Sacral stress fracture as a cause of gluteal artery injury: An unusual complication of a common fracture (original) (raw)
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Insufficiency Fractures of the Sacrum After Radiotherapy for Gynaecological Malignancy
Acta Oncologica, 1990
An entity is described which is characterized by low back pain and increased radionuclide uptake in the sacrum at bone scintigraphy in postmenopausal women having received radiotherapy towards the pelvis because of gynaecological malignancy. The findings simulate bone metastases, but are in all likelihood caused by insufficiency fractures of the sacrum promoted by bone weakness induced by postmenopausal osteoporosis and radiotherapy combined. The increased radionuclide activity has a characteristic appearance which in the fully developed fracture acquires the shape of an 'H'. In plain radiography, changes are absent or subtle. The proper complementary examination is CT, in which the fractures can be visualized and malignant changes excluded. Awareness of this benign entity is important to avoid overdiagnosis of bone metastases.
Pelvic Insufficiency Fractures after Chemoradiation for
2013
Background: Radiation-induced pelvic insufficiency fracture (PIF) is an important complication associated with pelvic radiation therapy (RT) for patients with gynecologic malignancies. Despite known risk factors and recent reports describing the incidence on the order of 30 percent, there has been a dearth of translational research or consensus statements to guide clinical management. Objective: The aim of this study is to describe seven cases of PIF diagnosed and managed at the Massachusetts General Hospital during a 5-year period and to perform a focused review of the literature to inform several clinical questions that remain unanswered. A secondary aim of this study is to highlight the need for additional research related to screening, prophylaxis, diagnostics, and treatment of PIF in patients with gynecologic malignancy. Methods: In the current retrospective review, we report 10 cases of PIF diagnosed over a 5-year period in 7 patients with vulvar (4), vaginal (2), and cervical (1) cancer following chemoradiation therapy at a single institution. Data were collected from the medical records by a single investigator and all diagnostic imaging was reviewed by a single radiologist to confirm the presence or absence of PIF. Results: All 7 patients were post-menopausal and received concurrent chemoradiation, 3 were over the age of 65 years old (42.8%), 3 had BMI < 25 kg/m 2 (42.8%), 2 had a history of osteoporosis (28.6%), and 1 had a history of hormone replacement therapy use (14.3%). No patients underwent standard screening for PIF and no patients were started on prophylaxis prior to diagnosis. The plain film was the most common initial imaging performed while MRI was the most common overall study used to diagnose PIF. Median time to the development of fracture was 16 months (range 4-114) with femoral neck fracture being the most common (40%) and sacral fractures trailing close behind (30%). 7 of 10 fractures were initially managed expectantly with 1 ultimately failing expectant management and requiring surgical intervention. 4 of 10 fractures required surgical intervention. All patients had resolution of symptoms by 12 months after diagnosis. Conclusion: Radiation-induced PIF remains an important complication associated with pelvic RT. Significant risk factors have been identified and studies have compared various diagnostic imaging modalities. Future studies are needed to compare screening algorithms and evaluate the comparative effectiveness of prophylactic pharmacotherapies. Future studies are also needed to determine the cost-effectiveness of PET/CT versus MRI and compare the morbidity associated with expectant management versus surgical intervention in patients with symptomatic fractures.
International Journal of Clinical Medicine, 2013
Background: Radiation-induced pelvic insufficiency fracture (PIF) is an important complication associated with pelvic radiation therapy (RT) for patients with gynecologic malignancies. Despite known risk factors and recent reports describing the incidence on the order of 30 percent, there has been a dearth of translational research or consensus statements to guide clinical management. Objective: The aim of this study is to describe seven cases of PIF diagnosed and managed at the Massachusetts General Hospital during a 5-year period and to perform a focused review of the literature to inform several clinical questions that remain unanswered. A secondary aim of this study is to highlight the need for additional research related to screening, prophylaxis, diagnostics, and treatment of PIF in patients with gynecologic malignancy. Methods: In the current retrospective review, we report 10 cases of PIF diagnosed over a 5-year period in 7 patients with vulvar (4), vaginal (2), and cervical (1) cancer following chemoradiation therapy at a single institution. Data were collected from the medical records by a single investigator and all diagnostic imaging was reviewed by a single radiologist to confirm the presence or absence of PIF. Results: All 7 patients were post-menopausal and received concurrent chemoradiation, 3 were over the age of 65 years old (42.8%), 3 had BMI < 25 kg/m 2 (42.8%), 2 had a history of osteoporosis (28.6%), and 1 had a history of hormone replacement therapy use (14.3%). No patients underwent standard screening for PIF and no patients were started on prophylaxis prior to diagnosis. The plain film was the most common initial imaging performed while MRI was the most common overall study used to diagnose PIF. Median time to the development of fracture was 16 months (range 4-114) with femoral neck fracture being the most common (40%) and sacral fractures trailing close behind (30%). 7 of 10 fractures were initially managed expectantly with 1 ultimately failing expectant management and requiring surgical intervention. 4 of 10 fractures required surgical intervention. All patients had resolution of symptoms by 12 months after diagnosis. Conclusion: Radiation-induced PIF remains an important complication associated with pelvic RT. Significant risk factors have been identified and studies have compared various diagnostic imaging modalities. Future studies are needed to compare screening algorithms and evaluate the comparative effectiveness of prophylactic pharmacotherapies. Future studies are also needed to determine the cost-effectiveness of PET/CT versus MRI and compare the morbidity associated with expectant management versus surgical intervention in patients with symptomatic fractures.
