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Lowry MKJ, Buchanan ME. Sacroiliac Joint: Mimics and Pitfalls. Semin Musculoskelet Radiol 2025; 29:210-220. [PMID: 40164078 DOI: 10.1055/s-0045-1802971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2025]
Abstract
Sacroiliac joint pathology presents a complex diagnostic challenge due to the diverse range of conditions, both mechanical and inflammatory, that can affect the joint. Although axial spondyloarthritis-related sacroiliitis is often the most recognized pathology, numerous other conditions closely mimic axial spondyloarthritis in both clinical presentation and imaging features. This review describes key anatomical aspects of the sacroiliac joint, including its distinct morphology, ligamentous support, and histologic characteristics, essential for understanding and differentiating various pathologies. It also examines detailed imaging findings from magnetic resonance imaging, computed tomography, and radiography in relation to each pathologic condition. By providing a framework for distinguishing between common and rare sacroiliac joint disorders and axial spondyloarthritis, this article will enhance diagnostic accuracy and offer insights into the anatomical nuances that impact clinical and imaging assessments.
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Affiliation(s)
- Mary K Jesse Lowry
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Morrison WB, Deely D, Fox MG, Blankenbaker DG, Dodds JA, French CN, Frick MA, Jawetz ST, Khurana B, Kresin M, Nacey N, Reitman C, Said N, Stensby JD, Walker EA, Chang EY. ACR Appropriateness Criteria® Stress (Fatigue-Insufficiency) Fracture Including Sacrum Excluding Other Vertebrae: 2024 Update. J Am Coll Radiol 2024; 21:S490-S503. [PMID: 39488356 DOI: 10.1016/j.jacr.2024.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Accepted: 08/31/2024] [Indexed: 11/04/2024]
Abstract
Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in a variety of patients (athletes, older patients, and patients with predisposing conditions). Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Nuclear medicine scintigraphy and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go on to healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential to progress to completion, necessitating surgery. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated differently (ie, metastatic disease). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Diane Deely
- Research Author, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Julie A Dodds
- Michigan State University, East Lansing, Michigan; American Academy of Orthopaedic Surgeons
| | - Cristy N French
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Bharti Khurana
- Brigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER
| | - Molly Kresin
- Mayo Clinic Arizona, Glendale, Arizona, Primary care physician
| | - Nicholas Nacey
- University of Virginia Health System, Charlottesville, Virginia
| | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina; North American Spine Society
| | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | | | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Eric Y Chang
- Specialty Chair, VA San Diego Healthcare System, San Diego, California
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Hiranaka Y, Miyazaki S, Inoue S, Ryu M, Kuroshima K, Yurube T, Kakutani K, Tadokoro K. Clinical Features and Therapeutic Process of Sacral Fatigue Fractures in Adolescents. Am J Sports Med 2024; 52:2046-2054. [PMID: 38819096 DOI: 10.1177/03635465241251848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Sacral fatigue fractures are a rare injury but should be considered as a differential diagnosis for low back and buttock pain in young adults. Collective reports are limited, most of which have focused on long-distance runners. PURPOSE To investigate the characteristics of sacral fatigue fractures in adolescents. STUDY DESIGN Case series; Level of evidence, 4. METHODS We analyzed patient background characteristics, physical examination and imaging findings, and treatment courses of those diagnosed with sacral fatigue fractures using magnetic resonance imaging. RESULTS Among 34 patients with sacral fatigue fractures, 15 and 19 were male and female patients, respectively, with an age range of 11 to 19 years (mean age, 15.0 years). Almost all patients were athletes, and 29 patients performed their sport ≥5 times a week. Long-distance runners were the most commonly affected, comprising 7 patients, and participants in other common sports such as baseball (6 patients), basketball (4 patients), and soccer (3 patients) were also affected. Physical examination revealed tension sign (Lasègue test) on the affected side in 6 patients and tight hamstrings in 24 patients. Imaging findings included 18 patients with right-side involvement, 12 with left-side involvement, and 4 with involvement on both sides. In 11 patients, spina bifida occulta was observed at S1 and 8 patients had a history of lumbar spondylolysis with 4 patients having concurrent sacral fatigue fractures. Physical therapy was performed concurrently with the cessation of exercise, and return to exercise was permitted if the pain had been relieved after 1 month. All patients returned to sports at a median of 48 days (range, 20-226 days) after symptom onset. However, 2 patients experienced recurrence (1 patient on the ipsilateral side and 1 patient on the contralateral side). CONCLUSION Sacral stress fractures are not limited to long-distance runners in this population and can manifest as lower back pain or buttock pain in athletes participating in a variety of sports. Although the course of treatment was generally good, the possibility of recurrence must always be considered.
