Not so simple but sitting and joking method : a “New Technique” for Reducing Anterior Shoulder Dislocation : Matsumoto’s or Orthopedix’ “Joking Planche à Sida” ?

I just read one very good japanese article with great enthousiasm, because for many years in a 120 000 inhabitants French West Indian Community (Saint Claude, Basse Terre Guadeloupe), I obtained not 80 per cent but 100 per cent success with a method very close to this japanese one, but still much simpler !

I obtained 100 per cent because my own method is probably still simpler than Matsumoto’s: sitting patient, with axillary board fixed by the foot of the quiet patient sitting surgeon (talling same old joke about sex) and simply pulling arm axially gently AND permanently (both hands) sometime many minutes, with elbow maintained in flexion.

That’s it ! and NOT THIS…

Falls from skiing accidents, (snow)boarding injuries, car accidents and other traumatic events account for many first-time shoulder dislocations.

When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket).

There are many ways to reduce the shoulder but most require anesthesia (and in 1983-1989 Basse Terre, anesthesiologists…) to put the patient asleep and relax the muscles or strong narcotic medications for pain.

In their clever report, surgeons from Japan propose a “new” method for reducing anterior (forward) shoulder dislocations.

Most shoulder dislocations are anterior so this approach would be useful in many cases, if not every case.

No medication or anesthesia is used.

The patient remained in the sitting position.

There were no complications from the technique such as fractures or nerve injury.

The sitting position used was more comfortable for patients who were already holding the dislocated arm with the other hand.

The patient was sitting in a chair facing the surgeon.

The surgeon took hold of the patient’s forearm very gently and (?) raised the arm straight forward 90 degrees.

The surgeon placed his other hand (?) on the patient’s chest wall against the front of the patient’s shoulder.

The (?) surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one (?) hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket.

If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again.

The hand against the shoulder helped control the tilt of the shoulder socket.

My axillary board is probably much more stable and accurate…

The technique is done slowly and gently.

If the surgeon wasn’t able to successfully reduce the shoulder after several(?)  tries, the patient was placed supine (lying on his or her back).

A forward elevation maneuver was used instead.

The dislocated arm was placed overhead while the surgeon applied traction, gently rotating the arm outward until the head of the humerus slipped back into the socket.

Afterwards, everyone was given a sling to wear to support the arm during the acute phase of healing. X-rays were taken to confirm reduction.

Results of this technique were evaluated by reviewing the charts of patients later.

Data collected included previous history of shoulder dislocation, use of medications for reduction, type of reduction technique used, and before and after X-rays.

A total of 34 patients were treated for anterior shoulder dislocation with this “new” reduction method.

The surgeon accomplished the task alone while talking with the patient.

Combining the sitting position with a (simpler, straight, gentle, firm, axial) traction technique may be “new”… in Japan and may be has never been described before in medical journals !

Compared with other methods of shoulder reduction, this was simple, unique, drug-free, and successful.

It worked for almost 80 per cent of the patients.

The key to this technique is to work with patients who are already seated and self-supporting their arm.

Changing positions causes the shoulder to tense up and can be avoided with this method.

This method can be tried first before using drugs, mechanical force, or surgery.

There was no clear reason why a small number of patients could not be reduced with this method.

The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics or interscalene block were needed was the added benefit.

Kazu Matsumoto, MD, PhD, et al. Anterior Dislocation of the Shoulder: A Simple and Sitting Method for Reduction. In Current Orthopaedic Practice. May/June 2009. Vol. 20. No. 3. Pp. 281-284.

Early (?) Diagnosis of Low-symptomatic Ceramic Acetabular Liner Fracture in Ceramic-on-Ceramic Total Hip Arthroplasty

"Catastrophic" failure of one-piece ceramic liner without major trauma in a very active and heavy patient also having controlateral hip disease and right total knee arthroplasty (asymetric squatting) AND right shoulder arthroplasty for advanced omarthosis with normal rotator cuff (sugar cane handpicking ?)

Alumina ceramics in total hip arthroplasty (THA) have been used in Europe since 1970.

Over the years, ceramic-on-ceramic coupling became a valid option in THA because of excellent biocompatibility and tribological properties.

The major disadvantages are possible squeaking and mainly risk of breakage, usually disclosed by pain and functional impairment.

