Imaging of Sacral Stress and Insufficiency Fractures

Ulrich Josef Albert Spiegl; Klaus John Schnake; Georg Osterhoff; Max J. Scheyerer; Bernhard Ullrich; Philipp Bula; Holger Siekmann

doi:10.1055/a-0640-8933

Zeitschrift für Orthopädie und Unfallchirurgie, Table of Contents

Z Orthop Unfall 2019; 157(02): 144-153
DOI: 10.1055/a-0640-8933

Review/Übersicht

Georg Thieme Verlag KG Stuttgart · New York

Imaging of Sacral Stress and Insufficiency Fractures

Article in several languages: English | deutsch

Ulrich Josef Albert Spiegl

¹Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinik Leipzig

,

Klaus John Schnake

²Zentrum für Wirbelsäulentherapie, Schön Kliniken, Fürth

,

Georg Osterhoff

³Klinik für Traumatologie, Universitätsspital Zürich, Zürich, Schweiz

,

Max J. Scheyerer

⁴Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinik Köln

,

Bernhard Ullrich

⁵Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle

,

Philipp Bula

⁶Klinik für Unfall- und Wiederherstellungschirurgie, Orthopädie, Plastische-, Hand- und Mikrochirurgie, Städtisches Klinikum Gütersloh gGmbH, Gütersloh

,

Holger Siekmann

⁷Unfallchirurgie, Universität Halle

› Author Affiliations

Abstract

Fractures of the os sacrum without relevant trauma history are defined as stress or insufficiency fractures and often affect the anterior pelvis. Sacral insufficiency fractures are associated with osteoporosis and occur under physiological load. In contrast, sacral stress fractures are caused by mechanical overloading. Diagnostic confirmation is delayed in many of these patients. Thus, MRI and/or CT should be performed early. Fracture stability should be evaluated by CT. MRI is the better approach to rule out fractures and is highly sensitive. It is indicated in young patients and in patients with non-specific lumbosacral pain. Nuclear imaging techniques are viable alternatives in patients with a contraindication for MRI.