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Affiliation(s)
- Yoshiaki Hiranaka
- Department of Orthopaedic Surgery, Anshin Hospital, Kobe City, Hyogo Prefecture, Japan
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Shingo Miyazaki
- Department of Orthopaedic Surgery, Anshin Hospital, Kobe City, Hyogo Prefecture, Japan
| | - Shinichi Inoue
- Department of Orthopaedic Surgery, Anshin Hospital, Kobe City, Hyogo Prefecture, Japan
| | - Masao Ryu
- Department of Orthopaedic Surgery, Anshin Hospital, Kobe City, Hyogo Prefecture, Japan
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kohei Kuroshima
- Department of Orthopaedic Surgery, Anshin Hospital, Kobe City, Hyogo Prefecture, Japan
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takashi Yurube
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | | | - Ko Tadokoro
- Department of Orthopaedic Surgery, Anshin Hospital, Kobe City, Hyogo Prefecture, Japan
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Willaume T, Delmas L, Tochon L, Bierry G. A comparison of smooth and sharp kernel CT reconstructions in the detection of unilateral sacral fractures. Skeletal Radiol 2023:10.1007/s00256-023-04313-8. [PMID: 36869891 DOI: 10.1007/s00256-023-04313-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/19/2023] [Accepted: 02/25/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE The goal of this study is to determine whether smooth kernel reconstructions are more sensitive than sharp kernel ones for the detection of sacral stress fractures (SF) using MRI as the reference standard. MATERIALS AND METHODS This retrospective study included 100 subjects in whom CT and MR of the pelvis were performed for a clinical suspicion of SF from January 2014 to May 2020 in our institution. MR was used as the reference standard for the presence of SF. Smooth and sharp kernel CT datasets of the 100 patients were pooled and analyzed randomly. Three readers of various experiences in MSK imaging independently evaluated the axial CT images for the presence of a SF. RESULTS SF was present on MR in 31 patients (22 women, 9 men; mean age 73.6 ± 19.6) and absent in 69 (48 women, 21 men; mean age 68.8 ± 19.0). Depending on readers, sensitivities ranged from 58 to 77% for the smooth kernel and from 52 to 74% for the sharp kernel reconstructions. For each reader, sensitivities (as well as negative predictive values) of CT were slightly greater on the smooth kernel reconstructions. CONCLUSION The use of smooth kernel reconstructions improved the sensitivity of CT for the detection of SF compared to the sharp kernel reconstructions usually used and regardless of the experience of the radiologist. Smooth kernel reconstructions should, therefore, be scrutinized in patients with suspicion of SF.
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Affiliation(s)
- Thibault Willaume
- MSK Imaging, Strasbourg University Hospital, 1 Avenue Molière, 67098, Strasbourg, France
| | - Louis Delmas
- MSK Imaging, Strasbourg University Hospital, 1 Avenue Molière, 67098, Strasbourg, France
| | - Ludivine Tochon
- MSK Imaging, Strasbourg University Hospital, 1 Avenue Molière, 67098, Strasbourg, France
| | - Guillaume Bierry
- MSK Imaging, Strasbourg University Hospital, 1 Avenue Molière, 67098, Strasbourg, France.
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Sacral stress fractures in athletes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:1-9. [PMID: 34727235 DOI: 10.1007/s00586-021-07043-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/23/2021] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Fatigue stress fractures are a common overuse injury, frequently associated with high load-bearing endurance activities such as running, military training and aerobic exercise. While these fractures can arise at any site, sacral stress fractures are poorly studied with evidence consisting mainly of case reports and limited case series. This review aims to analyze and summarize all reports published to date describing cases of sacral stress fracture in athletes. METHODS PubMed, Embase, Web of Science and the Cochrane Database were systematically searched for studies reporting on Stress Fractures of the Sacrum. Insufficiency fractures of the elderly were excluded. RESULTS The literature review revealed 49 studies reporting on 124 cases of sacral stress fractures. Seventy-six patients (61%) were professional or collegiate level athletes, and 37 (30%) were military recruits or police officers in training. Seventeen female athletes were identified as suffering from low bone mineral density (25%), 9 of which reported menstrual irregularities. Thirteen female patients (19%) had a history of eating disorders. CONCLUSION While most sacral stress fractures occur in normal bones exposed to abnormal repetitive loads, the high percentage of lower bone mineral density can blur the lines between fatigue fractures and insufficiency fractures. The causes of these fractures are multifactorial. High endurance sports and the features of the female athlete triad were found in high percentage of the cases. Conservative treatment is the mainstay of treatment, consisting of ceasing of training and a period of rehabilitation and gradual return to training and competition.
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Rudran B, Super J, Jandoo R, Babu V, Nathan S, Ibrahim E, Wiik AV. Current concepts in the management of bisphosphonate associated atypical femoral fractures. World J Orthop 2021; 12:660-671. [PMID: 34631450 PMCID: PMC8472443 DOI: 10.5312/wjo.v12.i9.660] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/21/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.
