The diagnosis was delayed in most cases because the . sharing sensitive information, make sure youre on a federal 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. Thirty-eight of the 64 (59.49%) CT studies were performed with IV contrast material. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. In our study, we used all available imaging data and imaging follow-up, together with the clinical history, as a standard of reference. [21] in 15 patients with longitudinal stress fractures at the tibia. Disclaimer, National Library of Medicine Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Kabra U, Subchondral insufficiency fracture - femoral head. 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, statistical analysis proved this difference to be insignificant (p = 0.243). Table 2 lists locations of all 307 fractures found in the 145 patients. Patients 2, 3, and 4 were treated for osteoporosis without a documented bone mineral density score in their current medical record. Utsunomiya T, Yamamoto T, Motomura G, Hamai S, Iwamoto Y. Skeletal Radiol. 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. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. Before the injury, patient 4 reported suffering from pain in the lateral aspect of her hip and groin, which was misdiagnosed as sciatica. -, Gerontology. Phoenix, AZ 85018, Privacy Policy | Sitemap | Copyright 2022 OrthoArizona | Digital Marketing by CD Agency. November 2018; Radiology Case Reports 14(2):179-183; . Patients were included in the study only if clinical history, imaging findings, and cross-sectional follow-up studies were consistent with the diagnosis of an insufficiency fracture. This, in effect, restores the appearance of the insufficiency fracture in the lateral cortex. 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. No prior thigh or groin pain was documented in records. Also, the number of fractures in an individual patient increased with age. Characteristic features were seen in retrospect on complete fracture. Increased awareness of this condition will hopefully lead to earlier diagnosis and a successful outcome of conservative treatment. 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, exact data from a larger patient population are not available. It is advisable to image the contralateral femur if characteristic findings are apparent [3, 58]. Sensitivities were calculated as the percentage of patients identified by each technique based on this standard of reference, and confidence intervals were provided. Because a number of patients with insufficiency fractures have limited renal functionsuch as older patients and cancer patients undergoing chemotherapythe risk is increased that gadolinium will induce nephrogenic systemic fibrosis, so standard contrast administration is not recommended at our institution. 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. 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. The appearance of the fracture mimics that of a tibial striation, or stress fracture, seen in the anterior cortex of the tibia. Fracture lines were better shown on T1-weighted sequences, and proximal femur fracture lines were best shown on sequences obtained in a coronal orientation. 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. The standard of reference we usedlongitudinal imaging, clinical follow-up, and all other available imaging studies over several yearsis the best available alternative. 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). Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, Neumann G, Valentin-Opran A, Lang P. AJR Am J Roentgenol. Bisphosphonates function by inhibiting bone resorption by suppressing osteoclasts through apoptosis [7, 8]. Osteoporosis is the most common cause of insufficiency fractures, although there are many causes 7-9: disrupted bone mineral homeostasis: hyperparathyroidism, diabetes mellitus, osteomalacia. Before Slice thickness was 4 mm; matrix size, 256 192 mm; and field of view, 1624 cm. 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. 12 a-c) may be found as an early manifestation of bone failure in patients after renal transplantation as reported by a . Comparisons were also drawn between MRI and CT in the ability to detect soft-tissue abnormalities. 2012 Sep;4(3):173-80. doi: 10.4055/cios.2012.4.3.173. From the search results, MRI and CT studies with a reported diagnosis of pelvic, sacral, or proximal femur insufficiency fractures were selected. MRI of the pelvis revealed a thickened lateral cortex with a focus of abnormally high signal. It presents as a transverse fracture line through a localized area of thickening involving the lateral aspect of the cortex [1, 68]. Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know, Review. 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. 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. When the radiologist encounters fractures involving the proximal femur in the setting of a low-energy inciting event, demographic and historical information should be sought. Most frequently, insufficiency fractures were characterized by the presence of a bone marrow edema pattern and fracture lines (267/307, 87%). We used binomial exact confidence intervals, also known as Clopper and Pearson confidence intervals. Many insufficiency fractures present with completely displaced fractures of the femoral shaft, whereas such complete fractures in femoral stress fracture are uncommon [15]. doi: 10.1016/j.annpat.2009.07.051. 