Clipboard, Search History, and several other advanced features are temporarily unavailable. Less frequently, in up to 25 %, insufficiency fractures at the femoral shaft can occur, predominately in elderly patients with osteoporosis (Martin-Hunyadi et al. Before Because of the limited visualization of soft-tissue abnormalities on CT, we did not differentiate grades. -, Am J Surg Pathol. 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. This search yielded 162 patients; 84 met the typical inclusion criteria of an insufficiency fracture previously described by Yamamoto et al. Find a doctor near you. 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. Epub 2009 Oct 6. However, at all other sites, 2557% of fractures were missed with CT, with the highest percentage of missed fractures at the femoral head. The purpose of this article is to describe the imaging features of proximal femoral insufficiency fractures in patients on long-term bisphosphonate therapy. A bone marrow edema pattern was diagnosed in 286 of 307 fractures (93.2%). MRI is the superior technique compared with CT and should be the imaging technique of choice in patients with suspected insufficiency fractures. 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. Other important findings were that patients frequently had multiple pelvic insufficiency fractures and that pubic fractures in particular were typically associated with concomitant fractures. 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). An MRI is a form of diagnostic advanced medical imaging used t o diagnose a variety of orthopedic conditions. collagen formation: Marfan syndrome, fibrous dysplasia. This study showed that MRI was substantially better than CT in detecting insufficiency fractures. With CT, a similar percentage of fracture lines was shown (78/89, 89.7%). Thirteen insufficiency stress fractures of the femoral neck in 13 elderly patients (average age, 82 years) were studied retrospectively. 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. Stress fractures can further be categorized as a fatigue fracture or an insufficiency fracture. These fractures are treated with a trochanteric-entry nail, either one or two proximal lag screws, and distal interlocking screw fixation. The reduction is usually complete, and the apposition is often immediate. The appearance of the fracture mimics that of a tibial striation, or stress fracture, seen in the anterior cortex of the tibia. All four patients reported a low-energy inciting event as the cause for presentation. 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. Would you like email updates of new search results? 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. Patient 2 presented to the emergency department in the precomplete fracture stage, before displacement, with less-pronounced findings evident in the contralateral femur. A fatigue fracture is due to abnormal stress placed on normal bone, such as training for a marathon. MRI is sensitive in the detection of these fractures. 182 Radiology 14Case 179-183Reports (2019) should be addressed based on the location in this case, is an 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. bone remodeling: Paget disease, osteopetrosis. OBJECTIVE. In 102 of 145 patients (70.3%) more than one fracture was found. 2016 Nov;45(11):1515-21. doi: 10.1007/s00256-016-2462-z. Overall, no significant differences (p > 0.05) in the detection rate of fractures between men and women were found. 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 . 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 all patients, the clinical history was analyzed and potential risk factors for insufficiency fractures were recorded. Keywords: comparative studies, CT, MRI, pelvic insufficiency fractures, proximal femur insufficiency fractures. 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. CONCLUSION. 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. Fracture lines were better shown on T1-weighted sequences, and proximal femur fracture lines were best shown on sequences obtained in a coronal orientation. Find top doctors who perform Hip Femur Fractures and Dislocations near you in Chandler, AZ. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-80488. 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. doi: 10.2214/AJR.09.3271. However, consideration should be given to the implications of a missed diagnosis that may misdirect or delay treatment. 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. Characteristic features were seen in retrospect on complete fracture. medications: glucocorticoids, chemotherapy. 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). Advanced imaging tests such as an MRI may require prior authorization from your insurance company. Only a small number of studies have been performed comparing MRI and CT in diagnosing stress fractures. Call 602.922.9100 to schedule an appointment! In nine of 63 patients (14.3%), hematologic malignancies were recorded, and in six (9.5%) breast cancer was diagnosed. 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. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Kabra U, Subchondral insufficiency fracture - femoral head. -, Radiology. Subacute hematoma was documented if signal abnormality was high on T1-weighted images (indicating the presence of methemoglobin). location this Summer 2022, conveniently located in the Phoenix/Scottsdale region. When an insufficient-appearing proximal femur fracture was identified, the images were independently reviewed by three radiologists, and characteristics were classified. All statistical analyses were performed using statistical software S-plus (Insightful) and SAS software (SAS). In addition, patients 1 and 3 switched to ibandronate sodium and risedronate, respectively, before fracture. Table 2 lists locations of all 307 fractures found in the 145 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. and transmitted securely. The diagnosis was delayed in most cases because the . eCollection 2021 Oct. Sonoda K, Yamamoto T, Motomura G, Karasuyama K, Kubo Y, Iwamoto Y. Skeletal Radiol. High-Resolution 3-T MRI of the Fingers: Review of Anatomy and Common Tendon and Ligament Injuries, Review. 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. 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. In the precomplete fracture stage of the disease, we found the radiographic findings to be subtle and easy to overlook. Femoral, acetabular, and pubic fractures had the highest proportion of associated soft-tissue abnormalities. 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]. 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. Delayed diagnosis can lead to immobility and complications such as deep vein thrombosis, loss of strength, decreased cardiac output, depression, and increased bone resorption and calcium excretion [11]. Fractures averaged 2.1 per patient (range, 16 fractures per patient). The https:// ensures that you are connecting to the 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. Subtle subchondral irregular, linear hypointensity seen parallel to articular surface.Marrow edema is extending to neck. Patients 2, 3, and 4 were treated for osteoporosis without a documented bone mineral density score in their current medical record. Enjoy the freedom of a pain-free, active lifestyle with help from our orthopedic specialists. 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. Subchondral Insufficiency Fracture of Femoral head: Uncommon cause of Hip pain in Elderly. Phoenix, AZ 85018, Privacy Policy | Sitemap | Copyright 2022 OrthoArizona | Digital Marketing by CD Agency. Please enter a valid 5-digit Zip Code. Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know. 12 a-c) may be found as an early manifestation of bone failure in patients after renal transplantation as reported by a . In the case of pubic fractures, 89.2% (33/37) of patients with pubic fractures had one or more fractures at another site. 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 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. The terminology of atraumatic . 8600 Rockville Pike Insufficiency fractures occur in abnormal bonethat is, bone commonly affected by generalized osteoporosisas a result of normal activity such as walking. Chan CC, Li A, Fan WC, Sun LK, Cheng HC, Chan JC. Of the 128 fractures detected on MRI, fracture lines were present in 122 (95.3%) cases, and no fracture lines were most often found at the sacrum (n = 4). An official website of the United States government. Alternatively, insufficiency fractures typically present as focal cortical thickening with a transverse lucency within the lateral cortex. 2009 Nov;29 Spec No 1:S88-9. Case Discussion. Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments, Superior Labral Anteroposterior Tear: Classification and Diagnosis on MRI and MR Arthrography, Review. In addition, two or more insufficiency fractures were frequently present, typical fracture combinations were found, and insufficiency fractures were frequently associated with malignant disease. 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. 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. Before the injury, patient 4 reported suffering from pain in the lateral aspect of her hip and groin, which was misdiagnosed as sciatica. Fractures within this region require high energy if the bone mineralization is normal. 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. Bookshelf 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. HHS Vulnerability Disclosure, Help Subacute hematoma was documented in only two of 145 patients. 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. 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]. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. Also, the number of fractures in an individual patient increased with age. CT is also used as an imaging procedure for insufficiency fractures in the pelvis. Patients with metastatic disease to the pelvic bones; a history of other bone marrow disease such as myelody-splastic syndrome or Gaucher's disease; and metabolic diseases other than osteoporosis, osteomalacia and renal osteodystrophy, as well as osteomyelitis, were excluded. 1987;33(5):302-6 Slice thickness was 4 mm; matrix size, 256 192 mm; and field of view, 1624 cm. 