium ranelate
  • Teriparatide
  • Hormone replacement therapy (HRT)




For persons with compression fractures of a vertebral segment or segments, the procedure known as kyphoplasty is recommended. This procedure involves forcing the vertebrae back to its original shape with an inflating device, then removing the device and filling the empty space with special bone cement. This keeps the vertebral segment in the correct shape, restoring movement and relieving pain.


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Tommy John Surgery

By  aenriquez  published  June 12, 2019

When people think of major league baseball pitcher Tommy John, two things might pop into their minds. The first has to do with his baseball career, which was certainly an exemplary and enduring career that included a record (at the time) for a pitcher of 26 seasons in big league baseball. The second thing people associate with Tommy John is the surgery that bears his name.


John’s career included participation in three dramatic Worlds Series between the Los Angeles Dodgers and the New York Yankees. Twice he was voted as a baseball All-Star. But one statistic from his career has been the focus of speculation for many years, which is John’s pre-operation success on the pitcher’s mound and his post-operation success.

Any surgical procedure needs to be thoroughly discussed with qualified physicians, and elective surgery is not an exemption to that rule

Before And After Surgery

Prior to surgery, which took place in 1974, John had notched 124 victories as a major league pitcher. After taking a year off to recuperate, John returned in 1976 and from then on amassed 164 more wins. As such, the operation not only worked, but it gave rise to speculation that John threw the ball harder after the surgery than before.


John’s comeback from surgery was startling in its success and the pitcher’s longevity. And it wasn’t long before parents of healthy young baseball prospects were requesting the operation for their offspring, hoping the elective procedure would turn their child into a major league baseball player.


Buyer Beware


Any surgical procedure needs to be thoroughly discussed with qualified physicians, and elective surgery is not an exemption to that rule. Certainly, if you could buy a bionic mechanism that could turn your child into a baseball star, people would line up around the block to grab a hold of that slice of the American Dream. Only your physician and yourself can make the call on whether or not to go through with that option. Here, let’s discuss how the procedure works.


Ulnar collateral ligament reconstruction surgery


Recommended if the ulnar collateral ligament is frayed or stretched beyond healing, this reconstruction surgery was first performed on Tommy Johns by Dodgers team physician Frank Jobe. Technically, the procedure is a surgical graft. This entails replacing the damaged ligament with a tendon taken from a donor or from another portion of the patient’s body.


Needless to say, if the tendon is taken from the patient’s body, the physician selects one that will not have a major negative impact when removed. The tendons commonly used are the patellar tendon, which comes from a knee joint, or the palmaris tendon, selected from the opposite forearm.


The procedure involves drilling holes in the ulna and humerus bones of the elbow, then wrapping the donated tendon through the holes in a figure eight fashion. The ends of the tendon are then anchored in place. At times, the procedure also involves moving the ulnar nerve, which is made necessary if the new scar tissue is likely to push on the nerve causing post-operative pain.


Not Just for Pitchers


Pitchers are not the only baseball players prone to ulnar collateral ligament distress. The condition, however, is predominantly a baseball-specific injury. For pitchers, the recovery time is more significant for pitchers than for other players.

Meanwhile, the rise in ulnar collateral ligament procedures on youth – elective or not – has been on the rise, prompting Major League Baseball and Little League Baseball to encourage injury prevention pitching by following a program called Pitch Smart.

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Shoulder Replacement Surgery For Younger Patients

By  aenriquez  published  June 4, 2019

Shoulder replacement surgery – called a shoulder arthroplasty – has traditionally been relegated to helping elderly patients who suffer from long-term arthritis that is leading to the deterioration of cartilage and possibly bone structure. However, doctors now see advancements in both material and technique may allow the option to be extended to select younger patients. Let’s see if you are a candidate for this type of operation.


The shoulder is a ball and socket style joint with a design that is likely not quite what most people imagine. While many envision a ball and socket as a mechanism that includes a socket wrapping almost completely around a ball, the shoulder has a ball that simply rests against a slightly concave structure, held in place by muscles and a series of tendons and ligaments. Picture a round-bottomed cup resting against an almost flat saucer, held there by rubber bands. The saucer doesn’t wrap around the cup, it provides a settling place for it and, under normal conditions, it stays where it is while allowing for a wide range of motions.

There are pros and cons of each procedure, which should be discussed thoroughly with a physician

The joint, however, is not a system in which bone moves against bone. This occurs when debilitating conditions, like arthritis, become advanced. Normally, a shoulder joint includes healthy cartilage that allows for smooth motions.

Conditions Change

Arthritis is a condition marked by painful movement owing to the deterioration of cartilage. This can occur with age, but it can also be accelerated by prolonged athletic activity. As such, some of the more dedicated athletes – because they practice or play a lot – develop arthritis prematurely.

