Lower Bone Mineral Density is Associated with Intertrochanteric Hip Fracture.

BACKGROUND: A better understanding of how bone mineral density and vitamin D levels are associated with femoral neck and intertrochanteric hip fractures may help inform healthcare providers. We asked: 1) In patients age ≥ 55 years, is there a difference in quantitative ultrasound of the heel (QUS) t-score between patients with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors 2) In patients age ≥ 55 years, is there a difference in vitamin D level between those with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors? 3) Is there an association between vitamin D level and QUS t-score? METHODS: In this retrospective cohort study, 1,030 patients were identified using CPT codes for fixation of hip fractures between December 2010 and September 2013. Patients ≥ 55 years of age who underwent operative management for a hip fracture following a fall from standing height were included. Three orthopaedic surgeons categorized fracture type using patient radiographs. Upon hospital admission, QUS t-scores and vitamin D levels were determined. Descriptive statistics, bivariate analyses and multivariable regression were performed. RESULTS: Accounting for potential confounders, patients with lower QUS t-scores were more likely to have intertrochanteric femur fractures than femoral neck fractures. In a bivariate analysis, there was no association between vitamin D level and either fracture type. There was no association between vitamin D level and bone mineral density. CONCLUSION: Patients with lower bone density that fracture their hips are more likely to fracture in the intertrochanteric region than the femoral neck, but vitamin D levels are unrelated. Awareness of this association emphasizes the importance of bone mineral density screening to assist with intertrochanteric hip fracture prevention. LEVEL OF EVIDENCE: III.

Oculomotor nerve palsy in the setting of an anterior cerebral A2 segment aneurysm.

INTRODUCTION: A case is presented which highlights a rare cause of oculomotor nerve palsy (third nerve palsy) in the setting of subarachnoid hemorrhage secondary to an A2 segment anterior cerebral aneurysm. A third nerve palsy is most often associated with posterior communicating artery aneurysms which are explained by the anatomic proximity of nerve and artery. Third nerve palsies from remote aneurysms however are more difficult to understand. PRESENTATION: A patient presented to the emergency department with severe headache, dizziness, nausea and vomiting. Her examination was remarkable only for a partial left third nerve palsy manifest as a non-pupil sparing mild ptosis. A CT scan and digital subtraction cerebral angiography revealed subarachnoid hemorrhage secondary to a small ruptured aneurysm at the A2 segment of the anterior cerebral artery. The aneurysm was deemed treatable by endovascular coil embolization and the patient underwent successful placement of a detachable helical coil. At 1 month follow-up, the patient had no complaints and showed complete resolution of all oculomotor symptoms. CONCLUSION: While oculomotor nerve palsy is an incredibly rare sequelae of anterior cerebral artery aneurysm rupture, it is important that clinicians and researchers continue to report and study such cases. It has been hypothesized that mass effect, hemotoxicity and ischemia are all possible causes of third nerve injury in remote aneurysms, as in this case.