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European Journal of Trauma and Emergency Surgery

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01-02-2021 | Magnetic Resonance Imaging | Original Article

Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases

Authors: Thomas Mendel, Bernhard Wilhelm Ullrich, Gunther Olaf Hofmann, Philipp Schenk, Felix Goehre, Stefan Schwan, Friederike Klauke

Published in: European Journal of Trauma and Emergency Surgery | Issue 1/2021

Abstract

Purpose

The pathogenetic mechanism, progression, and instability in geriatric bilateral fragility fractures of the sacrum (BFFSs) remain poorly understood. This study investigated the hypothesis of sequential BFFS progression by analysing X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) datasets.

Methods

Imaging data from 78 cases were retrospectively analysed. Fractures were categorized using the CT-based Fragility Fractures of the Pelvis classification. MRI datasets were analysed to detect relevant fracture location information. The longitudinal sacral fracture was graded as stage 1 (bone oedema) on MRI, stage 2 (recent fracture), stage 3 (healing fracture), or stage 4 (non-union) on CT. Ligamentous avulsions at the L5 transverse process and iliac crest were also captured.

Results

Contralateral sacral lesions were only recognized by initial bone oedema on MRI in 17/78 (22%) cases. There were 22 cases without and 56 cases with an interconnecting transverse fracture component (TFC) [between S1/S2 (n = 39) or between S2/S3 (n = 17)]. With 30/78 patients showing bilateral fracture lines at different stages (1/2: n = 13, 2/3: n = 13, 1/3: n = 4) and 38 at similar stages, Wilcoxon tests showed a significant stage difference (p < 0.001). Forty cases had a coexistent L5 transverse process avulsion, consistent with a failing iliolumbar ligament. Analysis of variance revealed significant increases in ligamentous avulsions with higher fracture stages (p < 0.001).

Conclusion

Our results support the hypothesis of stagewise BFFS progression starting with unilateral sacral disruption followed by a contralateral lesion. Loss of sacral alar support leads to a TFC. Subsequent bone disruption causes iliolumbar ligament avulsion. MRI is recommended to detect bone oedema.

Leung ASO, Gordon LM, Skrinskas T, Szwedowski T, Whyne CM. Effects of bone density alterations on strain patterns in the pelvis: application of a finite element model. Proc Inst Mech Eng H. 2009;223:965–79. https://doi.org/10.1243/09544119JEIM618.CrossRefPubMed

Pentacost RL, Murray RA, Brindley HH. Fatigue, Insufficiency and the pathologic fractures. JAMA. 1964;187:1001–4. https://doi.org/10.1001/jama.1964.03060260029006.CrossRef

Lourie H. Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA. 1982;248:715–7.CrossRef

Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22:465–75. https://doi.org/10.1359/jbmr.061113.CrossRef

Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine. 1993;18:2507–12.CrossRef

Andrich S, Haastert B, Neuhaus E, Neidert K, Arend W, Ohmann C, et al. Epidemiology of Pelvic Fractures in Germany: considerably high incidence rates among older people. PLoS ONE. 2015;10:e0139078. https://doi.org/10.1371/journal.pone.0139078.CrossRefPubMedPubMedCentral

Mendel T, Radetzki F, Schwan S, Hofmann GO, Goehre F. The influence of injecting an epidural contrast agent into the sacral canal on the fluoroscopic visibility of bony landmarks for sacroiliac screw fixation: a feasibility study. J Neurosurg Spine. 2015;22:199–204. https://doi.org/10.3171/2014.10.SPINE14160.CrossRefPubMed

Park J, Park S, Lee HJ, Lee C, Chang B, Kim H. Mortality following benign sacral insufficiency fracture and associated risk factors. Arch Osteoporos. 2017;12:100. https://doi.org/10.1007/s11657-017-0395-3.CrossRefPubMed

Lattauschke A, Klauke F, Ullrich BW, Hofmann GO, Mendel T. Behandlungsverlauf der operativen Versorgung einer Sakruminsuffizienzfraktur: erfolgreiches oder folgenreiches Handeln? Unfallchirurg. 2017;120:890–5. https://doi.org/10.1007/s00113-017-0403-5.CrossRefPubMed

10.

Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury. 2013;44:1733–44. https://doi.org/10.1016/j.injury.2013.06.023.CrossRefPubMed

11.

Denis F, Davis S, Comfort T. Sacral fractures: an important problemRetrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67–81.PubMed

12.