Doctors, however, have traditionally been reluctant to recommend shoulder replacement surgery for someone who is still young. The reasons for this included the expectation that wear and tear of the replacement material, a metal ball and a plastic cup that allows for smooth motion — would eventually wear out, requiring a second operation.

Doctors at the Mayo Clinic now say that carefully selected younger patients could benefit from shoulder replacement surgery. Here are the criteria that doctors should look for when selecting a younger patient for this type of operation:

  • healthy rotator cuff that can hold the new joint in place
  • Healthy socket bone stock (called the glenoid bone)
  • Intact deltoid muscle
  • Persistent pain that does not respond well to conventional treatment
  • A patient motivated to complete physical therapy for post-operative healing and restoration


Patients should be aware of the options for a shoulder arthroplasty before selecting the right procedure for them. There are pros and cons of each procedure, which should be discussed thoroughly with a physician.

The options for surgery include a traditional shoulder arthroplasty, a partial shoulder replacement in which just the ball is replaced and a reverse shoulder arthroplasty.

Reverse Arthroplasty

Doctors came to the realization that the ball, which is normally the terminal part of your arm, and the socket, which is on the proximal side, could be reversed. In fact, it is beneficial to reverse the ball and the socket in conditions in which there is a complete rotator cuff tear, which no longer functions well to hold the joint in place.

The gains of a reverse shoulder arthroplasty is better stability when there is little or no functioning soft tissue that can hold the joint together.

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Considering Joint Replacement Surgery? As Your Local AI

By  aenriquez  published  May 31, 2019

Let’s preface this news with the clear understanding that patients undergoing total knee or total hip replacement surgery should consult with their physicians and ask every question they can think to ask. Then ask a few more questions. Then ask a few more.

However, to whom shall your physician go to ask questions? It turns out, the answer to that may well be to a machine. The reason: A new study conducted at the Hospital for Special Surgery in New York City found that computers plowing through various algorithms could reasonably predict which patients undergoing these two critical operations would benefit from the surgery and which ones would not.

Predicting the outcome is not always easy for man or machine, but there may be better outcomes if the two work together

“Machine learning has the potential to improve clinical decision making and patent care by helping prioritize resources for post-surgical monitoring and informing pre-surgical discussions of likely outcomes,” the study found. In so many words, that means, patients should ask their doctors every question they can think up. Doctors, on the other hand, would do well to consult the Oracle, which is to say, they should turn to their computers to help guide their decisions.

Predicting the outcome is not always easy for man or machine, but there may be better outcomes if the two work together. This should never mean allow the computer to take a decision out of your hands. But algorithms in the study did have reasonable predictions concerning whether or not patients, two years after surgery, were benefiting from the knee or hip replacements.

The study was lengthy and included thousands of patients. The data collected involved 7,239 hip replacement surgeries and 6,480 knee replacement surgeries done between 2007 and 2012. According to a press release, “using data about both physical and mental status of patients before and two years after procedures, the investigators were able to calculate whether a patient achieved an MCID across four patient-reported outcome measure scores.” Those scores included self-reporting assessments of general physical health, general mental health, plus measures for hip health and knee health.

An MCID, meanwhile, is a clinical term for “did it work?” Technically, MCID stands for minimal clinically important differences. So, maybe the better translations would be: “did you even notice that the surgery worked?”

Of course, this may be the type of study that will not cause much excitement in the general public, which includes those too cynical to believe these predictions are possible and those who assumed computers were helping orthopedic surgeons make critical decisions all along. But, the point for physicians is a bit more important, because doctors live so close to the action that any miscalculation in this regard is considered a very bad day at work.

Nobody likes unnecessary surgery, but especially so if predictions of outcomes are made easier or more accurate. “The least valuable health care is that which is not wanted or needed,” said one of the senior authors of the study Catherine MacLean, MD, Ph.D., HSS, Chief Value Medical Officer at the hospital.

“Accurate prediction of whether individual patients will achieve a meaningful improvement after the procedure will greatly assist patients and their physicians in determining the best course of therapy,” MacLean said.

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Pathologic Fractures

By  aenriquez  published  May 2, 2019

A pathologic fracture may be defined as a break in a bone caused by an underlying disease. An otherwise healthy bone typically fractures as a result of trauma. A diseased bone may do so either without trauma or due to minimal trauma. Diseases of the bone that predispose bones to fracture easily include osteoporosis, osteomyelitis, osteomalacia, Paget’s disease and malignancy (primary or secondary).


Pathologic fractures can affect any bone that is diseased, and the symptoms depend on the type and location of the bone involved. Many diseases affect the spinal vertebrae, which are prone to pathologic fractures, which can cause a range of symptoms from pain in back, legs, and arms to neurological impairment, such as numbness and/or weakness in the arms or legs.

