Only studies that covered the whole sacrum were included. No statistically significant differences were seen between the two groups in any of these covariates. As shown by the results of this study, MRI detected significantly (p < 0.01) more pelvic insufficiency fractures than CT. [22] argued that CT was better because of cost, diagnostic rate, and ease of fracture line visualization. Fractures averaged 2.1 per patient (range, 16 fractures per patient). In particular, fractures at the femoral head and acetabulum were better detected with MRI. Increased awareness of this condition will hopefully lead to earlier diagnosis and a successful outcome of conservative treatment. A fracture line was defined as a linear structure visualized on either STIR, T1-weighted, or fat-saturated T2-weighted fast spin-echo sequences. The underlying nature of the fracture was also evident on radiographs of the complete fracture of the femur before and after open reduction and internal fixation (Figs. 11). Scintigraphy showed increased uptake in the femoral head. These were obtained using a standard radiographic technique, placing the patient on the Bucky table, and using a grid, whenever possible, with standard exposure parameters of 20 mAs and 75 kVp. PMC Accessibility 1 Department of Radiology and Biomedical Imaging, University of California at San Francisco, 400 Parnassus Ave, A-367, San Francisco, CA 94131. . Figure 4A, 4B, 4C, 4D shows an example of a patient with multiple insufficiency fractures at both femoral necks and the ischia. RESULTS. doi: 10.1016/j.annpat.2009.07.051. The amount and intensity of soft-tissue edema were also graded higher in patients with pubic, acetabular, and femur fractures versus sacral fractures. 1E). Announcement for Patients Regarding COVID-19, o diagnose a variety of orthopedic conditions, We are so happy when we can make our patients' day, Get to know our newest Foot & Ankle surgeon, Dr. B, Shout out to our Director of Sports Performance, @, You can tell our offices take Halloween VERY serio, Happy Halloween from OrthoArizona! No prior thigh or groin pain was documented in records. The clinicopathologic findings of a subchondral insufficiency fracture of the femoral head in a male patient: a case report. Previous radiation therapy to the pelvis was noted in 29 of 145 (20%) patients, and previous chemotherapy, in 24 of 145 (16.6%) patients (Fig. In addition, bone scintigraphy and dual x-ray absorptiometry (DXA) were not included in our analysis, which may be considered a limitation of the study. November 2018; Radiology Case Reports 14(2):179-183; . Twenty-five CT studies were obtained with a slice thickness of < 5 mm, and of the 56 total fractures diagnosed, 76.8% (43/56) were detected. Arthroplast Today. It seems a paradox that a fracture would be associated with bisphosphonate therapy because bisphosphonates are prescribed for generalized osteoporosis to increase bone mineral density and decrease the chance of fracture. In all patients, the clinical history was analyzed and potential risk factors for insufficiency fractures were recorded. Fractures within this region require high energy if the bone mineralization is normal. Delayed diagnosis can lead to immobility and complications such as deep vein thrombosis, loss of strength, decreased cardiac output, depression, and increased bone resorption and calcium excretion [11]. From January through October 2009, we searched for cases of transverse fractures involving the proximal femur in postmenopausal women with the previously reported characteristic radiographic appearance suggestive of insufficiency injury related to long-term bisphosphonate . Note that, although a high percentage of soft-tissue edema was found with pubic and acetabular bone fractures, it was less frequently seen with sacral fractures. -, Gerontology. The MRI, CT, and radiographic studies were analyzed separately in random order by two radiologists in consensus. -, Radiology. 