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. In addition, two or more insufficiency fractures were frequently present, typical fracture combinations were found, and insufficiency fractures were frequently associated with malignant disease. Subchondral insufficiency fracture of the femoral head. 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. RESULTS. Schilcher and Aspenberg calculated the relative risk and found a 46 times increased risk of insufficiency fractures for patients taking bisphosphonates. ADVERTISEMENT: Supporters see fewer/no ads. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. 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. The outcome of subchondral insufficiency fracture is thus unclear. Case Discussion. MRI has greatly improved our ability 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. Patients 3 and 4 presented with a completely displaced transverse fracture of the proximal femoral diaphysis. All four patients reported a low-energy inciting event as the cause for presentation. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-80488. We will be responding to your message shortly! This retrospective study was approved by our local committee on human research. In addition, bone scintigraphy and dual x-ray absorptiometry (DXA) were not included in our analysis, which may be considered a limitation of the study. November 2018; Radiology Case Reports 14(2):179-183; . Subacute hematoma was documented in only two of 145 patients. 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. The standard of reference we usedlongitudinal imaging, clinical follow-up, and all other available imaging studies over several yearsis the best available alternative. Fractures averaged 2.1 per patient (range, 16 fractures per patient). 1 Department of Radiology and Biomedical Imaging, University of California at San Francisco, 400 Parnassus Ave, A-367, San Francisco, CA 94131. . This article is available for CME credit. Twenty-five patients were diagnosed with acetabular fractures, and in 19 (76%) of these patients concomitant fractures were present. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. Comparisons were also drawn between MRI and CT in the ability to detect soft-tissue abnormalities. Means and SDs were calculated for continuous variables, and frequency and proportion for categoric variables. 11). 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. CT showed all ischial fractures. Of the 108 fractures diagnosed with MRI, radiography visualized only 16 (14.8%). 2010 Jul;195(1):W63-8. Only one patient (2%) had a fracture that was detected on CT but not on MRI, 33 patients (52%) had fractures that were detected on both CT and MRI, and 30 patients (47%) had fractures detected on MRI but not on CT. In 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. Unable to process the form. Caution should be exercised when one site with an insufficiency fracture is discovered because other fracture sites likely exist. 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. You can use Radiopaedia cases in a variety of ways to help you learn and teach. A mild bone marrow edema pattern was more frequently associated with femoral fractures (18/49, 36.7%). A third MRI location will be opening at our Arcadia (44th St. & Thomas Rd.) PMC 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]. 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. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. All four patients had taken alendronate for at least 3 years before injury. This is currently the established standard at our institution and is requested by our orthopedic surgeons in patients with suspected fractures and negative radiographic findings. Federal government websites often end in .gov or .mil. Find a doctor near you. 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. Ann Pathol. It needs to be differentiated from avascular necrosis, wherein a double line is seen which is convex to the articular surface as opposed to insufficiency fracture which is parallel to the articular surface. The clinicopathologic findings of a subchondral insufficiency fracture of the femoral head in a male patient: a case report. -, Gerontology. In the case of pubic fractures, 89.2% (33/37) of patients with pubic fractures had one or more fractures at another site. 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. Patient 3 tripped over a small step while exiting her home and heard a crack with the next step. 2000 Mar;24(3):464-8 All occurred in Caucasian women with severe osteoporosis. Although our patients did not undergo MRI or nuclear medicine imaging, a case report by Bush and Chew [2] describes these findings. The sacrum (n = 13), pubis (n = 12), and femur (n = 11) were sites of 36 of the 37 fractures that occurred with acetabular fractures. 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. The diagnosis was confirmed histologically in 4 patients. 100 Atypical femoral fractures (AFF) are stress or 'insufficiency' fractures, often complicated by the use of bisphosphonates or other bone turnover inhibitors. In all 145 subjects, MRI studies obtained at 1.5 T (Signa, GE Healthcare) were available. The terminology of atraumatic . Again, sacral fractures were shown infrequently (6.1%, 2/33). If proximal femur fractures are suspected, mobility of the patient should not be permitted before cross-sectional imaging has been obtained. Epidemiology 1675 E. Melrose St., Ste. Abstract. 