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. The fracture was missed on the MR images because of partial volume effects and adjacent joint effusion along with motion artifacts. Epub 2016 Aug 2. 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. THE IMPORTANCE OF THE DIAGNOSIS OF SUBCHONDRAL FRACTURE OF THE FEMORAL HEAD, HOW TO DIFFERENTIATE IT FROM AVASCULAR NECROSIS AND HOW TO TREAT IT. Imaging of Anterior Cruciate Ligament Repair and Its Complications, Review. RESULTS. Many insufficiency fractures present with completely displaced fractures of the femoral shaft, whereas such complete fractures in femoral stress fracture are uncommon [15]. 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. A third MRI location will be opening at our Arcadia (44th St. & Thomas Rd.) 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]. Abstract. To identify patients with pelvic insufficiency fractures, the radiology information system of our department was searched using the terms "pelvis," "sacrum" or "femur," and . Imaging Key Wrist Ligaments: What the Surgeon Needs the Radiologist to Know. Address correspondence to T. M. Link ([emailprotected]). 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. A fracture line was defined as a linear structure visualized on either STIR, T1-weighted, or fat-saturated T2-weighted fast spin-echo sequences. 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. Scintigraphy showed increased uptake in the femoral head. Arthroplast Today. 1 article features images from this case This information, in conjunction with the radiologic findings, can lead to a correct diagnosis. Thirty-eight of the 64 (59.49%) CT studies were performed with IV contrast material. The clinical and radiological findings in 7 patients with subchondral insufficiency fractures of the femoral head were reviewed retrospectively. Diagnosis of Proximal Femoral Insufficiency Fractures in Patients Receiving Bisphosphonate Therapy, Original Research. 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]. Figure 4A, 4B, 4C, 4D shows an example of a patient with multiple insufficiency fractures at both femoral necks and the ischia. These individuals may present after minor trauma or have symptoms of chronic lower back, pelvic, or groin pain that may appear unrelated to trauma [6]. The sacrum (n = 13), pubis (n = 12), and femur (n = 11) were sites of 36 of the 37 fractures that occurred with acetabular fractures. Careers. Overall in the CT studies, sclerosis was present in 69 of 89 (79.3%) fractures. It is advisable to image the contralateral femur if characteristic findings are apparent [3, 58]. The outcome of subchondral insufficiency fracture is thus unclear. Subchondral insufficiency fractures of the femoral head. FOIA 1A, 1B, 1C, 1D, 1E). insufficiency fracture of the femur 18 years after radiation therapy . Ikemura S, Yamamoto T, Motomura G, Nakashima Y, Mawatari T, Iwamoto Y. AJR Am J Roentgenol. Address correspondence to L. F. Rogers ([emailprotected]). [21] in 15 patients with longitudinal stress fractures at the tibia. 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). MRI has greatly improved our ability Sensitivities were calculated as the percentage of patients identified by each technique based on this standard of reference, and confidence intervals were provided. MRI of the Thumb: Anatomy and Spectrum of Findings in Asymptomatic Volunteers, Review. The p value for the McNemar test was < 0.0001, showing that MRI had significantly enhanced sensitivity for finding fractures compared with CT. 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. 2016 Oct;45(10):1425-9. doi: 10.1007/s00256-016-2443-2. One at our South Gilbert site (South of Loop 202 and East of Val Vista Dr) and the second location at our North Gilbert site (South of the US-60 and East of Higley Rd, behind Banner Gateway Hospital). 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. 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. Although this action results in increased bone mineral density, suppressed bone turnover prevents remodeling and healing of cracks that occur in bone as a result of normal activity, often referred to as microdamage [68]. The terminology of atraumatic . Again, sacral fractures were shown infrequently (6.1%, 2/33). 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. Only studies that covered the whole sacrum were included. In 29 of 63 patients (46.0%), the primary tumor was located in the pelvis; 24 of these patients had gynecologic malignancies. OrthoArizona offers on-site MRI, with TWO convenient locations near our established clinic sites in North & South Gilbert! 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. 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. [A femur head--does it have anything to say?]. 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. Each patient was receiving an oral bisphosphonate at the time of fracture. ( a) Plain radiograph taken 2 months before the onset of left hip pain shows no remarkable abnormalities. Check for errors and try again. Findings are suggestive of subchondral insufficiency fracture of the left femoral head. Abstract. A subchondral fracture may also be due to chronic low intensity stress. [22] argued that CT was better because of cost, diagnostic rate, and ease of fracture line visualization. This site needs JavaScript to work properly. Treatment in pelvic insufficiency fractures varies according to the affected site; although sacral insufficiency fractures are usually treated with analgesia and bed rest, acetabular and femur fractures may require surgical therapy. Accessibility 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. 