2000) (Fig. Radiography is the imaging modality of choice for baseline diagnosis. Skeletal Radiol. -. Medical records were retrospectively reviewed to determine patient demographics, history of oral bisphosphonate therapy, most recent documented bone mineral density, when available, and presentation of injury. These individuals may present after minor trauma or have symptoms of chronic lower back, pelvic, or groin pain that may appear unrelated to trauma [6]. A third MRI location will be opening at our Arcadia (44th St. & Thomas Rd.) However, MRI findings may not always show a fracture line, and abnormalities on MRI may sometimes be interpreted as metastatic disease if the radiologist is not familiar with the appearance of these imaging findings [1, 12]. bone remodeling: Paget disease, osteopetrosis. Imaging of Anterior Cruciate Ligament Repair and Its Complications, Review. Therefore, if it is available, MRI should be the primary diagnostic technique when insufficiency or occult pelvic fractures are suspected. The rationale for this cutoff value was the altered bone metabolism in patients with insufficiency fractures that also induced delayed fracture healing, with a healing period of at least several months [17, 18]. Fracture detection rates for CT and MRI were calculated using the previously described standard of reference. Thirty-eight of the 64 (59.49%) CT studies were performed with IV contrast material. Call 602.922.9100 to schedule an appointment! However, those authors concluded that MRI, although more sensitive than CT, may be misleading; they controversially recommended CT as the better imaging technique. Careers. Polesello G, Sakai DS, Ono NK, Honda EK, Guimaraes RP, Jnior WR. Imaging Key Wrist Ligaments: What the Surgeon Needs the Radiologist to Know. 1A, 1B, 1C, 1D, 2A, 2B, 2C, 3A, 3B, 3C). Imaging included the entire pelvis in all studies. The site is secure. Fracture lines were better shown on T1-weighted sequences, and proximal femur fracture lines were best shown on sequences obtained in a coronal orientation. 125 Before The slice thickness ranged from 1.25 to 7 mm; 25 studies were performed with a slice thickness of < 5 mm and 39 studies, with a slice thickness of 5 mm. While a bone marrow edema pattern alone was more frequently found at the sacrum (10/162), only one fracture at the proximal femur showed no fracture line (1/49). Only one patient (2%) had a fracture that was detected on CT but not on MRI, 33 patients (52%) had fractures that were detected on both CT and MRI, and 30 patients (47%) had fractures detected on MRI but not on CT. In total, 31 fractures occurring with femoral fractures were found, which occurred mostly at the sacrum (13/31, 42%) and the acetabulum (10/31, 32.3%). 3A, 3B, 3C). Frequently these fractures are radiographically occult [7, 8]; and some of these fractures, in particular sacral insufficiency fractures, are relatively underdiagnosed [9]. In addition, patients 1 and 3 switched to ibandronate sodium and risedronate, respectively, before fracture. The amount and intensity of soft-tissue edema give additional information on the extent of injury and may have clinical implications relating to the degree of pain and disability as well as indicating the prognosis of an insufficiency fracture. Additional comparisons were made between thin-section (slice thickness < 5 mm) and thick-section (slice thickness 5 mm) CT studies. CT has been shown to be sensitive in depicting fracture lines and in the assessment of biomechanical stability [14]. Rheumatologic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, were found in six of 145 patients (4.1%). OBJECTIVE. Of the 108 fractures diagnosed with MRI, radiography visualized only 16 (14.8%). For several months, patient 1 had reported thigh pain that was misdiagnosed as being statin related. Utsunomiya T, Yamamoto T, Motomura G, Hamai S, Iwamoto Y. Skeletal Radiol. . 2010 Jul;195(1):W63-8. MRI is sensitive in the detection of these fractures. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. Email | workcomp@orthoarizona.org. Femoral, acetabular, and pubic fractures had the highest proportion of associated soft-tissue abnormalities. This retrospective study was approved by our local committee on human research. The significance of dif ferences between individual groups was calculated using the Student's two-tailed t tests for continuous variables and the chi-square test for categoric variables, with a 5% level of significance. Although our patients did not undergo MRI or nuclear medicine imaging, a case report by Bush and Chew [2] describes these findings. Federal government websites often end in .gov or .mil. 2 and 3A, 3B). The terminology of atraumatic . The outcome of subchondral insufficiency fracture is thus unclear. Many fractures were frequently associated with concomitant fractures in typical locations (Table 3). The ability of both imaging techniques to detect fracture lines was compared. Of the 64 cases in which MR and CT could be compared side by side, a total of 129 fractures were identified (average fractures per patient, 2.02; range, 16 fractures). However, comparison with our study is limited because those investigators examined fatigue fractures, which have different bone mass and quality. In addition, the absence or presence of a bone marrow edema pattern and fracture lines was documented. Most frequently, insufficiency fractures were characterized by the presence of a bone marrow edema pattern and fracture lines (267/307, 87%). In a subset of patients, anteroposterior pelvic and hip radiographs were also analyzed. Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. Their presence is sometimes unexpected and can lead to incorrect diagnoses and many unnecessary, costly diagnostic procedures [10]. In addition to determining which technique performed better in visualizing fractures, we also compared the two methods for depiction of fracture morphology. 3A and B), patchy geographic areas of signal isointense to mildly hyperintense to skeletal muscle were present in the femur diaphysis proximal to the fracture.These areas were thought to represent areas of osteonecrosis related to prior radiotherapy. This is currently the established standard at our institution and is requested by our orthopedic surgeons in patients with suspected fractures and negative radiographic findings. 12 a-c) may be found as an early manifestation of bone failure in patients after renal transplantation as reported by a . Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. The fracture was missed on the MR images because of partial volume effects and adjacent joint effusion along with motion artifacts. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. Presence or absence of soft-tissue lesions was also documented. The diagnosis was delayed in most cases because the . Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-80488. Abstract. Less frequently, in up to 25 %, insufficiency fractures at the femoral shaft can occur, predominately in elderly patients with osteoporosis (Martin-Hunyadi et al. Although they are rarely life-threatening, these fractures deserve special attention as a source of functional disability that frequently results in loss of independence in elderly, mostly female patients [5]. The overall incidence of insufficiency fractures of the femoral shaft in patients receiving continuous bisphosphonates was 1 per 1,000 annually (95% CI, 0.32), compared with 0.02 per 1,000 (95% CI, 0.0040.1) for untreated women. MeSH Pseudofractures, or Looser zones, also show a transverse lucency through the cortex of the femur, but again involve the medial cortex and are often multiple and without significant associated cortical thickening [16, 17]. Overall in the CT studies, sclerosis was present in 69 of 89 (79.3%) fractures. Fifty-seven of the 64 patients had at least one soft-tissue lesion, for a total of 103 lesions. The characteristic clinical and imaging findings of bisphosphonate-related proximal femoral insufficiency fracture are described in detail, with comparison made to other causes of proximal femoral shaft fractures in the setting of a low-energy inciting event. Lateral femoral condyle insufficiency fractures: imaging findings, demographics, and analysis of outcomes LFCIFs are associated with meniscus tears, high-grade chondrosis, and osteopenia/osteoporosis with more global knee pathology present when compared with medial femoral condyle insufficiency fracture. Subacute hematoma was documented if signal abnormality was high on T1-weighted images (indicating the presence of methemoglobin). Check for errors and try again. From the search results, MRI and CT studies with a reported diagnosis of pelvic, sacral, or proximal femur insufficiency fractures were selected. This article is a review of terminology, etiology, and key imaging features that affect management of atraumatic fractures including stress fractures, atypical femoral fractures, and pathologic fractures. In the remaining 3 patients radiographs showed a normal femoral head, regional osteoporosis and focal sclerosis, respectively. Unable to process the form. Slice thickness was 4 mm; matrix size, 192 192 mm; and field of view, 3236 cm. In 70.3% of cases, multiple fracture sites were present. According to a previously published study [8], MRI is more sensitive than bone scintigraphy in the early stages of insufficiency fractures. Elderly osteoporotic women are at greatest risk. Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know. Subchondral insufficiency fractures are typically found in older female patients with . A subchondral fracture may also be due to chronic low intensity stress. 