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Online ISSN Number 2455-538X
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Online ISSN Number 2455-538X
Fat Embolism in Long Bone Fracture Patients and its Complications: A Prospective Study
/in Jan. - Jun 2020 | Volume 6 | Issue 1Vol 6 | Issue 1 | Jan-Jun 2020 | page:2-5 – Dheeraj Attarde, Atul Patil, Chetan Pradhan, Chetan Puram, Adarsh Kota, Parag Sancheti, Ashok Shyam
Author: Dheeraj Attarde [1], Atul Patil [1], Chetan Pradhan [1], Chetan Puram [1], Adarsh Kota [1], Parag Sancheti [1], Ashok Shyam [1,2]
[1] Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India.
[2] Indian Orthopaedic research group, Thane, India.
Address of Correspondence
Dr. Dheeraj Attarde,
Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India.
E-mail: dheerajattarde@yahoo.in
Abstract
Background: Incidence of fat embolism after long bone fracture in Indian scenario is not studied much. In our study we try to analyse data over 2 years to find incidence and its complications.
Materials and Methods: Two hundred FES (fat embolism syndrome ) suspected patients secondary to long bone fractures admitted over a 1 year period included. Patients satisfying the clinical criteria proposed by Gurd and Wilson, and Schonfeld were included in the study. Clinical features, risk factors, complications and any sequelae were noted.
Results: Out of 200 patient’s majority were male patients. Maximum (85.5%) cases were used immobilizers to stabilize case. Isolated fractures (97%) were more compare to multiple fracture (3%). Associated features included features of altered sensoriam (n = 14, 7%), petechial rash (6%), tachycardia (16.5%) and fever (14.5%). Hypoxemia was demonstrable in 25.5% (51patients) cases. Fat embolism was found in 2% (4 cases) study population. Hypoxia @ 72 hours more in multiple fractures (50%) compare to isolated fractures (4.6%). This association was statistically significant. (P<0.05) No long-term sequelae were observed.
Conclusion: We conclude that in our representative population the incidence of fat embolism is slightly higher compared to other population. This amounts to 2% of people with long bone fractures of lower limb. Fat embolism was more in femur fractures compared to tibia fractures and the chance of fat embolism was more in multiple fractures when compared to isolated fractures. The incidence of fat embolism was more in closed fractures as compared to open fractures. Other salient features of the study were the increased incidence of fat embolism noted in fractures which were not immobilized.
Key Words: Accidents; ARDS; Fat embolism syndrome; Fracture.
References
1. Saigal R, Mittal M, Kansal A, Singh Y, Kolar P, Jain S. Fat embolism syndrome. JAPI. 2008 Apr;56.
2. Akhtar S. Fat embolism. Anesthesiology clinics. 2009 Sep 1;27(3):533-50.
3. Maitre S. Causes, clinical manifestations, and treatment of fat embolism. Virtual Mentor. 2006 Sep 1;8(9):590-2.
4. Stein PD, Yaekoub AY, Matta F, Kleerekoper M. Fat embolism syndrome. The American journal of the medical sciences. 2008 Dec 1;336(6):472-7.
5. Bulger EM, Smith DG, Maier RV, Jurkovich GJ. Fat embolism syndrome: a 10-year review. Archives of surgery. 1997 Apr 1;132(4):435-9.
6. Peltier L.F.: Fat embolism: A perspective. Clin Orthop 1988;232:263-270.
7. Allgower M., Durig M., Wolff G.: Infection and trauma. Surg Clin North Am 1980;60:133-144.
8. Beck J.P., Collins J.A.: Theoretical and clinical aspects of post-traumatic fat embolism syndrome. Instr Course Lect 1973;23:38-87..
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Journey Ahead!!
/in May- Dec 2019 | Volume 5 | Issue 2Vol 5 | Issue 2 | May-Dec 2019 | page: 01 | Ashok Shyam
DOI 10.13107/ti.2019.v05i02.084
Author: Dr. Ashok Shyam [1,2]
[1] Indian Orthopaedic Research Group, Thane, India
[2] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
Address of Correspondence
Dr. Ashok Shyam
IORG House, A-203, Manthan Apts, Shreesh, CHS, Hajuri Road, Thane, India. 400604
Email: drashokshyam@yahoo.co.uk
Trauma International marches ahead with full determination to contribute in the field of trauma. We are thankful to the authors who are contributing to the journals work and we are sure this response will continue in the future too. We thank authors for their contribution in the May-December 2019 issue of Trauma International. This issue contains case reports on Occult Femoral Neck Fracture, Bilateral
Uncemented Hemiarthroplasty, Bilateral femoral neck fracture in pregnancy and the review article on Galeazzi fracture associated with an ipsilateral fracture of ulna diaphysis and olecrane. We appreciate efforts of authors and hope for more contributions in the field of orthopaedic literature.
