Subchondral insufficiency fractures of the femoral head. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. When they are caused by metastatic disease, these fractures show poorly defined lucent margins, an aggressive bone marrow pattern of destruction, and endosteal scalloping [10, 17]. They are most commonly associated with osteopenic or osteoporotic bone and the female athlete triad in young athletes. Methods: Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. OrthoArizona offers on-site MRI, with TWO convenient locations near our established clinic sites in North & South Gilbert! MRI detected 102 of 103 lesions (99%), whereas CT identified only 13 of 103 lesions (12.6%). The sacrum (n = 13), pubis (n = 12), and femur (n = 11) were sites of 36 of the 37 fractures that occurred with acetabular fractures. Interestingly, fractures at the femoral head and acetabulum were better detected with MRI, which may be because these fractures are frequently horizontally aligned in the direction of the axial CT plane, and even thin-section reformations will be subject to partial volume effects and will not necessarily reveal fractures. Therefore, when a proximal femoral diaphyseal fracture is identified in the appropriate demographic after low-energy trauma, one should consider the possibility of long-term bisphosphonate therapy as the underlying cause. [21] in 15 patients with longitudinal stress fractures at the tibia. Using clinical history, all available imaging studies, and cross-sectional follow-up studies as a standard of reference, MRI identified 128 of 129 fractures (99.2%) in 63 of 64 patients (sensitivity, 98% [95% CI, 94100%]), whereas CT alone detected only 89 of 129 fractures (69%) in 34 of 64 patients (sensitivity, 53% [3964%]). Caution should be exercised when one site with an insufficiency fracture is discovered because other fracture sites likely exist. Keywords: bisphosphonate, femur, fracture, insufficiency, subtrochanteric. Figure 1A, 1B, 1C, 1D shows an example of a sacral fracture visualized with MRI but not with CT. 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. One at our South Gilbert site (South of Loop 202 and East of Val Vista Dr) and the second location at our North Gilbert site (South of the US-60 and East of Higley Rd, behind Banner Gateway Hospital). 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. 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. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Insufficiency fractures in the osteoporotic population in this region are said to be rare [2, 7, 9]. In the case of pubic fractures, 89.2% (33/37) of patients with pubic fractures had one or more fractures at another site. Forty percent of the 25 patients with femoral fractures had concomitant fractures. Only a small number of studies have been performed comparing MRI and CT in diagnosing stress fractures. Find a doctor near you. In addition, the absence or presence of a bone marrow edema pattern and fracture lines was documented. In 125 patients, MRI of the pelvis was performed; and in 20 patients, only MRI of the lumbar spine, including the complete sacrum, was available. Neck of femur fractures (NOF), a.k.a. In nine of 63 patients (14.3%), hematologic malignancies were recorded, and in six (9.5%) breast cancer was diagnosed. This, in effect, restores the appearance of the insufficiency fracture in the lateral cortex. Sensitivities were calculated as the percentage of patients identified by each technique based on this standard of reference, and confidence intervals were provided. If proximal femur fractures are suspected, mobility of the patient should not be permitted before cross-sectional imaging has been obtained. A 65-year-old woman with insufficiency-type subchondral stress fracture of the femoral head. Bisphosphonates function by inhibiting bone resorption by suppressing osteoclasts through apoptosis [7, 8]. Pathologic fractures of the proximal femoral diaphysis are nearly always transverse and typically are due to metastatic disease, Paget disease, or fractures through preexisting Looser zones. 1 article features images from this case 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]. To show that no significant selection bias existed between the subgroups of patients who underwent both CT and MRI versus the subgroup who underwent only MRI, we compared the covariates such as age, sex, fracture location, and number of fractures between those in each subgroup. 2000) (Fig. Unable to load your collection due to an error, Unable to load your delegates due to an error. Only studies that covered the whole sacrum were included. Figure 2A, 2B, 2C shows an example of a pubic fracture better shown on CT, whereas the sacral fracture in Figure 3A, 3B, 3C is better visualized on MRI. A third MRI location will be opening at our Arcadia (44th St. & Thomas Rd.) 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. Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. In our study, we used all available imaging data and imaging follow-up, together with the clinical history, as a standard of reference. 