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 the precomplete fracture stage of the disease, we found the radiographic findings to be subtle and easy to overlook. 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. MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur, Overall Characteristics of Insufficiency Fractures Based on MRI Findings, Review. CONCLUSION. Stress fractures occur in young military recruits and athletes and involve the medial cortex when in the proximal femur [1015]. 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. A vague pain about the hip, of spontaneous onset, was the main symptom on first visit. 2002 Jan;31(1):35-8 The terminology of atraumatic . Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know. 3A, 3B, 3C). A bone marrow edema pattern was diagnosed in 286 of 307 fractures (93.2%). The most common fractures were located at the sacrum (n = 67) and the pubic ramus (n = 29) (Figs. When they are caused by metastatic disease, these fractures show poorly defined lucent margins, an aggressive bone marrow pattern of destruction, and endosteal scalloping [10, 17]. -, Radiology. This is especially true of pubic fractures; 90% of the pubic fractures in this study had concomitant fractures present. Advanced imaging tests such as an MRI may require prior authorization from your insurance company. Rheumatologic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, were found in six of 145 patients (4.1%). In all patients, the clinical history was analyzed and potential risk factors for insufficiency fractures were recorded. The definition of a standard of reference for a study in which no surgical procedures or patho logic examinations are performed is challenging. Osteoporosis is the most common cause of insufficiency fractures, although there are many causes 7-9: disrupted bone mineral homeostasis: hyperparathyroidism, diabetes mellitus, osteomalacia. Email | [email protected]. However, exact data from a larger patient population are not available. Frequently these fractures are radiographically occult [7, 8]; and some of these fractures, in particular sacral insufficiency fractures, are relatively underdiagnosed [9]. In addition, patients 1 and 3 switched to ibandronate sodium and risedronate, respectively, before fracture. High-Resolution 3-T MRI of the Fingers: Review of Anatomy and Common Tendon and Ligament Injuries, Review. MRI missed one soft-tissue lesion at the erector spinae muscles because of incomplete fat saturation. 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]. This study showed that MRI was substantially better than CT in detecting insufficiency fractures. 2000) (Fig. Enjoy the freedom of a pain-free, active lifestyle with help from our orthopedic specialists. Find top doctors who perform Hip Femur Fractures and Dislocations near you in Chandler, AZ. Subtle subchondral irregular, linear hypointensity seen parallel to articular surface.Marrow edema is extending to neck. Signs of a soft-tissue lesion included muscle swelling, fat-tissue stranding, and active extravasation of contrast material on contrast-enhanced studies. Similar insufficiency fractures among patients not receiving bisphosphonates are extremely rare. Findings are suggestive of subchondral insufficiency of the medial femoral condyle, previously known as spontaneous osteonecrosis of the knee (SONK). Also, the number of fractures in an individual patient increased with age. Imaging Key Wrist Ligaments: What the Surgeon Needs the Radiologist to Know. [A femur head--does it have anything to say?]. 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. 2016 Nov;45(11):1515-21. doi: 10.1007/s00256-016-2462-z. Skeletal Radiol. Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know, Review. Many fractures were frequently associated with concomitant fractures in typical locations (Table 3). 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. 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. All patients underwent MRI and were assessed for the absence or presence of a fracture as well as number and location of fractures. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Kabra U, Subchondral insufficiency fracture - femoral head. MeSH [21] in 15 patients with longitudinal stress fractures at the tibia. Fracture lines were better shown on T1-weighted sequences, and proximal femur fracture lines were best shown on sequences obtained in a coronal orientation. Gaeta et al. 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. location this Summer 2022, conveniently located in the Phoenix/Scottsdale region. A fatigue fracture is due to abnormal stress placed on normal bone, such as training for a marathon. The sensitivities of CT and MRI were compared using a paired proportion test (the McNemar test). Please enable it to take advantage of the complete set of features! Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. Ikemura S, Yamamoto T, Motomura G, Nakashima Y, Mawatari T, Iwamoto Y. AJR Am J Roentgenol. Basic descriptive statistics were used. 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). 1988 Jun;167(3):753-5 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]. In 64 of 145 patients, MRI and multidetector CT (MDCT) findings were compared. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. Check for errors and try again. 