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.
terials 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)
terials 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
terials 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
terials 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
terials 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
esults
Fracture Locations and
Numbers in All 145 Subjects
esults

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)
esults

CT Versus MRI
Fracture detection rates and locations
esults
M/53, history of esophageal cancer, chemotherapy, osteoporotic
BMD on DXA
esults

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%)
esults

Overall characteristics
More than one fracture in 102 of 145 pts
(70.3%)
esults
M/18 with ulcerative colitis and primary sclerosing cholangitis

FST2
esults

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