180 Radiology Case Reports 14 (2019) 179-183. Gilbert, AZ 85234, 3033 N. 44th St. Ste. Epub 2016 Aug 2. It may be the more specific technique to diagnose insufficiency fractures [12], but at present it is not clear which imaging technique is better suited to this purpose. Subtle subchondral irregular, linear hypointensity seen parallel to articular surface.Marrow edema is extending to neck. Would you like email updates of new search results? Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, Neumann G, Valentin-Opran A, Lang P. AJR Am J Roentgenol. Staatz et al. Alternatively, insufficiency fractures typically present as focal cortical thickening with a transverse lucency within the lateral cortex. The diagnosis of an insufficiency fracture was supported by CT follow-up studies that showed fracture lines more clearly and areas of increased sclerosis or periosteal bone formation; and by MRI follow-up studies that showed persistent or decreasing areas of bone marrow edema or better visualization of fracture lines. To date, to our knowledge, there is only one report in the radiologic literature describing these fractures [2]. collagen formation: Marfan syndrome, fibrous dysplasia. We used binomial exact confidence intervals, also known as Clopper and Pearson confidence intervals. Upon stepping off a scale at her clinician's office, she heard a pop followed by weakness and eventually fell to the ground. All four patients reported a low-energy inciting event as the cause for presentation. The aims of our study were to compare the sensitivities of CT and MRI in detecting insufficiency fractures of the pelvis and proximal femur; to analyze the typical location, morphology, and combinations thereof in these fractures; to analyze typical imaging morphology; and to analyze associated clinical findings, such as prior radiation therapy or chemotherapy. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Many insufficiency fractures present with completely displaced fractures of the femoral shaft, whereas such complete fractures in femoral stress fracture are uncommon [15]. This site needs JavaScript to work properly. Other important findings were that patients frequently had multiple pelvic insufficiency fractures and that pubic fractures in particular were typically associated with concomitant fractures. She tripped at an unspecified event, falling from ground level, and felt severe pain in her leg. In our study, we used all available imaging data and imaging follow-up, together with the clinical history, as a standard of reference. 100 Similar insufficiency fractures among patients not receiving bisphosphonates are extremely rare. Chen et al. Address correspondence to T. M. Link ([emailprotected]). A mild bone marrow edema pattern was more frequently associated with femoral fractures (18/49, 36.7%). Epub 2016 Aug 24. 2021 Sep 4;11:122-126. doi: 10.1016/j.artd.2021.08.004. In conclusion, because insufficiency fractures are increasingly frequent, important yet underdiagnosed lesions, the radiologist must be familiar with these findings and their location, morphology, and associated clinical features. Gaeta et al. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Also, we did not have a true reference standard for insufficiency fractures because to do so would have required either surgery or autopsy, neither of which was feasible in our patients. In the 20 patients in whom only lumbar spine MRI was performed, sagittal and axial T1-weighted (TR range/TE, 500600 milliseconds/minimum) and fat-saturated T2-weighted fast spin-echo (TR range/TE range, 3,5004,000/6090) sequences as well as a coronal T1-weighted fast spin-echo (500 milliseconds/minimum) sequences were obtained. An insufficiency fracture refers to normal physiologic stress applied to bone . Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Subchondral Insufficiency Fracture of Femoral head: Uncommon cause of Hip pain in Elderly. Figure 5 illustrates the total number of fractures and locations as well as the number of fractures associated with soft-tissue abnormalities at each location and displays the proportion of fractures with soft-tissue abnormalities at a certain location. Epub 2012 Aug 14. From January through October 2009, we searched for cases of transverse fractures involving the proximal femur in postmenopausal women with the previously reported characteristic radiographic appearance suggestive of insufficiency injury related to long-term bisphosphonate . There are several reports identifying a strong relationship between prolonged receipt of bisphosphonate therapy and