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 fracture was missed on the MR images because of partial volume effects and adjacent joint effusion along with motion artifacts. These fractures are treated with a trochanteric-entry nail, either one or two proximal lag screws, and distal interlocking screw fixation. An incorrect diagnosis may initiate invasive and costly procedures that could be harmful to the patient or that could misguide therapy. Fractures averaged 2.1 per patient (range, 16 fractures per patient). Bone marrow edema pattern was also graded in all fractures in which it was present. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. 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). MRI missed one soft-tissue lesion at the erector spinae muscles because of incomplete fat saturation. The ability of both imaging techniques to detect fracture lines was compared. Patients 3 and 4 presented with a completely displaced transverse fracture of the proximal femoral diaphysis. PMC 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). 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. In the remaining 3 patients radiographs showed a normal femoral head, regional osteoporosis and focal sclerosis, respectively. OBJECTIVE. However, because of the limited metabolic activity of bone in these patients, imaging features of fractures are expected to persist over a period of several months, as has been shown by previous studies [17, 18]. Stress fractures occur in young military recruits and athletes and involve the medial cortex when in the proximal femur [1015]. 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. Location of soft-tissue abnor malities was documented, and severity was graded as severe (signal abnormality affecting the whole muscle compartment and fluid signal was noted in the muscles on STIR or fat-saturated T2-weighted fast spin-echo images), moderate (signal abnormality affecting muscles but signal intensity less than that of fluid), or mild (signal abnormality around muscles in adjacent soft tissues and only minimal muscle signal abnormality). Presence or absence of soft-tissue lesions was also documented. Gilbert, AZ 85297, 2940 E. Banner Gateway Dr., Ste. Objectives: To characterize the morphology and imaging findings of femoral head subchondral insufficiency fractures (SIF), and to investigate clinical outcomes in relation to imaging findings. Although our patients did not undergo MRI or nuclear medicine imaging, a case report by Bush and Chew [2] describes these findings. Prior data suggest that a significant percentage of patients with evidence of cortical stress in this region or insufficiency fracture have similar findings in the contralateral femur, such as that seen in patient 2 (Fig. 102 The fracture missed on MRI was diagnosed in a 78-year-old woman who underwent 2.5-mm-slice-thickness CT 1 day previously that showed a probable fracture. This search yielded 162 patients; 84 met the typical inclusion criteria of an insufficiency fracture previously described by Yamamoto et al. 2002 Jan;31(1):35-8 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. The contralateral femur showed similar findings [2]. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. Insufficiency fractures can occur throughout the skeleton but are common in the tibia, femoral head and neck, sacrum, pelvis, and feet. The reduction is usually complete, and the apposition is often immediate. Because of the limited visualization of soft-tissue abnormalities on CT, we did not differentiate grades. Enjoy the freedom of a pain-free, active lifestyle with help from our orthopedic specialists. For more information, or to schedule the treatment of an injured worker, please contact one of our dedicated Workers' Compensation Specialists: Phone | 602.648.5440. However, consideration should be given to the implications of a missed diagnosis that may misdirect or delay treatment. 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! The sensitivities of CT and MRI were compared using a paired proportion test (the McNemar test). Call 602.922.9100 to schedule an appointment! Frequently these fractures are radiographically occult [7, 8]; and some of these fractures, in particular sacral insufficiency fractures, are relatively underdiagnosed [9]. Their presence is sometimes unexpected and can lead to incorrect diagnoses and many unnecessary, costly diagnostic procedures [10]. Such cortical thickening along the lateral, or tension, side of the femur is apparent before eventual complete fracture, as seen in patients 1 and 2 (Fig. 