Diagnosis and treatment of post-traumatic osteoporosis

DIAGNOSIS AND TREATMENT OF POST/TRAUMATIC OSTEOPOROSIS* LOUISG. HERRMANN, M.D. AND JOHN A. CALDWELL, M.D. CINCINNATI,

OHIO

T

HE importance of post-traumatic osteoporosis as a major cause for the prolonged Ioss of function or severe aching pain, in or about muItiarticuIar joints, which frequently foIIows in the wake of trivia1 as we11 as serious injury to an extremity, is not generaIIy recognized. As a resuIt, many innocent persons are unjustIy accused of malingering or of being grossIy unto-operative simpIy because their disabiIity continues Iong after the effects of the origina trauma have subsided, or after the fractured bones have had a chance to become firmly united in good position. Post-traumatic osteoporosis is rare after trauma to the diaphysis of bones yet it is reIativeIy common after injury, either with or without osseous fractures, to the periarticuIar or juxta-articular tissues. As earIy as IgoI both Sudeck’ and Kienbijck2 studied this disease entity and showed that inactivity aIone couId not account for such a severe degree of trophic changes in bones; that these trophic changes came on much earIier than the changes which resuIt from simpIe disuse; and that the reflex or trophic changes characteristic of posttraumatic osteoporosis usuaIIy came on whiIe the extremity was stiI1 in active use. In 19x6, NobeI and Hauser reviewed the various theories about the causation and came to the concIusion that the onIy theory which couId satisfactoriIy expIain a11 of the pathoIogic physioIogy of bone in true osteoporosis was that the disturbance was a manifestation of a trophoneurosis as was originaIIy suggested by Kienbbck2 in rgor. CLINICAL

FORMS

In order to avoid a11 confusion with the atrophy of inactivity or disuse we shaI1 only refer to the trophic changes in bone which foIIow trauma and which are associated with other vasomotor and trophic changes in the extremity, as the true post-traumatic osteoporosis. characterized cIinicaIIy by (a) This disease entity is, therefore, * Fromthe

Department of Surgery of the College of Medicine of the University Cincinnati and the Cincinnati General Hospital.

630

of

HERRMANN,

CALDWELL4STEOPOROSIS

631

partiaI Ioss of motor function of the extremity; (b) characteristic changes in the roentgenograms; (c) the constant co-existence of vasomotor and other trophic manifestations; and (d) the usua1 association with severe aching pain. The disturbances of the function are aIways more extensive than couId be expIained on the basis of the trauma aIone, and the aching or viscera1 pain, when present, is greatIy out of proportion with the IocaI signs of injury to the tissues. If we disregard the IocaI effect of the trauma in these patients, we must stiI1 be impressed by the extensive Ioss of motor function and the obvious vasomotor manifestations which are present in such extremities. When the pain forms a characteristic part of the clinical picture, it has been our experience that such pain cannot be reIieved by immobilization of the part; whiIe the pain associated withsimpIe trauma, fracture of one or more of the bones, or even tuberculous or pyogenic osteoarthritis, is definiteIy reIieved by immobiIization of the affected extremity. RecentIy John CaIdweII discovered four patients in his fracture cIinic in whom a11of the cIassica1 signs and the disabiIity of true posttraumatic osteoporosis came on severa weeks after injury to an extremity but without the aching pain. These patients wiI1 be the subject of a thorough study and report at a Iater date. A common cIinica1 form of acute osteoporosis is frequentIy seen after fractures of the bones of the wrist or ankIe which have been properIy reduced. After the remova of the bandage or cast at the end of two or three weeks, the extremity is found to be swoIIen and sometimes the skin is reddened. (Fig. I .) SIight active or passive motion of the joint causes the patient great pain. Mechanotherapy, baking and massage usuaIIy make the pain more severe and the Ioss of function of the extremity continues to become worse. Diathermy gives onIy sIight relief from pain and in our experience even intensive diathermy does not aIter the course of the disturbance. From the clinica point of view, the extension of the functional disturbance beyond the area of traumatization and accompanied by constant aching pain which is usuaIIy made worse by immobiIization or proper physiotherapy, is pathognomonic of true post-traumatic osteoporosis. When acute osteoporosis was Iimited to the bones of the hands or feet, most of our patients have shown a hyperthermia of the skin over the affected parts. The association of the subacute varieties of post-traumatic osteoporosis with cyanosis, subjective and objective sensations of coIdness of the skin of the affected extremity, IocaI edema and trophic disturb-

632

HERRMANN,

CALDWELL-OSTEOPOROSIS

antes such as Aerations, hyperkeratosis, atrophy of the skin and hypertrichosis and constant aching pain in the entire extremity, have been repeatedIy pointed out by other observers. Congestion of the

