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]. In 29 of 63 patients (46.0%), the primary tumor was located in the pelvis; 24 of these patients had gynecologic malignancies. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-80488. 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 . Of the 88 fractures diagnosed with both imaging techniques, 32 of 88 (36.4%) fractures were better depicted with MRI, 26 (29.5%) better with CT, and 30 (34.1%) fractures were visualized equally well with both techniques. 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. 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). ( 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. Despite the cost of MRI and CT, it is important to quickly diagnose and treat these fractures. Gilbert, AZ 85297, 2940 E. Banner Gateway Dr., Ste. 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. 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. bone remodeling: Paget disease, osteopetrosis. All four patients had taken alendronate for at least 3 years before injury. The ability of both imaging techniques to detect fracture lines was compared. The MRI, CT, and radiographic studies were analyzed separately in random order by two radiologists in consensus. An official website of the United States government. Insufficiency fractures in the osteoporotic population in this region are said to be rare [2, 7, 9]. Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, Neumann G, Valentin-Opran A, Lang P. AJR Am J Roentgenol. 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]. All statistical analyses were performed using statistical software S-plus (Insightful) and SAS software (SAS). Accessibility Subtle subchondral irregular, linear hypointensity seen parallel to articular surface.Marrow edema is extending to neck. Address correspondence to L. F. Rogers ([emailprotected]). Federal government websites often end in .gov or .mil. 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. 180 Radiology Case Reports 14 (2019) 179-183. The insufficiency fracture lies within the lateral cortex of the proximal femur. 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. These include stress fractures (fractures involving normal bone subject to a repetitive stress), pseudofractures of osteomalacia, and pathologic fractures [10]. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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. 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. 2021 Sep 4;11:122-126. doi: 10.1016/j.artd.2021.08.004. J Orthop Case Rep. 2012 Apr-Jun;2(2):7-9. 2000 Mar;24(3):464-8 In addition, two or more insufficiency fractures were frequently present, typical fracture combinations were found, and insufficiency fractures were frequently associated with malignant disease. The fracture was missed on the MR images because of partial volume effects and adjacent joint effusion along with motion artifacts. [2] Insufficiency fractures of the spine are often a sign of frailty. A noncontrast magnetic resonance imaging (MRI) of the right femur was performed in conjunction with the CT ().On T1-weighted sequences (Figs. The clinical and radiological findings in 7 patients with subchondral insufficiency fractures of the femoral head were reviewed retrospectively. We used binomial exact confidence intervals, also known as Clopper and Pearson confidence intervals. These findings are considered characteristic of primary osteomalacia [10]. Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. However, only a small subset of patients underwent radionuclide and DXA studies, which prevented a statistically representative analysis. Subchondral Insufficiency Fracture of Femoral head: Uncommon cause of Hip pain in Elderly. 2016 Oct;45(10):1425-9. doi: 10.1007/s00256-016-2443-2. Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know. 2009 Nov;29 Spec No 1:S88-9. Subacute hematoma was documented in only two of 145 patients. In six of 145 patients (4.1%) organ transplantation had been performed (two heart and two liver transplants), and in eight of 145 patients (5.5%) chronic renal failure was recorded. [A femur head--does it have anything to say?]. Types of Insufficiency Fractures Insufficiency fractures are most likely to happen in areas of your body that carry a lot of your weight, particularly your pelvis, spine, and hips. To date, to our knowledge, there is only one report in the radiologic literature describing these fractures [2]. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. 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. Interestingly, insufficiency fractures were associated with prior malignancy in 63 of 145 (34.4%) patients. The purpose of this article is to describe the imaging features of proximal femoral insufficiency fractures in patients on long-term bisphosphonate therapy. 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. MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur, Original Research. Fractures within this region require high energy if the bone mineralization is normal. An incorrect diagnosis may initiate invasive and costly procedures that could be harmful to the patient or that could misguide therapy. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. 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. 12 a-c) may be found as an early manifestation of bone failure in patients after renal transplantation as reported by a . 11). 1987;33(5):302-6 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. doi: 10.2214/AJR.09.3271. The most common fractures were located at the sacrum (n = 67) and the pubic ramus (n = 29) (Figs. sharing sensitive information, make sure youre on a federal Each patient was receiving an oral bisphosphonate at the time of fracture. Case Discussion. She tripped at an unspecified event, falling from ground level, and felt severe pain in her leg. In particular, fractures at the femoral head and acetabulum were better detected with MRI. 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. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. 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. Gaeta et al. 