Key words

insufficiency fracture - sacrum - stress fracture - MRI - CT

Full Text

References

References/Literatur
1 Peh WC, Khong PL, Ho WY. et al. Sacral insufficiency fractures. Spectrum of radiological features. Clin Imaging 1995; 19: 92-101
2 Finiels H, Finiels PJ, Jacquot JM. et al. [Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases]. Presse Med 1997; 26: 1568-1573
3 Newhouse KE, el-Khoury GY, Buckwalter JA. Occult sacral fractures in osteopenic patients. J Bone Joint Surg Am 1992; 74: 1472-1477
4 Kahanov L, Eberman L, Alvey T. et al. Sacral stress fracture in a distance runner. J Am Osteopath Assoc 2011; 111: 585-591
5 Fredericson M, Jennings F, Beaulieu C. et al. Stress fractures in athletes. Top Magn Reson Imaging 2006; 17: 309-325
6 Nusselt T, Klinger HM, Schultz W. et al. Fatigue stress fractures of the pelvis: a rare cause of low back pain in female athletes. Acta Orthop Belg 2010; 76: 838-843
7 Tins BJ, Garton M, Cassar-Pullicino VN. et al. Stress fracture of the pelvis and lower limbs including atypical femoral fractures-a review. Insights Imaging 2015; 6: 97-110
8 Yoder K, Bartsokas J, Averell K. et al. Risk factors associated with sacral stress fractures: a systematic review. J Man Manip Ther 2015; 23: 84-92
9 Nattiv A, Kennedy G, Barrack MT. et al. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am J Sports Med 2013; 41: 1930-1941
10 Bennell KL, Brukner PD. Epidemiology and site specificity of stress fractures. Clin Sports Med 1997; 16: 179-196
11 Gotis-Graham I, McGuigan L, Diamond T. et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 1994; 76: 882-886
12 Klineberg E, McHenry T, Bellabarba C. et al. Sacral insufficiency fractures caudal to instrumented posterior lumbosacral arthrodesis. Spine (Phila Pa 1976) 2008; 33: 1806-1811
13 Lapina O, Tiskevicius S. Sacral insufficiency fracture after pelvic radiotherapy: a diagnostic challenge for a radiologist. Medicina 2014; 50: 249-254
14 Grangier C, Garcia J, Howarth NR. et al. Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skeletal Radiol 1997; 26: 517-524
15 Abe H, Nakamura M, Takahashi S. et al. Radiation-induced insufficiency fractures of the pelvis: evaluation with 99mTc-methylene diphosphonate scintigraphy. AJR Am J Roentgenol 1992; 158: 599-602
16 Gottfried ON, Daubs MD, Patel AA. et al. Spinopelvic parameters in postfusion flatback deformity patients. Spine J 2009; 9: 639-647
17 Dasgupta B, Shah N, Brown H. et al. Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 1998; 37: 789-793
18 Deschamps Perdomo A, Tome-Bermejo F, Pinera AR. et al. Misdiagnosis of sacral stress fracture: an underestimated cause of low back pain in pregnancy?. Am J Case Rep 2015; 16: 60-64
19 Major NM, Helms CA. Sacral stress fractures in long-distance runners. AJR Am J Roentgenol 2000; 174: 727-729
20 Connolly LP, dʼHemecourt PA, Connolly SA. et al. Skeletal scintigraphy of young patients with low-back pain and a lumbosacral transitional vertebra. J Nucl Med 2003; 44: 909-914
21 Takahashi Y, Kobayashi T, Miyakoshi N. et al. Sacral stress fracture in an amateur rugby player: a case report. J Med Case Rep 2016; 10: 327
22 Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine (Phila Pa 1976) 1993; 18: 2507-2512
23 Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthop Surg 2007; 15: 339-346
24 Dalstra M, Huiskes R. Load transfer across the pelvic bone. J Biomech 1995; 28: 715-724
25 Burge R, Dawson-Hughes B, Solomon DH. et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007; 22: 465-475
26 Richards AM, Coleman NW, Knight TA. et al. Bone density and cortical thickness in normal, osteopenic, and osteoporotic sacra. J Osteoporos 2010; 2010
27 Wagner D, Kamer L, Sawaguchi T. et al. Sacral Bone Mass Distribution Assessed by Averaged Three-Dimensional CT Models: Implications for Pathogenesis and Treatment of Fragility Fractures of the Sacrum. J Bone Joint Surg Am 2016; 98: 584-590
28 Wagner D, Kamer L, Sawaguchi T. et al. Morphometry of the sacrum and its implication on trans-sacral corridors using a computed tomography data-based three-dimensional statistical model. Spine J 2017; 17: 1141-1147
29 Linstrom NJ, Heiserman JE, Kortman KE. et al. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine (Phila Pa 1976) 2009; 34: 309-315