FIG. I. Characteristic gross changes in the soft tissues of the hand in post-traumatic osteoporosis during the acute or active phase of the disease process.

skin of the foot which is accentuated when the Iimb is pIaced in the pe’ndant position, marked edema and a thinning of the skin with a disappearance of a11 of the surface markings giving it a “glossy” appearance is characteristic of the chronic phase of osteoporosis. ROENTGENOLOGIC

ASPECTS

Two main forms of post-traumatic osteoporosis have been described as showing constant and characteristic changes in the roentgenograms. Sudeck’ named these apparentIy distinct stages in the evolution of the disease the (a) acute form and (b) the chronic form. The so-caIIed acuteform is characterized by a mottled appearance of the bones due to the irreguIar rarefied areas in the spongiosa of the bones. This mottling is usuaIIy most marked in the carpa and tarsa bones and in the heads of the metacarpa1 and metatarsa1 bones. In advanced cases the cortex of the smaI1 bones becomes very thin and the outline of the individua1 bones is frequentIy Iost. The IameIIae fade into one another and produce an ilLdefined or homogeneous shadow in the roentgenogram.

HERRMANN,

CALDWELL-OSTEOPOROSIS

633

In the so-caIIed &o&c form the trabeculae of the bones are very fine and sometimes diffIcuIt to. recognize. The Iimits of the individua1 bones again become demonstrabIe, but there stiI1 remains a genera1

FIG. 2. The characteristic mottIing of the bones of the Ieft hand as shown in the roentgenogram during the acute or active phase of post-traumatic osteoporosis.

Ioss of minera salts. The patchy areas of rarefaction have IargeIy disappeared. The increased strength of the bone is due to a thickening of the IongitudinaI IameIIae since the horizonta1 IameIIae remain very thin. In cases of post-traumatic osteoporosis of the short bones, especiaIIy the carpa and the tarsa bones, we recognize three stages in the evoIution of the disease. These three stages are: (a) the onset, (b) the height of the disease, and (c) the reorganization. We beIieve that each of these three stages presents characteristic roentgenoIogic changes. This evoIution of the disease from the standpoint of the roentgenoIogic changes can best be portrayed as foIIows : In the period of onset there is a genera1 mottIed appearance of the

634

HERRMANN,

CALDWELL4STEOPOROSIS

bones in the roentgenogram. (Fig. 2.) The outhnes of the bones are stiII easiIy discernibIe. The rarefaction continues to become more marked and more extensive. The irregular areas of rarefaction soon

FIG. 3. Roentgenogram showing the characteristic changes in the structure of the small bones of the foot during the late or chronic phase of posttraumatic osteoporosis.

disappear and the bones become uniformIy permeable to the roentgen rays. This stage of diffuse and marked decaIcification marks the height of the disease. The absorption of the bone seems to spread to the neighboring bones and thus invoIves the heads of the metacarpaIs or metatarsaIs, then the phaIanges and finaIIy the adjoining ends of the radius and uIna or the tibia and fibula, as the case may be. Marked thinning of the cortex of the bones takes pIace and IongitudinaI streaks appear in the thinned cortex. In the region of the carpa and tarsa bones this thinning of the cortex of the bones resuIts in the disappearance of the Iimits of the bones and thus transforms the entire area into a homogenous mass which is very permeabIe to roentgen rays. It is at this stage that a diagnosis of tubercuIous osteoarthritis is frequentIy made. During the period of reconstruction there is a sIow reappearance of the caIcium in the bones. In most cases compIete recalcification never takes pIace. Roentgenograms taken during this stage show that the Iimits of the smaI1 bones have again become visibIe and the IongitudinaI IameIIae have become thickened. (Fig. 3.) The duration of each of these stages is very variabIe. The factor of time seems to be of IittIe importance. In generaI, however, the

HERRMANN,

CALDWELL-OSTEOPOROSIS

first two stages are reIativeIy rapid in their evoIution, while the third or reconstructive stage is usuaIIy extremeIy sIow. CompIete anatomica1 restoration of the density of the bone, however, is not necessary for compIete symptomatic relief or the return of norma function. CLINICAL

