doi: 10.2214/AJR.09.3271. collagen formation: Marfan syndrome, fibrous dysplasia. 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. 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. 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]. Unable to load your collection due to an error, Unable to load your delegates due to an error. 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]. Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. . The rationale for this cutoff value was the altered bone metabolism in patients with insufficiency fractures that also induced delayed fracture healing, with a healing period of at least several months [17, 18]. The Rotator Interval: A Review of Anatomy, Function, and Normal and Abnormal MRI Appearance, Pictorial Essay. In 29 of 63 patients (46.0%), the primary tumor was located in the pelvis; 24 of these patients had gynecologic malignancies. High-Resolution 3-T MRI of the Fingers: Review of Anatomy and Common Tendon and Ligament Injuries, Review. ADVERTISEMENT: Supporters see fewer/no ads. 8600 Rockville Pike 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. Only studies that covered the whole sacrum were included. We used binomial exact confidence intervals, also known as Clopper and Pearson confidence intervals. Keywords: comparative studies, CT, MRI, pelvic insufficiency fractures, proximal femur insufficiency fractures. The reduction is usually complete, and the apposition is often immediate. Therefore, if it is available, MRI should be the primary diagnostic technique when insufficiency or occult pelvic fractures are suspected. 1675 E. Melrose St., Ste. A mild bone marrow edema pattern was more frequently associated with femoral fractures (18/49, 36.7%). 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. 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. Pathologic fractures of the proximal femoral diaphysis are nearly always transverse and typically are due to metastatic disease, Paget disease, or fractures through preexisting Looser zones. Again, sacral fractures were shown infrequently (6.1%, 2/33). Fax | 480.324.3162. 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. Arthroplast Today. 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. 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). Characteristic features were seen in retrospect on complete fracture. 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]. Despite the cost of MRI and CT, it is important to quickly diagnose and treat these fractures. 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. 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]. Diagnosis of Proximal Femoral Insufficiency Fractures in Patients Receiving Bisphosphonate Therapy, Original Research. MATERIALS AND METHODS. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-80488. 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. sharing sensitive information, make sure youre on a federal Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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). 1987;33(5):302-6 Fracture lines were better shown on T1-weighted sequences, and proximal femur fracture lines were best shown on sequences obtained in a coronal orientation. 182 Radiology 14Case 179-183Reports (2019) should be addressed based on the location in this case, is an Overall, no significant differences (p > 0.05) in the detection rate of fractures between men and women were found. MRI is sensitive in the detection of these fractures. 1989 Apr;171(1):135-40 Rapid Destruction of the Hip Joint After Acetabular Fracture in an Elderly Patient. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. This site needs JavaScript to work properly. The purpose of this article is to describe the imaging features of proximal femoral insufficiency fractures in patients on long-term bisphosphonate therapy. ( a) Plain radiograph taken 2 months before the onset of left hip pain shows no remarkable abnormalities. OrthoArizona offers on-site MRI, with TWO convenient locations near our established clinic sites in North & South Gilbert! Search doctors, conditions, or procedures . Insufficiency fractures occur in abnormal bonethat is, bone commonly affected by generalized osteoporosisas a result of normal activity such as walking. 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 .gov means its official. An MRI is a form of diagnostic advanced medical imaging used to diagnose a variety of orthopedic conditions. 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 . 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. Upon stepping off a scale at her clinician's office, she heard a pop followed by weakness and eventually fell to the ground. Epub 2016 Aug 24. In our study, we used all available imaging data and imaging follow-up, together with the clinical history, as a standard of reference. THE IMPORTANCE OF THE DIAGNOSIS OF SUBCHONDRAL FRACTURE OF THE FEMORAL HEAD, HOW TO DIFFERENTIATE IT FROM AVASCULAR NECROSIS AND HOW TO TREAT IT. Most notably, only 3.8% (2/53) of sacral fractures and only 11% (1/9) of acetabular fractures were detected. The terminology of atraumatic . J Orthop Case Rep. 2012 Apr-Jun;2(2):7-9. Many insufficiency fractures present with completely displaced fractures of the femoral shaft, whereas such complete fractures in femoral stress fracture are uncommon [15]. However, at all other sites, 2557% of fractures were missed with CT, with the highest percentage of missed fractures at the femoral head. official website and that any information you provide is encrypted 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. Patient 1 presented 5 days before complete fracture with complaints of hip pain. Femoral, acetabular, and pubic fractures had the highest proportion of associated soft-tissue abnormalities. An insufficiency fracture refers to normal physiologic stress applied to bone . Subchondral insufficiency fracture of the femoral head. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. 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. Gilbert, AZ 85234, 3033 N. 44th St. Ste. MRI studies obtained at 1.5 T were analyzed in 145 patients with pelvic insufficiency fractures. Thirty-eight of the 64 (59.49%) CT studies were performed with IV contrast material. The pelvis protocol covered the proximal femur at least down to the lesser tro chanter and was used also for suspected hip fractures. Signs of a soft-tissue lesion included muscle swelling, fat-tissue stranding, and active extravasation of contrast material on contrast-enhanced studies. 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. 2000) (Fig. Epub 2012 Aug 14. RESULTS. 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. Rheumatologic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, were found in six of 145 patients (4.1%). This search yielded 162 patients; 84 met the typical inclusion criteria of an insufficiency fracture previously described by Yamamoto et al. In addition, patient 1 incurred a similar fracture in the contralateral femur 1 year before her current injury. Call 602.922.9100 to schedule an appointment! Also, the number of fractures in an individual patient increased with age. 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. [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. Overall in the CT studies, sclerosis was present in 69 of 89 (79.3%) fractures. PMC medications: glucocorticoids, chemotherapy. Fifty-seven of the 64 patients had at least one soft-tissue lesion, for a total of 103 lesions. All four patients had taken alendronate for at least 3 years before injury. 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. 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. Bone marrow edema pattern was also graded in all fractures in which it was present. 2012 Sep;4(3):173-80. doi: 10.4055/cios.2012.4.3.173. 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. Imaging of Anterior Cruciate Ligament Repair and Its Complications, Review. When an insufficient-appearing proximal femur fracture was identified, the images were independently reviewed by three radiologists, and characteristics were classified. 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. 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. OBJECTIVE. The diagnosis was delayed in most cases because the . Many fractures were frequently associated with concomitant fractures in typical locations (Table 3). 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. However, those authors concluded that MRI, although more sensitive than CT, may be misleading; they controversially recommended CT as the better imaging technique. Comparisons were also drawn between MRI and CT in the ability to detect soft-tissue abnormalities. 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. These findings are considered characteristic of primary osteomalacia [10]. All occurred in Caucasian women with severe osteoporosis. November 2018; Radiology Case Reports 14(2):179-183; . 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 patients underwent MRI and were assessed for the absence or presence of a fracture as well as number and location of fractures. eCollection 2021 Oct. Sonoda K, Yamamoto T, Motomura G, Karasuyama K, Kubo Y, Iwamoto Y. Skeletal Radiol. 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%). 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]. 1A, 1B, 1C, 1D, 2A, 2B, 2C, 3A, 3B, 3C). Interestingly, insufficiency fractures were associated with prior malignancy in 63 of 145 (34.4%) patients. 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. 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. 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). Sensitivities were calculated as the percentage of patients identified by each technique based on this standard of reference, and confidence intervals were provided. In nine of 63 patients (14.3%), hematologic malignancies were recorded, and in six (9.5%) breast cancer was diagnosed. MRI is the superior technique compared with CT and should be the imaging technique of choice in patients with suspected insufficiency fractures. 2003 Feb;180(2):363-8. doi: 10.2214/ajr.180.2.1800363. 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. 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. The ability of both imaging techniques to detect fracture lines was compared. The amount and intensity of soft-tissue edema were also graded higher in patients with pubic, acetabular, and femur fractures versus sacral fractures. 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. Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. The standard pelvis protocol consisted of coronal T1-weighted fast spinecho (TR/TE, 600 milli seconds/minimum) and STIR (3,000/68; inver sion time, 150 milliseconds) sequences as well as axial T1-weighted (600 milliseconds/minimum) and fat-saturated T2-weighted fast spin-echo (3,000/68) sequences. Basic descriptive statistics were used. ( 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. 2016 Nov;45(11):1515-21. doi: 10.1007/s00256-016-2462-z. 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]. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. Radiologists also must be aware that multiple pelvic insufficiency fractures are frequently found, particularly in the presence of a pubic or an acetabular fracture. MRI has greatly improved our ability 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. The appearance of the fracture mimics that of a tibial striation, or stress fracture, seen in the anterior cortex of the tibia. 