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]. Subchondral insufficiency fractures are a relatively common cause of knee pain, particularly in older patients. The clinicopathologic findings of a subchondral insufficiency fracture of the femoral head in a male patient: a case report. 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. A vague pain about the hip, of spontaneous onset, was the main symptom on first visit. In particular, proximal femur neck and intertro-chanteric fractures are prone to substantial complications and displacement if they are not surgically revised [2325], which has implications for clinical management and recommendations from radiologists to referring physicians, particularly when radiographs are negative and there is a strong clinical suspicion of a fracture. Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know. [2]; these include a low-signal band on T1-weighted imaging adjacent to the subchondral . Rev Bras Ortop. Also, 76% of acetabular fractures had concomitant fractures. 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]. Although our patients did not undergo MRI or nuclear medicine imaging, a case report by Bush and Chew [2] describes these findings. 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. We will be responding to your message shortly! Twenty-five patients were diagnosed with acetabular fractures, and in 19 (76%) of these patients concomitant fractures were present. An official website of the United States government. 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! [A femur head--does it have anything to say?]. A fracture line was defined as a linear structure visualized on either STIR, T1-weighted, or fat-saturated T2-weighted fast spin-echo sequences. This information, in conjunction with the radiologic findings, can lead to a correct diagnosis. 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 aims of this study were to compare the sensitivity of CT and MRI in detecting insufficiency fractures; to analyze the typical location, morphology, and combinations thereof in these fractures; to analyze imaging morphology; and to analyze associated clinical findings. A fatigue fracture is due to abnormal stress placed on normal bone, such as training for a marathon. Suggestive changes were seen on initial roentgenograms in only one case, whereas increased radionuclide uptake was a consistent . To date, to our knowledge, there is only one report in the radiologic literature describing these fractures [2]. High-Resolution 3-T MRI of the Fingers: Review of Anatomy and Common Tendon and Ligament Injuries, Review. 180 Radiology Case Reports 14 (2019) 179-183. Patients 3 and 4 presented with a completely displaced transverse fracture of the proximal femoral diaphysis. Most notably, only 3.8% (2/53) of sacral fractures and only 11% (1/9) of acetabular fractures were detected. government site. According to a previously published study [8], MRI is more sensitive than bone scintigraphy in the early stages of insufficiency fractures. Table 1 shows the number of fractures at each fracture site as well as the percentage of fractures detected at the location for each imaging technique. 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 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]. Upon stepping off a scale at her clinician's office, she heard a pop followed by weakness and eventually fell to the ground. HHS Vulnerability Disclosure, Help Patient 2 presented to the emergency department in the precomplete fracture stage, before displacement, with less-pronounced findings evident in the contralateral femur. 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. Insufficiency fractures in the osteoporotic population in this region are said to be rare [2, 7, 9]. In the precomplete fracture stage of the disease, we found the radiographic findings to be subtle and easy to overlook. 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. Signs of a soft-tissue lesion included muscle swelling, fat-tissue stranding, and active extravasation of contrast material on contrast-enhanced studies. bone remodeling: Paget disease, osteopetrosis. Find a doctor near you. She tripped at an unspecified event, falling from ground level, and felt severe pain in her leg. A bone marrow edema pattern was classified as severe if signal intensity on STIR or fat-saturated T2-weighted fast spin-echo images was similar to that of spinal fluid or urine in the bladder, as mild if the bone marrow edema pattern was visualized only along the fracture line (within 5 mm diameter) but not in the periphery, and as moderate if the bone marrow edema pattern was visualized > 5 mm around the fracture line or had a diameter of > 10 mm if no fracture line was present and signal intensity was less than that of spinal fluid and urine. 2010 Jul;195(1):W63-8. 2016 Nov;45(11):1515-21. doi: 10.1007/s00256-016-2462-z. 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]. Clin Orthop Surg. Clipboard, Search History, and several other advanced features are temporarily unavailable. MRI of the Thumb: Anatomy and Spectrum of Findings in Asymptomatic Volunteers, Review. The contralateral femur showed similar findings [2]. 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]. dyle insufficiency fracture,^ Bspontaneous osteonecrosis knee,^ and/or BSONK^ in the radiology report impression. 1988 Jun;167(3):753-5 2021 Sep 4;11:122-126. doi: 10.1016/j.artd.2021.08.004. An MRI is a form of diagnostic advanced medical imaging used t o diagnose a variety of orthopedic conditions. Call 602.922.9100 to schedule an appointment! 