Pathologic fractures can affect any bone that is diseased, and the symptoms depend on the type and location of the bone involved

Pathologic fractures are detected on imaging, which is initiated either by a suggestive history and physical exam or staging, restaging or surveillance workup for cancers.


  • X-ray – plain film radiographs provide an overall assessment of bone integrity and the presence and the extent of the fracture. It can also detect spinal dislocation or slippage, kyphosis, scoliosis, etc. In addition to these, it can detect specific bony abnormalities such as bone spurs, disc space narrowing, vertebral body fracture, collapse or erosion, etc. Dynamic or flexion/extension X-rays may help in detecting any abnormal or excessive movement or instability in the spine at the affected levels.
  • Computed tomography scan (CT scan) – shows more detailed images of the bones and the soft tissue, and is best suited for evaluating the extent of the fracture.
  • Magnetic resonance imaging (MRI) – is more suitable for evaluating soft tissue damage occurring as a result of the fracture. It is especially useful for the detection of neural damage. MR (or CT) angiography is considered when vascular compromise is suspected.
  • Nuclear bone scan – this scan can be helpful when surveilling for distant bone metastases, in addition to detecting bone infections, especially when MRI is not possible.


The goals of treatment are pain relief, reversal or stabilization of neurological deficits and stabilization. For less severe pathologic fractures, nonoperative/conservative management is considered. Severe pathologic fractures require surgical treatment, and the choice of procedure is based on the location of the bone and the extent of the injury. Spinal pathologic fractures can lead to collapsed vertebrae and vertebroplasty or kyphoplasty is required, during which a cement mixture is injected into the fractured bone to stabilize the fracture, treat pain, and prevent further spinal deformity from progressing. In cases where the collapsed vertebrae impinge on the nerve roots or the spinal cord itself, the surgeon may need to remove diseased bone to relieve pressure and possibly perform a spinal fusion to stabilize the spine until it heals. The underlying disease process needs to be adequately managed as well – whether it’s bisphosphonates for osteoporosis or suitable cancer treatment for metastatic disease.

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Sacral Fractures

By  aenriquez  published  April 25, 2019

The sacrum is formed by the fusion of 5 sacral vertebrae and articulates with 5th lumbar vertebra proximally and coccyx distally, and with ilia at sacroiliac joints bilaterally. It contains 4 foramina which transmit sacral nerves (L5-S5), which are responsible for the functions of anal sphincter tone / voluntary contracture, bulbocavernosus reflex and perianal sensation. As an osseous structure, sacrum transmits the load distributed by the first sacral segment through iliac wings to the acetabulum.

Sacral fractures are quite common, occurring in up to 45% of pelvic ring injuries related to high energy trauma (in young adults) or low energy falls (in elderly). They are often underdiagnosed and as a consequence, they are frequently mistreated and lead to serious complications such as neural damage (25% of all cases).

Transverse sacral fractures also have a high incidence of nerve dysfunction

The presence of a neurologic deficit is the most single most important factor in predicting the outcome. Untreated fractures with neurologic deficits lead to symptoms of lower extremity motor/sensory deficits and/or urinary/rectal/sexual dysfunction.

Sacral fractures are classified according to the Denis classification. Zone 1 fractures (50% of all) are lateral to the foramina and are least related to a nerve injury. Zone 2 fractures are through foramina, and based on whether they are stable or unstable, have an increased risk of nonunion, nerve damage and poor functional outcome. Fractures that are medial to foramina are associated with the highest rate of neurological deficit (60%), such as bowel, bladder, and sexual dysfunction. Transverse sacral fractures also have a high incidence of nerve dysfunction.  The u-type sacral fractures result from axial loading and represent spino-pelvic dissociation; these too have a high incidence of neurologic complications.

The clinical diagnosis begins with taking a proper history – motor vehicle accident or fall from height are the most common causes of these fractures, but repetitive stress, insufficiency fracture in osteoporotic adults are also important predisposing factors. The most prominent symptom is peripelvic pain. The physical exam should include testing for pelvic ring stability by internally and externally rotating iliac wings, palpating for subcutaneous fluid mass indicative of lumbosacral fascial degloving, as well as performing a vaginal exam in women to rule-out open injury. A focused neurologic, vascular and rectal exams are also important to assess the degree of tissue damage.

Radiographs are required to diagnose a sacral fracture, although only 30% show sacral fractures. CT is by far the diagnostic study of choice for proper assessment of the fracture, while MRI is considered when neural compromise is suspected.

Nonoperative management includes progressive weight bearing with orthosis if needed, and can only be considered in patients with <1 cm displacement and no neurologic deficit, and in cases of insufficiency fractures. Surgical fixation (without decompression) should be considered if there is a displaced fracture >1 cm with associated soft tissue compromise and persistent pain after non-operative management, and also if there is displacement of fracture after non-operative management. Surgical fixation with decompression is the treatment of choice whenever there is evidence for neurologic injury.

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