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). 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. Elderly osteoporotic women are at greatest risk. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. A 65-year-old woman with insufficiency-type subchondral stress fracture of the femoral head. 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. 2016 Oct;45(10):1425-9. doi: 10.1007/s00256-016-2443-2. According to a previously published study [8], MRI is more sensitive than bone scintigraphy in the early stages of insufficiency fractures. Forty-eight patients had radiographs available as well as MR images. However, comparison with our study is limited because those investigators examined fatigue fractures, which have different bone mass and quality. 12 a-c) may be found as an early manifestation of bone failure in patients after renal transplantation as reported by a . Gilbert, AZ 85297, 2940 E. Banner Gateway Dr., Ste. Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, Neumann G, Valentin-Opran A, Lang P. AJR Am J Roentgenol. Only studies that covered the whole sacrum were included. Rapid Destruction of the Hip Joint After Acetabular Fracture in an Elderly Patient. 1 article features images from this case In addition, the absence or presence of a bone marrow edema pattern and fracture lines was documented. FOIA 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. 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. Conversely, insufficiency fractures occur in the elderly and involve the lateral cortex. In particular, fractures at the femoral head and acetabulum were better detected with MRI. 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. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. [22] argued that CT was better because of cost, diagnostic rate, and ease of fracture line visualization. -, Am J Surg Pathol. These were obtained using a standard radiographic technique, placing the patient on the Bucky table, and using a grid, whenever possible, with standard exposure parameters of 20 mAs and 75 kVp. It is advisable to image the contralateral femur if characteristic findings are apparent [3, 58]. When an insufficient-appearing proximal femur fracture was identified, the images were independently reviewed by three radiologists, and characteristics were classified. Utsunomiya T, Yamamoto T, Motomura G, Hamai S, Iwamoto Y. Skeletal Radiol. The https:// ensures that you are connecting to the Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments, Superior Labral Anteroposterior Tear: Classification and Diagnosis on MRI and MR Arthrography, Review. 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. 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. Fifty-seven of the 64 patients had at least one soft-tissue lesion, for a total of 103 lesions. However, the clinical presentation and imaging features of these entities provide differentiating clues. Sensitivities were calculated as the percentage of patients identified by each technique based on this standard of reference, and confidence intervals were provided. Subchondral insufficiency fractures of the hip have been identified as a cause of accelerated osteoarthritis . Call 602.922.9100 to schedule an appointment! Thirty-eight of the 64 (59.49%) CT studies were performed with IV contrast material. medications: glucocorticoids, chemotherapy. 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. The site is secure. government site. CT has been shown to be sensitive in depicting fracture lines and in the assessment of biomechanical stability [14]. Epub 2016 Aug 24. The most recent lumbar spine bone mineral density T score for patient 1, acquired over 1 year before fracture, was 2. Chan CC, Li A, Fan WC, Sun LK, Cheng HC, Chan JC. 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. However, irradiated bone is especially weakened and prone to insufficiency fractures, as shown previously [13]. 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. Staatz et al. Keywords: bisphosphonate, femur, fracture, insufficiency, subtrochanteric. 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. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. OBJECTIVE. With CT, a similar percentage of fracture lines was shown (78/89, 89.7%). Search doctors, conditions, or procedures . Fax | 480.324.3162. 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. She tripped at an unspecified event, falling from ground level, and felt severe pain in her leg. 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. 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]. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. 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. 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. These include stress fractures (fractures involving normal bone subject to a repetitive stress), pseudofractures of osteomalacia, and pathologic fractures [10]. 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. 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. These fractures are treated with a trochanteric-entry nail, either one or two proximal lag screws, and distal interlocking screw fixation. MRI of the Thumb: Anatomy and Spectrum of Findings in Asymptomatic Volunteers, Review. The fracture was missed on the MR images because of partial volume effects and adjacent joint effusion along with motion artifacts. 