EVOLUTION

It is commonly believed that post-traumatic osteoporosis is a seIAimited disease and that after a few weeks or months, recaIc&cation takes pIace without Ieaving any serious deformities. Sudeckl stated that favorabIe evolution is onIy occasionaIIy seen, and it is not the usual end resuIt of the disease entity. It has been our experience that after the disease has reached the cIimax or stage of aImost compIete decalcification, the process of recaIcification may begin spontaneousIy, but years later, the roentgenograms may stiI1 show thinning of the cortex of the bones and thin IameIIae containing irreguIar areas of recaIcification. From these facts one might get the impression that the disease heaIs spontaneousIy since it is aIso we11 known that the vasomotor manifestations and pain may disappear without adequate treatment. In such cases, however, the recovery offunction of the extremity requires many months and frequentIy during the stage of recaIcification extensive fusion of the carpa or tarsa bones takes pIace. This ankylosis usuaIIy causes great economic Ioss to the patient. Undoubtedly many of the miId forms of post-traumatic osteoporosis do hea spontaneousIy and give no permanent disturbance of function; therefore, one must be carefu1 not to assume that some particuIar form of therapy used in any one patient is a true remedy for the disease entity under a11 circumstances. TREATMENT

The treatment of post-traumatic osteoporosis has, unti1 recentIy, been symptomatic and preventative rather than curative in nature. Sudeck’ recommended minimum immobiIization and then active movement in most of his cases. In 1926, NobeI and Hauser recommended heat to the point of toIerance either in the form of radiant heat or paraffin baths. They aIso advised massage and voIuntary motion of the joints in spite of a IittIe pain, but they empbasized that forceful

manipulation

under anestbesia

was definitely

contraindicated.

Any form of fixation with pIaster-of-Paris casts or orthopedic apparatus causes increased pain to the patient. DeIorme4 recommended treatment by thyroid and parathyroid extracts and Pech5 advised heIiotherapy.

636

HERRMANN,

CALDWELL-OSTEOPOROSIS

In 1924, CIarence Heyman’ suggested periarteria1 sympathectomy for the treatment of painfuI osteoporosis. The reIief of pain and the restoration of function promptIy foIIowed this operation. The true function of the IongitudinaIIy coursing fibers in the adventitia of Iarge arteries has never been actuaIIy demonstrated, yet there is IittIe doubt in the minds of students of this probIem that remova of the adventitia of the main arteries of the extremity does bring about definite changes in the nutrition in the periphery of that Iimb. It is our beIief that these fibers in the adventitia of the arteries have a definite trophic function, and it is the interruption of abnorma1 trophic reflexes that course aIong the fibers in the adventitia that accounts for the striking beneficia1 resuIts obtained after periarteria1 sympathectomy in patients with post-traumatic painfu1 osteoWe do not recommend periarteria1 sympathectomy as porosis. 8~g~10 treatment for the true vasomotor instabiIity of Raynaud’s syndrome. In 1934, Fraser Gurd6 advised the use of “waIking pIaster casts” and physiotherapy, and reported satisfactory cIinica1 improvement. The recent (1938) recommendation of roentgenotherapy for acute painfu1 osteoporosis by Mumford, l1 of IndianapoIis, has interested us a great dea1 and during the past year Dr. Jack E. Singer, of the Department of Roentgenology of the Cincinnati General HospitaI, has treated four patients with acute painful osteoporosis of the posttraumatic type, and John CaIdweII has had under his observation two other patients who had received adequate roentgen-ray therapy for osteoporosis. SUMMARY

OF

CASES

During the eight years from June, 1932, to June, 1940, we studied eighty-four patients with post-traumatic osteoporosis in the out-patient clinics of the Cincinnati Genera1 HospitaI. Thirty-four of these patients presented the signs and symptoms of the acute painful variety of post-traumatic osteoporosis and were treated by periarteria1 sympathectomy. AI1 of these patients who were subjected to periarteria1 sympathectomy had reIief of the severe aching pain within twenty-four hours after the operation with disappearance of the edema and functional disturbance within a few days. These patients were abIe to resume their work within an average time of approximateIy three months. CompIete return of function in the contro1 group treated by means of physica therapy together with other conservative measures took more than nine months.