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. Shout out to o, OrthoArizona team members had a blast at the @maki, We are so excited to support the @makingstridespho, Dr. Boyle had a blast speaking with some second gr. medications: glucocorticoids, chemotherapy. The standard pelvis protocol consisted of coronal T1-weighted fast spinecho (TR/TE, 600 milli seconds/minimum) and STIR (3,000/68; inver sion time, 150 milliseconds) sequences as well as axial T1-weighted (600 milliseconds/minimum) and fat-saturated T2-weighted fast spin-echo (3,000/68) sequences. Follow-up CT 3 months later showed an area of increased sclerosis and periosteal bone formation in the region of the initially described probable fracture, consistent with a healing fracture. Call 602.922.9100 to schedule an appointment! Therefore, awareness of this disorder is especially important for the radiologist, particularly in the setting of existing malignant disease, to avoid misinterpretation as bone metastases. The appearance of the fracture mimics that of a tibial striation, or stress fracture, seen in the anterior cortex of the tibia. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Kabra U, Subchondral insufficiency fracture - femoral head. Radiography is the imaging modality of choice for baseline diagnosis. The standard of reference we usedlongitudinal imaging, clinical follow-up, and all other available imaging studies over several yearsis the best available alternative. -, Am J Surg Pathol. In all 145 subjects, MRI studies obtained at 1.5 T (Signa, GE Healthcare) were available. Epub 2009 Oct 6. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Accessibility CT examinations were studied for absence or presence of a fracture as well as number and location of fractures. The imaging characteristics of bisphosphonate-related insufficiency fractures that we describe are, in our experience, unique and easily recognized by a trained observer. Ikemura S, Yamamoto T, Motomura G, Nakashima Y, Mawatari T, Iwamoto Y. AJR Am J Roentgenol. In addition, patients 1 and 3 switched to ibandronate sodium and risedronate, respectively, before fracture. RESULTS. The p value for the McNemar test was < 0.0001, showing that MRI had significantly enhanced sensitivity for finding fractures compared with CT. The location you tried did not return a result. 1987;33(5):302-6 Concerning the diagnostic confidence of both radiologists, probable fractures were identified in 8.5% of cases (11/129) on MRI and in 9.3% (12/129) on CT. MRI identified 117 of 129 (89.9%) definite fractures and only one (0.8%) fracture was not visualized, whereas CT found only 77 of 129 (59.7%) definite fractures and in 40 cases (31.0%) no definite fractures were visualized. Insufficiency fractures at the tibia (Fig. Upon stepping off a scale at her clinician's office, she heard a pop followed by weakness and eventually fell to the ground. . A fatigue fracture is due to abnormal stress placed on normal bone, such as training for a marathon. 2 and 3A, 3B). An MRI is a form of diagnostic advanced medical imaging used t o diagnose a variety of orthopedic conditions. In 63 of 145 (43.4%) patients, a previous malignancy was found; in only 93 of 145 (64.1%) patients, the leading symptom responsible for the MRI examination was pain. Figure 4A, 4B, 4C, 4D shows an example of a patient with multiple insufficiency fractures at both femoral necks and the ischia. However, irradiated bone is especially weakened and prone to insufficiency fractures, as shown previously [13]. Before the injury, patient 4 reported suffering from pain in the lateral aspect of her hip and groin, which was misdiagnosed as sciatica. Also, the number of fractures in an individual patient increased with age. In 64 of 145 patients, MRI and multidetector CT (MDCT) findings were compared. As a criterion for the comparison between CT and MRI, we restricted analysis to studies obtained within 3 months of the first cross-sectional study that showed the fracture. Thirteen insufficiency stress fractures of the femoral neck in 13 elderly patients (average age, 82 years) were studied retrospectively. Comparisons were also drawn between MRI and CT in the ability to detect soft-tissue abnormalities. In all patients, the clinical history was analyzed and potential risk factors for insufficiency fractures were recorded. 182 Radiology 14Case 179-183Reports (2019) should be addressed based on the location in this case, is an Address correspondence to L. F. Rogers ([emailprotected]). Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Staatz et al. Although the exact mechanism for bisphosphonate-related insufficiency fracture of the proximal femur is not yet entirely understood, a relationship is evident [4, 5, 9]. Interestingly, insufficiency fractures were associated with prior malignancy in 63 of 145 (34.4%) patients. A vague pain about the hip, of spontaneous onset, was the main symptom on first visit. We present a case of subchondral insufficiency fracture diagnosed radiographically and confirmed by histology that progressed to rapid hip destruction over a 1-month period. Fax | 480.324.3162. To date, to our knowledge, there is only one report in the radiologic literature describing these fractures [2]. The MRI, CT, and radiographic studies were analyzed separately in random order by two radiologists in consensus. sharing sensitive information, make sure youre on a federal Radiographs were performed in all patients, MRI in 5 and scintigraphy in 4 patients. A fracture line was defined as a linear structure visualized on either STIR, T1-weighted, or fat-saturated T2-weighted fast spin-echo sequences. 