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]. 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. 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 . ( a) Plain radiograph taken 2 months before the onset of left hip pain shows no remarkable abnormalities. 2012 Sep;4(3):173-80. doi: 10.4055/cios.2012.4.3.173. Before In the remaining 3 patients radiographs showed a normal femoral head, regional osteoporosis and focal sclerosis, respectively. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Additional comparisons were made between thin-section (slice thickness < 5 mm) and thick-section (slice thickness 5 mm) CT studies. 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). ( b) Radiographs taken 2 months after the onset of the left hip pain show joint space narrowing of the left hip without any other bony abnormality. In 70.3% of cases, multiple fracture sites were present. 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]. 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. Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. Again, cases with no fractures lines were most often located at the sacrum (n = 6); and in all of these cases, increased sclerosis was present. THE IMPORTANCE OF THE DIAGNOSIS OF SUBCHONDRAL FRACTURE OF THE FEMORAL HEAD, HOW TO DIFFERENTIATE IT FROM AVASCULAR NECROSIS AND HOW TO TREAT IT. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. Other frequent combinations of concomitant fractures were noted. 2 and 3A, 3B). 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]. Interestingly, insufficiency fractures were associated with prior malignancy in 63 of 145 (34.4%) patients. Radiography is the imaging modality of choice for baseline diagnosis. 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. 1989 Apr;171(1):135-40 However, consideration should be given to the implications of a missed diagnosis that may misdirect or delay treatment. 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. We used binomial exact confidence intervals, also known as Clopper and Pearson confidence intervals. 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. A history of corticosteroid therapy within the previous 6 months was recorded in 18 of 145 (12.4%) patients. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Also, 76% of acetabular fractures had concomitant fractures. 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. 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. Grangier et al. This, in effect, restores the appearance of the insufficiency fracture in the lateral cortex. doi: 10.2214/AJR.09.3271. 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. dyle insufficiency fracture,^ Bspontaneous osteonecrosis knee,^ and/or BSONK^ in the radiology report impression. Scintigraphy showed increased uptake in the femoral head. insufficiency fracture of the femur 18 years after radiation therapy . collagen formation: Marfan syndrome, fibrous dysplasia. 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. The MRI, CT, and radiographic studies were analyzed separately in random order by two radiologists in consensus. Most frequently, insufficiency fractures were characterized by the presence of a bone marrow edema pattern and fracture lines (267/307, 87%). Patients 2, 3, and 4 were treated for osteoporosis without a documented bone mineral density score in their current medical record. MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. Subchondral insufficiency fractures of the femoral head. Despite the cost of MRI and CT, it is important to quickly diagnose and treat these fractures. MRI studies obtained at 1.5 T were analyzed in 145 patients with pelvic insufficiency fractures. 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. 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. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. 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]. 1987;33(5):302-6 182 Radiology 14Case 179-183Reports (2019) should be addressed based on the location in this case, is an Polesello G, Sakai DS, Ono NK, Honda EK, Guimaraes RP, Jnior WR. The pelvis protocol covered the proximal femur at least down to the lesser tro chanter and was used also for suspected hip fractures. CT is also used as an imaging procedure for insufficiency fractures in the pelvis. The amount and intensity of soft-tissue edema were also graded higher in patients with pubic, acetabular, and femur fractures versus sacral fractures. CONCLUSION. Unable to load your collection due to an error, Unable to load your delegates due to an error. For several months, patient 1 had reported thigh pain that was misdiagnosed as being statin related. 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 . 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. Their presence is sometimes unexpected and can lead to incorrect diagnoses and many unnecessary, costly diagnostic procedures [10]. MATERIALS AND METHODS. 1A, 1B, 1C, 1D, 1E). eCollection 2021 Oct. Sonoda K, Yamamoto T, Motomura G, Karasuyama K, Kubo Y, Iwamoto Y. Skeletal Radiol. Upon stepping off a scale at her clinician's office, she heard a pop followed by weakness and eventually fell to the ground. 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. doi: 10.1016/j.annpat.2009.07.051. They are most commonly associated with osteopenic or osteoporotic bone and the female athlete triad in young athletes. Epub 2016 Aug 2. 