HERRMANN,

CALDWELLaSTEOPOROSIS

637

We have found that operations upon the autonomic nervous system offer a rationa and effective surgicaI treatment for this disease entity ij the operation can be performed during the acute phases of the disease process. The reIief of pain and the sudden disappearance of the functiona impairment has frequentIy been aImost immediate and the undesirabIe sequeIIae of this disease have been prevented in the patients with acute osteoporosis whom we have studied. In previousIy reported studies8 we found that the patients in whom the symptoms were present for more than nine months received rehively little benefit from periarterial sympatbectomy. Four of the patients of this series were treated by roentgenotherapy according to the method of Mumford. In a11 cases there was reIief of pain within one week after the radiation therapy was started. Subsequent foIIow up studies upon these patients, however, reveaI that the functiona disturbance does not show corresponding improvement. From our own studies of this smaI1 group of patients we get the impression that the period of disabiIity is not greatIy shortened by the roentgenotherapy but the prompt reIief of pain is a great comfort to the patient, and it does permit the partia1 use of the extremity earIier in the convaIescent period even though the degree of disabiIity remains high. The remaining forty-six patients came under our observation during the subacute or chronic phases of the evoIution of the disease and were, therefore, given onIy intensive physiotherapy consisting of massage, functiona stimuIation, infra-red and uItra-vioIet radiation and hydrotherapy. AnaIysis of these patients showed that the course of the disease was onIy sIightIy shortened and the unfavorabIe sequeIIae were about as frequent as when the process was Ieft untreated. CONCLUSIONS I. Post-traumatic osteoporosis is a disease entity with characteristic roentgenoIogica1 changes in the three main stages in the evoIution of the disease. 2. Post-traumatic osteoporosis which is Ieft untreated may resuIt in ankyIosis of one or more of the joints in the region of the trophic disturbance in the short bones. 3. Operations upon the sympathetic nervous system offer a rationa and effective surgica1 treatment for this disease entity. 4. Cases of post-traumatic osteoporosis treated by sympathectomy during the active phases of the disease respond quickIy and the undesirabIe sequeIae of the disease are prevented.

HERRMANN,

638

5. PeriarteriaI post-traumatic

CALDWELL-OSTEOPOROSIS

sympathectomy osteoporosis

is usuaIIy

which

is Iimited

sufficient to the dista1

for cases part

of

of the

extremities. BIBLIOGRAPHY I. SUDECK, P. Uber die akute

(reIIektorische) Knochenatrophie nach Entziindungen und Verletzungen an den Extremitlten und ibre klinischen Erscheinungen. Fortscbr. a. d. Geb. d. Roentgenstr., 5: 277, IgoI-Igoz. 2. KIENB~~CK,R. Uber akute Knochenatrophie bei Entziindungs-processen an den Extremitlten (f&Ischlich sogenannte Inactivitiitsatrophie der Knochen) und ibre Diagnose nach dem Riintgen-BiIde. Wien. med. Wcbnscbr., 51: 1345, Igor. 3. NOBEL, T. and HAWSER, E. Acute bone atrophy. Arch. Surg., 12: 75, 1926. 4. DELORME, E. Sur la d&aIciIication dans les traumatismes de guerre. Bull. Acad. M&d., 77: 577, 1917. 5. PECH, L. L’atrophie osseuse. Montpellier 6. GURD, FRASER, B. Post-traumatic Sum 99: 449, 1934. 7. HEYMAN, C. H. Osteoporosis

Med., 42: 12, rg2o. acute bone atrophy (Sudeck’s

relieved by sympathectomy.

atrophy).

Ann.

J. A. M. A., 82: 1333,

1924.

8. FONTAINE, R. and HERRMANN, L. G. Ann. Surg., 97: 26, 1933. g. HERRMANN, L. G. J. Med., 16: 21, 1935. IO. HERRMANN, L. G. Post-traumatic painful osteoporosis. Cyclopedia of Medicine, 2nd ed. PhiIadeIphia, 1940. F. A. Davis Company. I I. MUMFORD, E. B. Roentgenotherapy in acute osteoporosis. J. Bone P Joint Surg., 20: No. 4, 1938. DISCUSSION

JOHN A. CALDWELL (Cincinnati, Ohio): It has been my privilege to be associated with Dr. Herrmann in this work principaIIy as a suppIier of material I was infected with his enthusiasm from the first and since then we have gone aIong together. It is not possibIe, even if it were necessary, to add anything more to what he has said, but probabIy to emphasize a little bit some of the outstanding features which make it important to persons who are dealing with the surgery of trauma. First, I shouId like to caI1 attention to the fact that he has mentioned that it is very frequentIy associated with trivia1 injuries. Quite a number were not associated with any fracture at aI1, and one of the things that we have begun to regard as aImost symptomatic of the condition is that it is very IikeIy to deveIop in fractures that have been we11 reduced. The CoIIes’ fracture, impacted in such good position that the parts require IittIe manipulation, is quite prone to be folIowed by osteoporosis; whiIe the badIy cornminuted and smashed OS caIcis in severe injuries of the foot is frequently found exempt from this condition. Great injustice is done these patients by Iack of recognition of this condition. I can best show that by reciting a recent case of a young man who feI1 down an elevator shaft and sustained a Pott’s fracture which was easiIy and