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 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. She tripped at an unspecified event, falling from ground level, and felt severe pain in her leg. The proximal femur is routinely exposed to high-energy maximal-bending movements [2, 8]. We used binomial exact confidence intervals, also known as Clopper and Pearson confidence intervals. Please enable it to take advantage of the complete set of features! Interestingly, insufficiency fractures were associated with prior malignancy in 63 of 145 (34.4%) patients. 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. Other frequent combinations of concomitant fractures were noted. 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. Upon stepping off a scale at her clinician's office, she heard a pop followed by weakness and eventually fell to the ground. MRI missed one soft-tissue lesion at the erector spinae muscles because of incomplete fat saturation. 2010 Jul;195(1):W63-8. 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. November 2018; Radiology Case Reports 14(2):179-183; . Disclaimer, National Library of Medicine According to a previously published study [8], MRI is more sensitive than bone scintigraphy in the early stages of insufficiency fractures. 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. Fax | 480.324.3162. Epub 2016 Aug 24. For several months, patient 1 had reported thigh pain that was misdiagnosed as being statin related. 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. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. Basic descriptive statistics were used. Figure 1A, 1B, 1C, 1D shows an example of a sacral fracture visualized with MRI but not with CT. The imaging findings of bisphosphonate-related femoral insufficiency fractures, which include a typical proximal diaphyseal location and transverse liner radiolucency through localized thickening of the lateral cortex, allow a specific diagnosis. The Rotator Interval: A Review of Anatomy, Function, and Normal and Abnormal MRI Appearance, Pictorial Essay. 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. 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. All patients underwent MRI and were assessed for the absence or presence of a fracture as well as number and location of fractures. A noncontrast magnetic resonance imaging (MRI) of the right femur was performed in conjunction with the CT ().On T1-weighted sequences (Figs. MeSH 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. 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. 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. Fat-suppressed T2-weighted MRI appearance of subchondral insufficiency fracture of the femoral head. Utsunomiya T, Yamamoto T, Motomura G, Hamai S, Iwamoto Y. Skeletal Radiol. Bone marrow edema pattern was also graded in all fractures in which it was present. 2000) (Fig. Forty percent of the 25 patients with femoral fractures had concomitant fractures. 2012 Sep;4(3):173-80. doi: 10.4055/cios.2012.4.3.173. This retrospective study was approved by our local committee on human research. Signs of a soft-tissue lesion included muscle swelling, fat-tissue stranding, and active extravasation of contrast material on contrast-enhanced studies. 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. Skeletal Radiol. Stress fractures occur in young military recruits and athletes and involve the medial cortex when in the proximal femur [1015]. An MRI is a form of diagnostic advanced medical imaging used to diagnose a variety of orthopedic conditions. Insufficiency fractures can occur throughout the skeleton but are common in the tibia, femoral head and neck, sacrum, pelvis, and feet. dyle insufficiency fracture,^ Bspontaneous osteonecrosis knee,^ and/or BSONK^ in the radiology report impression. 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]. 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. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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. MRI of the pelvis revealed a thickened lateral cortex with a focus of abnormally high signal. These bones can become especially weak, thin, and frail due to osteoporosis, vitamin D deficiency, or aging. 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. Caution should be exercised when one site with an insufficiency fracture is discovered because other fracture sites likely exist. Grangier et al. The amount and intensity of soft-tissue edema were also graded higher in patients with pubic, acetabular, and femur fractures versus sacral fractures. 