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Skeletal Radiology

, Volume 38, Issue 1, pp 43–49 | Cite as

Radiological features of superomedial iliac insufficiency fractures: a possible mimicker of metastatic disease

  • Andrea DonovanEmail author
  • Mark E. Schweitzer
  • Mahvash Rafii
  • Allison Lax
Scientific Article

Abstract

Objective

Pelvic insufficiency fractures are common in elderly patients. Because both osteoporosis and metastatic disease occur in similar patient populations, insufficiency fractures may be mistaken for metastatic foci. Although the ilium is not an uncommon location for metastases, insufficiency fractures rarely involve the ilium. The radiological features of insufficiency fractures adjacent to the sacroiliac joint (superomedial ilium) have not been well described. We describe the computed tomography (CT), magnetic resonance (MR), and positron emission tomography (PET) imaging findings of these rare fractures.

Materials and methods

Six patients (five female, one male; mean age 66 years, age range 47–83 years) with iliac insufficiency fractures adjacent to the sacroiliac joint were identified following retrospective review of a clinical database. Imaging studies, including CT (n = 4), MR (n = 3), and PET (n = 2) were reviewed by two radiologists. Tissue biopsy result was available in one patient.

Results

CT demonstrated subtle fracture lucency (n = 2) or linear sclerosis (n = 3) adjacent to the sacroiliac joint; MR marrow changes adjacent to the sacroiliac joint demonstrated a low T1, high T2 signal intensity line (n = 2), or a low T1 and low T2 signal intensity line (n = 1). Fractures were fluorodeoxyglucose avid (n = 2) with average SUVmax 2.2. Iliac fractures were bilateral in three patients; additional pelvic insufficiency fractures were present in one patient. In one patient, CT-guided biopsy showed no evidence of malignancy.

Conclusion

Recognition of the radiological characteristics of iliac insufficiency fractures is important in order to distinguish them from malignancy. The presence of additional pelvic fractures in characteristic locations in the setting of osteoporosis may help to confirm the diagnosis.

Keywords

Iliac fractures Insufficiency fractures Osteoporosis MRI FDG-PET 

Notes

Acknowledgements

The authors wish to thank Dr. Panna Desai for assistance with histopathology slides.