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. A fatigue fracture is due to abnormal stress placed on normal bone, such as training for a marathon. However, the clinical presentation and imaging features of these entities provide differentiating clues. 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. 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. 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]. Careers. 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]. 2010 Jul;195(1):W63-8. However, exact data from a larger patient population are not available. Please enter a valid 5-digit Zip Code. Subchondral insufficiency fractures are a relatively common cause of knee pain, particularly in older patients. The appearance of the fracture mimics that of a tibial striation, or stress fracture, seen in the anterior cortex of the tibia. This is especially true of pubic fractures; 90% of the pubic fractures in this study had concomitant fractures present. Diagnosis of Proximal Femoral Insufficiency Fractures in Patients Receiving Bisphosphonate Therapy, Original Research. Also, the number of fractures in an individual patient increased with age. 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. In the case of pubic fractures, 89.2% (33/37) of patients with pubic fractures had one or more fractures at another site. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. A vague pain about the hip, of spontaneous onset, was the main symptom on first visit. 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. Hip Anatomic Variants That May Mimic Abnormalities at MRI: Labral Variants, Review. 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. An MRI is a form of diagnostic advanced medical imaging used t o diagnose a variety of orthopedic conditions. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. 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). insufficiency fracture of the femur 18 years after radiation therapy . 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. We will be responding to your message shortly! -, Am J Surg Pathol. 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. dyle insufficiency fracture,^ Bspontaneous osteonecrosis knee,^ and/or BSONK^ in the radiology report impression. 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. A transverse fracture of the proximal femur with associated localized thickening of the lateral cortex in a postmenopausal woman receiving long-term bisphosphonate therapy should be considered diagnostic for a bisphosphonate-related insufficiency fracture. and transmitted securely. 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. Epidemiology Patient 3 tripped over a small step while exiting her home and heard a crack with the next step. 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. A mild bone marrow edema pattern was more frequently associated with femoral fractures (18/49, 36.7%). A fracture line was defined as a linear structure visualized on either STIR, T1-weighted, or fat-saturated T2-weighted fast spin-echo sequences. Phoenix, AZ 85018, Privacy Policy | Sitemap | Copyright 2022 OrthoArizona | Digital Marketing by CD Agency. Epub 2009 Oct 6. 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). Find top doctors who perform Hip Femur Fractures and Dislocations near you in Chandler, AZ. Comparisons were also drawn between MRI and CT in the ability to detect soft-tissue abnormalities. The definition of a standard of reference for a study in which no surgical procedures or patho logic examinations are performed is challenging. 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]. 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. Additional comparisons were made between thin-section (slice thickness < 5 mm) and thick-section (slice thickness 5 mm) CT studies. In all 145 subjects, MRI studies obtained at 1.5 T (Signa, GE Healthcare) were available. Overall in the CT studies, sclerosis was present in 69 of 89 (79.3%) fractures. Again, sacral fractures were shown infrequently (6.1%, 2/33). MRI has greatly improved our ability 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. MRI missed one soft-tissue lesion at the erector spinae muscles because of incomplete fat saturation. Increased awareness of this condition will hopefully lead to earlier diagnosis and a successful outcome of conservative treatment. 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. High-Resolution 3-T MRI of the Fingers: Review of Anatomy and Common Tendon and Ligament Injuries, Review. FOIA No prior thigh or groin pain was documented in records. MATERIALS AND METHODS. 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%). To identify patients with pelvic insufficiency fractures, the radiology information system of our department was searched using the terms pelvis, sacrum or femur, and stress fractures or insufficiency fractures, for the time period from January 1, 1997, through June 27, 2007. Fractures averaged 2.1 per patient (range, 16 fractures per patient). Sensitivities were calculated as the percentage of patients identified by each technique based on this standard of reference, and confidence intervals were provided. 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. Rev Bras Ortop. 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. Elderly osteoporotic women are at greatest risk. Staatz et al. Thank you for contacting our Performance Team! Imaging Key Wrist Ligaments: What the Surgeon Needs the Radiologist to Know. However, comparison with our study is limited because those investigators examined fatigue fractures, which have different bone mass and quality. MeSH Arthroplast Today. Skeletal Radiol. Radiologists also must be aware that multiple pelvic insufficiency fractures are frequently found, particularly in the presence of a pubic or an acetabular fracture. 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. 2012 Sep;4(3):173-80. doi: 10.4055/cios.2012.4.3.173. 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. 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. 