MRI and CT of

Insufficiency Fractures of the Pelvis

and the Proximal Femur
AJR 2008;191:995-1001
R4

Stress fracture
Fatigue fracture
Normal bone is subjected to repetitive
stresses
Common site : Metatarsal, calcaneus, tibial
shaft, femoral neck, pubic ramus

Insufficiency fracture
Normal stress applied to Abnormal bone
Risk factors : Osteoporosis (most often
afflicting elderly women), chronic steroid use,
radiation therapy to the pelvis, RA

Purpose
To compare the sensitivity of CT and MRI
in detecting insufficiency fractures; to
analyze the typical location, morphology,
and combinations thereof in these
fractures.

Materials and Methods

Subjects
January 1997~ June 2007
MRI and CT studies with a reported diagnosis of pelvic, sacral,
or proximal femur insufficiency fractures
Pts who had clinical history, imaging findings, cross-sectional
f/u studies consistent with the diagnosis of an insufficiency
fracture.
- absence of metastatic disease to pelvic bones, other bone
marrow disease, metabolic disease
307 fractures in 145 consecutive patients
( 41 men, 104 women; average age, 65.9 17.7 years)

Materials and Methods

MRI

1.5 T (Signa, GE Healthcare)

All 145 subjects
Pelvis MRI in 125 pts
coronal T1-wieghted fast spin-echo (TR/TE : 600msec/minimum)
coronal T1-wieghted STIR (3000/68; inversion time, 150msec)
axial T1-weighted (600msec/minimum)
fat-saturated T2-weighted fast spin-echo (3000/68)
section thickness : 4mm, matrix size : 192x192 mm, FOV : 32-36cm

Lumbar spine including sacrum in 20 pts

sagittal and axial T1-wieghted (TR/TE : 500-600msec/minimum)
fat-saturated T2-weighted fast spin-echo (TR/TE : 3500-4000msec/60-90)
coronal T1-weighted fast spin-echo (500msec/minimum)
section thickness : 4mm, matrix size : 256x192 mm, FOV : 16-24cm

Materials and Methods

CT
MDCT
8-, 16-, 64-MDCT (Lightspeed series, GE Healthcare)

64/145 subjects
Entire pelvis
slice thickness : 1.25-7mm,
125 kVp, 150-300mA

Materials and Methods

Image Analysis
Two radiologists, by consensus
Analyze MRI and CT separately in random order
Standard of reference

clinical history, imaging datas, imaging follow up

Materials and Methods

Image Analysis
CT and MRI
- presence, number and location of fracture
- fracture lines
- presence of soft tissue lesions
MRI : presence of BM edema pattern
CT: focal sclerotic areas, adjacent radiolucency

Results

Fracture Locations and

Numbers in All 145 Subjects

Results

CT Versus MRI
Detection of pelvic insufficiency fractures
Among 64 pts, 129 fractures
MRI : 128 fractures in 63 pts (sensitivity, 98%, 128/129)
CT: 89 fractures in 34 pts (sensitivity, 53%, 89/129)

MRI > CT (p <

0.01)

Results

CT Versus MRI

Fracture detection rates and locations

Results
M/53, history of esophageal cancer, chemotherapy, osteoporotic
BMD on DXA

Results

CT Versus MRI

Depiction of fracture morphology

32/88 (36.4%, MRI>CT), 26/88 (29.5%, CT>MRI)

Detection of fracture lines

122/128 on MRI (95.3%), 78/89 on CT (89.7%)

Detection of soft tissue abnormalities

103 lesions in 57 of 64 pts
102/103 on MRI (99%), 13/103 on CT (12.6%)

Results

Overall characteristics

More than one fracture in 102 of 145 pts

(70.3%)

Results
M/18 with ulcerative colitis and primary sclerosing cholangitis

FST2

Results

Overall characteristics on MRI

Presence of BM edema pattern and fracture lines

267/307 (87%), BM edmea with fracture line
21/307 cases (6.8%),only fracture lines
19/307 (6.2%) cases, only BM edema

Soft tissue abnormalities

Common in femoral, acetabular, pubic fractures
Less in sacral fractures

Associated clinical finding

Associated with
Prior malignancy: 63/145 (34.4%)
Rheumatologic disease : 6/145(4.1%)
Corticosteroid tx : 18/145(12.4%)

Conclusion
Must be familiar with these findings, their
location, morphology, and associated clinical
features(malignancy)
MRI is superior technique compared with CT
and should be imaging technique of choice
Multiple pelvic insufficiency fractures are
frequently found (pubic or acetabular)
fracture
Careful search for concomitant fractures