Squeaking is an audible noise arising from ceramic-on-ceramic bearings, the incidence of which is reported to range from 1% to 7% of THAs.

Component positioning, stripe wear, and edge loading have all been implicated.

Clicking sounds and scratching have also been anecdotally described.

Breakage of a ceramic component due to brittleness of the material still seems a rare complication.

Trauma, high activity level, and obesity may increase the risk of fracture.

Defective ceramic manufacture, inadequate (sandwich with polyethylene) implant design, and errors in surgical technique may contribute to breakage.

Rather than Caucasian, Asian (by extension West Indian) population lifestyle, including squatting, kneeling, and possibly sitting cross-legged, has been correlated to liner rim impingement and fracture.

Additional reports concerning failure of various, mainly sandwich, but not exclusively, ceramic liners have recently been described.

I will describe here a unique case of apparently early diagnosis of a low-symptomatic fracture of an Anca-Fit acetabular liner occurring 3 years after implantation of an uncemented ceramic-on-ceramic modular THA.

Diagnostic imaging in acute para- and tetraplegia in Guadeloupe (1983-2009)

Introduction

Since I had to leave Saint- Claude Camp Jacob General Hospital in Basse-Terre as it closed 40 out of its 60 surgical beds in 1989, there was a sudden developement and change in diagnosic imaging.

Some of these technologies use new physical priciples like MRI, others were developed using computerized processing of information gained by well known methods such as reconstruction of CT scans.

Older and well established methods like conventional x-ray imaging, tomography and myelography (Dr JCW) are still available.

This situation gave me reason to reevaluate the position of these techniques in our clinical management, especially in the acute setting.

Diagnostic approach

The diagnostic approach to acute para and tetraplegia lined out in the following diagramms is based on my experience as Chef de Clinique Assistant with patients from year 1964 to year 1980 in Paris best spine centers.

To define a pragmatic and clinically relevant way of using diagnostic procedures it is a must to have a clear scheme of differential diagnostic possibilites.

Spine Imaging Decision Tree

This is why I propose this decision-tree…

A patient presenting with an acute paraplegia may or may not have been exposed to a trauma.

I will first focus on the majority of patients in Camp Jacob Hospital which had suffered a trauma.

The important question is whether the trauma was

1. adequate – such as a car or motorcyle accident – or
2. inadequate – like lifting a case of bottles or kicking a spade.

If there was a “adequate trauma” (the two Galion Bus Accident of january 10^th 1984 and 1985…), I look for destructed vertebrae – that is

1. fractures – and/or
2. destructed soft tissue which are disc herniations and ruptures of ligaments.

Additional possibilites are intraspinal bleeding or a spinal contusion.

If there was a trauma, I consider as inadequate compared to the damage to the spine, I look for destruction of vertebra because of osteoporosis, tumors or spondylitis.

Other possibilities which involve no destruction of vertebra are arachnoitis, discitis, stenosis of the spinal canal or adhesions of the spinal cord.

If the patient reports no trauma at all, there might be

• a intraspinal tumor (ex. one psammomatous meningioma in 2 month bedridden 82 old lady also kwown to have uterus cancer),
• a vascular process,
• a hemorrhage or edema.

An acute inflammation or any kind (HTLV) of neurologic disease producing the symptoms of para- or tetraplegia also have to be considered.

Finally, there is always the possibility of a trauma which the patient does not report.

A diagramm will soon demonstrate the frequency of the conditions that led to paraplegia in patients I admitted for primary care during all these years.

The vast majority of paraplegia was caused by fractures.

Other important groups were tumor and disc problems.

Imaging strategy – adequate trauma

One Imaging Strategy

I outline here one diagnostic strategy in patients with an adequate trauma.

The first thing – which is always nescessary – is to get plain film x-rays of the segment of the spine which corresponds with the neurologic staging.

I know of a “second hand trauma case” who left the university hospital with high dorsal paraplegia from a T2 displaced fracture and had had “only”  diagnosed a T12 undisplaced fracture with “no compression CT” at T12 level and finally no proper managing : spine palpation and full history in hurry was probably omitted.

When I was on duty at Camp Jacob, the patient should and DID not leave the x-ray department without (if possible) palpation guided readable films in two planes and dynamic lateral cervical flexion views supervised by me.

In almost all cases at least the presence of fractures (if not by palpation !) could be diagnosed on these films.

The next step depends indeed on the overall approach to the management of these fractures.