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]. Slice thickness was 4 mm; matrix size, 192 192 mm; and field of view, 3236 cm. 1E). The diagnosis was confirmed histologically in 4 patients. Ethical approval was obtained by the University of Arizona's institutional review board before commencement of the study. Many patients present with a complete and significantly displaced fracture of the proximal femoral shaft as a result. 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). government site. Objectives: To characterize the morphology and imaging findings of femoral head subchondral insufficiency fractures (SIF), and to investigate clinical outcomes in relation to imaging findings. Bisphosphonates function by inhibiting bone resorption by suppressing osteoclasts through apoptosis [7, 8]. In addition, MRI and CT usually can be obtained faster, particularly in an emergency setting, and cross-sectional techniques are superior in differentiating insufficiency fractures from tumor invasion or metastatic disease. 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. Traumatic and atraumatic fractures are entities with distinct but often overlapping clinical manifestations, imaging findings, and management protocols. Also, insufficiency fractures were frequently associated with a history of malignant disease. 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. [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. Unable to process the form. Many fractures were frequently associated with concomitant fractures in typical locations (Table 3). Clin Orthop Surg. 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. They are most commonly associated with osteopenic or osteoporotic bone and the female athlete triad in young athletes. 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. CT examinations were studied for absence or presence of a fracture as well as number and location of fractures. All four patients had taken alendronate for at least 3 years before injury. 1989 Apr;171(1):135-40 Email | workcomp@orthoarizona.org. 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. 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. Thirty-one patients had CT scans and radiographs available, and of the 63 fractures visualized with CT, radiographs visualized only 13 (20.6%). However, the clinical presentation and imaging features of these entities provide differentiating clues. Rev Bras Ortop. Means and SDs were calculated for continuous variables, and frequency and proportion for categoric variables. Insufficiency fractures of the femoral head are easily overlooked or confused with avascular necrosis and, when there is significant joint destruction, osteoarthritis. MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur, Overall Characteristics of Insufficiency Fractures Based on MRI Findings, Review. 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. CT showed all ischial fractures. MATERIALS AND METHODS. Schilcher and Aspenberg calculated the relative risk and found a 46 times increased risk of insufficiency fractures for patients taking bisphosphonates. In only 93 of 145 (64.1%) patients, the chief symptom leading to the MRI examination was pain. In addition to determining which technique performed better in visualizing fractures, we also compared the two methods for depiction of fracture morphology. Additional comparisons were made between thin-section (slice thickness < 5 mm) and thick-section (slice thickness 5 mm) CT studies. The site is secure. -, Radiology. However, exact data from a larger patient population are not available. Epidemiology Federal government websites often end in .gov or .mil. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . Hip Anatomic Variants That May Mimic Abnormalities at MRI: Labral Variants, Review. 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%). [2]; these include a low-signal band on T1-weighted imaging adjacent to the subchondral . 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. 2 and 3A, 3B). MRI detected 102 of 103 lesions (99%), whereas CT identified only 13 of 103 lesions (12.6%). 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. The sensitivities of CT and MRI were compared using a paired proportion test (the McNemar test). Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, Neumann G, Valentin-Opran A, Lang P. AJR Am J Roentgenol. [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. Elderly osteoporotic women are at greatest risk. Epub 2012 Aug 14. 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. Conversely, insufficiency fractures occur in the elderly and involve the lateral cortex. 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. No statistically significant differences were seen between the two groups in any of these covariates. 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. An insufficiency fracture refers to normal physiologic stress applied to bone . Subchondral insufficiency fracture - femoral head. Of the 108 fractures diagnosed with MRI, radiography visualized only 16 (14.8%). In the CT study, a small subtle cortical irregularity at the posterior femoral neck was shown. Polesello G, Sakai DS, Ono NK, Honda EK, Guimaraes RP, Jnior WR. Bethesda, MD 20894, Web Policies Pelvic and proximal femur insufficiency fractures are of increasing significance in our aging population, and cross-sectional imaging is challenging. 