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Affiliation(s)
- Branavan Rudran
- Department of Orthopaedic Surgery, Chelsea and Westminster NHS Trust, London TW7 6AF, United Kingdom
- The MSk Lab, Imperial College London, London W12 0BZ, United Kingdom
| | - Jonathan Super
- The MSk Lab, Imperial College London, London W12 0BZ, United Kingdom
| | - Rajan Jandoo
- Department of Orthopaedic Surgery, Chelsea and Westminster NHS Trust, London TW7 6AF, United Kingdom
| | - Victor Babu
- Department of Orthopaedic Surgery, Chelsea and Westminster NHS Trust, London TW7 6AF, United Kingdom
| | - Soosai Nathan
- Department of Orthopaedic Surgery, Chelsea and Westminster NHS Trust, London TW7 6AF, United Kingdom
| | - Edward Ibrahim
- Department of Orthopaedic Surgery, Chelsea and Westminster NHS Trust, London TW7 6AF, United Kingdom
| | - Anatole Vilhelm Wiik
- Department of Orthopaedic Surgery, Chelsea and Westminster NHS Trust, London TW7 6AF, United Kingdom
- Department of Surgery and Cancer, Charing Cross Hospital, London W6 8RF, United Kingdom
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Barbeau P, Michaud A, Hamel C, Rice D, Skidmore B, Hutton B, Garritty C, da Silva DF, Semeniuk K, Adamo KB. Musculoskeletal Injuries Among Females in the Military: A Scoping Review. Mil Med 2021; 186:e903-e931. [PMID: 33367692 DOI: 10.1093/milmed/usaa555] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/04/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Musculoskeletal injuries (MSKi) are a common challenge for those in military careers. Compared to their male peers, reports indicate that female military members and recruits are at greater risk of suffering MSKi during training and deployment. The objectives of this study were to identify the types and causes of MSKi among female military personnel and to explore the various risk factors associated with MSKi. MATERIALS AND METHODS A scoping review was conducted over a 4-month time frame of English language, peer-reviewed studies published from 1946 to 2019. Search strategies for major biomedical databases (e.g., MEDLINE; Embase Classic + Embase; and the following EBM Reviews-Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment, and the NHS Economic Evaluation Database) were developed by a senior medical information specialist and included 2,891 titles/abstracts. Study selection and data collection were designed according to the Population, Concept, and Context framework. Studies were included if the study population provided stratified data for females in a military context. RESULTS From a total of 2,287 citations captured from the literature searches, 168 peer-reviewed publications (144 unique studies) were eligible for inclusion. Studies were identified from across 10 countries and published between 1977 and 2019. Study designs were primarily prospective and retrospective cohorts. Most studies assessed both prevalence/incidence and risk factors for MSKi (62.50%), with few studies assessing cause (13.69%). For MSKi of female recruits compared to active female members, the prevalence was higher (19.7%-58.3% vs. 5.5%-56.6%), but the incidence (0.02%-57.7% vs. 13.5%-71.9%) was lower. The incidence of stress fractures was found to be much higher in female recruits than in active members (1.6%-23.9% vs. 2.7%). For anthropometric risk factors, increased body fat was a predictor of MSKi, but not stress fractures. For physiological risk factors for both female military groups, being less physically fit, later menarche, and having no/irregular menses were predictors of MSKi and stress fractures. For biomechanical risk factors, among female recruits, longer tibial length and femoral neck diameter increased the risk of stress fractures, and low foot arch increased risk of an ankle sprain. For female active military members, differences in shoulder rotation and bone strength were associated with risk of MSKi. For biological sex, being female compared to male was associated with an increased risk of MSKi, stress fractures, and general injuries. The consequences of experiencing MSKi for active military included limited duties, time off, and discharge. For recruits, these included missed training days, limited duty days, and release. CONCLUSIONS This scoping review provides insight into the current state of the evidence regarding the types and causes of MSKi, as well as the factors that influence MSKi among females in the military. Future research endeavors should focus on randomized controlled trials examining training paradigms to see if women are more susceptible. The data presented in the scoping review could potentially be used to develop training strategies to mitigate some of the identified barriers that negatively impact women from pursuing careers in the military.
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Affiliation(s)
- Pauline Barbeau
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Alan Michaud
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Candyce Hamel
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Danielle Rice
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Becky Skidmore
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Brian Hutton
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Chantelle Garritty
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, K1H 8L6, Canada
| | - Danilo F da Silva
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Kevin Semeniuk
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Kristi B Adamo
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Miller Olson EK, Kraus E, Fredericson M. Stress Fractures in Sport: Pelvis and Acetabulum. FRACTURES IN SPORT 2021:509-522. [DOI: 10.1007/978-3-030-72036-0_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Pisquiy JJ, Carter JT, Chan A, Kusnezov N, Adler A. Incidence of Pelvic Ring Fractures in the U.S. Military Population. Cureus 2020; 12:e6899. [PMID: 32190457 PMCID: PMC7061778 DOI: 10.7759/cureus.6899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Pelvic ring fractures occur frequently among the elderly population, but some studies demonstrate a bimodal distribution where the incidence is elevated among younger age groups as well. The mechanisms of injury also vary based on age groups. Previous studies are specific to trauma registries and centers, but epidemiological data within the U.S. military are sparse. In the U.S. military population, pelvic ring fractures can be related to high-energy trauma including motor vehicle accidents and combat warfare. The purpose of this study was to determine the incidence of pelvic ring fractures among active duty U.S. military service members between 2006 and 2015, while also describing the demographics associated with the findings. Materials and Methods All data were collected from the U.S. Defense Medical Epidemiology Database (DMED). To calculate the incidence rates, only first-time occurrences for pelvic ring fractures among military members were used. Each point was identified using International Classification of Diseases, Ninth Revision (ICD-9), clinical modification code 808 for “fractures of the pelvis.” A multivariate Poisson regression analysis was used to estimate the incidence rate per 1,000 person-years and 95% confidence intervals while controlling for sex, race, age, rank, and service. Rate ratios were calculated using different referent factors based on differences in sex, race, age, rank, and service branch. This study was IRB exempt as all the data used were de-identified patient data from the DMED system. Results Over the 10-year study period, a total of 4,802 incident cases of pelvic ring fractures, and a total of 13,748,429 person-years were documented. The overall incidence rate of pelvic ring fractures was 0.35 per 1,000 person-years. The incidence of pelvic ring fractures was highest among the youngest age group (<20 years) and among the lower-ranking service members. Additionally, other demographic groups such as the White race, female sex, and Army service members showed the highest incidence rates. Conclusion Our study determined baseline epidemiological data on incidence rates of pelvic ring fractures in the U.S. military. Patient demographics may be contributing factors, and the present analysis was able to elucidate associated underlying demographics. We demonstrated that the incidence was highest among the younger age groups, and that incidence rates may be specific to age cohorts. This study also found that lower-ranking service members had the highest incidence in all service branches, suggesting a form of occupational risk. Furthermore, our findings suggest that females, White race groups, and Army enlisted service members show a significantly higher incidence rate and may be at a greater risk. Our findings are important as they broaden the understanding of the patterns of pelvic ring fractures in the U.S. military population and occupational risks associated with this population.