One or two each year in a 120 000 population

Since I do intend to stabilize all instable spinal fractures as soon as possible (with an anterior and posterior approach if appropriate) – a film showing an instable spine as demonstrated here would at that time, give me enough information to proceed with surgery.

From 1983 to June 1989, I managed one case each year of these traumatic paraplegia (Galion falls, coco tree falls, windows fall).

If the fracure does not appear to be unstable or for example only a posterior stabilisation is discussed, a CT-scan should be obtained, to give the nescessary information about intraspinal fragments, fractured pedicles as well as traumatic herniations of intervertebral discs.

The above picture demonstrates one of these  common cases where the plain film does not show too much of a stenosis of the spinal canal through fractures.

Only the CT – Scan  would reveal the extend of an intraspinal fragment, I finally found during surgical approach.

In our Camp Jacob cases, these fractures were still reduced using a Roy-Camille  Screw and Blade Internal System, whereas a Cotrel Dubousset System (used later for tumors) would have been much easier to manage….

Clinical results, very good although not controlled intraoperatively by myelography nor later with a CT-scan

The very good clinical results were neither controlled intraoperatively by myelography but using a flouroscope nor later documented with a CT-scan, as I would probably do now.

In one case (first Galion accident of Jan, 10^th,1984) of a T7 burst fracture with complete and resolutive paraplegia, preop CT scan (no CT at that time) would have shown a sharp pedicle bit pinned in the middle of the spinal cord.

According to this experience of mine, 3D reconstructions would not have yield any additional information.

It should be mentioned at this place that according to experience, most surgeons in the late 90ties did stick to the plain films while they were performing the surgery – even if CT-scan or MRI scans were beginning to be available.

In cases where no definite fracture could be seen on the conventional x-ray films, many authors would still follow in the late 90ties a conservative stepladder of diagnostic imaging including

• CT-scans,
• Myelography and
• repeated CT-scan after Myelography.

However, MRI would still be employed as a last resort.

The growing experience, gathered from my own last 15 years MRI-Studies changed that.

I learned reading clear but painful "myélographie gazeuse" with the La Pitié Paris Hospital Fischgold-Metzger-Aboulker team in... 1967

I start now with MRI imaging and feel confident to use it to diagnose soft tissue problems – for example disc herniations, as demonstrated above as well as fractures.

According to my “recent” experience, MRI is by no means “boneblind”.

Of course other conditions, such as intraspinal hemorrhage or edema following spinal contusion are also demonstrated precisely.

Only when Magnetic Resonance Imaging would be not possible or  not available we would still use a combination of Myelography and CT scanning, as we had to do in the 80ties at Camp Jacob Hospital.

Imaging strategy – no adequate trauma

If there was no or no adequate Trauma, I still do plain film x-ray studies as described above, to diagnose destructed vertebra and tumor or spondylitis induced fractures.

If these films or the patient history indicate a possibility of muliple lesions – such as a kown prostata carcinoma – I obtain a MRI because it provides a fast overview to the extend of the disease.

It also shows details of the impact to the spinal cord.

If it is reasonable to expect only a single lesion I would do a CT-scan.

CT scans might be very reliable to define the extend of intravertebral lesions and show the remnants of a vertebra with metastasis.

If no fractures are visible and intraspinal changes such as tumors or hemorrhage are to be diagnosed, I proceed with an MRI-Scan.

As example : bleeding ependymoma which caused a paraplegia with an acute onset.

Summary

I would summarize frequent problems we encoutered.

First points

I underscore that imaging diagnostic has to be based on exact clinical neurological staging.

Usually minor neurological deficts are missed, which are present in neurologic segments above the level of the dominating symptoms.

This problem is especially important if the patient is unconscious, intoxicated or suffered a headinjury.

Second fractures are missed usually because a lesion is found, which seems to “explain” the symptoms (CHU one case).

It is important to keep this in mind and to look for associated fractures if the circumstances of the injury indicate the possibility.

An especially difficult area for conventional x-ray imaging is the cervico-thoracic transition.

With an x-ray image not demonstrating all seven cervical vertebrae, I was once called for a complete C7 dislocation in a young paraplegic motobike suspected of pithiatism by the general surgeon on duty…

We can only support that these important X rays (as well as immediate dynamic lateral flexion views should be done in spine surgeon’s presence, when there is a good chance of a fracture or luxation of the lower cervical spine or in any case of cervical spine trauma as I instituted this in Camp Jacob with very reactive radio technicians in the 80ties..