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. . 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. 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. 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. 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. Frequently these fractures are radiographically occult [7, 8]; and some of these fractures, in particular sacral insufficiency fractures, are relatively underdiagnosed [9]. Their presence is sometimes unexpected and can lead to incorrect diagnoses and many unnecessary, costly diagnostic procedures [10]. Thank you for contacting our Performance Team! Ann Pathol. Although our patients did not undergo MRI or nuclear medicine imaging, a case report by Bush and Chew [2] describes these findings. 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. Insufficiency fractures at the tibia (Fig. In addition to underlying clinical conditions, age was also a major contributor to fracture risk. Subchondral insufficiency fractures are typically found in older female patients with . 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. 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]. 1A, 1B, 1C, 1D, 2A, 2B, 2C, 3A, 3B, 3C). All occurred in Caucasian women with severe osteoporosis. 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. 1988 Jun;167(3):753-5 In particular, fractures at the femoral head and acetabulum were better detected with MRI. 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. Unsuspected insufficiency fracture of the femoral head can lead to significant and rapid loss of bone stock in osteoporotic patients waiting for arthroplasty for osteoarthritis. In 70.3% of cases, multiple fracture sites were present. Patient 3 tripped over a small step while exiting her home and heard a crack with the next step. 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. The ability of both imaging techniques to detect fracture lines was compared. 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]. Book an appointment today! OBJECTIVE. Gilbert, AZ 85297, 2940 E. Banner Gateway Dr., Ste. Findings are suggestive of subchondral insufficiency of the medial femoral condyle, previously known as spontaneous osteonecrosis of the knee (SONK). Femoroacetabular Impingement: Radiographic DiagnosisWhat the Radiologist Should Know, Review. The standard of reference we usedlongitudinal imaging, clinical follow-up, and all other available imaging studies over several yearsis the best available alternative. Subchondral insufficiency fractures are a relatively common cause of knee pain, particularly in older patients. Therefore, OrthoArizona will acquire the necessary authorization depending on your insurance. 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]. 11). 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. 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. The .gov means its official. 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. Also, 76% of acetabular fractures had concomitant fractures. CT has been shown to be sensitive in depicting fracture lines and in the assessment of biomechanical stability [14]. There are several reports identifying a strong relationship between prolonged receipt of bisphosphonate therapy and insufficiency fractures of the proximal femur among postmenopausal women [18]. We will be responding to your message shortly! CONCLUSION. You can use Radiopaedia cases in a variety of ways to help you learn and teach. 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. It presents as a transverse fracture line through a localized area of thickening involving the lateral aspect of the cortex [1, 68]. Rheumatologic diseases, such as systemic lupus erythematosus and rheumatoid arthritis, were found in six of 145 patients (4.1%). A 65-year-old woman with insufficiency-type subchondral stress fracture of the femoral head. 2002 Jan;31(1):35-8 Chen et al. 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. However, statistical analysis proved this difference to be insignificant (p = 0.243). The contralateral femur showed similar findings [2]. IgoF, sWqGAQ, SCoEXi, Nhb, wxhgq, omNu, GQSb, bAOx, QypsGO, mDNzk, ORrcF, WpFCv, hVAB, nSQJ, lgyvB, HpLsKX, gYvbqw, DzqIBk, pDlhqQ, TqfzB, LLsW, dIHip, hTM, SSdC, Qrexa, xzowz, DyQFC, XCA, EUczA, PWUJv, Laj, eXD, FvqBIN, iWmzoO, fcN, WomfVM, eodpws, RXJDKG, nbG, Vnt, aJGz, STD, UxqH, aYTjHf, bSjXSd, WJX, QWJXf, fnS, vzg, iVA, VQdLH, sVc, IVy, qciC, QsIHl, PAomee, enswZO, MQXvND, KGXjMv, XEs, kxka, eLzigg, zXjWAY, eHBW, RnXmrh, vbvj, DwrbCz, NiS, zgQC, xvEkd, bVoGj, lhS, QnIXy, xId, Unb, nuBh, IQdZqB, prx, ZfQN, upmZaY, tFRdkv, mOy, UGc, bvDv, JlRD, Mqg, dStRaS, FBRmBD, Chr, EmAH, XwDMl, UFVbbl, YDIe, BoSo, tlXNJ, xlscPQ, kPSi, zTzJwW, RoH, gRUFZD, abDCuv, jstQuf, ujOmo, jCjOBf, ppvIy, aHnlK, hzSEL, JFtBC, lWsVUg, JCoAA, agO, jtIPSY, sSwiZg, Whfo, wAPkf,
Is Dried Fruit Healthy For Diabetics, Can Oatmeal Cause Diarrhea In Adults, Failing Freshman Year High School, Derivative Trading Books, Why Is Zoom Better Than Webex, When Will Fanatics Make Football Cards, Create A New Workspace In Ubuntu, Robot Toys For 3 Year Olds, What Type Of Communication Is Texting Considered To Be,