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Affiliation(s)
- John J Pisquiy
- Orthopaedic Surgery, Texas Tech University Health Science Center, El Paso, USA
| | - Jordan T Carter
- Orthopaedics, Texas Tech University Health Sciences Center, El Paso, USA
| | - Andrew Chan
- Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, USA
| | - Nicholas Kusnezov
- Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, USA
| | - Adam Adler
- Orthopaedic Surgery, Texas Tech University Health Science Center, El Paso, USA
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Vassalou EE, Klontzas ME, Tsifountoudis IP, Spanakis K, Karantanas AH. Spectrum of skeletal disorders during the peripartum period: MRI patterns. ACTA ACUST UNITED AC 2020; 25:245-250. [PMID: 31063145 DOI: 10.5152/dir.2019.18354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pregnancy is a normal condition in which a combination of biomechanical and hormonal changes may result in a wide spectrum of skeletal disorders. Skeletal overloading due to postural and weight changes, combined with increased ligamentous laxity stemming from the action of relaxing and the risk of pregnancy-related osteoporosis during childbearing, childbirth, and postpartum, have been associated with various pathologies. Owing to the heterogeneity of proposed contributing factors, skeletal lesions in the peripartum period may be related to different pathogenesis depending on the metabolic status of the patient and the degree of biomechanical stress; thus, a fatigue or insufficiency discrimination is not always easy to make. When combined with clinical data, magnetic resonance imaging (MRI) is a powerful tool in clarifying the cause of skeletal pain in the majority of patients or alerting clinicians to proceed to further investigations. Early detection and tailored treatment are important in order to avoid disease progression and long-term restriction of daily activities which may have an adverse impact on the relationship between the mother and the newborn. This pictorial essay provides an overview of the MRI characteristics and pattern of involvement of skeletal lesions presenting during the peripartum period, combined with demographic data and dual-energy X-ray absorptiometry (DEXA) measurements.
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Affiliation(s)
- Evangelia E Vassalou
- Department of Medical Imaging, University Hospital, Heraklion, Greece; Department of Medical Imaging, General Hospital of Sitia, Lasithi, Greece
| | - Michail E Klontzas
- Department of Medical Imaging University Hospital, Heraklion, Greece; Imperial College London, London, United Kingdom
| | | | - Konstantinos Spanakis
- Department of Medical Imaging, University Hospital, Heraklion, Greece; Department of Medical Imaging, General Hospital of Sitia, Lasithi, Greece
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Tsoi C, Griffith JF, Lee RKL, Wong PCH, Tam LS. Imaging of sacroiliitis: Current status, limitations and pitfalls. Quant Imaging Med Surg 2019; 9:318-335. [PMID: 30976556 DOI: 10.21037/qims.2018.11.10] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The clinical need to diagnose sacroiliitis at an earlier stage has led to the sacroiliac joints being more frequently imaged, particularly with magnetic resonance imaging (MRI). This review outlines the imaging approach to sacroiliitis, emphasizing the imaging protocols, diagnostic criteria, limitations and potential mimics of MRI examination. The value of imaging-guided intervention in sacroiliac joint disease is also briefly outlined.
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Affiliation(s)
- Carita Tsoi
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - James Francis Griffith
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Ryan Ka Lok Lee
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Priscilla Ching Han Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Lai Shan Tam
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Kim YY, Chung BM, Kim WT. Lumbar spine MRI versus non-lumbar imaging modalities in the diagnosis of sacral insufficiency fracture: a retrospective observational study. BMC Musculoskelet Disord 2018; 19:257. [PMID: 30045747 PMCID: PMC6060517 DOI: 10.1186/s12891-018-2189-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/12/2018] [Indexed: 11/10/2022] Open
Abstract
Background Sacral insufficiency fractures (SIFs) are a common cause of lower back pain in the elderly. However, because clinical symptoms are frequently vague and nonspecific and can mimic lumbar spine pathologies, initial imaging in SIF patients is frequently targeted at the lumbar spine rather than the sacrum, resulting in delayed diagnosis. The purpose of this study is to show the proportions of modalities used in diagnosing SIF in practice and to compare the clinical and imaging features of SIF diagnosed by lumbar spine MRI (L-spine MRI) with those diagnosed by non-lumbar imaging modalities (bone scan, pelvic bone CT, pelvis MRI). Methods Forty-two patients with SIF were enrolled in this study. SIFs diagnosed by L-spine were assigned to group 1 and SIFs diagnosed by non-lumbar imaging modalities (bone scan, pelvic bone CT, pelvis MRI) were assigned to group 2. The clinical and imaging features of SIFs were assessed and compared between two groups. Results SIF were more commonly diagnosed by L-spine MRI (group 1: n = 27, 64.3%) than non-lumbar imaging modalities (group 2: n = 15, 35.7%), which was comprised of pelvic bone CT (n = 6, 14.3%), bone scan (n = 5, 11.9%), and pelvis MRI (n = 4, 9.5%). Lower back pain, radiating pain and comorbid other causes of pain were more frequently identified in group 1. Fracture involving bilateral sacral ala with horizontal component was the most common shape and S2 being the most commonly involved horizontal component, without significant difference between two groups. Conclusion SIFs are more commonly diagnosed by L-spine MRI than non-lumbar imaging modalities, because of symptoms that mimic lumbar spine pathology and variable comorbid causes of pain. To know that L-spine MRI commonly reveal SIF and to be familiar with SIF features on L-spine MRI would help increase sensitivity in detecting this commonly underrecognized entity and achieve earlier and more appropriate management.