If it is impossible to obtain readeable images by applying traction to the shoulders, a conventional midline tomography might be done, but in my extensive experience plain X rays would be enough..

Concerning CT-scans there still might be three frequent problems.

The first is a missing topogramm.

If the topogramm is missing, there is always an incertainty where exactly the scans were done and where the lesion extends.

Another mistake is a CT-scan which is only documented in a bone window.

Patients with traumatic disc herniation may be missed out of this reason.

The last point regarding CT scans which lead to missing of lesions is an inappropriate gapping between slides.

I recommend a maximum slice thickness of  2 to 3 mm with no gap if a study of the cervical spine is done.

To achieve this, a restriction of the examination area to two or a maximum of three cervical segments might still be often necessary.

As a last point we would like to warn against elaborate additional studies and reconstruction processes.

Once you have the nescessary information you should terminate diagnostic imaging.

As said earlier, I do not see yet in 2009 any benefit in added information if a time consuming 3D reconstruction is done.

Frequent problems with imaging methods

Common problems

The imaging is focused on a wrong soinal segment due to incorrect neurological staging

Additional fractures are missed

Conventional X-ray imaging

Fractures of the cervico-thoracic transition are missed because the 7th cervical vertebra is not properly demonstrated

CT-scans

Missing topogramm

Gap between the scans too wide (especially in the C-spine)

No soft-tissue window generated

CT- and MRI-scans

Elaborate reconstruction yielding no additional information

Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 2 cases

Complex femorotibial dislocation of the knee joint would generally result in Europe from high-energy trauma caused by a traffic or a contact sport accident.

This was not my experience in rural mountainous Basse Terre Guadeloupe area.

Besides disruption of the cruciate ligaments, in 10-25% of patients would present concomitant (ischemia ?) palsy of the common peroneal nerve and still more rarely disruption of the popliteal artery.

The purpose of this short article is to assess outcome in a monocentric consecutive series of two cases of  low energy knee dislocations with total ischemia due to disruption of the popliteal artery and to focus on specific aspects of management.

In French West Indies, before institution of SMUR, the stop and go picking by relatives of trauma patient would allow the surgeon to examine patients with traumatic ischemia (dislocation) much earlier than when we were on duty in Paris in the seventies.

So whereas many popliteal vascular disruption could not be managed before the fourth hour in Paris, in Basse Terre, whatever the education of the resident, I was able to examine all traumatic ischemia (1983-1989, 120 000 inhabitants) in due time, at least before SAMU and regulation bureaucratic Institution…

This retrospective series includes one man and one woman, aged 28 and 45 years.

The left  knee was injured in both.

Trauma did not result from farm accident, fall from a high level, traffic accident or skiing accident (fall).

The woman was 7 months pregnant.

Both were fall victims.

There was no morbid obesity.

Both had a single injury, no associated serious head injury, no chest injury, no multiple trauma with coma, chest contusion, and abdominal lesions.

No patient had  fracture.

No dislocation was open.

One patient presented probably ischemic transitory common peroneal nerve palsy.

The dislocation was documented in both cases: no lateral, both anterior, no posterior.

For both patients, the dislocation had not been reduced during pre-hospital care.

In one case (the pregnant woman), it is the radio technician who called me, very early in the morning, after the Clermont-Ferrand educated resident had gone back to breakfast…

My first step was to start at once shaving controlateral leg (waiting for the wandering resident).

Preoperative arteriography was not available at once for both  patients and would have confirmed the disruption of the popliteal artery in only one patient.

Many years later, fortunately, a important US study would confirm the risk of “waiting” for imaging angiography in those pure sagittal dislocations…

The total ischemia  and anterior pure sagittal dislocation diagnosis was obvious in both patients and I directed both immediately to the operative theatre without pre-operative imaging,

Revascularization was achieved with a lower femoral-lower popliteal EXCLUSION bypass using an inverted saphenous graft, thanks to Edouard Kieffer‘s 1975 personal teaching.

The graft was harvested from the controlateral greater saphenous.

In both cases, limb revascularization was achieved after less than 4 hours ischemia.

Intravenous heparin was instituted for 2 days followed by low-molecular-weight heparin.