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%). For each of the two imaging techniques, confidence of fracture diagnosis was graded on a scale of 13, where 1 represented a definite fracture; 2, a probable fracture; and 3, no definite fracture. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. Involvement of the contralateral femur varies in the literature, ranging from 20% to 64% [3, 68]. 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. The most recent lumbar spine bone mineral density T score for patient 1, acquired over 1 year before fracture, was 2. It has also been found that insufficiency fractures tend to occur in multiple locations, and concomitant soft-tissue abnormalities are frequently shown [7, 15, 16]. Findings are suggestive of subchondral insufficiency of the medial femoral condyle, previously known as spontaneous osteonecrosis of the knee (SONK). doi: 10.2214/AJR.09.3271. 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 fractures of the hip have been identified as a cause of accelerated osteoarthritis . The clinical and radiological findings in 7 patients with subchondral insufficiency fractures of the femoral head were reviewed retrospectively. Fractures, or fracturelike conditions, within this area in the absence of high-energy trauma can occur in other clinical settings but are either related to unusual causes, such as pyknodysostosis or fluoride therapy, or provide differentiating radiographic and clinical clues [7, 1015]. In addition to underlying clinical conditions, age was also a major contributor to fracture risk. The pelvis protocol covered the proximal femur at least down to the lesser tro chanter and was used also for suspected hip fractures. 8600 Rockville Pike The sites most commonly associated with pubic fractures were the sacrum and the acetabulum, with 40 (70.1%) and nine (15.8%) concomitant fractures, respectively. 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]. A noncontrast magnetic resonance imaging (MRI) of the right femur was performed in conjunction with the CT ().On T1-weighted sequences (Figs. Schilcher and Aspenberg calculated the relative risk and found a 46 times increased risk of insufficiency fractures for patients taking bisphosphonates. doi: 10.1016/j.annpat.2009.07.051. Book an appointment today! ( b) Radiographs taken 2 months after the onset of the left hip pain show joint space narrowing of the left hip without any other bony abnormality. The terminology of atraumatic . All statistical analyses were performed using statistical software S-plus (Insightful) and SAS software (SAS). Of the 128 fractures detected on MRI, fracture lines were present in 122 (95.3%) cases, and no fracture lines were most often found at the sacrum (n = 4). Thus, when a fracture of the femoral shaft is identified in an older patient with the characteristic imaging features we have described, it is highly likely that the patient has been receiving long-term bisphosphonate therapy [9]. The https:// ensures that you are connecting to the 2016 Oct;45(10):1425-9. doi: 10.1007/s00256-016-2443-2. location this Summer 2022, conveniently located in the Phoenix/Scottsdale region. dyle insufficiency fracture,^ Bspontaneous osteonecrosis knee,^ and/or BSONK^ in the radiology report impression. Of note, severe bone marrow edema patterns were found to be frequently associated with pubic fractures (15/54, 27.8%), whereas a moderate bone marrow edema pattern was most frequently associated with sacral fractures (79/172, 48.8%). MRI studies obtained at 1.5 T were analyzed in 145 patients with pelvic insufficiency fractures. Imaging of Anterior Cruciate Ligament Repair and Its Complications, Review. 2012 Sep;4(3):173-80. doi: 10.4055/cios.2012.4.3.173. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-80488. Although this action results in increased bone mineral density, suppressed bone turnover prevents remodeling and healing of cracks that occur in bone as a result of normal activity, often referred to as microdamage [68]. Grangier et al. Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head. Gaeta et al. 1E). Find top doctors who perform Hip Femur Fractures and Dislocations near you in Chandler, AZ. 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. Medical records confirmed prolonged (> 3 years) oral bisphosphonate use of various agents in four patients with findings suggestive of insufficiency fracture related to long-term bisphosphonate therapy. Disclaimer, National Library of Medicine Federal government websites often end in .gov or .mil. 1A, 1B, 1C, 1D, 1E). Of the 108 fractures diagnosed with MRI, radiography visualized only 16 (14.8%). Chen et al. However, the clinical presentation and imaging features of these entities provide differentiating clues. This information, in conjunction with the radiologic findings, can lead to a correct diagnosis. Unable to process the form. In total, 57 fractures occurred with pubic fractures. Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments, Superior Labral Anteroposterior Tear: Classification and Diagnosis on MRI and MR Arthrography, Review. 