180 Radiology Case Reports 14 (2019) 179-183. In 70.3% of cases, multiple fracture sites were present. In addition to underlying clinical conditions, age was also a major contributor to fracture risk. location this Summer 2022, conveniently located in the Phoenix/Scottsdale region. In the case of pubic fractures, 89.2% (33/37) of patients with pubic fractures had one or more fractures at another site. In all 145 subjects, MRI studies obtained at 1.5 T (Signa, GE Healthcare) were available. In only 93 of 145 (64.1%) patients, the chief symptom leading to the MRI examination was pain. Phoenix, AZ 85018, Privacy Policy | Sitemap | Copyright 2022 OrthoArizona | Digital Marketing by CD Agency. Many patients present with a complete and significantly displaced fracture of the proximal femoral shaft as a result. government site. The proximal femur is routinely exposed to high-energy maximal-bending movements [2, 8]. 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. Fractures, or fracturelike conditions, within the proximal femoral diaphysis seen in the setting of low-energy trauma do occur in other clinical situations. In particular, fractures at the femoral head and acetabulum were better detected with MRI. Additional comparisons were made between thin-section (slice thickness < 5 mm) and thick-section (slice thickness 5 mm) CT studies. Please enable it to take advantage of the complete set of features! Fractures averaged 2.1 per patient (range, 16 fractures per patient). Bookshelf Patients 2, 3, and 4 were treated for osteoporosis without a documented bone mineral density score in their current medical record. 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]. Call 602.922.9100 to schedule an appointment! Utsunomiya T, Yamamoto T, Motomura G, Hamai S, Iwamoto Y. Skeletal Radiol. Patients 3 and 4 presented with a completely displaced transverse fracture of the proximal femoral diaphysis. Address correspondence to L. F. Rogers ([emailprotected]). A subchondral fracture may also be due to chronic low intensity stress. Also, insufficiency fractures were frequently associated with a history of malignant disease. 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. Subchondral insufficiency fractures of the hip have been identified as a cause of accelerated osteoarthritis . 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. [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. MRI detected 102 of 103 lesions (99%), whereas CT identified only 13 of 103 lesions (12.6%). A bone marrow edema pattern was diagnosed in 286 of 307 fractures (93.2%). All four patients reported a low-energy inciting event as the cause for presentation. Neck of femur fractures (NOF), a.k.a. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. MRI of the Thumb: Anatomy and Spectrum of Findings in Asymptomatic Volunteers, Review. The anteroposterior radiograph of the affected hip acquired on initial presentation included the proximal femoral shaft; however, the insufficiency fracture was overlooked. 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. The p value for the McNemar test was < 0.0001, showing that MRI had significantly enhanced sensitivity for finding fractures compared with CT. Each patient was receiving an oral bisphosphonate at the time of fracture. Thirteen insufficiency stress fractures of the femoral neck in 13 elderly patients (average age, 82 years) were studied retrospectively. Patient 3 tripped over a small step while exiting her home and heard a crack with the next step. 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. [2] Insufficiency fractures of the spine are often a sign of frailty. In addition, the absence or presence of a bone marrow edema pattern and fracture lines was documented. 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. 125 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. Skeletal Radiol. Interestingly, in our study the presence and severity of soft-tissue edema varied according to the location of the fractures: Although a high percentage of soft-tissue edema was found with pubic and acetabular fractures, it was less frequently seen with sacral fractures. In addition, two or more insufficiency fractures were frequently present, typical fracture combinations were found, and insufficiency fractures were frequently associated with malignant disease. Fractures within this region require high energy if the bone mineralization is normal. The clinicopathologic findings of a subchondral insufficiency fracture of the femoral head in a male patient: a case report. Staatz et al. Gaeta et al. The contralateral femur showed similar findings [2]. 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. Epub 2009 Oct 6. 2000 Mar;24(3):464-8 CT showed all ischial fractures. Chen et al. The sensitivities of CT and MRI were compared using a paired proportion test (the McNemar test). 2010 Jul;195(1):W63-8. It is advisable to image the contralateral femur if characteristic findings are apparent [3, 58]. You can use Radiopaedia cases in a variety of ways to help you learn and teach. 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. Hip Anatomic Variants That May Mimic Abnormalities at MRI: Labral Variants, Review. 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. 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! Slice thickness was 4 mm; matrix size, 256 192 mm; and field of view, 1624 cm. 2002 Jan;31(1):35-8 Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, Neumann G, Valentin-Opran A, Lang P. AJR Am J Roentgenol. Osteoporosis is the most common cause of insufficiency fractures, although there are many causes 7-9: disrupted bone mineral homeostasis: hyperparathyroidism, diabetes mellitus, osteomalacia. 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]. 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. MRI missed one soft-tissue lesion at the erector spinae muscles because of incomplete fat saturation. Marrow edema involving head of left femur with subchondral flattening, irregularity of anterosuperior aspects. CT examinations were studied for absence or presence of a fracture as well as number and location of fractures. However, statistical analysis proved this difference to be insignificant (p = 0.243). 