The dislocation was secondarily stabilized by a cast in both.

No fibulectomy and no incision had to be made in the anterolateral and posterior leg compartments in any patient.

No revision procedure was necessary because of recurrent ischemia. No thin skin grafts were used (no aponeurotomy surfaces).

Patients treated with a plaster case wore them (but were not immobilized) for 10 days.

Surgical ligament repair was not performed in these two patients.

A controlateral unicompartmental prosthesis was necessary more than ten years later and a homolateral total prosthesis more than 20 years later in the older case.

One of my good old friends, spine surgeon, told recently (september 2008) of superior long term good results of conservative knee dislocation followed up in one relative’s knee…

Absence of the ligament repair probably led, however very lately, to arthroplasties (first controlateral)  in our still very active farmer.

Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in both patients.

No transient acute renal failure required.

Pregnancy ended normally…

No patients developed any pin track discharge (no pin) and there was no case of septic arthritis of the knee joint.

Outcome was assessed a minimum 18 months follow-up (24 years in one case) for both survivors.

Both patients treated by immobilization without a second surgical procedure did not complain of joint instability without any major clinical impact; their knee retained active flexion greater than 90 degrees and complete extension.

An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma.

The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation may be between 4 and 20%.

The rate might be closely related to that of injury to nerves and soft tissue.

Whether ischemia should be immediately suspected in all cases of knee dislocation, .

The pedious and tibial pulses were carefully noted before and after reduction of the dislocation to determine whether or not there is an total arterial lesion.

If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction.

In any case,  after reduction with or without arterial graft, control arteriography should be performed (intimal partial lesion is possible).

Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture.

Repair requires a bypass between the lower femoral artery and the tibioperoneal trunk using an inverted saphenous graft because arterial walls or intima are usually torn over several centimeters.

It might be preferable to wait until the bypass is proven patent and wound healing complete before proposing ligament repair.

This should be done after a precise anatomic work-up to assess each ligament lesion.

Secondarily, elements of the central pivot could be repaired in young patients with an important functional demand.

Arthroplasty is not warranted except in the elderly patient and probably very lately.

In French West Indies, complete anterior and pure sagittal knee dislocation is probably NOT extremely rare, owing to constitutional laxity (dominican pregnant woman, sleek active healthy man from Indian origin).

It might also be in 2009 caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy.

Compression, contusion or disruption of the popliteal artery is not so rarely caused by low energy anterior displacement of the tibia on the femur.

Limb survival may be compromised.

Mandatory emergency restoration of blood supply would possibly modify immediate and subsequent surgical strategies.

There has not however been any study exclusively devoted to double joint and vascular involvement.

This article of mines presents a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single rural center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.

Bilateral femoral neck fractures due to transient osteoporosis of pregnancy

Figure 1. Antero-posterior radiograph of the pelvis post partum.

Figure 1. Antero-posterior radiograph of the pelvis post partum.

Figure 2. T1 weighted coronal MRI scan of the pelvis post partum.

Figure 2. T1 weighted coronal MRI scan of the pelvis post partum.

Figure 3. Antero-posterior radiograph of the pelvis post fixation with dynamic hip screws.

Figure 3. Antero-posterior radiograph of the pelvis post fixation with dynamic hip screws.

Transient osteoporosis of pregnancy (TOP)

Transient osteoporosis of pregnancy (TOP) is a rare, idiopathic self-limiting condition typically associated with the third trimester of pregnancy.

It almost always affects a single hip although bilateral presentation and involvement of the knee have been reported [1-3].

TOP usually presents with a sudden, quite severe onset of unilateral groin pain with no history of trauma.

The patient may be unable to walk, or may have an antalgic gait.

Pain is elicited by hip rotation, although a full range of motion is common.

Radiographs are avoided in pregnancy where possible, and are a poor investigation for demonstrating early osteopaenia.

Magnetic Resonance Imaging (MRI) reveals low signal intensity of bone marrow on T1 weighted images, and high signal on T2 weighted images suggestive of bone marrow oedema[4].

The natural history is of resolution of symptoms over the course of 3 to 6 months

Hip fracture secondary to TOP

Hip fracture secondary to TOP is very rare with only 12 reported patients in the literature to date; in two cases the hip fractures were bilateral[2,3,5-8].

The majority of these fractures were caused by a traumatic event.