12 a-c) may be found as an early manifestation of bone failure in patients after renal transplantation as reported by a . The diagnosis was confirmed histologically in 4 patients. In the 39 thick-section CT studies, 73 total fractures were diagnosed and only 65.7% (48/73) were detected. In the CT study, a small subtle cortical irregularity at the posterior femoral neck was shown. Given the large number of referring physicians from different subspecialties, the referral pattern for this study was therefore broad and may also be representative of other institutions. 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. All four patients had taken alendronate for at least 3 years before injury. The four postmenopausal women ranged in age from 57 to 77 years at the time of injury, with a mean age of 66.5 years. Case Report Ann Pathol. Other frequent combinations of concomitant fractures were noted. Skeletal Radiol. CONCLUSION. Imaging Key Wrist Ligaments: What the Surgeon Needs the Radiologist to Know. MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. The amount and intensity of soft-tissue edema were also graded higher in patients with pubic, acetabular, and femur fractures versus sacral fractures. Our results clearly show that MRI is the superior imaging technique for visualizing insufficiency fractures of the pelvis and associated soft-tissue abnormalities when the clinical status suggests a fracture in the setting of negative radiographs. 1 Department of Radiology and Biomedical Imaging, University of California at San Francisco, 400 Parnassus Ave, A-367, San Francisco, CA 94131. . Means and SDs were calculated for continuous variables, and frequency and proportion for categoric variables. The aim of this study was to increase awareness of, and to show the variable clinical and radiological features of, subchondral insufficiency fractures of the femoral head. 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]. The diagnosis was delayed in most cases because the . 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. 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. Suggestive changes were seen on initial roentgenograms in only one case, whereas increased radionuclide uptake was a consistent . The anteroposterior radiograph of the affected hip acquired on initial presentation included the proximal femoral shaft; however, the insufficiency fracture was overlooked. 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. This site needs JavaScript to work properly. Each patient was receiving an oral bisphosphonate at the time of fracture. Patients with metastatic disease to the pelvic bones; a history of other bone marrow disease such as myelody-splastic syndrome or Gaucher's disease; and metabolic diseases other than osteoporosis, osteomalacia and renal osteodystrophy, as well as osteomyelitis, were excluded. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. 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. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. 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. Insufficiency fractures occur in abnormal bonethat is, bone commonly affected by generalized osteoporosisas a result of normal activity such as walking. Despite the cost of MRI and CT, it is important to quickly diagnose and treat these fractures. Signs of a soft-tissue lesion included muscle swelling, fat-tissue stranding, and active extravasation of contrast material on contrast-enhanced studies. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. Additional documented findings included presence or absence of a fracture line, focal area of sclerosis, adjacent radioluc ency consistent with resorptive bone changes, and vacuum phenomenon. Gilbert, AZ 85234, 3033 N. 44th St. Ste. [2] Insufficiency fractures of the spine are often a sign of frailty. Overall in the CT studies, sclerosis was present in 69 of 89 (79.3%) fractures. Patient 1 presented 5 days before complete fracture with complaints of hip pain. Thus, a better understanding of insufficiency fractures of the pelvis is required, and further study is needed to determine whether CT or MRI is better suited to investigate these fractures. To identify patients with pelvic insufficiency fractures, the radiology information system of our department was searched using the terms "pelvis," "sacrum" or "femur," and . The insufficiency fracture lies within the lateral cortex of the proximal femur. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. [22] argued that CT was better because of cost, diagnostic rate, and ease of fracture line visualization. Before Subchondral Insufficiency Fracture of Femoral head: Uncommon cause of Hip pain in Elderly. 100 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. -, Radiology. We will be responding to your message shortly! Elderly osteoporotic women are at greatest risk. 1989 Apr;171(1):135-40 A history of corticosteroid therapy within the previous 6 months was recorded in 18 of 145 (12.4%) patients. Case Discussion. bone remodeling: Paget disease, osteopetrosis. Many patients present with a complete and significantly displaced fracture of the proximal femoral shaft as a result. 