1 Department of Radiology and Biomedical Imaging, University of California at San Francisco, 400 Parnassus Ave, A-367, San Francisco, CA 94131. . 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. OrthoArizona offers on-site MRI, with TWO convenient locations near our established clinic sites in North & South Gilbert! This search yielded 162 patients; 84 met the typical inclusion criteria of an insufficiency fracture previously described by Yamamoto et al. The anteroposterior radiograph of the affected hip acquired on initial presentation included the proximal femoral shaft; however, the insufficiency fracture was overlooked. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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. 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. doi: 10.2214/AJR.09.3271. In addition to underlying clinical conditions, age was also a major contributor to fracture risk. In 64 of 145 patients, MRI and multidetector CT (MDCT) findings were compared. The terminology of atraumatic . These bones can become especially weak, thin, and frail due to osteoporosis, vitamin D deficiency, or aging. A history of corticosteroid therapy within the previous 6 months was recorded in 18 of 145 (12.4%) patients. The imaging characteristics of bisphosphonate-related insufficiency fractures that we describe are, in our experience, unique and easily recognized by a trained observer. 1 article features images from this case 2 and 3A, 3B). 2016 Oct;45(10):1425-9. doi: 10.1007/s00256-016-2443-2. Case Discussion. Each patient was receiving an oral bisphosphonate at the time of fracture. In 64 of 145 patients, CT studies performed with one of several MDCT scanners (8-, 16-, and 64-MDCT scanners, LightSpeed Series, GE Healthcare) were available in addition to MRI. eCollection 2021 Oct. Sonoda K, Yamamoto T, Motomura G, Karasuyama K, Kubo Y, Iwamoto Y. Skeletal Radiol. MRI is the superior technique compared with CT and should be the imaging technique of choice in patients with suspected insufficiency fractures. CT is also used as an imaging procedure for insufficiency fractures in the pelvis. Fractures, or fracturelike conditions, within the proximal femoral diaphysis seen in the setting of low-energy trauma do occur in other clinical situations. Bookshelf 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. In addition, the absence or presence of a bone marrow edema pattern and fracture lines was documented. Epidemiology Radiologists also must be aware that multiple pelvic insufficiency fractures are frequently found, particularly in the presence of a pubic or an acetabular fracture. Skeletal Radiol. Only studies that covered the whole sacrum were included. Specifically, the location of the fracture with respect to the femoral shaft, the presence of localized lateral cortical thickening, and the appearance of the fracture lucency (transverse, oblique, or comminuted) were documented. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . 2000) (Fig. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. An MRI is a form of diagnostic advanced medical imaging used to diagnose a variety of orthopedic conditions. 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]. The diagnosis was confirmed histologically in 4 patients. 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%). Gilbert, AZ 85297, 2940 E. Banner Gateway Dr., Ste. 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. [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. Fractures within this region require high energy if the bone mineralization is normal. The clinical and radiological findings in 7 patients with subchondral insufficiency fractures of the femoral head were reviewed retrospectively. FOIA The site is secure. The ability of both imaging techniques to detect fracture lines was compared. Diagnosis of Proximal Femoral Insufficiency Fractures in Patients Receiving Bisphosphonate Therapy, Original Research. However, only a small subset of patients underwent radionuclide and DXA studies, which prevented a statistically representative analysis. Subchondral insufficiency fracture of the femoral head. A subchondral fracture may also be due to chronic low intensity stress. The most common fractures were located at the sacrum (n = 67) and the pubic ramus (n = 29) (Figs. In the subgroup undergoing both imaging techniques, MRI detected 128 of 129 (99%) fractures in 63 of 64 (98%) subjects, whereas CT detected only 89 of 129 (69%) fractures in 34 of 64 (53%) subjects. 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. 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. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. All occurred in Caucasian women with severe osteoporosis. 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]. Enjoy the freedom of a pain-free, active lifestyle with help from our orthopedic specialists. ( 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. In a subset of patients, anteroposterior pelvic and hip radiographs were also analyzed. In addition, two or more insufficiency fractures were frequently present, typical fracture combinations were found, and insufficiency fractures were frequently associated with malignant disease. MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur, Original Research. Subchondral insufficiency fracture - femoral head. Forty percent of the 25 patients with femoral fractures had concomitant fractures. Email | workcomp@orthoarizona.org. collagen formation: Marfan syndrome, fibrous dysplasia. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. Thank you for contacting our Performance Team! A third MRI location will be opening at our Arcadia (44th St. & Thomas Rd.) Fifty-seven of the 64 patients had at least one soft-tissue lesion, for a total of 103 lesions. Magnetic resonance imaging showed a low-signal band on T1- and T2-weighted images in the subchondral bone adjacent or parallel to the articular surface associated with bone marrow oedema. However, the clinical presentation and imaging features of these entities provide differentiating clues. 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]. Subchondral insufficiency fractures are typically found in older female patients with . location this Summer 2022, conveniently located in the Phoenix/Scottsdale region. A 65-year-old woman with insufficiency-type subchondral stress fracture of the femoral head. Grangier et al. Methods: Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. These fractures are treated with a trochanteric-entry nail, either one or two proximal lag screws, and distal interlocking screw fixation. These findings are considered characteristic of primary osteomalacia [10]. 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. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. Thirty-one patients had CT scans and radiographs available, and of the 63 fractures visualized with CT, radiographs visualized only 13 (20.6%). Schilcher and Aspenberg [9] report a study of 91,956 women older than 55 years of whom 3,087 (3.4%) were receiving continuous treatment with bisphosphonate drugs. 2003 Feb;180(2):363-8. doi: 10.2214/ajr.180.2.1800363. 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. You can use Radiopaedia cases in a variety of ways to help you learn and teach. official website and that any information you provide is encrypted MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur, Overall Characteristics of Insufficiency Fractures Based on MRI Findings, Review. In nine of 63 patients (14.3%), hematologic malignancies were recorded, and in six (9.5%) breast cancer was diagnosed. -, Radiology. 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. Fractures related to Paget disease show one or more fracture lucencies projecting through the cortex along the convex margin of the femur; however, concomitant deformity of the femoral shaft is also present [10]. Check for errors and try again. In the 39 thick-section CT studies, 73 total fractures were diagnosed and only 65.7% (48/73) were detected. The proximal femur is routinely exposed to high-energy maximal-bending movements [2, 8]. Subchondral insufficiency fractures of the hip have been identified as a cause of accelerated osteoarthritis . Would you like email updates of new search results? 182 Radiology 14Case 179-183Reports (2019) should be addressed based on the location in this case, is an Thirteen insufficiency stress fractures of the femoral neck in 13 elderly patients (average age, 82 years) were studied retrospectively. We report six cases of insufficiency fractures of the medial femoral condyle responsible for severe mechanical pain in the medial knee compartment in the absence of any identifiable precipitating factor. Alternatively, insufficiency fractures typically present as focal cortical thickening with a transverse lucency within the lateral cortex. -, Radiology. In the CT study, a small subtle cortical irregularity at the posterior femoral neck was shown. The fracture was missed on the MR images because of partial volume effects and adjacent joint effusion along with motion artifacts. MRI is sensitive in the detection of these fractures. When an insufficient-appearing proximal femur fracture was identified, the images were independently reviewed by three radiologists, and characteristics were classified. Unable to load your collection due to an error, Unable to load your delegates due to an error. In addition, patients 1 and 3 switched to ibandronate sodium and risedronate, respectively, before fracture. 100 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]. 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. Forty-eight patients had radiographs available as well as MR images. 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. 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%]). They are most commonly associated with osteopenic or osteoporotic bone and the female athlete triad in young athletes. 1987;33(5):302-6 Key features of atypical femoral fractures, essential for the diagnosis, are: location in the subtrochanteric region and diaphysis; lack of trauma history and comminution; and a transverse or short oblique configuration. Neck of femur fractures (NOF), a.k.a. 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. Frequently these fractures are radiographically occult [7, 8]; and some of these fractures, in particular sacral insufficiency fractures, are relatively underdiagnosed [9]. Other important findings were that patients frequently had multiple pelvic insufficiency fractures and that pubic fractures in particular were typically associated with concomitant fractures. 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. 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]. Caution should be exercised when one site with an insufficiency fracture is discovered because other fracture sites likely exist. 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. 