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Affiliation(s)
- Yoon Yi Kim
- Department of Radiology, Veterans Health Service Medical Center, 53, Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul, 05368, Republic of Korea
| | - Bo Mi Chung
- Department of Radiology, Veterans Health Service Medical Center, 53, Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul, 05368, Republic of Korea.
| | - Wan Tae Kim
- Department of Radiology, Veterans Health Service Medical Center, 53, Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul, 05368, Republic of Korea
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Bencardino JT, Stone TJ, Roberts CC, Appel M, Baccei SJ, Cassidy RC, Chang EY, Fox MG, Greenspan BS, Gyftopoulos S, Hochman MG, Jacobson JA, Mintz DN, Mlady GW, Newman JS, Rosenberg ZS, Shah NA, Small KM, Weissman BN. ACR Appropriateness Criteria ® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiol 2018; 14:S293-S306. [PMID: 28473086 DOI: 10.1016/j.jacr.2017.02.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 11/30/2022]
Abstract
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. Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Tc-99m bone scan and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go onto healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential of progressing to completion and requiring more invasive treatment or delay in return to activity. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated significantly different (ie, osteoid osteoma, osteomyelitis, and metastasis). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jenny T Bencardino
- Principal Author and Panel Vice-Chair, New York University School of Medicine, New York, New York.
| | - Taylor J Stone
- Research Author, Charlotte Radiology, Charlotte, North Carolina
| | | | - Marc Appel
- James J. Peters VA Medical Center, Bronx, New York; American Academy of Orthopaedic Surgeons
| | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons
| | - Eric Y Chang
- VA San Diego Healthcare System, San Diego, California
| | - Michael G Fox
- University of Virginia Health System, Charlottesville, Virginia
| | | | | | - Mary G Hochman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jon A Jacobson
- University of Michigan Medical Center, Ann Arbor, Michigan
| | | | - Gary W Mlady
- University of New Mexico, Albuquerque, New Mexico
| | | | | | - Nehal A Shah
- Brigham & Women's Hospital, Boston, Massachusetts
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Kaneko H, Murakami M, Nishizawa K. Prevalence and clinical features of sports-related lumbosacral stress injuries in the young. Arch Orthop Trauma Surg 2017; 137:685-691. [PMID: 28349205 DOI: 10.1007/s00402-017-2686-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stress injuries (stress fractures and stress reactions) of the lumbosacral region are one of the causes of sports-related lower back pain in young individuals. These injuries can be detected by bone marrow edema lesion on MRI. However, little is known about the prevalence and clinical features of early stage lumbosacral stress injuries. This study aimed to evaluate the epidemiology of lumbosacral stress injuries. METHODS A total of 312 patients (under 18 years of age) who complained of sports-related lower back pain that had lasted for ≥7 days underwent magnetic resonance imaging (MRI) scans. We reviewed patients' records retrospectively. RESULTS MRI showed that 33.0% of the patients had lumbar stress injuries and 1.6% had sacral stress injuries. Lumbar stress injuries were more common in males than in females and were found in 30% of 13- to 18-year-old patients. About 50% of the patients that participated in soccer or track and field were diagnosed with lumbar stress injuries. No clinical patterns in the frequencies of sacral stress injuries were detected due to the low number of patients that suffered this type of injury. Plain radiography is rarely able to detect the early stage lesions associated with lumbosacral stress injuries, but such lesions can be detected in the caudal-ventral region of the pars interarticularis on sagittal computed tomography scans. Thirty-three percent of young patients that complained of sports-related lower back pain for ≥7 days had lumbar stress injuries, while 1.6% of them had sacral stress injuries. Clinicians should be aware of the existence of these injuries. MRI is useful for diagnosing lumbosacral stress injuries.
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Affiliation(s)
- Hideto Kaneko
- Murakami Orthopaedic Clinic, 1095-4 Nishiura, Mushono, Minakuchi-cho, Koka, Shiga, 528-0041, Japan.
| | - Mototsune Murakami
- Murakami Orthopaedic Clinic, 1095-4 Nishiura, Mushono, Minakuchi-cho, Koka, Shiga, 528-0041, Japan
| | - Kazuya Nishizawa
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan
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15
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Postpartum Sacral Stress Fracture: An Atypical Case Report. Case Rep Orthop 2015; 2015:704393. [PMID: 26246926 PMCID: PMC4515257 DOI: 10.1155/2015/704393] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/08/2015] [Indexed: 11/18/2022] Open
Abstract
Sacral stress fractures are common in elderly people. However, sacral stress fracture should be always screened in the differential diagnoses of low back pain during the postpartum period. We present a case of sacral fracture in a thirty-six-year-old woman with low back pain and severe right buttock pain two days after cesarean section delivery of a 3.9 Kg baby. The diagnosis was confirmed by MRI and CT scan, while X-ray was unable to detect the fracture. Contribution of mechanical factors during the cesarean section is not a reasonable cause of sacral fracture. Pregnancy and lactation could be risk factors for sacral stress fracture even in atraumatic delivery such as cesarean section. Our patient had no risk factors for osteoporosis except for pregnancy and lactation. Transient or focal osteoporosis is challenging to assess and it cannot be ruled out even if serum test and mineral density are within the normal range.