30 Cooper KL, Beabout JW, Swee RG. Insufficiency fractures of the sacrum. Radiology 1985; 156: 15-20
31 De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 1985; 145: 601-606
32 Lyders EM, Whitlow CT, Baker MD. et al. Imaging and treatment of sacral insufficiency fractures. AJNR Am J Neuroradiol 2010; 31: 201-210
33 Bohme J, Hoch A, Josten C. [Osteoporotic fractures of the pelvis]. Chirurg 2012; 83: 875-881
34 White JH, Hague C, Nicolaou S. et al. Imaging of sacral fractures. Clin Radiol 2003; 58: 914-921
35 Montana MA, Richardson ML, Kilcoyne RF. et al. CT of sacral injury. Radiology 1986; 161: 499-503
36 Resnik CS, Stackhouse DJ, Shanmuganathan K. et al. Diagnosis of pelvic fractures in patients with acute pelvic trauma: efficacy of plain radiographs. AJR Am J Roentgenol 1992; 158: 109-112
37 Cabarrus MC, Ambekar A, Lu Y. et al. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol 2008; 191: 995-1001
38 Schicho A, Schmidt SA, Seeber K. et al. Pelvic X-ray misses out on detecting sacral fractures in the elderly – Importance of CT imaging in blunt pelvic trauma. Injury 2016; 47: 707-710
39 Oberkircher L, Ruchholtz S, Rommens PM. et al. Osteoporotic Pelvic Fractures. Dtsch Arztebl Int 2018; 115: 70-80
40 Routt jr. ML, Simonian PT, Swiontkowski MF. Stabilization of pelvic ring disruptions. Orthop Clin North Am 1997; 28: 369-388
41 Nystrom LM, McKinley TO, Marsh JL. Radiographic Measurement of Rotational Deformity in Pelvic Fractures: A Novel Method With Validity and Reliability Testing. J Orthop Trauma 2015; 29: 365-369
42 Goetzen M, Ortner K, Lindtner RA. et al. A simple approach for the preoperative assessment of sacral morphology for percutaneous SI screw fixation. Arch Orthop Trauma Surg 2016; 136: 1251-1257
43 Nork SE, Jones CB, Harding SP. et al. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma 2001; 15: 238-246
44 Josten C, Heyde CE, Spiegl UJ. [Complex Pathologies of the Spine: Trauma meets Degeneration]. Z Orthop Unfall 2016; 154: 440-448
45 Stover MD, Edelstein AI, Matta JM. Chronic Anterior Pelvic Instability: Diagnosis and Management. J Am Acad Orthop Surg 2017; 25: 509-517
46 Scheyerer MJ, Osterhoff G, Wehrle S. et al. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury 2012; 43: 1326-1329
47 Blake SP, Connors AM. Sacral insufficiency fracture. Br J Radiol 2004; 77: 891-896
48 Longhino V, Bonora C, Sansone V. The management of sacral stress fractures: current concepts. Clin Cases Miner Bone Metab 2011; 8: 19-23
49 Murthy NS. Imaging of stress fractures of the spine. Radiol Clin North Am 2012; 50: 799-821
50 Sun H, Xue HD, Jin ZY. et al. Non-enhanced low-tube-voltage high-pitch dual-source computed tomography with sinogram affirmed iterative reconstruction algorithm of the abdomen and pelvis. Chin Med Sci 2014; 29: 214-220
51 Hackenbroch C, Riesner HJ, Lang P. et al. Dual Energy Computed Tomography in Musculoskeletal Imaging, with Focus on Fragility Fractures of the Pelvis. Z Orthop Unfall 2017; 155: 708-715
52 Memetoglu OG, Ozkan FU, Boy NS. et al. Sacroiliitis or insufficiency fracture?. Osteoporos Int 2016; 27: 1265-1268
53 Ugurluer G, Akbas T, Arpaci T. et al. Bone complications after pelvic radiation therapy: evaluation with MRI. J Med Imaging Radiat Oncol 2014; 58: 334-340
54 Byun WM, Jang HW, Kim SW. et al. Diffusion-weighted magnetic resonance imaging of sacral insufficiency fractures: comparison with metastases of the sacrum. Spine (Phila Pa 1976) 2007; 32: E820-E824
55 Mammone JF, Schweitzer ME. MRI of occult sacral insufficiency fractures following radiotherapy. Skeletal Radiol 1995; 24: 101-104
56 König MA, Jehan S, Boszczyk AA. et al. Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies. Eur Spine J 2012; 21: 829-836
57 Roy-Camille R, Saillant G, Gagna G. et al. Transverse fracture of the upper sacrum. Suicidal jumperʼs fracture. Spine (Phila Pa 1976) 1985; 10: 838-845
58 Thiryayi WA, Thiryayi SA, Freemont AJ. Histopathological perspective on bone marrow oedema, reactive bone change and haemorrhage. Eur J Radiol 2008; 67: 62-67
59 Rangger C, Kathrein A, Freund MC. et al. Bone bruise of the knee: histology and cryosections in 5 cases. Acta Orthop Scand 1998; 69: 291-294
60 Ishibashi Y, Okamura Y, Otsuka H. et al. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med 2002; 12: 79-84