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. ADVERTISEMENT: Supporters see fewer/no ads. Case Report Figure 1A, 1B, 1C, 1D shows an example of a sacral fracture visualized with MRI but not with CT. A mild bone marrow edema pattern was more frequently associated with femoral fractures (18/49, 36.7%). Again, cases with no fractures lines were most often located at the sacrum (n = 6); and in all of these cases, increased sclerosis was present. 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. MRI studies obtained at 1.5 T were analyzed in 145 patients with pelvic insufficiency fractures. The MRI, CT, and radiographic studies were analyzed separately in random order by two radiologists in consensus. 1A, 1B, 1C, 1D, 1E). Femoral, acetabular, and pubic fractures had the highest proportion of associated soft-tissue abnormalities. Radiation-induced insufficiency fracture of the femur 18 years after radiation therapy. Find top doctors who perform Hip Femur Fractures and Dislocations near you in Chandler, AZ. Many patients present with a complete and significantly displaced fracture of the proximal femoral shaft as a result. On average, patients with sacral fractures were older (67.6 17.5 years) than those with femoral fractures (61.2 19.8 years), yet differences were not significant. Radiography is the imaging modality of choice for baseline diagnosis. Ikemura S, Yamamoto T, Motomura G, Nakashima Y, Mawatari T, Iwamoto Y. AJR Am J Roentgenol. 1675 E. Melrose St., Ste. In addition, MRI and CT usually can be obtained faster, particularly in an emergency setting, and cross-sectional techniques are superior in differentiating insufficiency fractures from tumor invasion or metastatic disease. MRI has greatly improved our ability As shown by the results of this study, MRI detected significantly (p < 0.01) more pelvic insufficiency fractures than CT. Interestingly, insufficiency fractures were associated with prior malignancy in 63 of 145 (34.4%) patients. [20] reported six patients with osteoporotic sacral insufficiency fractures; although all six were visualized with MRI, only five were shown with CT. Those authors recommended gadolinium-enhanced MRI to better differentiate insufficiency fracture from malignant disease and to exclude intraosseous tumor formation. Therefore, if it is available, MRI should be the primary diagnostic technique when insufficiency or occult pelvic fractures are suspected. femoral neck fractures, are common injuries sustained by older patients who are both more likely to have unsteadiness of gait and reduced bone mineral density, predisposing to fracture. 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. The p value for the McNemar test was < 0.0001, showing that MRI had significantly enhanced sensitivity for finding fractures compared with CT. A noncontrast magnetic resonance imaging (MRI) of the right femur was performed in conjunction with the CT ().On T1-weighted sequences (Figs. 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]. Consequently, the entire pelvis must be imaged in these patients, and a careful search for concomitant fractures is always warranted. Basic descriptive statistics were used. Marrow edema involving head of left femur with subchondral flattening, irregularity of anterosuperior aspects. 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. Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head. Polesello G, Sakai DS, Ono NK, Honda EK, Guimaraes RP, Jnior WR. In 29 of 63 patients (46.0%), the primary tumor was located in the pelvis; 24 of these patients had gynecologic malignancies. Bethesda, MD 20894, Web Policies Again, sacral fractures were shown infrequently (6.1%, 2/33). However, those authors concluded that MRI, although more sensitive than CT, may be misleading; they controversially recommended CT as the better imaging technique. In our study, we used both STIR and fat-saturated T2-weighted sequences, which are sensitive to fractures and the bone marrow edema pattern, but we did not use gadolinium-based contrast agents. Subacute hematoma was documented if signal abnormality was high on T1-weighted images (indicating the presence of methemoglobin). ( a) Plain radiograph taken 2 months before the onset of left hip pain shows no remarkable abnormalities. 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. All four patients reported a low-energy inciting event as the cause for presentation. CT examinations were studied for absence or presence of a fracture as well as number and location of fractures. Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in both athletes and patients with predisposing conditions. 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. MRI detected 102 of 103 lesions (99%), whereas CT identified only 13 of 103 lesions (12.6%). Subchondral Insufficiency Fracture of Femoral head: Uncommon cause of Hip pain in Elderly. The imaging findings of bisphosphonate-related femoral insufficiency fractures, which include a typical proximal diaphyseal location and transverse liner radiolucency through localized thickening of the lateral cortex, allow a specific diagnosis. The definition of a standard of reference for a study in which no surgical procedures or patho logic examinations are performed is challenging. Keywords: comparative studies, CT, MRI, pelvic insufficiency fractures, proximal femur insufficiency fractures. No statistically significant differences were seen between the two groups in any of these covariates. Stress fractures can further be categorized as a fatigue fracture or an insufficiency fracture. THE IMPORTANCE OF THE DIAGNOSIS OF SUBCHONDRAL FRACTURE OF THE FEMORAL HEAD, HOW TO DIFFERENTIATE IT FROM AVASCULAR NECROSIS AND HOW TO TREAT IT. 125 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. 