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Geissler JR, Bajaj D, Fritton JC. American Society of Biomechanics Journal of Biomechanics Award 2013: cortical bone tissue mechanical quality and biological mechanisms possibly underlying atypical fractures. J Biomech 2015; 48:883-94. [PMID: 25683519 PMCID: PMC4380555 DOI: 10.1016/j.jbiomech.2015.01.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/20/2015] [Indexed: 01/15/2023]
Abstract
The biomechanics literature contains many well-understood mechanisms behind typical fracture types that have important roles in treatment planning. The recent association of “atypical” fractures with long-term use of drugs designed to prevent osteoporosis has renewed interest in the effects of agents on bone tissue-level quality. While this class of fracture was recognized prior to the introduction of the anti-resorptive bisphosphonate drugs and recently likened to stress fractures, the mechanism(s) that lead to atypical fractures have not been definitively identified. Thus, a causal relationship between these drugs and atypical fracture has not been established. Physicians, bioengineers and others interested in the biomechanics of bone are working to improve fracture-prevention diagnostics, and the design of treatments to avoid this serious side-effect in the future. This review examines the mechanisms behind the bone tissue damage that may produce the atypical fracture pattern observed increasingly with long-term bisphosphonate use. Our recent findings and those of others reviewed support that the mechanisms behind normal, healthy excavation and tunnel filling by bone remodeling units within cortical tissue strengthen mechanical integrity. The ability of cortical bone to resist the damage induced during cyclic loading may be altered by the reduced remodeling and increased tissue age resulting from long-term bisphosphonate treatment. Development of assessments for such potential fractures would restore confidence in pharmaceutical treatments that have the potential to spare millions in our aging population from the morbidity and death that often follow bone fracture.
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Affiliation(s)
- Joseph R Geissler
- Department of Orthopaedics, New Jersey Medical School, Rutgers University, 205 S. Orange Avenue, Newark, NJ 07103, USA; Joint Program in Biomedical Engineering, Rutgers Biomedical and Health Sciences, and the New Jersey Institute of Technology, Newark, NJ, USA.
| | - Devendra Bajaj
- Department of Orthopaedics, New Jersey Medical School, Rutgers University, 205 S. Orange Avenue, Newark, NJ 07103, USA.
| | - J Christopher Fritton
- Department of Orthopaedics, New Jersey Medical School, Rutgers University, 205 S. Orange Avenue, Newark, NJ 07103, USA; Joint Program in Biomedical Engineering, Rutgers Biomedical and Health Sciences, and the New Jersey Institute of Technology, Newark, NJ, USA.
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17
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Kilcoyne A, Kavanagh EC. Unusual presentation of sacral fatigue fractures. Spine J 2014; 14:1063-4. [PMID: 24448189 DOI: 10.1016/j.spinee.2013.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/18/2013] [Accepted: 12/29/2013] [Indexed: 02/03/2023]
Affiliation(s)
- Aoife Kilcoyne
- Department of Radiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland
| | - Eoin C Kavanagh
- Department of Radiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland
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18
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Abstract
CONTEXT Pelvic stress fractures, osteitis pubis, and snapping hip syndrome account for a portion of the overuse injuries that can occur in the running athlete. EVIDENCE ACQUISITION PUBMED SEARCHES WERE PERFORMED FOR EACH ENTITY USING THE FOLLOWING KEYWORDS: snapping hip syndrome, coxa sultans, pelvic stress fracture, and osteitis pubis from 2008 to 2013. Topic reviews, case reports, case series, and randomized trials were included for review. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Collectively, 188 articles were identified. Of these, 58 were included in this review. CONCLUSION Based on the available evidence, the majority of these overuse injuries can be managed non-operatively. Primary treatment should include removal from offending activity, normalizing regional muscle strength/length imbalances and nutritional deficiencies, and mitigating training errors through proper education of the athlete and training staff. STRENGTH OF RECOMMENDATION TAXONOMY C.
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Affiliation(s)
- P. Troy Henning
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
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19
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MRI of the SI joints commonly shows non-inflammatory disease in patients clinically suspected of sacroiliitis. Eur J Radiol 2014; 83:179-84. [DOI: 10.1016/j.ejrad.2013.10.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 08/19/2013] [Accepted: 10/04/2013] [Indexed: 01/25/2023]
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20
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Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: Recommendations for surgical treatment. Injury 2013; 44:1733-44. [PMID: 23871193 DOI: 10.1016/j.injury.2013.06.023] [Citation(s) in RCA: 319] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 06/20/2013] [Indexed: 02/02/2023]
Abstract
Due to the increasing life expectancy, orthopaedic surgeons are more and more often confronted with fragility fractures of the pelvis (FFPs). These kinds of fractures are the result of a low-energy impact or they may even occur spontaneously in patients with severe osteoporosis. Due to some distinct differences, the established classifications for pelvic ring lesions in younger adults do not fully reflect the clinical and morphological criteria of FFPs. Most FFPs are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to increasing displacement, nonunion and persisting instability. Therefore, new concepts for surgical treatment have to be developed to address the functional needs of the elderly patients. Based on an analysis of 245 consecutive patients with FFPs, we propose a novel classification system for this condition. This classification is based on morphological criteria and it corresponds with the degree of instability. Also in the elderly, these criteria are the most important for the decision on the type of treatment as well as type and extent of surgery. The estimation of the degree of instability is based on radiological and clinical findings. The classification gives also hints for treatment strategies, which may vary between minimally invasive techniques and complex surgical reconstructions.
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Affiliation(s)
- Pol Maria Rommens
- Department of Trauma Surgery, Centre for Muskuloskeletal Surgery, University Medical Centre Mainz, Mainz, Germany.