1E). Marrow edema involving head of left femur with subchondral flattening, irregularity of anterosuperior aspects. Note that, although a high percentage of soft-tissue edema was found with pubic and acetabular bone fractures, it was less frequently seen with sacral fractures. 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. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. 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]. and transmitted securely. 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]. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Each patient was receiving an oral bisphosphonate at the time of fracture. In a subset of patients, anteroposterior pelvic and hip radiographs were also analyzed. In the 39 thick-section CT studies, 73 total fractures were diagnosed and only 65.7% (48/73) were detected. Imaging included the entire pelvis in all studies. 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. [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. The contralateral femur showed similar findings [2]. The imaging characteristics of bisphosphonate-related insufficiency fractures that we describe are, in our experience, unique and easily recognized by a trained observer. Address correspondence to L. F. Rogers ([emailprotected]). 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%). It presents as a transverse fracture line through a localized area of thickening involving the lateral aspect of the cortex [1, 68]. Keywords: comparative studies, CT, MRI, pelvic insufficiency fractures, proximal femur insufficiency fractures. 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]. 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. Gilbert, AZ 85234, 3033 N. 44th St. Ste. 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. In addition to underlying clinical conditions, age was also a major contributor to fracture risk. All studies were performed with 120 kVp and milliampere values ranging from 150 to 300 mA. Diagnosis of Proximal Femoral Insufficiency Fractures in Patients Receiving Bisphosphonate Therapy, Original Research. 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. Femoral, acetabular, and pubic fractures had the highest proportion of associated soft-tissue abnormalities. [2]; these include a low-signal band on T1-weighted imaging adjacent to the subchondral . Neck of femur fractures (NOF), a.k.a. 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. -. In addition, patient 1 incurred a similar fracture in the contralateral femur 1 year before her current injury. From the search results, MRI and CT studies with a reported diagnosis of pelvic, sacral, or proximal femur insufficiency fractures were selected. Bisphosphonates function by inhibiting bone resorption by suppressing osteoclasts through apoptosis [7, 8]. 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. Forty percent of the 25 patients with femoral fractures had concomitant fractures. Thirty-one patients had CT scans and radiographs available, and of the 63 fractures visualized with CT, radiographs visualized only 13 (20.6%). 102 Chen et al. These bones can become especially weak, thin, and frail due to osteoporosis, vitamin D deficiency, or aging. 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. 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%). Table 2 lists locations of all 307 fractures found in the 145 patients. This site needs JavaScript to work properly. As shown by the results of this study, MRI detected significantly (p < 0.01) more pelvic insufficiency fractures than CT. official website and that any information you provide is encrypted A subchondral fracture may also be due to chronic low intensity stress. All statistical analyses were performed using statistical software S-plus (Insightful) and SAS software (SAS). 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. The ability of both imaging techniques to detect fracture lines was compared. A noncontrast magnetic resonance imaging (MRI) of the right femur was performed in conjunction with the CT ().On T1-weighted sequences (Figs. However, statistical analysis proved this difference to be insignificant (p = 0.243). Other important findings were that patients frequently had multiple pelvic insufficiency fractures and that pubic fractures in particular were typically associated with concomitant fractures. The anteroposterior radiograph of the affected hip acquired on initial presentation included the proximal femoral shaft; however, the insufficiency fracture was overlooked. . 180 Radiology Case Reports 14 (2019) 179-183. 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%]). 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. An insufficiency fracture refers to normal physiologic stress applied to bone . 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. However, at all other sites, 2557% of fractures were missed with CT, with the highest percentage of missed fractures at the femoral head. 