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MRI and CT of Insufficiency Fractures of the Pelvis and the Proximal Femur

Miguel C. Cabarrus1,2, Avanti Ambekar1, Ying Lu1 and Thomas M. Link1

1 Department of Radiology, University of California, San Francisco, 400 Parnassus Ave., A-367, San Francisco, CA 94143.
2 School of Medicine, University of California, San Francisco, San Francisco, CA.


Figure 1
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  		Fig. 1A —70-year-old man with lower back pain and history of esophageal cancer, chemotherapy, and osteoporotic bone mineral density on dual x-ray absorptiometry. Axial T1-weighted (A), axial fat-saturated T2-weighted (B), and sagittal fat-saturated T2-weighted (C) MR images show bilateral sacral fractures (arrows), with mild displacement at S2 visualized on sagittal image (C).

 

Figure 2
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  		Fig. 1B —70-year-old man with lower back pain and history of esophageal cancer, chemotherapy, and osteoporotic bone mineral density on dual x-ray absorptiometry. Axial T1-weighted (A), axial fat-saturated T2-weighted (B), and sagittal fat-saturated T2-weighted (C) MR images show bilateral sacral fractures (arrows), with mild displacement at S2 visualized on sagittal image (C).

 

Figure 3
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  		Fig. 1C —70-year-old man with lower back pain and history of esophageal cancer, chemotherapy, and osteoporotic bone mineral density on dual x-ray absorptiometry. Axial T1-weighted (A), axial fat-saturated T2-weighted (B), and sagittal fat-saturated T2-weighted (C) MR images show bilateral sacral fractures (arrows), with mild displacement at S2 visualized on sagittal image (C).

 

Figure 4
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  		Fig. 1D —70-year-old man with lower back pain and history of esophageal cancer, chemotherapy, and osteoporotic bone mineral density on dual x-ray absorptiometry. CT image obtained within 2 weeks after MRI using standard pelvis protocol (contrast-enhanced; slice thickness, 5 mm) does not show these fractures.

 

Figure 5
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  		Fig. 2A —79-year-old woman with lower back pain radiating to hip and extremities. Both CT and MRI showed pubic bone and sacral fractures. Full extent of left pubic bone fracture is better shown on CT image (arrow, A), whereas axial T1-weighted (arrow, B) and fat-saturated T2-weighted (arrow, C) fast spin-echo sequences show edema (dark on T1-weighted and bright on T2-weighted fast spin-echo images) but do not show true extent of fracture as well as CT.

 

Figure 6
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  		Fig. 2B —79-year-old woman with lower back pain radiating to hip and extremities. Both CT and MRI showed pubic bone and sacral fractures. Full extent of left pubic bone fracture is better shown on CT image (arrow, A), whereas axial T1-weighted (arrow, B) and fat-saturated T2-weighted (arrow, C) fast spin-echo sequences show edema (dark on T1-weighted and bright on T2-weighted fast spin-echo images) but do not show true extent of fracture as well as CT.

 

Figure 7
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  		Fig. 2C —79-year-old woman with lower back pain radiating to hip and extremities. Both CT and MRI showed pubic bone and sacral fractures. Full extent of left pubic bone fracture is better shown on CT image (arrow, A), whereas axial T1-weighted (arrow, B) and fat-saturated T2-weighted (arrow, C) fast spin-echo sequences show edema (dark on T1-weighted and bright on T2-weighted fast spin-echo images) but do not show true extent of fracture as well as CT.

 

Figure 8
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  		Fig. 3A —49-year-old woman with hip and lower back pain who underwent radiation therapy for cervical cancer 10 years previously. CT scan shows left sacral fracture anteriorly without displacement. This fracture is characterized by increased sclerosis and subtle fracture line on CT image (arrow).

 

Figure 9
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  		Fig. 3B —49-year-old woman with hip and lower back pain who underwent radiation therapy for cervical cancer 10 years previously. Injury, including fracture line and bone marrow edema pattern, is substantially better visualized on axial T1-weighted (arrow, B) and fat-saturated T2-weighted (arrow, C) fast spin-echo sequences.

 

Figure 10
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  		Fig. 3C —49-year-old woman with hip and lower back pain who underwent radiation therapy for cervical cancer 10 years previously. Injury, including fracture line and bone marrow edema pattern, is substantially better visualized on axial T1-weighted (arrow, B) and fat-saturated T2-weighted (arrow, C) fast spin-echo sequences.

 

Figure 11
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  		Fig. 4A —18-year-old man with ulcerative colitis and primary sclerosing cholangitis who is scheduled to undergo liver transplantation. Coronal STIR (A) and T1-weighted fast spin-echo (B) sequences show bilateral femoral neck fractures (small arrows) and focal signal abnormalities in right femoral head (large arrow, A), which are nonspecific and could indicate either insufficiency reaction or ischemic changes.

 

Figure 12
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  		Fig. 4B —18-year-old man with ulcerative colitis and primary sclerosing cholangitis who is scheduled to undergo liver transplantation. Coronal STIR (A) and T1-weighted fast spin-echo (B) sequences show bilateral femoral neck fractures (small arrows) and focal signal abnormalities in right femoral head (large arrow, A), which are nonspecific and could indicate either insufficiency reaction or ischemic changes.

 

Figure 13
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  		Fig. 4C —18-year-old man with ulcerative colitis and primary sclerosing cholangitis who is scheduled to undergo liver transplantation. Axial fat-saturated T2-weighted fast spin-echo sequences show additional fractures at bilateral ischium (arrows). In D, signal changes at bilateral femoral neck are also shown, reflecting neck fractures. Note relatively low signal of bone marrow on T1-weighted fast spin-echo image (B), which is likely reflecting activated hematopiesis due to anemia.

 

Figure 14
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  		Fig. 4D —18-year-old man with ulcerative colitis and primary sclerosing cholangitis who is scheduled to undergo liver transplantation. Axial fat-saturated T2-weighted fast spin-echo sequences show additional fractures at bilateral ischium (arrows). In D, signal changes at bilateral femoral neck are also shown, reflecting neck fractures. Note relatively low signal of bone marrow on T1-weighted fast spin-echo image (B), which is likely reflecting activated hematopiesis due to anemia.

 

Figure 15
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  		Fig. 5 —Distribution of all detected fractures (n = 307) on MRI is shown in this graph according to presence (black bars; total, n = 142) and absence (gray bars; total, n = 165) of soft-tissue abnormalities. Numbers are shown at top of each bar: total number of fractures first followed by, in parentheses, number of fractures with and without soft-tissue abnormalities. Note that although most pubic and acetabulum fractures show soft-tissue abnormalities, sacral fractures show soft-tissue abnormalities less frequently.

 

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