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Bilateral Uncemented Hemiarthroplasty in a Patient with Bilateral Lower limb PPRP with Right Knee Arthrodesis: Surgical Difficulties and Techniques
/in May- Dec 2019 | Volume 5 | Issue 2Vol 5 | Issue 2 | May-Dec 2019 | page: 05-07 | Bipul Kumar Garg, Harshit Dave, Dhiraj V. Sonawane, Om Parshuram Patil
DOI 10.13107/ti.2019.v05i01.088
Author: Bipul Kumar Garg [1], Harshit Dave [1], Dhiraj V. Sonawane [1], Om Parshuram Patil [1]
[1] Department Of Orthopaedics,
Grant Medical College And Sir J.J. Group Of Hospitals Mumbai.
Address of Correspondence
Dr. Bipul Kumar Garg,
Department Of Orthopaedics,
Grant Medical College And Sir J.J. Group Of Hospitals Mumbai.
E-mail: garg.bipul@gmail.com
Abstract
Introduction: Standard references such as knee and lower leg position cannot be used in patients with knee arthrodesis with a bilateral neck of femur fracture during bipolar hemiarthroplasty. We describe a simple technique that guides a surgeon in assessing the femoral stem version in such cases.
Case report: We present a case of 52 years old male with bilateral lower limb Post Polio Residual Paralysis with right knee arthrodesis who sustained bilateral neck of femur fractures. The difficulties, in this case, were the inability to flex the knee and to use the ankle or the opposite limb and its bony landmarks as reference.
Conclusion: We describe a simple surgical technique of inserting a Steinmann pin in the distal femur in the coronal plane parallel to the transcondylar axis for intraoperative assessment of neutral position and version of the femoral stem.
Keywords: Bilateral; hemiarthroplasty; femoral stem; anteversion; knee arthrodesis.
References
1. Hirata M, Nakashima Y, Ohishi M, Hamai S, Hara D, Iwamoto Y. Surgeon error in performing intraoperative estimation of stem anteversion in cementless total hip arthroplasty. The Journal of arthroplasty. 2013 Oct 1;28(9):1648-53.
2. Lewinnek GE, Lewis JL, Tarr RI, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. The Journal of bone and joint surgery. American volume. 1978 Mar;60(2):217-20.
3. D’lima DD, Urquhart AG, Buehler KO, Walker RH, Colwell Jr CW. The effect of the orientation of the acetabular and femoral components on the range of motion of the hip at different head-neck ratios. JBJS. 2000 Mar 1;82(3):315-21.
4. Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. JBJS. 2007 Aug 1;89(8):1832-42.
5. Patel AB, Wagle RR, Usrey MM, Thompson MT, Incavo SJ, Noble PC. Guidelines for implant placement to minimize impingement during activities of daily living after total hip arthroplasty. The Journal of arthroplasty. 2010 Dec 1;25(8):1275-81.
6. Patii ND, Patel HB, Hussain N, Saidane K. Cemented Hemiarthroplasty of the Hip in a Patient with Ipsilateral Knee Arthrodesis: Surgical Difficulties and Techniques. Journal of orthopaedic case reports. 2018 Jan;8(1):75.
7. Unlu MC, Kesmezacar H, Kantarci F, Unlu B, Botanlioglu H. Intraoperative estimation of fe-moral anteversion in cementless total hip arthroplasty using the lesser trochanter. Archives of or-thopaedic and trauma surgery. 2011 Sep 1;131(9):1317-23..
8. Yun HH, Yoon JR, Yang JH, Song SY, Park SB, Lee JW. A validation study for estimation of femoral anteversion using the posterior lesser trochanter line: an analysis of computed tomography measurement. The Journal of arthroplasty. 2013 Dec 1;28(10):1776-80.