An Undiagnosed Sacral Insufficiency Fracture in an Osteoporotic Elderly Woman
Fiziksel Tıp ve Rehabilitasyon Bilimleri Dergisi
ABS TRACT Insufficiency fractures occur when normal stress is applied to bone with low mineralization and elastic resistance. Postmenopausal osteoporosis, pregnancy, postpartum period, and sports activities can result in insufficiency fractures. Clinical suspicion is important in sacral insufficiency fractures. Computed tomography, scintigraphy, and magnetic resonance imaging are used in undiagnosed cases. Bed rest, analgesics, anti-inflammatory drugs, and physical therapy modalities can be used for pain control. Sacral insufficiency fracture should be kept in mind in elderly osteoporotic patients with low back and/or hip pain unresponsive to treatment. In this case report, we will present a 77-year-old patient with overlooked sacral insufficiency fracture. The patient, who had persistent low back and hip pain for three months, was misdiagnosed as sacroiliitis.
Profile of geriatric pelvic fractures presenting to the emergency department
The American Journal of Emergency Medicine, 1997
Few studies have examined differences in mechanism, presentation, and outcome of trauma in geriatric patients. This study compared pelvic fractures and associated injuries in geriatric and nongeriatric patients. The medical charts of all patients presenting to a large urban emergency medicine teaching program with a pelvic fracture between January 1, 1987 and December 31, 1993 were retrospectively reviewed by studyblinded physicians. Data collected included mechanism and site of injury, associated injuries, disposition (admission or discharge), need for operative repair, length of hospital stay, as well as subsequent deaths and causes. The data were stratified into patients less than 65 years of age (group A) and 65 years or older (group B). Two-hundred five pelvic fractures were reviewed with 85 (41%) in group B. A significantly greater number of pelvic fractures in group B occurred by fall (86% v 25%, P < .05) and significantly less by motor vehicle accident (14% v 75%, P < .05). Site of pelvic fracture differed significantly only in the decreased number of geriatric lilac fractures (6% v 16%, P < .05). The sites of pelvic fractures for geriatric patients in descending order were multiple sites (58%), pubic rami (56%), acetabulum (19%), ischium (11%), lilac (6%), and sacroiliac (2%), and did not differ from nongeriatric patients. Geriatric patients had significantly fewer total associated injuries (40% v 61%, P < .05) although associated chest injuries were significantly more common (21% v 8%, P < .05). Death occurred in three (3%) nongeriatric and nine (11%) geriatric patients. Six geriatric deaths were caused by exacerbation of underlying cardiovascular disease. Geriatric patients underwent significantly fewer operative procedures (6% v 43%, P < .05) but there were no significant differences in the percent admitted (85%) or mean length of hospital stay (9.59 days). Despite the decreased severity of pelvic fractures, care must be taken to prevent morbidity caused by exacerbation of premorbid illnesses in geriatric patients with pelvic fractures.
Pelvic insufficiency fractures in patients with pelvic irradiation
International Journal of Radiation Oncology*Biology*Physics, 1999
Background: Insufficiency fractures (IF) occur as a result of normal physiological stress on bones with deficient elastic resistance. Pelvic insufficiency fractures are a complication of osteoporosis due to postmenopausal status, high dose of corticosteroids, or local irradiation. They are important because differential diagnosis includes pelvic bone metastases. Diagnosis is based on both clinical manifestations and radiographic and scintigraphic findings. Methods and Materials: We examined eight patients with pelvic cancer who had previously undergone external beam radiation therapy as part of their treatment. In the follow-up, they developed insufficiency fractures, and no factor other than pelvic irradiation was present. Diagnosis was confirmed by radionuclide bone scan followed by conventional radiography and computed tomography (CT) scan. Results: The average onset of symptoms was 13.7 months after radiation therapy was completed. The initial symptom in all cases was pain. In all of the patients, the bone scan showed abnormalities. One to four increased uptake foci were observed, in the sacroiliac joint in all cases, and in the pubis in three cases. The initial diagnosis was bone metastases in five patients. CT scan showed fractures in all of the patients, in sacrum and pubis, both endostic and cortical. Treatment, consisting of nonsteroidal anti-inflammatory drugs and rest, led to symptomatic relief in all cases. Conclusion: Knowledge of pelvic insufficiency fractures is essential in order to rule out metastasic disease, and thus avoid inaccurate treatment. Although radionuclide bone scan is useful in early detection of pelvic IF, definitive diagnosis is provided by CT scan.