Atraumatic hip fractures secondary to TOP are even more unusual and are easily overlooked and hence may present to the orthopaedic surgeon at a late stage, making management more challenging.

Musculoskeletal complaints are very common in pregnancy.

The position and weight of the gravid uterus alters the centre of gravity and loading patterns of the axial and appendicular skeleton, whilst hormonal changes lead to joint laxity, and fluid retention may cause neural compression[9].

The majority of musculoskeletal complaints are not serious, and are managed conservatively without a specific diagnosis.

Pregnant women frequently complain of hip or pelvic pain.

The differential diagnosis includes some serious problems that need to be excluded, namely

1. transient osteoporosis,
2. osteonecrosis and
3. pubic symphysiolysis.

Conventionally ionising radiation is avoided during pregnancy although Brodell et al. suggested that in the third trimester of pregnancy the benefits of adequate investigation of hip pain may outweigh the minimal risks[5].

MRI during pregnancy

There is no conclusive evidence that MRI has deleterious effects, however the safety of MRI has yet to be definitively proven[10].

It is in common use in the third trimester of pregnancy where clinically indicated[11] and is generally considered to be safe[12].

MRI has a high sensitivity for diagnosis of occult hip fracture[13] and can reliably distinguish between osteonecrosis and transient osteoporosis[4], making it the investigation of choice for hip pain in the third trimester of pregnancy.

Displaced intracapsular fractures have a high incidence of non-union and avascular necrosis[14].

It has however been shown that the risk of non-union is independent of bone quality[15] therefore in young patients with high value hips internal fixation should be the goal.

References

1.	Lloyd JM, Lewis M, Jones A: Transient osteoporosis of the knee in pregnancy. J Knee Surg 2006, 19:121–123. [PubMed]
2.	Aynaci O, Kerimoglu S, Ozturk C, Saracoglu M: Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-associated osteoporosis. Arch Orthop Trauma Surg 2008, 128:313–316. [PubMed] [CrossRef]
3.	Munker R, Niedhart C, Niethard FU, Schmidt-Rohlfing B: [Bilateral fracture of the femoral neck following transient osteoporosis in pregnancy]. Z Orthop Ihre Grenzgeb 2007, 145:88–90. [PubMed] [CrossRef]
4.	Takatori Y, Kokubo T, Ninomiya S, Nakamura T, Okutsu I, Kamogawa M: Transient osteoporosis of the hip. Magnetic resonance imaging. Clin Orthop Relat Res 1991, :190–194. [PubMed]
5.	Brodell JD, Burns JE, Heiple KG: Transient osteoporosis of the hip of pregnancy. Two cases complicated by pathological fracture. J Bone Joint Surg Am 1989, 71:1252–1257. [PubMed]
6.	Cohen I, Melamed E, Lipkin A, Robinson D: Transient osteoporosis of pregnancy complicated by a pathologic subcapital hip fracture. J Trauma 2007, 62:1281–1283. [PubMed]
7.	Fokter SK, Vengust V: Displaced subcapital fracture of the hip in transient osteoporosis of pregnancy. A case report. Int Orthop 1997, 21:201–203. [PubMed] [CrossRef]
8.	Wood ML, Larson CM, Dahners LE: Late presentation of a displaced subcapital fracture of the hip in transient osteoporosis of pregnancy. J Orthop Trauma 2003, 17:582–584. [PubMed] [CrossRef]
9.	Smith MW, Marcus PS, Wurtz LD: Orthopedic issues in pregnancy. Obstet Gynecol Surv 2008, 63:103–111. [PubMed] [CrossRef]
10.	Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y: Fast MR imaging in obstetrics. Radiographics 2002, 22:563–580. [PubMed]
11.	De Wilde JP, Rivers AW, Price DL: A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 2005, 87:335–353. [PubMed] [CrossRef]
12.	Garcia-Bournissen F, Shrim A, Koren G: Safety of gadolinium during pregnancy. Can Fam Physician 2006, 52:309–310. [PubMed]
13.	Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R: Early diagnosis of occult hip fractures MRI versus CT scan. Injury 2005, 36:788–792. [PubMed] [CrossRef]
14.	Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE: 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. [PubMed]
15.	Heetveld MJ, Raaymakers EL, van Eck-Smit BL, van Walsum AD, Luitse JS: Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome? J Bone Joint Surg Br 2005, 87:367–373. [PubMed] [CrossRef]