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. For several months, patient 1 had reported thigh pain that was misdiagnosed as being statin related. 1E). Patient 2 presented to the emergency department in the precomplete fracture stage, before displacement, with less-pronounced findings evident in the contralateral femur. -, Gerontology. doi: 10.1016/j.annpat.2009.07.051. 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. A history of corticosteroid therapy within the previous 6 months was recorded in 18 of 145 (12.4%) patients. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. 2021 Sep 4;11:122-126. doi: 10.1016/j.artd.2021.08.004. However, exact data from a larger patient population are not available. Clipboard, Search History, and several other advanced features are temporarily unavailable. Schilcher and Aspenberg calculated the relative risk and found a 46 times increased risk of insufficiency fractures for patients taking bisphosphonates. Although the entity is most frequently encountered at the weightbearing surface of the medial femoral condyle, the lateral femoral condyle or the tibia may also be involved (3a,4a). Email | workcomp@orthoarizona.org. The most recent lumbar spine bone mineral density T score for patient 1, acquired over 1 year before fracture, was 2. 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. and transmitted securely. Alternatively, insufficiency fractures typically present as focal cortical thickening with a transverse lucency within the lateral cortex. In the CT study, a small subtle cortical irregularity at the posterior femoral neck was shown. 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%]). A vague pain about the hip, of spontaneous onset, was the main symptom on first visit. 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. Conversely, insufficiency fractures occur in the elderly and involve the lateral cortex. The diagnosis was confirmed histologically in 4 patients. Stress fractures occur in young military recruits and athletes and involve the medial cortex when in the proximal femur [1015]. 12 a-c) may be found as an early manifestation of bone failure in patients after renal transplantation as reported by a . 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. The most common fractures were located at the sacrum (n = 67) and the pubic ramus (n = 29) (Figs. The terminology of atraumatic . In all patients, the clinical history was analyzed and potential risk factors for insufficiency fractures were recorded. Subchondral insufficiency fracture - femoral head. Disclaimer, National Library of Medicine Their presence is sometimes unexpected and can lead to incorrect diagnoses and many unnecessary, costly diagnostic procedures [10]. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Kabra U, Subchondral insufficiency fracture - femoral head. A fracture line was defined as a linear structure visualized on either STIR, T1-weighted, or fat-saturated T2-weighted fast spin-echo sequences. Subacute hematoma was documented if signal abnormality was high on T1-weighted images (indicating the presence of methemoglobin). 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. A third MRI location will be opening at our Arcadia (44th St. & Thomas Rd.) 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. Imaging included the entire pelvis in all studies. However, only a small subset of patients underwent radionuclide and DXA studies, which prevented a statistically representative analysis. 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. Thirty-one patients had CT scans and radiographs available, and of the 63 fractures visualized with CT, radiographs visualized only 13 (20.6%). Rev Bras Ortop. Ikemura S, Yamamoto T, Motomura G, Nakashima Y, Mawatari T, Iwamoto Y. AJR Am J Roentgenol. insufficiency fracture of the femur 18 years after radiation therapy . In the 39 thick-section CT studies, 73 total fractures were diagnosed and only 65.7% (48/73) were detected. Table 2 lists locations of all 307 fractures found in the 145 patients. Insufficiency fractures at the tibia (Fig. 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. 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]. Thank you for contacting our Performance Team! Radiation-induced insufficiency fracture of the femur 18 years after radiation therapy. 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%). This information, in conjunction with the radiologic findings, can lead to a correct diagnosis. Also, 76% of acetabular fractures had concomitant fractures. In total, 57 fractures occurred with pubic fractures. However, consideration should be given to the implications of a missed diagnosis that may misdirect or delay treatment. Fracture detection rates for CT and MRI were calculated using the previously described standard of reference. With CT, a similar percentage of fracture lines was shown (78/89, 89.7%). In the precomplete fracture stage of the disease, we found the radiographic findings to be subtle and easy to overlook. Abstract. An MRI is a form of diagnostic advanced medical imaging used t o diagnose a variety of orthopedic conditions. Increased awareness of this condition will hopefully lead to earlier diagnosis and a successful outcome of conservative treatment. -. The fracture was missed on the MR images because of partial volume effects and adjacent joint effusion along with motion artifacts. Atypical femoral fractures (AFF) are stress or 'insufficiency' fractures, often complicated by the use of bisphosphonates or other bone turnover inhibitors. Because of the limited visualization of soft-tissue abnormalities on CT, we did not differentiate grades. Insufficiency fractures in the osteoporotic population in this region are said to be rare [2, 7, 9]. Malignant lesions are frequently suspected in patients who have undergone radiation therapy and chemotherapy of the pelvis. Accessibility OBJECTIVE. 