2016 Nov;45(11):1515-21. doi: 10.1007/s00256-016-2462-z. You can use Radiopaedia cases in a variety of ways to help you learn and teach. [3] compared MRI and CT findings in nine patients with insufficiency fractures of the sacrum and acetabular roof and found that three fractures were missed on CT. Those authors also recommended MRI as the best diagnostic test, comparing it not only with CT but also with bone scintigraphy and radiography. According to a previously published study [8], MRI is more sensitive than bone scintigraphy in the early stages of insufficiency fractures. In 70.3% of cases, multiple fracture sites were present. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments, Superior Labral Anteroposterior Tear: Classification and Diagnosis on MRI and MR Arthrography, Review. -, Radiology. All four patients reported a low-energy inciting event as the cause for presentation. Means and SDs were calculated for continuous variables, and frequency and proportion for categoric variables. Subacute hematoma was documented if signal abnormality was high on T1-weighted images (indicating the presence of methemoglobin). Patient 1 presented 5 days before complete fracture with complaints of hip pain. MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur, Overall Characteristics of Insufficiency Fractures Based on MRI Findings, Review. Enjoy the freedom of a pain-free, active lifestyle with help from our orthopedic specialists. Keywords: comparative studies, CT, MRI, pelvic insufficiency fractures, proximal femur insufficiency fractures. 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. From the search results, MRI and CT studies with a reported diagnosis of pelvic, sacral, or proximal femur insufficiency fractures were selected. Femoral, acetabular, and pubic fractures had the highest proportion of associated soft-tissue abnormalities. Table 2 lists locations of all 307 fractures found in the 145 patients. 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. Frequently these fractures are radiographically occult [7, 8]; and some of these fractures, in particular sacral insufficiency fractures, are relatively underdiagnosed [9]. location this Summer 2022, conveniently located in the Phoenix/Scottsdale region. 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. Rheumatologic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, were found in six of 145 patients (4.1%). This, in effect, restores the appearance of the insufficiency fracture in the lateral cortex. Methods: Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. ADVERTISEMENT: Supporters see fewer/no ads. Clin Orthop Surg. -, Gerontology. Patients 3 and 4 presented with a completely displaced transverse fracture of the proximal femoral diaphysis. Scintigraphy showed increased uptake in the femoral head. However, those authors concluded that MRI, although more sensitive than CT, may be misleading; they controversially recommended CT as the better imaging technique. This site needs JavaScript to work properly. 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. The .gov means its official. eCollection 2021 Oct. Sonoda K, Yamamoto T, Motomura G, Karasuyama K, Kubo Y, Iwamoto Y. Skeletal Radiol. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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. 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. 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. [2]; these include a low-signal band on T1-weighted imaging adjacent to the subchondral . In 64 of 145 patients, MRI and multidetector CT (MDCT) findings were compared. 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. The pelvis protocol covered the proximal femur at least down to the lesser tro chanter and was used also for suspected hip fractures. 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. Epub 2016 Aug 2. In addition to determining which technique performed better in visualizing fractures, we also compared the two methods for depiction of fracture morphology. 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]. Rapid Destruction of the Hip Joint After Acetabular Fracture in an Elderly Patient. 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 . Bethesda, MD 20894, Web Policies The anteroposterior radiograph of the affected hip acquired on initial presentation included the proximal femoral shaft; however, the insufficiency fracture was overlooked. 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 addition, the absence or presence of a bone marrow edema pattern and fracture lines was documented. The reduction is usually complete, and the apposition is often immediate. [21] in 15 patients with longitudinal stress fractures at the tibia. 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. 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. Fracture lines were better shown on T1-weighted sequences, and proximal femur fracture lines were best shown on sequences obtained in a coronal orientation. Insufficiency fractures occur in abnormal bonethat is, bone commonly affected by generalized osteoporosisas a result of normal activity such as walking. Before 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. Similar insufficiency fractures among patients not receiving bisphosphonates are extremely rare. Less frequently, in up to 25 %, insufficiency fractures at the femoral shaft can occur, predominately in elderly patients with osteoporosis (Martin-Hunyadi et al. The most recent lumbar spine bone mineral density T score for patient 1, acquired over 1 year before fracture, was 2. Call 602.922.9100 to schedule an appointment! Stress fractures can further be categorized as a fatigue fracture or an insufficiency fracture. No statistically significant differences were seen between the two groups in any of these covariates. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. With CT, a similar percentage of fracture lines was shown (78/89, 89.7%). This search yielded 162 patients; 84 met the typical inclusion criteria of an insufficiency fracture previously described by Yamamoto et al. 