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21
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22
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Rommens PM, Wagner D, Hofmann A. Surgical management of osteoporotic pelvic fractures: a new challenge. Eur J Trauma Emerg Surg 2012; 38:499-509. [PMID: 23162670 PMCID: PMC3495273 DOI: 10.1007/s00068-012-0224-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 08/24/2012] [Indexed: 11/24/2022]
Abstract
The number and variety of osteoporotic fractures of the pelvis are rapidly growing around the world. Such fractures are the result of low-impact trauma. The patients have no signs of hemodynamic instability and do not require urgent stabilization. The clinical picture is dominated by immobilizing pain in the pelvic region. Fractures may be located in both the ventral and the dorsal pelvic ring. The current well-established classification of pelvic ring lesions in younger adults does not fully reflect the criteria for osteoporotic and insufficiency fractures of the pelvic ring. Most osteoporotic fractures are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to complex displacement and instability. Therefore, vertical sacral ala fractures, fracture dislocations of the sacroiliac joint, and spinopelvic dissociations are best treated with operative stabilization. Angular stable bridge plating, the insertion of a transsacral positioning bar, and iliolumbar fixation are operative techniques that have been adapted to the low bone mineral density of the pelvic ring and the high forces acting on it.
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Affiliation(s)
- P M Rommens
- Department of Trauma Surgery, Center of Musculoskeletal Surgery, University Medical Center, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
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23
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Bousson V, Wybier M, Petrover D, Parlier C, Chicheportiche V, Hamzé B, Sverzut JM, Daguet E, Wyler A, Thabet J, Bossard P, Laredo JD. [Stress fractures]. ACTA ACUST UNITED AC 2011; 92:188-207. [PMID: 21501759 DOI: 10.1016/j.jradio.2011.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Accepted: 02/03/2011] [Indexed: 10/18/2022]
Abstract
In 1892, J. Wolff, an orthopedic surgeon, stated that the internal architecture and shape of a bone were related to the direction of stresses placed upon it. Conventional radiographs and MRI can demonstrate the adaptability of bones to stresses. Imaging also demonstrates that this adaptability has limitations, and that excessive stress may lead to fracture.
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Affiliation(s)
- V Bousson
- Service de radiologie ostéoarticulaire, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
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24
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Abstract
Bone densitometric studies have shown that osteoporosis is a result of prolonged, slow bone loss and that the pattern of loss is different for trabecular and cortical bone. Structurally-insufficient osteoporotic bone is predisposed to fractures. Among the clinically manifest osteoporotic fractures, distal radius leads the list, followed by hip, spine, and proximal humerus. This article examines the use of conventional radiography as well as other imaging-based modalities for the evaluation of osteoporosis and associated fractures in the axial and appendicular skeleton.
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Affiliation(s)
- Gopinathan Anil
- Department of Radiology, Changi General Hospital, 2 Simei Street 3, Singapore
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25
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Bone stress injuries are common in female military trainees: a preliminary study. Clin Orthop Relat Res 2009; 467:2962-9. [PMID: 19384560 PMCID: PMC2758974 DOI: 10.1007/s11999-009-0851-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 04/07/2009] [Indexed: 01/31/2023]
Abstract
Although bone stress injuries are common in male military trainees, it is not known how common they are in female trainees. It also is unclear whether asymptomatic bone stress injuries heal if intensive training is continued. We prospectively followed 10 female trainees of a military Reserve Officer Course. The subjects underwent clinical and MRI examinations of the pelvis, thighs, and lower legs at the beginning, once during, and at the end of their 3-month course. We identified two to five injuries in every female trainee, all of whom already had the injuries at the beginning of the officer course. None of these injuries increased their severity despite vigorous training. Two-thirds were asymptomatic and low grade. Femoral and tibial shafts were the most common locations. Higher-grade injuries were more likely symptomatic, but regardless of the MRI findings, female trainees expressed only mild to moderate symptoms. Asymptomatic, low-grade bone stress injuries of the femoral and tibial shaft are common in female recruits undergoing heavy physical training. Because these injuries seem to remain constant or even disappear despite continued heavy physical activity, we do not recommend routine screening of asymptomatic trainees. As some bone stress fractures may have severe consequences (eg, in the femoral neck), symptomatic bone stress injuries should be examined and treated.
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26
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Karadeli E, Uslu N. Postpartum Sacral Fracture Presenting as Lumbar Pain. J Womens Health (Larchmt) 2009; 18:663-5. [DOI: 10.1089/jwh.2008.1189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Elif Karadeli
- Baskent University Faculty of Medicine, Radiology Department, Ankara, Turkey
| | - Nihal Uslu
- Baskent University Faculty of Medicine, Radiology Department, Ankara, Turkey
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Peh WCG, Koh WL, Kwek JW, Htoo MM, Tan PH. Imaging of painful solitary lesions of the sacrum. ACTA ACUST UNITED AC 2008; 51:507-15. [PMID: 17958684 DOI: 10.1111/j.1440-1673.2007.01861.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In patients with sacral pain, the painful symptoms may be caused by a variety of bony and soft tissue lesions. Benign lesions include giant cell tumour, neurogenic tumour, insufficiency fracture, infection and giant bone island. Malignant lesions include primary bone tumours, Ewing sarcoma, plasmacytoma, lymphoma and chordoma. Soft tissue tumours adjacent to or involving the sacrum may cause painful symptoms. A multimodality approach to imaging is required for full assessment of these lesions. This pictorial essay describes a range of common solitary sacral lesions that may cause pain, with emphasis on imaging features.
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Affiliation(s)
- W C G Peh
- Department of Diagnostic Radiology, Alexandra Hospital, Singapore.