61 Scheyerer MJ, Hullner M, Pietsch C. et al. Evaluation of pelvic ring injuries using SPECT/CT. Skeletal Radiol 2015; 44: 217-222
62 Scheyerer MJ, Pietsch C, Zimmermann SM. et al. SPECT/CT for imaging of the spine and pelvis in clinical routine: a physicianʼs perspective of the adoption of SPECT/CT in a clinical setting with a focus on trauma surgery. Eur J Nucl Med Mol Imaging 2014; 41 (Suppl. 01) S59-S66
63 Lau TW, Leung F. Occult posterior pelvic ring fractures in elderly patients with osteoporotic pubic rami fractures. J Orthop Surg 2010; 18: 153-157
64 Fujii M, Abe K, Hayashi K. et al. Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 2005; 30: 165-169
65 Salavati A, Shah V, Wang ZJ. et al. F-18 FDG PET/CT findings in postradiation pelvic insufficiency fracture. Clin Imaging 2011; 35: 139-142
66 Dachverband Osteologie e.V.. Prophylaxe, Diagnostik und Therapie der OSTEOPOROSE bei Männern ab dem 60. Lebensjahr und bei postmenopausalen Frauen. Im Internet: http://www.dv-osteologie.org/uploads/Leitlinie 2014/DVO-Leitlinie Osteoporose 2014 Kurzfassung und Langfassung Version 1a 12 01 2016.pdf Stand: 13.01.2018
67 Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int 1994; 4: 368-381
68 Neuerburg C, Schmidmaier R, Schilling S. et al. Identifikation, Diagnostik und leitliniengerechte Osteoporosetherapie (DVO) unfallchirurgischer Patienten. Unfallchirurg 2015; 118: 913-924
69 Neuerburg C, Stumpf U, Schmidmaier R. et al. Neue Osteoporose-Leitlinie DVO 2014 und ihre Bedeutung für den Unfallchirurgen. Unfallchirurg 2015; 118: 905-912
70 Pickhardt PJ, Pooler BD, Lauder T. et al. Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med 2013; 158: 588-595
71 Pompe E, Willemink MJ, Dijkhuis GR. et al. Intravenous contrast injection significantly affects bone mineral density measured on CT. Eur Radiol 2015; 25: 283-289
72 Bauer JS, Henning TD, Mueller D. et al. Volumetric quantitative CT of the spine and hip derived from contrast-enhanced MDCT: conversion factors. AJR Am J Roentgenol 2007; 188: 1294-1301
73 Schonenberg D, Guggenberger R, Frey D. et al. CT-based evaluation of volumetric bone density in fragility fractures of the pelvis-a matched case-control analysis. Osteoporos Int 2018; 29: 459-465
74 Wagner D, Kamer L, Sawaguchi T. et al. Sacral bone mass distribution assessed by averaged three-dimensional CT models: implications for pathogenesis and treatment of fragility fractures of the sacrum. J Bone Joint Surg Am 2016; 98: 584-590
75 Schwaiger BJ, Gersing AS, Baum T. et al. Bone mineral density values derived from routine lumbar spine multidetector row CT predict osteoporotic vertebral fractures and screw loosening. AJNR Am J Neuroradiol 2014; 35: 1628-1633
76 Bredow J, Boese CK, Werner CM. et al. Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg 2016; 136: 1063-1067
77 Tile M. Pelvic ring fractures: should they be fixed?. J Bone Joint Surg Br 1988; 70: 1-12
78 Young JW, Burgess AR, Brumback RJ. et al. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986; 160: 445-451
79 Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: Recommendations for surgical treatment. Injury 2013; 44: 1733-1744
80 Rommens PM, Vanderschot PM, Broos PL. Conventional radiography and CT examination of pelvic ring fractures. A comparative study of 90 patients. Unfallchirurg 1992; 95: 387-392
81 Mattila VM, Niva M, Kiuru M. et al. Risk factors for bone stress injuries: a follow-up study of 102,515 person-years. Med Sci Sports Exerc 2007; 39: 1061-1066
82 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: 835-839
83 Giannoulis DK, Koulouvaris P, Zilakou E. et al. Atraumatic Sacral Fracture in Late Pregnancy: A Case Report. Global Spine J 2015; 5: 248-251
84 Rommens PM, Wagner D, Hofmann A. Fragility Fractures of the Pelvis. JBJS Rev 2017; 5: 101-112
85 Hoch A, Ozkurtul O, Pieroh P. et al. Outcome and 2-Year Survival Rate in Elderly Patients With Lateral Compression Fractures of the Pelvis. Geriatr Orthop Surg Rehabil 2017; 8: 3-9
86 Rommens PM, Wagner D, Hofmann A. Minimal Invasive Surgical Treatment of Fragility Fractures of the Pelvis. Chirurgia (Bucur) 2017; 112: 524-537
87 Schreiber JJ, Anderson PA, Rosas HG. et al. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am 2011; 93: 1057-1063