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A Case Series of Occult Femoral Neck Fracture, Why Plain Radiograph is not Enough?
/in May- Aug 2019 | Volume 5 | Issue 2Vol 5 | Issue 2 | May-Dec 2019 | page: 02-04 | John Butarbutar, Rio Aditya, Prettysia Suvarly, Nyoman Aditya Sindunata
DOI 10.13107/ti.2019.v05i02.086
Author: John Butarbutar [1], Rio Aditya [2], Prettysia Suvarly [2], Nyoman Aditya Sindunata [2]
[1] Department of Orthopedic & Traumatology, Siloam Hospitals Lippo Village – Pelita Harapan University, Jl. Siloam No. 6, Lippo Karawaci 1600 Tangerang 15811, Indonesia.
[2] Clinical Researcher at Orthopedic & Traumatology Department, Siloam Hospitals Lippo Village – Pelita Harapan University, Jl. Siloam No. 6, Lippo Karawaci 1600 Tangerang 15811, Indonesia.
Address of Correspondence
Dr. John Butarbutar,
Department of Orthopedic & Traumatology, Siloam Hospitals Lippo Village – Pelita Harapan University, Jl. Siloam No. 6, Lippo Karawaci 1600 Tangerang 15811, Indonesia.
E-mail: johnbutar2@gmail.com
Abstract
Background: About 10% of hip fractures are missed on initial presentation and potentially expose patients to increased morbidity and unnecessary complex surgeries. 2,3 CT-scan and MRI in the emergency settings have been proposed to avoid a misdiagnosis.3,6,7
Case Series: three cases (two female and one male patient) patients with hip pain were presented with normal x-ray on initial presentation. Further investigation using CT-scan and MRI revealed femoral neck fractures.
Case 1 : A 77 years-old female presented with right hip pain after a ground-level fall. Plain radiograph was normal and the patient was discharged from emergency. One week later, her hip pain worsened and a follow up x-ray showed a displaced femoral neck fracture. The fracture then treated with bipolar hemiarthroplasty.
Case 2 : An 87 years-old female presented with left hip pain after a fall in the bathroom. She was able to bear weight. Initial hip x-ray appeared normal. Further investigation with a pelvic CT scan revealed a displaced femoral neck fracture.
Case 3 : A 49 years-old male presented with worsening right hip pain since more than a week. The patient was physically active and has no history of trauma or associated hip injury. Initial x-ray showed a normal hip but further imaging study using MRI revealed an undisplaced femoral neck fracture. The patient was treated conservatively as he refused to do surgery.
Conclusion: Traumatic hip pain with negative plain radiograph should be followed by MRI or CT -scan to avoid misdiagnosis.
Keywords : Occult hip fracture, Missed hip fracture, Femoral Neck Fracture, Elderly patient
References
1. B. Gullberg, O. Johnell and J. Kanis, “World-wide projections for hip fracture,” Osteoporosis International, vol. 7, no. 5, pp. 407-13, 1997.
2. O. Lubovsky, M. Libergall, Y. Mattan, Y. Weil and R. Mosheiff, “Early diagnosis of occult hip fractures,” Injury, vol. 36, no. 6, pp. 788-92, 2005.
3. J. Cannon, S. Silvestri and M. Muntro, “Imaging choices in occult hip fracture,” The hournal of emergency medicine, vol. 37, no. 2, pp. 144-52, 2009.
4. W. Brox, K. Roberts and S. Taksali, “The American academy of orthopaedic surgeons evidence-based guideline on management of hip fracture in the elderly,” Journal of Bone and Joint Surgery, vol. 97, pp. 1196-9, 2015.
5. N. Yoshida, Y. Komaru and Y. Tsuchida, “Occult femoral neck fracture,” Case reports, vol. 2017, 2017.
6. S. Gill, J. Smith, R. Fox and C. T, “Investigation of occult hip fractures : the use of CT and MRI,” The scientific world journal, vol. 2013, pp. 1-4, 2013.
7. D. Collin, D. Dunker, J. Gothlin and M. Geijer, “Observer variation for radiography, computed tomograpy, and magnetic resonance imaging of occult hip fractures.,” Acta Radiologica, vol. 52, no. 8, pp. 871-4, 2011.