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30
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Fredericson M, Moore W, Biswal S. Sacral stress fractures: magnetic resonance imaging not always definitive for early stage injuries: a report of 2 cases. Am J Sports Med 2007; 35:835-9. [PMID: 17261568 DOI: 10.1177/0363546506296519] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Michael Fredericson
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California 94305-5336, USA.
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31
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Haun DW, Kettner NW, Yochum TR, Green RL. Sacral fatigue fracture in a female runner: a case report. J Manipulative Physiol Ther 2007; 30:228-33. [PMID: 17416277 DOI: 10.1016/j.jmpt.2007.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 05/18/2006] [Accepted: 06/01/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This case report describes and discusses the clinical presentation, diagnosis, and management of a patient with a sacral fatigue fracture. CLINICAL FEATURES A 26-year-old female long-distance runner presented with nonspecific low-back and buttock pain that prevented her from training. INTERVENTION AND OUTCOME Radiographic findings on the patient's lumbar spine and pelvis were interpreted as normal. Single-photon emission computed tomography and magnetic resonance imaging were performed, revealing a fatigue fracture of the left sacral ala. The patient discontinued training for 6 months and gradually returned to running. CONCLUSIONS A high index of suspicion should prompt investigation with skeletal scintigraphy, computed tomography, or magnetic resonance imaging. Sacral stress fractures may respond well to conservative measures if diagnosed in a timely fashion.
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Affiliation(s)
- Daniel W Haun
- Logan College of Chiropractic, Chesterfield, MO, USA
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Abstract
GOAL The aim of this article is to describe rare and often unrecognized causes of spinal pain syndromes. METHOD Intervertebral disc degeneration frequently appears in early adulthood and can have a symptomatic or asymptomatic course. This article discusses incidence, pathophysiology, imaging, and pain symptomatology involved in the origin of back pain. RESULTS Anulus tears are often found in asymptomatic individuals but could be implicated in lumbar pain symptomatology in correlation with the provocative discography. Transient disorders can lead to pseudarthrosis of the iliac bone and to degeneration or to a reactive hypermobility with intervertebral disc degeneration in the level above. Modic type 1 erosive osteochondrosis is characterized by bone marrow edema near the hyaline cartilage end plate, which mostly elicits severe pain and results in serious limitations in everyday activities. The most important differential diagnosis is spondylodiscitis. Schmorl's nodes can exhibit considerable surrounding bone marrow edema that can be mistaken for metastases. A combination of MRI and CT should be employed for the diagnostic work-up of fatigue fracture of the interarticular portion, which is often overlooked due to its location. Synovial cysts of the facet joints can lead to radicular symptoms. Insufficiency fracture of the sacrum is frequently mistaken for metastasis due to intense scintigraphic enhancement and its signal behavior in MRI. CT provides instructive information. CONCLUSION Differential diagnosis should include less common causes such as anulus tears, transient disorders, activated Schmorl's nodes, synovial cysts of the facet joints, fatigue fractures of the interarticular portion of the spine and the sacrum and distinguish from metastases in particular.
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Affiliation(s)
- A Baur-Melnyk
- Institut für Klinische Radiologie, Klinikum Grosshadern der Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 München.
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Silva RT, De Bortoli A, Laurino CFS, Abdalla RJ, Cohen M. Sacral stress fracture: an unusual cause of low back pain in an amateur tennis player. Br J Sports Med 2006; 40:460-1. [PMID: 16632580 PMCID: PMC2577498 DOI: 10.1136/bjsm.2005.023473] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2005] [Indexed: 11/03/2022]
Abstract
Stress fractures are common in athletes, and their incidence in sport is estimated at 2-4%. A case is reported of a stress fracture of the sacrum in an amateur tennis player. The patient was treated with rest and physiotherapy, focusing on stretching programmes and analgesic treatments, followed by an educational programme of tennis training and muscle strengthening. This appears to be the first report of this pathology in a tennis player.
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Affiliation(s)
- R T Silva
- Center for Sports Medicine, Rua Carmelo Damato 40, Sao Paulo 04084-100, Brazil.
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Abstract
Stress fractures of the pars, pedicle, and sacrum are important considerations in the differential diagnosis of lower back pain in the child or adolescent athlete. A thorough history and physical examination as well as a high index of suspicion are essential when assessing a patient with lower back pain. Diagnostic imaging, including radiographs, bone scans, CT scans, and other imaging modalities are important for further narrowing the diagnosis. The early identification and proper management of stress fractures of the pars, pedicle, and sacrum are integral in the prevention of stress fractures in the adolescent athlete population. This article reviews current concepts in the assessment and management of stress fractures of the lumbosacral spine, particularly of the pars (spondylolysis), pedicles, and sacrum.
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Affiliation(s)
- Lyle J Micheli
- Division of Sports Medicine, Department of Orthopedics, Children's Hospital Boston, Boston, MA 02115, USA.
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Bodner G, Stöckl B, Fierlinger A, Schocke M, Bernathova M. Sonographic findings in stress fractures of the lower limb: preliminary findings. Eur Radiol 2004; 15:356-9. [PMID: 15503040 DOI: 10.1007/s00330-004-2525-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2004] [Revised: 08/20/2004] [Accepted: 08/23/2004] [Indexed: 10/26/2022]
Abstract
Stress fractures are common injuries frequently overlooked on first radiographs, especially in the early course. The gold standard for accurate diagnosis is MRI and scintigraphy. We report six cases of stress fractures of the lower limb diagnosed with sonography and describe typical sonographic features.
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Affiliation(s)
- Gerd Bodner
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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