2002 Jan;31(1):35-8 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. MRI missed one soft-tissue lesion at the erector spinae muscles because of incomplete fat saturation. 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. 1E). -, Am J Surg Pathol. Stress fractures occur in young military recruits and athletes and involve the medial cortex when in the proximal femur [1015]. 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. The purpose of this article is to describe the imaging features of proximal femoral insufficiency fractures in patients on long-term bisphosphonate therapy. Involvement of the contralateral femur varies in the literature, ranging from 20% to 64% [3, 68]. 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. 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. With CT, a similar percentage of fracture lines was shown (78/89, 89.7%). Subtle subchondral irregular, linear hypointensity seen parallel to articular surface.Marrow edema is extending to neck. 1A, 1B, 1C, 1D, 2A, 2B, 2C, 3A, 3B, 3C). Student's two-tailed t tests and Fisher's exact tests with a 5% level of significance were used to compare known fracture risk factors and patient characteristics between patients in the two subgroups. The https:// ensures that you are connecting to the J Orthop Case Rep. 2012 Apr-Jun;2(2):7-9. 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%). All four patients had taken alendronate for at least 3 years before injury. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. Subacute hematoma was documented in only two of 145 patients. Atypical femoral fractures (AFF) are stress or 'insufficiency' fractures, often complicated by the use of bisphosphonates or other bone turnover inhibitors. The technetium-99mlabeled methylene diphosphonate bone scan appearance is that of a focus of increased uptake within the lateral cortex of the affected proximal femur. Treatment in pelvic insufficiency fractures varies according to the affected site; although sacral insufficiency fractures are usually treated with analgesia and bed rest, acetabular and femur fractures may require surgical therapy. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-80488. However, irradiated bone is especially weakened and prone to insufficiency fractures, as shown previously [13]. The most recent lumbar spine bone mineral density T score for patient 1, acquired over 1 year before fracture, was 2. Radiographs were performed in all patients, MRI in 5 and scintigraphy in 4 patients. The sensitivities of CT and MRI were compared using a paired proportion test (the McNemar test). Keywords: bisphosphonate, femur, fracture, insufficiency, subtrochanteric. Similar insufficiency fractures among patients not receiving bisphosphonates are extremely rare. Insufficiency fractures occur in abnormal bonethat is, bone commonly affected by generalized osteoporosisas a result of normal activity such as walking. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The Rotator Interval: A Review of Anatomy, Function, and Normal and Abnormal MRI Appearance, Pictorial Essay. 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. 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 retrospective study was approved by our local committee on human research. 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. Staatz et al. 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. -. CT showed all ischial fractures. Conversely, insufficiency fractures occur in the elderly and involve the lateral cortex. The terminology of atraumatic . Means and SDs were calculated for continuous variables, and frequency and proportion for categoric variables. Epub 2016 Aug 2. 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. Book an appointment today! Careers. Call 602.922.9100 to schedule an appointment! MeSH Their presence is sometimes unexpected and can lead to incorrect diagnoses and many unnecessary, costly diagnostic procedures [10]. Only a small number of studies have been performed comparing MRI and CT in diagnosing stress fractures. 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. In 102 of 145 patients (70.3%) more than one fracture was found. 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. [2] Insufficiency fractures of the spine are often a sign of frailty. insufficiency fracture of the femur 18 years after radiation therapy . A bone marrow edema pattern was diagnosed in 286 of 307 fractures (93.2%). Patient 1 presented 5 days before complete fracture with complaints of hip pain. Chen et al. Malignant lesions are frequently suspected in patients who have undergone radiation therapy and chemotherapy of the pelvis. 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. The insufficiency fracture lies within the lateral cortex of the proximal femur. Subchondral insufficiency fractures of the femoral head. A total of 145 subjects, 104 women and 41 men, with an average age of 65.9 17.7 years (average age in women, 67.7 16.2 years; in men, 61.1 20.5 years; age range, 13101 years) were identified and included in this study. An insufficiency fracture refers to normal physiologic stress applied to bone . Imaging studies were analyzed by two radiologists; combined clinical history, findings from all imaging studies, and follow-up imaging studies served as the 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]. Bone marrow edema pattern was also graded in all fractures in which it was present. Findings are suggestive of subchondral insufficiency of the medial femoral condyle, previously known as spontaneous osteonecrosis of the knee (SONK). 