HERRMANN,

CALDWELL-OSTEOPOROSIS

well reduced under Iocal anesthesia. He had excruciating pain all night to such an extent that he required anodynes That continued for severa days, so that I feIt it was necessary to inspect, and on taking off the cast, found it was perfect. There was no pressure sore, nothing at a11 to account for this condition, and a second cast was applied and his pain continued. His foot remained painfu1 for the ten days he stayed in the hospital. At that time he stiI1 said it was painfu1 and I arrived at the aImost inevitahIe diagnosis of a functional condition. I interviewed first his employer and he gave me a very dehniteIy warm earfu1. The patient was a vaIuabIe empIoyee and compensation was not a question. They were anxious to do everything for him. At the end of two weeks, on removing his cast and taking contrasting plates of the two ankles, we couId see what we thought was very sIight change in the affected foot. Without further detail I can say that this patient went on to a compIete osteoporosis of a very aggravated degree. He would not submit to a sympathectomy. He received x-ray treatment, and it has given him definite subjective relief, but it has not been foIIowed by corresponding improvement in the bone picture. The principa1 thing in our experience, to bear in mind is that this is a rea1, definite, pathological thing which must not be mistaken for a neurosis. This atrophy is entireIy different from the atrophy of disuse, in that it appears very much more promptIy, deveIops more rapidIy, and is not a diffuse demineralization, but the spotty, rotten wood appearance, which is quite characteristic to anyone who is familiar with it. THOMAS PETERSON (Boston, Mass.): I should like to ask whether Dr. Herrmann beIieves the use of novocain has anything to do with the production of osteoporosis, and aIso I shouId Iike to know whether he beIieves age has anything to do with its production. JOHN A. CALDWELL (Cincinnati, Ohio): May I have a minute to speak about novocain? I can answer very definitely that novocain has nothing to do with osteoporosis, because a great many of these patients have not had fractures at aI1, so that they have had no treatment; others have had fractures with so IittIe dispIacement that they require no manipuIation. We have had severa cases in which the injury was at a distance from the deveIopment of the osteoporosis, for instance, a fracture of the knee joint, and the patient had an osteoporosis of the foot and ankIe. NELSON J. HOWARD (San Francisco, Calif.) : I shouId Iike to ask whether the authors have had experience with the sympathetic bIock of the Iumbar sympathetic or thoracic system, for the reason that the sympathetic is segmenta1, and the periarteria1 sympathetic, too, and I have wondered what the effects wouId be from the more compIete bIock. LOUIS G. HERRMANN (closing) : I have no positive information concerning the possibIe r6Ie which IocaI injections of novocain, in and about joints,

640

HERRMANN,

CALDWELL-OSTEOPOROSIS

have upon the productions of osteoporosis. It is not uncommon to see osteoporosis foIIow reIativeIy trivia1 injuries to the periarticuIar tissues, but I wouId be of the opinion that bIocking the sensory nerve endings in and about the joints would tend to reduce the chances for the development of true osteoporosis. Osteoporosis occurs mostIy in the third, fourth and fifth decades of life and it is rareIy observed in chiIdren. Extensive structura1 changes in the periphera1 arteries which occur in the sixth and seventh decades of Iife may give rise to osseous changes, viscera1 pain, IocaI vascuIar and trophic changes and produce a syndrome which is not unIike this post-traumatic type of osteoporosis. In regard to Dr. Howard’s question, I might say that it is possible to interrupt these pathways for abnorma1 reflexes by bIocking the regional however, requires considerable sympathetic chains. Such a procedure, specia1 training and ski11 and I do not believe shouId be routinely done by the average genera1 surgeon. We are convinced that periarteria1 sympathectomy is a simpIer procedure and a more effective way of assuring a compIete bIock of the abnorma1 reflexes. Recent cIinica1 studies have given us the information that the major pathways of these neurotrophic fibers are in the adventitia of Iarge arteries or are at Ieast segmentaIIy distributed to the periarteria1 network from the periphera1 somatic nerves. These fibers do not course through the regional sympathetic chains or gangIia and this, we beIieve, accounts for the faiIure of improvement of post-traumatic osteoporosis after the surgica1 removal of the regional sympathetic gangIia (sympathectomy) or the interruption of the rami to the gangIia (ramisection), whiIe striking improvement usuaIIy foIIows the denudation of the major artery to the affected part. In the present state of our knowIedge we do not recommend operations upon the sympathetic gangIionated cords in the management of post-traumatic osteoporosis. It has been a reaI pIeasure to have the opportunity of discussing this probIem before you and I hope that I have emphasized the importance of this troublesome compIication which foIIows so frequentIy in the wake of traumatization of an extremity.