Elsevier

Joint Bone Spine

Volume 70, Issue 3, June 2003, Pages 209-218
Joint Bone Spine

Original article
Insufficiency fracture. A survey of 60 cases and review of the literature

https://doi.org/10.1016/S1297-319X(03)00024-1Get rights and content

Abstract

We report findings on the site, risk factors and imaging of insufficiency fractures (IF) in 60 patients admitted to our department between 1989 and 1997.

Results. – Fifty-five women (mean age 72.5 years) and five men (mean age 59 years) had 91 fractures, accounting for 0.32% of admissions. Fractures occurred most commonly in the pelvic girdle (30.7%, 28/91) and in the sacrum (29.6%, 27/91). In eight patients fractures of the sacrum were associated with fractures of the pelvic girdle. The next most common sites of occurrence were the tibia (16.5%, 15/91: 11 transverse, four longitudinal) and the femoral neck (9.9%, 9/91). There were three subchondral fractures of the femoral head, three fractures of the femoral diaphysis (two longitudinal, one transversal), two of the astragalus, and one each of the ilium, perone, calcaneum and sternum. Thirty patients had osteoporosis: six had received fluoride treatment and five had corticosteroids. Other risk factors were rheumatoid arthritis (4), osteomalacia (4), corticosteroid treatment (4), and hyperparathyroidism (1). Radiography showed a fracture line or osteocondensation in 65% (39/60) of cases. Scintigraphy was positive in 87.5% of cases (21/24), showing a fracture line (15) or a callus (6). Bone computed tomography (CT) scan was positive in 98.1% (54/55) of cases. IF occurs in elderly women with osteoporosis and most commonly in the pelvis.

Conclusion. Since radiologic signs are inconstant, scintigraphy is the choice procedure.

Introduction

Stress fractures occur when the loads applied to a bone exceed the mechanical resistance. They fall into two groups: fatigue fractures, in which abnormal mechanical stress is applied to a normal bone, and insufficiency fractures (IF), in which fracture occurs after moderate or normal pressure is applied to a bone that has decreased resistance [1]. IFs are most often seen in elderly women with postmenopausal osteoporosis [1]. Risk factors for IFs include osteoporosis, osteomalacia, hyperparathyroidism, rheumatoid arthritis, fluoride treatment, diabetes mellitus, fibrous dysplasia, Paget’s disease of bone, osteogenesis imperfecta, irradiation and mechanical factors [1], [2]. We report on the sites, predisposing factors and imaging of 91 IFs in 60 patients. We will compare our results with those of a previously reported series [2] and present a review of the literature concerning each fracture site.

Section snippets

Materials and methods

A retrospective review was made of the medical records of all patients admitted to hospital for IF between 1 January 1989 and 31 December 1997. In the absence of any other etiology, IF was diagnosed when fracture occurred spontaneously or as a result of moderate pressure and when it was confirmed by standard radiographs and/or scintigraphy, computed tomography(CT)-scan or magnetic resonance imaging (MRI). Medical records included the following: age, sex, previous history of fracture, risk

Results

Fifty-five women with a mean age of 72.5 years and five men with a mean age of 59 years having 91 fractures (a bilateral fracture of the sacrum was considered as a single lesion) were reviewed. The fractures accounted for 0.32% (60/18 600) of admissions to the rheumatology department.

The most common locations were the pelvic ring (30.7%, 28/91) and the sacrum (29.6%, 27/91). The next most common sites were the tibia (16.5%, 15/91) with 11 transverse and four longitudinal fractures, and the

Discussion

Our review of 91 fractures in 60 patients along with that of Bouquillard documenting 87 fractures in 64 patients are the only two studies reported in rheumatology patients [2]. We have note including the patient series of Martin Hunyadi because it concerns spontaneous fracture in bedbound or wheelchair patients in hospital geriatric units [6]. There was a predominant female distribution both in our series (55 patients) and in that of Bouquillard (62 patients). Average age was slightly higher in

Conclusion

The main site of IFs is the pelvic ring but they can occur in all bones of the lower limbs. The diagnosis of IFs should be considered in postmenopausal women with one or more predisposing factors who present with mechanical pain. Clinical examination is generally unhelpful. Radiographs are usually negative at the onset of symptoms. Scintigraphy is almost always positive and allows definite diagnosis in the case of sacral fracture or a highly probable diagnosis that can be confirmed by follow-up

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      Citation Excerpt :

      Stress fractures include fatigue fractures and insufficiency fractures. Fatigue fractures occur when an abnormal mechanical stress is applied to a normal bone, whereas insufficiency fractures occur when moderate or normal stress is applied to a bone that has inadequate resistance.6 One of the risk factors for an insufficiency fracture is postmenopausal osteoporosis.6,7

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