Schreiber JJ, Hughes AP, Taher F, Girardi FP. An association can be found between hounsfield units and success of lumbar spine fusion. HSS J. 2014;10:25–9. https://doi.org/10.1007/s11420-013-9367-3.CrossRefPubMed

13.

Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N. Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med. 2013;158:588–95. https://doi.org/10.7326/0003-4819-158-8-201304160-00003.CrossRefPubMedPubMedCentral

14.

Wagner D, Kamer L, Sawaguchi T, Richards RG, Noser H, Rommens PM. 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;98:584–90. https://doi.org/10.2106/JBJS.15.00726.CrossRefPubMed

15.

Buckley R, Moran CG, Apivatthakkul T. AO Priciples of Fracture Management. 3rd ed. Stuttgart: Georg Thieme Verlag; 2017.

16.

Cohen J. A power primer. Psychol Bull. 1992;112:155–9. https://doi.org/10.1037//0033-2909.112.1.155.CrossRef

17.

Peretz AM, Hipp JA, Heggeness MH. The internal bony architecture of the sacrum. Spine. 1998;23:971–4. https://doi.org/10.1097/00007632-199805010-00001.CrossRefPubMed

18.

Na WC, Lee SH, Jung S, Jang HW, Jo S. Pelvic insufficiency fracture in severe osteoporosis patient. Hip Pelvis. 2017;29:120–6. https://doi.org/10.5371/hp.2017.29.2.120.CrossRefPubMedPubMedCentral

19.

Henes FO, Nüchtern JV, Groth M, Habermann CR, Regier M, Rueger JM, et al. Comparison of diagnostic accuracy of magnetic resonance imaging and multidetector computed tomography in the detection of pelvic fractures. Eur J Radiol. 2012;81:2337–422. https://doi.org/10.1016/j.ejrad.2011.07.012.CrossRefPubMed

20.

Nüchtern JV, Hartel MJ, Henes FO, Groth M, Jauch SY, Haegele J, et al. Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures. Injury. 2015;46:315–9. https://doi.org/10.1016/j.injury.2014.10.050.CrossRefPubMed

21.

Linstrom NJ, Heiserman JE, Kortman KE, Crawford NR, Baek S, Anderson RL, et al. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine. 2009;34:309–15. https://doi.org/10.1097/BRS.0b013e318191ea01.CrossRefPubMedPubMedCentral

22.

Rommens PM, Arand C, Hopf JC, Mehling I, Dietz SO, Wagner D. Progress of instability in fragility fractures of the pelvis: an observational study. Injury. 2019;50:1966–73. https://doi.org/10.1016/j.injury.2019.08.038.CrossRefPubMed

23.

Ueda Y, Inui T, Kurata Y, Tsuji H, Saito J, Shitan Y. Prolonged pain in patients with fragility fractures of the pelvis may be due to fracture progression. Eur J Trauma Emerg Surg. 2019. https://doi.org/10.1007/s00068-019-01150-0.CrossRefPubMed

24.

Sudhir G, Acharya S, Chahal R. Sacral insufficiency fractures mimicking lumbar spine pathology. Asian Spine J. 2016;10:558–64.CrossRef

25.

Tamaki Y, Nagamachi A, Inoue K, Takeuchi M, Sugiura K, Omichi Y, et al. Incidence and clinical features of sacral insufficiency fracture in the emergency department. Am J Emerg Med. 2017;35:1314–6. https://doi.org/10.1016/j.ajem.2017.03.037.CrossRefPubMed

26.

Lyders EM, Whitlow CT, Baker MD, Morris PP. Imaging and treatment of sacral insufficiency fractures AJNR. Am J Neuroradiol. 2010;31:201–10.CrossRef

27.

Cabarrus MC, Ambekar A, Lu Y, Link TM. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol. 2008;191:995–1001. https://doi.org/10.2214/AJR.07.3714.CrossRefPubMed

Title: Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases
Authors: Thomas Mendel
Bernhard Wilhelm Ullrich
Gunther Olaf Hofmann
Philipp Schenk
Felix Goehre
Stefan Schwan
Friederike Klauke
Publication date: 01-02-2021
Publisher: Springer Berlin Heidelberg
Keywords: Magnetic Resonance Imaging
Magnetic Resonance Imaging
Computed Tomography
Computed Tomography
Osteoporosis
Osteoporosis
Published in: European Journal of Trauma and Emergency Surgery / Issue 1/2021
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-020-01480-4

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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