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). 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). However, at all other sites, 2557% of fractures were missed with CT, with the highest percentage of missed fractures at the femoral head. Overall, no significant differences (p > 0.05) in the detection rate of fractures between men and women were found. Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. Overall in the CT studies, sclerosis was present in 69 of 89 (79.3%) fractures. Slice thickness was 4 mm; matrix size, 192 192 mm; and field of view, 3236 cm. Insufficiency fractures at the tibia (Fig. Scintigraphy showed increased uptake in the femoral head. Less frequently, in up to 25 %, insufficiency fractures at the femoral shaft can occur, predominately in elderly patients with osteoporosis (Martin-Hunyadi et al. Imaging included the entire pelvis in all studies. Abstract. Please enter a valid 5-digit Zip Code. 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. The location you tried did not return a result. 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. 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 therapy. 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]. Please enable it to take advantage of the complete set of features! Many fractures were frequently associated with concomitant fractures in typical locations (Table 3). 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 . Fax | 480.324.3162. 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. 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. 102 Federal government websites often end in .gov or .mil. To identify patients with pelvic insufficiency fractures, the radiology information system of our department was searched using the terms "pelvis," "sacrum" or "femur," and . RESULTS. medications: glucocorticoids, chemotherapy. This study showed that MRI was substantially better than CT in detecting insufficiency fractures. Search doctors, conditions, or procedures . Rheumatologic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, were found in six of 145 patients (4.1%). 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. For several months, patient 1 had reported thigh pain that was misdiagnosed as being statin related. Because of the limited visualization of soft-tissue abnormalities on CT, we did not differentiate grades. MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. Chan CC, Li A, Fan WC, Sun LK, Cheng HC, Chan JC. 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). Hip Anatomic Variants That May Mimic Abnormalities at MRI: Labral Variants, Review. In particular, fractures at the femoral head and acetabulum were better detected with MRI. 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. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. The outcome of subchondral insufficiency fracture is thus unclear. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. Ann Pathol. CONCLUSION. Address correspondence to L. F. Rogers ([emailprotected]). OBJECTIVE. In all patients, the clinical history was analyzed and potential risk factors for insufficiency fractures were recorded. PMC Limitations of our study include its retrospective study design and that a relatively long time elapsed between the CT and MRI studies in some patients. In only 93 of 145 (64.1%) patients, the chief symptom leading to the MRI examination was pain. Additional comparisons were made between thin-section (slice thickness < 5 mm) and thick-section (slice thickness 5 mm) CT studies. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. The amount and intensity of soft-tissue edema were also graded higher in patients with pubic, acetabular, and femur fractures versus sacral fractures. 11). In all 145 subjects, MRI studies obtained at 1.5 T (Signa, GE Healthcare) were available. Fracture detection rates for CT and MRI were calculated using the previously described standard of reference. If proximal femur fractures are suspected, mobility of the patient should not be permitted before cross-sectional imaging has been obtained. Other frequent combinations of concomitant fractures were noted. Imaging of Anterior Cruciate Ligament Repair and Its Complications, Review. This article is available for CME credit. Unable to process the form. CT has been shown to be sensitive in depicting fracture lines and in the assessment of biomechanical stability [14]. All statistical analyses were performed using statistical software S-plus (Insightful) and SAS software (SAS). Epub 2016 Aug 24. This is especially true of pubic fractures; 90% of the pubic fractures in this study had concomitant fractures present. Insufficiency fractures of the pelvis and proximal femur are usually found in elderly subjects and are the result of normal stress placed on abnormal bone that may be a complication of osteoporosis or previous radiation therapy but can also be the result of rheumatoid arthritis, prolonged corticosteroid therapy, renal failure, and mechanical changes after hip surgery [15]. Also, insufficiency fractures were frequently associated with a history of malignant disease. 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