References

  1. 1.
    Soubrier M, Dubost JJ, Boisgard S, Sauvezie B, Gaillard P, Michel JL, et al. Insufficiency fracture. A survey of 60 cases and review of the literature. Joint Bone Spine 2003;70(3): 209–218.PubMedCrossRefGoogle Scholar
  2. 2.
    Davies AM, Bradley SA. Iliac insufficiency fractures. Br J Radiol 1991;64(760): 305–309.PubMedCrossRefGoogle Scholar
  3. 3.
    Peh WC, Khong PL, Yin Y, Ho WY, Evans NS, Gilula LA, et al. Imaging of pelvic insufficiency fractures. Radiographics 1996;16(2): 335–348.PubMedCrossRefGoogle Scholar
  4. 4.
    Sugawara Y, Fisher SJ, Zasadny KR, Kison PV, Baker LH, Wahl RL. Preclinical and clinical studies of bone marrow uptake of fluorine-1-fluorodeoxyglucose with or without granulocyte colony-stimulating factor during chemotherapy. J Clin Oncol 1998;16(1): 173–180.PubMedCrossRefGoogle Scholar
  5. 5.
    Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine 1993;18(16): 2507–2512.PubMedCrossRefGoogle Scholar
  6. 6.
    Blomlie V, Rofstad EK, Talle K, Sundfor K, Winderen M, Lien HH. Incidence of radiation-induced insufficiency fractures of the female pelvis: evaluation with MR imaging. AJR Am J Roentgenol 1996;167(5): 1205–1210.PubMedCrossRefGoogle Scholar
  7. 7.
    Rafii M, Firooznia H, Golimbu C, Horner N. Radiation induced fractures of sacrum: CT diagnosis. J Comput Assist Tomogr 1988;12(2): 231–235.PubMedCrossRefGoogle Scholar
  8. 8.
    Cooper KL, Beabout JW, Swee RG. Insufficiency fractures of the sacrum. Radiology 1985;156(1): 15–20.PubMedCrossRefGoogle Scholar
  9. 9.
    Blake SP, Connors AM. Sacral insufficiency fracture. Br J Radiol 2004;77(922): 891–896.PubMedCrossRefGoogle Scholar
  10. 10.
    Aretxabala I, Fraiz E, Perez-Ruiz F, Rios G, Calabozo M, Alonso-Ruiz A. Sacral insufficiency fractures. High association with pubic rami fractures. Clin Rheumatol 2000;19(5): 399–401.PubMedCrossRefGoogle Scholar
  11. 11.
    Schneider R, Yacovone J, Ghelman B. Unsuspected sacral fractures: detection by radionuclide bone scanning. AJR Am J Roentgenol 1985;144(2): 337–341.PubMedCrossRefGoogle Scholar
  12. 12.
    De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 1985;145(3): 601–606.PubMedCrossRefGoogle Scholar
  13. 13.
    Hauge MD, Cooper KL, Litin SC. Insufficiency fractures of the pelvis that simulate metastatic disease. Mayo Clin Proc 1988;63(8): 807–812.PubMedCrossRefGoogle Scholar
  14. 14.
    Yousem DM, Magid D, Scott WW Jr., Fishman EK. Treated invasive cervical carcinoma. Utility of computed tomography in distinguishing between skeletal metastases and radiation necrosis. Clin Imaging 1989;13(2): 147–153.PubMedCrossRefGoogle Scholar
  15. 15.
    Theodorou SJ, Theodorou DJ, Schweitzer ME, Kakitsubata Y, Resnick D. Magnetic resonance imaging of para-acetabular insufficiency fractures in patients with malignancy. Clin Radiol 2006;61(2): 181–190.PubMedCrossRefGoogle Scholar
  16. 16.
    Brahme SK, Cervilla V, Vint V, Cooper K, Kortman K, Resnick D. Magnetic resonance appearance of sacral insufficiency fractures. Skeletal Radiol 1990;19(7): 489–493.PubMedCrossRefGoogle Scholar
  17. 17.
    Shon IH, Fogelman I. F-18 FDG positron emission tomography and benign fractures. Clin Nucl Med 2003;28(3): 171–175.PubMedGoogle Scholar
  18. 18.
    Kato K, Aoki J, Endo K. Utility of FDG-PET in differential diagnosis of benign and malignant fractures in acute to subacute phase. Ann Nucl Med 2003;17(1): 41–46.PubMedCrossRefGoogle Scholar
  19. 19.
    Fayad LM, Cohade C, Wahl RL, Fishman EK. Sacral fractures: a potential pitfall of FDG positron emission tomography. AJR Am J Roentgenol 2003;181(5): 1239–1243.PubMedCrossRefGoogle Scholar
  20. 20.
    Ravenel JG, Gordon LL, Pope TL, Reed CE. FDG-PET uptake in occult acute pelvic fracture. Skeletal Radiol 2004;33(2): 99–101.PubMedCrossRefGoogle Scholar
  21. 21.
    Schmitz A, Risse JH, Textor J, Zander D, Biersack HJ, Schmitt O, et al. FDG-PET findings of vertebral compression fractures in osteoporosis: preliminary results. Osteoporos Int 2002;13(9): 755–761.PubMedCrossRefGoogle Scholar
  22. 22.
    Tsuchida T, Kosaka N, Sugimoto K, Itoh H. Sacral insufficiency fracture detected by FDG-PET/CT: report of 2 cases. Ann Nucl Med 2006;20(6): 445–448.PubMedCrossRefGoogle Scholar
  23. 23.
    Shin DS, Shon OJ, Byun SJ, Choi JH, Chun KA, Cho IH. Differentiation between malignant and benign pathologic fractures with F-18-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography. Skeletal Radiol 2008;37(5): 415–421.PubMedCrossRefGoogle Scholar
  24. 24.
    Bredella MA, Essary B, Torriani M, Ouellette HA, Palmer WE. Use of FDG-PET in differentiating benign from malignant compression fractures. Skeletal Radiol 2008;37(5): 405–413.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© ISS 2008

Authors and Affiliations

  • Andrea Donovan
    • 1
    Email author
  • Mark E. Schweitzer
    • 1
  • Mahvash Rafii
    • 2
  • Allison Lax
    • 3
  1. 1.NYU Hospital for Joint DiseasesNew YorkUSA
  2. 2.New YorkUSA
  3. 3.Georgetown University HospitalWashingtonUSA

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