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. A 65-year-old woman with insufficiency-type subchondral stress fracture of the femoral head. 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. 1A, 1B, 1C, 1D, 1E). 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]. 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). 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]. Disclaimer, National Library of Medicine 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. The outcome of subchondral insufficiency fracture is thus unclear. Call 602.922.9100 to schedule an appointment! Their presence is sometimes unexpected and can lead to incorrect diagnoses and many unnecessary, costly diagnostic procedures [10]. 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. 1989 Apr;171(1):135-40 Only studies that covered the whole sacrum were included. 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. 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. Radiation-induced insufficiency fracture of the femur 18 years after radiation therapy. 2015 Nov 16;44(2):102-5. doi: 10.1016/S2255-4971(15)30055-0. eCollection 2009 Jan. Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. Schilcher and Aspenberg calculated the relative risk and found a 46 times increased risk of insufficiency fractures for patients taking bisphosphonates. Please enable it to take advantage of the complete set of features! Alternatively, insufficiency fractures typically present as focal cortical thickening with a transverse lucency within the lateral cortex. This information, in conjunction with the radiologic findings, can lead to a correct diagnosis. 3A, 3B, 3C). Fracture detection rates for CT and MRI were calculated using the previously described standard of reference. Grangier et al. This retrospective study was approved by our local committee on human research. Overall, no significant differences (p > 0.05) in the detection rate of fractures between men and women were found. Marrow edema involving head of left femur with subchondral flattening, irregularity of anterosuperior aspects. medications: glucocorticoids, chemotherapy. A subchondral fracture may also be due to chronic low intensity stress. The clinicopathologic findings of a subchondral insufficiency fracture of the femoral head in a male patient: a case report. 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. For several months, patient 1 had reported thigh pain that was misdiagnosed as being statin related. MRI is sensitive in the detection of these fractures. Abstract. collagen formation: Marfan syndrome, fibrous dysplasia. CT examinations were studied for absence or presence of a fracture as well as number and location of fractures. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. 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. 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. 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. Most patients with bisphosphonate-related proximal femoral insufficiency fractures have noted nonspecific prodromal pain in the affected thigh or groin, which has often been misconstrued or misdiagnosed as being due to degenerative disease of the lower lumbar spine and sacroiliac joints [7, 8]. CT is also used as an imaging procedure for insufficiency fractures in the pelvis. Upon stepping off a scale at her clinician's office, she heard a pop followed by weakness and eventually fell to the ground. CONCLUSION. 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]. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. As shown by the results of this study, MRI detected significantly (p < 0.01) more pelvic insufficiency fractures than CT. In addition, patients 1 and 3 switched to ibandronate sodium and risedronate, respectively, before fracture. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. In the precomplete fracture stage of the disease, we found the radiographic findings to be subtle and easy to overlook. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. MRI studies obtained at 1.5 T were analyzed in 145 patients with pelvic insufficiency fractures. OBJECTIVE. The contralateral femur showed similar findings [2]. Fax | 480.324.3162. 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]. An insufficiency fracture refers to normal physiologic stress applied to bone . A third MRI location will be opening at our Arcadia (44th St. & Thomas Rd.) The diagnosis was delayed in most cases because the . Epub 2016 Aug 24. All patients underwent MRI and were assessed for the absence or presence of a fracture as well as number and location of 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 . PMC Radiography is the imaging modality of choice for baseline diagnosis. OBJECTIVE. Many patients present with a complete and significantly displaced fracture of the proximal femoral shaft as a result. 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. In the CT study, a small subtle cortical irregularity at the posterior femoral neck was shown. However, consideration should be given to the implications of a missed diagnosis that may misdirect or delay treatment. Chan CC, Li A, Fan WC, Sun LK, Cheng HC, Chan JC. All occurred in Caucasian women with severe osteoporosis. Gilbert, AZ 85234, 3033 N. 44th St. Ste. Twenty-five patients were diagnosed with acetabular fractures, and in 19 (76%) of these patients concomitant fractures were present. 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. 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. 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. 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. 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]. 102 Ikemura S, Yamamoto T, Motomura G, Nakashima Y, Mawatari T, Iwamoto Y. AJR Am J Roentgenol. Other frequent combinations of concomitant fractures were noted. 182 Radiology 14Case 179-183Reports (2019) should be addressed based on the location in this case, is an 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. -, Radiology. 