8. C. Wei, W. Tsai, C. Tiu, H. Wu and H. Chiou, “Systematic analysis of missed extremity fractures in emergency radiolgy,” Acta Radiol, vol. 47, pp. 710-7, 2006.
9. B. Yun, M. Myriam Hunink, A. Prabhakar, M. Heng, R. Qudsi and A. Raja, “Diagnostic imaging strategies for occult hip fractures : a decision and cost-effectiveness analysis,” Academic Emergency Medicine, vol. 23, no. 10, pp. 1161-9, 2016.
10. F. Frihagen, L. Norsletten, R. Tariq and J. Madsen, “MRI diagnosis of occult hip fractures,” Acta Orthop, vol. 76, no. 4, pp. 524-30, 2005.
11. R. Pandey, E. McNally, A. Ali and C. Bulstrode, “The role of MRI in the diagnosis of occult hip fractures,” Injury, vol. 29, pp. 61-3, 1998.
12. M. Haubro, C. Stougaard, T. Torfing and e. al, “Sensitivity and specificity of CT and MRI scanning in evaluation of occult fracture of the proximal femur,” Injury, vol. 46, pp. 1557-61, 2015.
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Spontaneous Iliopsoas Hematoma After Total Hip Arthroplasty In A Patient On Rivaroxaban: A rare case report
/in May- Dec 2019 | Volume 5 | Issue 2Vol 5 | Issue 2 | May-Dec 2019 | page: 08-10 | Danai Grammatikopoulou, Themistoklis Vampertzis, Eirini Iosifidou, Christina Barmpagianni, Eleni Melikidou, Fotios Girtovitis, Stergios Papastergiou
DOI 10.13107/ti.2019.v05i02.090
Author: Danai Grammatikopoulou [1], Themistoklis Vampertzis [1], Eirini Iosifidou [1], Christina Barmpagianni [2], Eleni Melikidou [3], Fotios Girtovitis [4], Stergios Papastergiou [1]
[1] Orthopaedics Department, Agios Pavlos General Hospital of Thessaloniki, Thessaloniki, Greece;
[2] Aristotle University of Thessaloniki, Faculty of Medicine, Thessaloniki, Greece;
[3] Radiology Department, Agios Pavlos General Hospital of Thessaloniki, Thessaloniki, Greece;
[4] Blood Centre, AHEPA University Hospital, Thessaloniki, Greece.
Address of Correspondence
Dr. Themistoklis Vampertzis,
Orthopaedic Department, Agios Pavlos General Hospital Thessaloniki, Thessaloniki, Greece.
E-mail: themisvamper@yahoo.com
Abstract
Introduction: Pain in the inguinal region, frequently spreading to the femur, is a common symptom with a variable differential diagnosis. Spontaneous iliopsoas hematoma is a rarely reported adverse effect of anticoagulation therapy that can present with pain in the hip, with or without previous injury or surgery at the region. This case report aims to remind clinicians of this rare condition that can result in major complications.
Case Presentation: An 83 year old male patient presented to our Emergency Department with pain at the right hip which within a week expanded to the lower back and anterior femur. During clinical examination restriction of movement due to soreness was noted, the hip joint was kept in slight flexion, while there were no abnormal vascular findings. Medical history included a right-sided total hip replacement 8 years ago, chronic atrial fibrilation, chronic cardiac failure and hypertension. He was on anticoagulant (rivaroxaban) and anti-hypertensive regimen. Laboratory results showed low hematocrit (HTC) and hemoglobin (HB), elevated prothrombin time (PT) and increased international normalized ratio (INR). Imaging showed a large iliopsoas hematoma. Conservative treatment was decided. Subsequently, the hematocrit normalized, the hematoma regressed and the pain receded.
Conclusion: Despite being a frequent cause of complain, pain of the hip, lumbar or femur region could be the result of a more complex pathology. Such cases should therefore not be overlooked but examined thoroughly, especially if presenting with suspicious signs or symptoms or in a setting of co morbidities. When complains are with regard to an area that has been operated on, as in our case, clinicians should not attribute all symptoms on the presence of prior surgery.
Keywords: Anticoagulation, spontaneous hematoma, iliopsoas, total hip arthroplasty.
References
1.Kim SW, Kim DH, Jung S-N. Spontaneous Iliopsoas Hematoma: A Rare Complication of Anticoagulant Use. Archives of Plastic Surgery. 2015;42(4):507-510. doi:10.5999/aps.2015.42.4.507.