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. Fractures, or fracturelike conditions, within the proximal femoral diaphysis seen in the setting of low-energy trauma do occur in other clinical situations. Fractures within this region require high energy if the bone mineralization is normal. Book an appointment today! In 29 of 63 patients (46.0%), the primary tumor was located in the pelvis; 24 of these patients had gynecologic malignancies. An incorrect diagnosis may initiate invasive and costly procedures that could be harmful to the patient or that could misguide therapy. Less frequently, in up to 25 %, insufficiency fractures at the femoral shaft can occur, predominately in elderly patients with osteoporosis (Martin-Hunyadi et al. Only a small number of studies have been performed comparing MRI and CT in diagnosing stress 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. To date, to our knowledge, there is only one report in the radiologic literature describing these fractures [2]. Many patients present with a complete and significantly displaced fracture of the proximal femoral shaft as a result. 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. In 102 of 145 patients (70.3%) more than one fracture was found. Radiographs were performed in all patients, MRI in 5 and scintigraphy in 4 patients. MRI detected 102 of 103 lesions (99%), whereas CT identified only 13 of 103 lesions (12.6%). Before the injury, patient 4 reported suffering from pain in the lateral aspect of her hip and groin, which was misdiagnosed as sciatica. Thirteen insufficiency stress fractures of the femoral neck in 13 elderly patients (average age, 82 years) were studied retrospectively. Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head. Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. Malignant lesions are frequently suspected in patients who have undergone radiation therapy and chemotherapy of the pelvis. MRI is the superior technique compared with CT and should be the imaging technique of choice in patients with suspected insufficiency fractures. Would you like email updates of new search results? -, Radiology. Case Report Insufficiency fractures in the osteoporotic population in this region are said to be rare [2, 7, 9]. 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. 2003 Feb;180(2):363-8. doi: 10.2214/ajr.180.2.1800363. Bone marrow edema pattern was also graded in all fractures in which it was present. 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. Clipboard, Search History, and several other advanced features are temporarily unavailable. Announcement for Patients Regarding COVID-19, o diagnose a variety of orthopedic conditions, We are so happy when we can make our patients' day, Get to know our newest Foot & Ankle surgeon, Dr. B, Shout out to our Director of Sports Performance, @, You can tell our offices take Halloween VERY serio, Happy Halloween from OrthoArizona! The insufficiency fracture lies within the lateral cortex of the proximal femur. 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). 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. Thus, a better understanding of insufficiency fractures of the pelvis is required, and further study is needed to determine whether CT or MRI is better suited to investigate these fractures. In 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. Consequently, the entire pelvis must be imaged in these patients, and a careful search for concomitant fractures is always warranted. sharing sensitive information, make sure youre on a federal Methods: Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. 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. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. Bookshelf [2] Insufficiency fractures of the spine are often a sign of frailty. However, those authors concluded that MRI, although more sensitive than CT, may be misleading; they controversially recommended CT as the better imaging technique. OBJECTIVE. [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. Epub 2009 Oct 6. Therefore, if it is available, MRI should be the primary diagnostic technique when insufficiency or occult pelvic fractures are suspected. 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. Insufficiency fractures at the tibia (Fig. Abstract. 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. 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. Slice thickness was 4 mm; matrix size, 192 192 mm; and field of view, 3236 cm. 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]. An MRI is a form of diagnostic advanced medical imaging used t o diagnose a variety of orthopedic conditions. Patient 2 presented to the emergency department in the precomplete fracture stage, before displacement, with less-pronounced findings evident in the contralateral femur. Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of subchondral cancellous bone. 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. 2021 Sep 4;11:122-126. doi: 10.1016/j.artd.2021.08.004. Accessibility 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. Characteristic features were seen in retrospect on complete fracture. Subchondral insufficiency fractures are typically found in older female patients with . Involvement of the contralateral femur varies in the literature, ranging from 20% to 64% [3, 68]. The Rotator Interval: A Review of Anatomy, Function, and Normal and Abnormal MRI Appearance, Pictorial Essay. The location you tried did not return a result. In our study, we used all available imaging data and imaging follow-up, together with the clinical history, as a standard of reference. MRI is sensitive in the detection of these fractures. 1A, 1B, 1C, 1D, 2A, 2B, 2C, 3A, 3B, 3C). Phoenix, AZ 85018, Privacy Policy | Sitemap | Copyright 2022 OrthoArizona | Digital Marketing by CD Agency. 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