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. 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. Most frequently, insufficiency fractures were characterized by the presence of a bone marrow edema pattern and fracture lines (267/307, 87%). CT has been shown to be sensitive in depicting fracture lines and in the assessment of biomechanical stability [14]. Involvement of the contralateral femur varies in the literature, ranging from 20% to 64% [3, 68]. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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. MRI of the pelvis revealed a thickened lateral cortex with a focus of abnormally high signal. 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. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. They are most commonly associated with osteopenic or osteoporotic bone and the female athlete triad in young athletes. 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. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. Similar insufficiency fractures among patients not receiving bisphosphonates are extremely rare. 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. 2016 Oct;45(10):1425-9. doi: 10.1007/s00256-016-2443-2. dyle insufficiency fracture,^ Bspontaneous osteonecrosis knee,^ and/or BSONK^ in the radiology report impression. Forty-eight patients had radiographs available as well as MR images. These bones can become especially weak, thin, and frail due to osteoporosis, vitamin D deficiency, or aging. 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. Other important findings were that patients frequently had multiple pelvic insufficiency fractures and that pubic fractures in particular were typically associated with concomitant fractures. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. -, Am J Surg Pathol. This article is available for CME credit. To date, to our knowledge, there is only one report in the radiologic literature describing these fractures [2]. Subchondral insufficiency fractures are typically found in older female patients with . Methods: Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. In 64 of 145 patients, MRI and multidetector CT (MDCT) findings were compared. Subchondral Insufficiency Fracture of Femoral head: Uncommon cause of Hip pain in Elderly. All statistical analyses were performed using statistical software S-plus (Insightful) and SAS software (SAS). LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . Advanced imaging tests such as an MRI may require prior authorization from your insurance company. 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. Clin Orthop Surg. 102 Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. Address correspondence to T. M. Link ([emailprotected]). Gilbert, AZ 85297, 2940 E. Banner Gateway Dr., Ste. 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. Keywords: bisphosphonate, femur, fracture, insufficiency, subtrochanteric. 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. 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]. Caution should be exercised when one site with an insufficiency fracture is discovered because other fracture sites likely exist. -, Radiology. Bethesda, MD 20894, Web Policies Before Stress fractures can further be categorized as a fatigue fracture or an insufficiency fracture. Bisphosphonates function by inhibiting bone resorption by suppressing osteoclasts through apoptosis [7, 8]. MeSH CT is also used as an imaging procedure for insufficiency fractures in the pelvis. From the search results, MRI and CT studies with a reported diagnosis of pelvic, sacral, or proximal femur insufficiency fractures were selected. 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. 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. In addition, patients 1 and 3 switched to ibandronate sodium and risedronate, respectively, before fracture. 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. 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. Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments, Superior Labral Anteroposterior Tear: Classification and Diagnosis on MRI and MR Arthrography, Review. The site is secure. Of the 108 fractures diagnosed with MRI, radiography visualized only 16 (14.8%). Abstract. 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. This, in effect, restores the appearance of the insufficiency fracture in the lateral cortex. A 65-year-old woman with insufficiency-type subchondral stress fracture of the femoral head. The sacrum (n = 13), pubis (n = 12), and femur (n = 11) were sites of 36 of the 37 fractures that occurred with acetabular fractures. [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. The https:// ensures that you are connecting to the 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]. Please enter a valid 5-digit Zip Code. 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 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. If proximal femur fractures are suspected, mobility of the patient should not be permitted before cross-sectional imaging has been obtained. 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 . All studies were performed with 120 kVp and milliampere values ranging from 150 to 300 mA. 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. 2 and 3A, 3B). 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. 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). 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]. The standard of reference we usedlongitudinal imaging, clinical follow-up, and all other available imaging studies over several yearsis the best available alternative. 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