2.Yegen SF, Ekiz T, Gilikli BE, Dogan A. Spontaneous Iliopsoas Haematoma Presenting with Groin Pain under Warfarin Therapy. Pain Physician. 2015 Nov;18(6):E1145-6.
3.Boţianu AM, Demian S, Macarie I, Georgescu D, Oltean G, Băţagă S. Acquired haemophilia complicated with gastrointestinal bleeding and spontaneous iliopsoasmuscle haematoma in woman with chronic C hepatitis under treatment with pegylated IFNalpha 2a and ribavirin. J Gastrointestin Liver Dis. 2012 Mar;21(1):93-5
4.Kumar A, Mondal S, Sethi P, Manchanda S, Biswas A, Wig N. Spontaneous iliopsoas haematoma in a patient with dengue haemorrhagic fever (DHF): A casereport. J Vector Borne Dis. 2017 Jan-Mar;54(1):103-105.
5.Selton J, Perrin J, Ropion H, et al. Iliopsoas Hematoma in Gauchers D i s e a s e . I n t e r n a l Me d i c i n e . 2 0 1 1 ; 5 0 ( 2 1 ) : 2 6 4 3 – 2 6 4 7 . doi:10.2169/internalmedicine.50.5215.
6.Keikhaei B, Shirazi AS. Spontaneous iliopsoas muscle hematoma in a patient with von Willebrand disease: a case report. Journal of Medical Case Reports. 2011;5(1). doi:10.1186/1752-1947-5-274.
7.Sarcon A, Botta GP, Patel N, Saven A. Spontaneous Iliopsoas Muscle Hemorrhage Secondary to Ibrutinib (Imbruvica; Pharmacyclics). Journal of Investigative Medicine High Impact Case Reports. 2016;4(2):232470961664845. doi:10.1177/2324709616648457.
8.Yogarajah M, Sivasambu B, Jaffe EA. Spontaneous iliopsoas haematoma: a complication of hypertensive urgency. Case Reports. 2015;2015(feb26 1). doi:10.1136/bcr-2014-207517.
9.Lee KS, Jeong IS, Oh SG, Ahn BH. Subsequently occurring bilateral iliopsoas hematoma: a case report. Journal of Cardiothoracic Surgery. 2015;10(1). doi:10.1186/s13019-015-0386-7.
10.Rock J, Basheer A, Jain R, Anton T. Bilateral iliopsoas hematoma: Case report and literature review. Surgical Neurology International. 2013;4(1):121. doi:10.4103/2152-7806.118561.
11.Podger H, Kent M. Femoral nerve palsy associated with bilateral spontaneous iliopsoas haematomas: a complication of venous thromboembolism therapy. Age and Ageing. 2016;45(1):175-176. doi:10.1093/ageing/afv176.
12.Andreani L, Nucci AM, Giuntoli M, Lisanti M .Compressive Femoral Neuropathy Associated with Iliopsoas Hematoma Complicating Hip Hemiarthroplasty: A Case Report. J Orthop Case Rep. 2017 Sep- Oct;7(5):3-6. doi: 10.13107/jocr.2250-0685.872.
13.Torres GM, Cernigliaro JG, Abbitt PL, Mergo PJ, Hellein VF, Fernandez S, Ros PR. Iliopsoas compartment: normal anatomy and pathologic processes. Radiographics. 1995 Nov; 15(6): 1285–1297. doi: 10.1148/radiographics.15.6.8577956
14.Retselas I, Vaiopoulos C, Chronopoulos P, Kaisidis G, Fotopoulou C, Skandalos I. Spontaneous iliopsoas muscle haematoma during anticoagulant treatment. Hell J Surg 2015;87:434-6
15. Llitjos JF, Daviaud F, Grimaldi D, et al. Ilio-psoas hematoma in the intensive care unit: a multicentric study. Annals of Intensive Care. 2016;6:8. doi:10.1186/s13613-016-0106-z.
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Bilateral femoral neck fracture in pregnancy- outcome of conservative and operative treatment: a case report
/in May- Dec 2019 | Volume 5 | Issue 2Vol 5 | Issue 2 | May-Dec 2019 | page: 11-13 | Hemjit Das, Shyam Sunder. S
DOI 10.13107/ti.2019.v05i01.092
Author: Hemjit Das [1], Shyam Sunder. S [1]
[1] Department Of Orthopaedics, Assam Medical college and hospital, Dibrugarh, Assam, India-786002. India.