insufficiency fractures of the proximal femur among postmenopausal women [18]. That only insufficiency fractures were included from the beginning, and that the sensitivities of CT and MRI can only be estimated, are other limitations, yet these are limitations of the retrospective study design, and the sensitivity of these techniques in a typical clinical scenario seems most important. The sacrum (n = 13), pubis (n = 12), and femur (n = 11) were sites of 36 of the 37 fractures that occurred with acetabular fractures. Patient 2 stated that she suffered from non-remitting left thigh pain that was worst during ambulation for 1 month before presentation to the emergency department. This is especially true of pubic fractures; 90% of the pubic fractures in this study had concomitant fractures present. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. All studies were performed with 120 kVp and milliampere values ranging from 150 to 300 mA. Table 2 lists locations of all 307 fractures found in the 145 patients. In the case of pubic fractures, 89.2% (33/37) of patients with pubic fractures had one or more fractures at another site. A fatigue fracture is due to abnormal stress placed on normal bone, such as training for a marathon. All patients underwent MRI and were assessed for the absence or presence of a fracture as well as number and location of fractures. Caution should be exercised when one site with an insufficiency fracture is discovered because other fracture sites likely exist. 2012 Sep;4(3):173-80. doi: 10.4055/cios.2012.4.3.173. MRI detected 102 of 103 lesions (99%), whereas CT identified only 13 of 103 lesions (12.6%). It needs to be differentiated from avascular necrosis, wherein a double line is seen which is convex to the articular surface as opposed to insufficiency fracture which is parallel to the articular surface. Address correspondence to L. F. Rogers ([emailprotected]). Thirty-one patients had CT scans and radiographs available, and of the 63 fractures visualized with CT, radiographs visualized only 13 (20.6%). Subchondral insufficiency fracture - femoral head. The standard of reference we usedlongitudinal imaging, clinical follow-up, and all other available imaging studies over several yearsis the best available alternative. Patient 3 tripped over a small step while exiting her home and heard a crack with the next step. dyle insufficiency fracture,^ Bspontaneous osteonecrosis knee,^ and/or BSONK^ in the radiology report impression. All statistical analyses were performed using statistical software S-plus (Insightful) and SAS software (SAS). J Orthop Case Rep. 2012 Apr-Jun;2(2):7-9. The limitation of that study was that thin-slice MDCT with multiplanar reformations was not available at the time the study was performed; only 4- to 8-mm axial images with sagittal reconstructions were available. Malignant lesions are frequently suspected in patients who have undergone radiation therapy and chemotherapy of the pelvis. Before the injury, patient 4 reported suffering from pain in the lateral aspect of her hip and groin, which was misdiagnosed as sciatica. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. The number of fractures increased with age; most of the fractures were found in patients 7089 years old (146/307) compared with 50 of 307 and 83 of 307 at age groups 3049 and 5069 years, respectively. 1987;33(5):302-6 This area of the proximal femur is susceptible to stress fracture because of the origin of the vastus medialis and insertion of the adductor brevis [11]. In the complete population, two or more fractures were found in 70.3% (102/145) of patients, and 89.2% (33/37) of patients with pubic insufficiency fractures had concomitant fractures at other locations. Insufficiency fractures can occur throughout the skeleton but are common in the tibia, femoral head and neck, sacrum, pelvis, and feet. location this Summer 2022, conveniently located in the Phoenix/Scottsdale region. However, exact data from a larger patient population are not available. However, only a small subset of patients underwent radionuclide and DXA studies, which prevented a statistically representative analysis. 102 Signs of a soft-tissue lesion included muscle swelling, fat-tissue stranding, and active extravasation of contrast material on contrast-enhanced studies. MRI is the superior technique compared with CT and should be the imaging technique of choice in patients with suspected insufficiency fractures. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. 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