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. Fracture detection rates for CT and MRI were calculated using the previously described standard of reference. Chan CC, Li A, Fan WC, Sun LK, Cheng HC, Chan JC. In a subset of patients, anteroposterior pelvic and hip radiographs were also analyzed. Subchondral insufficiency fracture - femoral head. In addition to the better visualization of fractures, MRI was also more sensitive than CT in detecting soft-tissue abnormalities, as has also been shown by Feydy et al. Epidemiology Less frequently, in up to 25 %, insufficiency fractures at the femoral shaft can occur, predominately in elderly patients with osteoporosis (Martin-Hunyadi et al. However, this recommendation may apply for the tibia in fatigue fractures, but not for pelvic insufficiency fractures if the radiologist is familiar with typical imaging findings. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 1A, 1B, 1C, 1D, 2A, 2B, 2C, 3A, 3B, 3C). All imaging studies originated from our medical center, which is a large teaching facility composed of four hospitals and two outpatient imaging facilities serving a major U.S. city. Table 2 lists locations of all 307 fractures found in the 145 patients. Characteristic features were seen in retrospect on complete fracture. Bookshelf Overall, no significant differences (p > 0.05) in the detection rate of fractures between men and women were found. Also, 76% of acetabular fractures had concomitant fractures. [19] examined stress fractures at the tibia in 42 athletes and found a higher sensitivity for MRI than for CT (88% vs 42%) in diagnosing stress injuries. 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]. The most common fractures were located at the sacrum (n = 67) and the pubic ramus (n = 29) (Figs. 11). Unsuspected insufficiency fracture of the femoral head can lead to significant and rapid loss of bone stock in osteoporotic patients waiting for arthroplasty for osteoarthritis. However, only a small subset of patients underwent radionuclide and DXA studies, which prevented a statistically representative analysis. Address correspondence to T. M. Link ([emailprotected]). Interestingly, in our study the presence and severity of soft-tissue edema varied according to the location of the fractures: Although a high percentage of soft-tissue edema was found with pubic and acetabular fractures, it was less frequently seen with sacral fractures. In particular, fractures at the femoral head and acetabulum were better detected with MRI. Rev Bras Ortop. Malignant lesions are frequently suspected in patients who have undergone radiation therapy and chemotherapy of the pelvis. Check for errors and try again. Rheumatologic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, were found in six of 145 patients (4.1%). In 21 of 307 cases (6.8%), only fracture lines were shown; and in 19 of 307 (6.2%) cases, only a bone marrow edema pattern was found. Epub 2012 Aug 14. Because most of the patients in this study were elderly and a large number underwent chemotherapy or radiation therapy, thus reducing bone metabolism, bone scintigraphy may have had limited sensitivity. 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. However, comparison with our study is limited because those investigators examined fatigue fractures, which have different bone mass and quality. -, Radiology. In addition, two or more insufficiency fractures were frequently present, typical fracture combinations were found, and insufficiency fractures were frequently associated with malignant disease. Consequently, the entire pelvis must be imaged in these patients, and a careful search for concomitant fractures is always warranted. Subacute hematoma was documented if signal abnormality was high on T1-weighted images (indicating the presence of methemoglobin). Subchondral insufficiency fractures are a relatively common cause of knee pain, particularly in older patients. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . -. An official website of the United States government. 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. We used binomial exact confidence intervals, also known as Clopper and Pearson confidence intervals. 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. All occurred in Caucasian women with severe osteoporosis. In 29 of 63 patients (46.0%), the primary tumor was located in the pelvis; 24 of these patients had gynecologic malignancies. Radiographs of stress fractures, when positive, typically show foci of periosteal reaction with an obliquely oriented linear lucency within the medial cortex [10, 11, 13]. Many fractures were frequently associated with concomitant fractures in typical locations (Table 3). Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of subchondral cancellous bone. In only 93 of 145 (64.1%) patients, the chief symptom leading to the MRI examination was pain. 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. 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].