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. Polesello G, Sakai DS, Ono NK, Honda EK, Guimaraes RP, Jnior WR. Malignant lesions are frequently suspected in patients who have undergone radiation therapy and chemotherapy of the pelvis. Conversely, insufficiency fractures occur in the elderly and involve the lateral cortex. Involvement of the contralateral femur varies in the literature, ranging from 20% to 64% [3, 68]. 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%). Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. In the 39 thick-section CT studies, 73 total fractures were diagnosed and only 65.7% (48/73) were detected. Although the institution has specialized centers such as a cancer center, it also covers all other medical subspecialties, including family medicine, and it has a large emergency department. Find a doctor near you. Most notably, only 3.8% (2/53) of sacral fractures and only 11% (1/9) of acetabular fractures were detected. 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. Radiographs were performed in all patients, MRI in 5 and scintigraphy in 4 patients. 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. Subchondral insufficiency fractures of the hip have been identified as a cause of accelerated osteoarthritis . In all patients, the clinical history was analyzed and potential risk factors for insufficiency fractures were recorded. Would you like email updates of new search results? 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 presents as a transverse fracture line through a localized area of thickening involving the lateral aspect of the cortex [1, 68]. 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 IMPORTANCE OF THE DIAGNOSIS OF SUBCHONDRAL FRACTURE OF THE FEMORAL HEAD, HOW TO DIFFERENTIATE IT FROM AVASCULAR NECROSIS AND HOW TO TREAT IT. The location you tried did not return a result. 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. 1 Department of Radiology and Biomedical Imaging, University of California at San Francisco, 400 Parnassus Ave, A-367, San Francisco, CA 94131. . 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. 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. This study showed that MRI was substantially better than CT in detecting insufficiency fractures. Bisphosphonates function by inhibiting bone resorption by suppressing osteoclasts through apoptosis [7, 8]. In only 93 of 145 (64.1%) patients, the chief symptom leading to the MRI examination was pain. 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! Patient 2 presented to the emergency department in the precomplete fracture stage, before displacement, with less-pronounced findings evident in the contralateral femur. Insufficiency fractures at the tibia (Fig. 8600 Rockville Pike Slice thickness was 4 mm; matrix size, 256 192 mm; and field of view, 1624 cm. 1675 E. Melrose St., Ste. In our study, we used all available imaging data and imaging follow-up, together with the clinical history, as a standard of reference. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. Forty-eight patients had radiographs available as well as MR images. The sensitivities of CT and MRI were compared using a paired proportion test (the McNemar test). The Rotator Interval: A Review of Anatomy, Function, and Normal and Abnormal MRI Appearance, Pictorial Essay. 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. November 2018; Radiology Case Reports 14(2):179-183; . Fractures, or fracturelike conditions, within the proximal femoral diaphysis seen in the setting of low-energy trauma do occur in other clinical situations. Email | workcomp@orthoarizona.org. 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]. A bone marrow edema pattern was diagnosed in 286 of 307 fractures (93.2%). These fractures are treated with a trochanteric-entry nail, either one or two proximal lag screws, and distal interlocking screw fixation. 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. However, irradiated bone is especially weakened and prone to insufficiency fractures, as shown previously [13]. 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. 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]. The site is secure. Other important findings were that patients frequently had multiple pelvic insufficiency fractures and that pubic fractures in particular were typically associated with concomitant fractures. [22] argued that CT was better because of cost, diagnostic rate, and ease of fracture line visualization. Basic descriptive statistics were used. 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. 2002 Jan;31(1):35-8 The diagnosis was confirmed histologically in 4 patients. Signs of a soft-tissue lesion included muscle swelling, fat-tissue stranding, and active extravasation of contrast material on contrast-enhanced studies. 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. Many fractures were frequently associated with concomitant fractures in typical locations (Table 3). CONCLUSION. The imaging characteristics of bisphosphonate-related insufficiency fractures that we describe are, in our experience, unique and easily recognized by a trained observer. 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. Fifty-seven of the 64 patients had at least one soft-tissue lesion, for a total of 103 lesions. MRI of the pelvis revealed a thickened lateral cortex with a focus of abnormally high signal. Thirty-one patients had CT scans and radiographs available, and of the 63 fractures visualized with CT, radiographs visualized only 13 (20.6%). 100 Keywords: bisphosphonate, femur, fracture, insufficiency, subtrochanteric. Consequently, the entire pelvis must be imaged in these patients, and a careful search for concomitant fractures is always warranted. 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. However, statistical analysis proved this difference to be insignificant (p = 0.243). A history of corticosteroid therapy within the previous 6 months was recorded in 18 of 145 (12.4%) patients. 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. Ann Pathol. In a subset of patients, anteroposterior pelvic and hip radiographs were also analyzed. 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). 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