Address of Correspondence
Dr. Shyam Sunder. S,
Department Of Orthopaedics, Assam Medical college and hospital,
Dibrugarh, Assam, India-786002.
E-mail: shyam.arun90@gmail.com
Abstract
Introduction: Transient osteoporosis of pregnancy is usually benign in nature. Rarely serious complication like fragility fracture of neck of femur can occur. Usually idiopathic in nature and self-limiting. So far only 12 such cases and bilateral in only 2 patients have been reported in literature. Since, X-rays are usually avoided in pregnancy this condition is usually missed leading to late diagnosis.
Case report: A 26-year-old primigravida was referred to our institute on her 7th month of gestation with bilateral hip pain and limp. She developed bilateral hip pain on her 5th month of gestation which was progressive in nature. Her radiograph showed bilateral femoral neck fracture. To avoid radiation hazard to the fetus fracture fixation was delayed till caesarean section on her 38th week of gestation. Closed reduction and internal fixation with three CC screws was done for left femur neck fracture. Fixation was planned for right side fracture simultaneously but since the patient did not consent for bilateral surgery she was asked to review after one month for right femur neck fracture fixation. The patient who lost to follow-up showed up after 6 months walking comfortably. Radiological examination showed that in the nonoperated side the fracture united in Varus with shortening of 0.5 cm.
Conclusion: Musculoskeletal problems during pregnancy should not be overlooked. MRI should be used for early diagnosis whenever feasible. Fracture Neck of femur in pregnancy in-spite of delayed diagnosis and treatment has a better prognosis even with conservative treatment.
Keywords: transient osteoporosis, pregnancy, femoral neck fracture, spontaneous healing.
References
1. Lakhanpal s, Ginsburg W, Luthra H, Hunder G. Transient regional osteoporosis, a study of 56 cases and review of the literature. Ann Intern Med. 1987;(106: 444-450).
2. Aynaci O, Kerimoglu S, Ozturk C, Sarcoglu M. Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-assosiated osteoporosis. Arch Orthop Trauma Surg. 2008;(128 :313-316).
3. Munker R, Niedart C, Niedart F, Schmidt RB. Bilateral fracture of the femoral neck following transient osteoporosis in pregnancy. Z Orthop thre Grenzgeb. 2007;(145:88-90).
4. Willis-Owen C, Daurka J, Chen A, Lewis L. Bilateral femoral neck fractures due to transient osteoporosis of pregnancy. Cases J. 2008;(1:120).
5. Kyoko K, Nobuyuki K. Bilateral femoral neck fractures resulting from pregnancy assosiated osteoporosis showed bone marrow edema on magnetic resonance imaging. The journal of obstetrics and gynaecology research. 2017 jun; 43((6 )1067-1070).
6. Cohen I, Melamed E, Lipkin A, Robinson D. Transient osteoporosis of pregnancy complicated by a pathologic sub-capital hip fracture. J Trauma. 2007; 62(1281-3).
7. Rishi V, Wahi P, Mahajan A. Transient osteoporosis of hip (migratory ). JK Science. 2008; 10(194-6).
8. Smith R, Athanosou NA, Ostlere SJ, Viponf SE. pregnnacy assosisted osteoporosis. QJM. 1995; 88(865-878).
9. Alioune GB, Lamine S, Badara D, Alioune DB, Andre DS, Charles DB. Bilateral fracture of femoral neck during pregnancy:A case of spontaneous Healing. SM journal of orthopaedics. 2017.
10. British tF. thyroid disorders and osteoporosis ,revised 2018. ; 2018.
11. Dominika T, Marek B. the influence of thyroid disfunction on bone metabolism. thyroid research. 2014;(7:12).
12. CDC. CDC guidelines. US Govt emergency.cdc.gov.
13. Vakil C. Radiation and medical procedures.how do we do no harm? Canadian family physician. 2017 oct; 63((10)774-775).
14. Lu-Yao GL ,Keller RB, Littenberg B. Outcomes after displaced fractures of the femoral neck. a meta analysis of one hundred and six published reports. J bone Joint Surg Am. 1994; 76(15-25).
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