Imaging Features and Management of Stress, Atypical, and Pathologic Fractures

Marshall, Richard; Mandell, Jacob; Weaver, Michael J.; Ferrone, Marco; Sodickson, Aaron; Khurana, Bharti

doi:10.1148/rg.2018180073

Cited by 114 publications

(85 citation statements)

References 83 publications

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“…Plain radiographs have poor sensitivity (15-35%) in early-stage injuries, which increases in latestage injuries (30-70%). MRI is the modality of choice with a sensitivity reported to reach close to 100% [7].…”

Section: Discussionmentioning

confidence: 99%

Symmetrical Synchronous Stress Fractures of Bilateral Tibial Medial Condyles

Kaur¹,

Garg²

2019

JCR

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Background: Stress fractures are microscopic fractures caused by repetitive cumulative micro trauma on the bone over a period of time. Stress fracture is seen to occur in military personnel and sports persons who indulge in intense physical activity. It causes morbidity, economic loss and long periods of absence from duty and training. Tibia stress fractures are more commonly unilateral and are usually in the diaphyseal portion of the tibia. Case Report: We present a case of bilateral symmetrical synchronous stress fractures of medial condyles of bilateral tibia in a military man. X-ray, computed tomography and MRI of the knees revealed the stress fractures. A symmetrical and synchronous presence of stress fractures in the lower limbs is unusual. Conclusion: Radiological investigations are conclusive in cases of stress fractures. In case of unilateral stress fracture, contralateral side should also be investigated to diagnose bilateral injury.

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Section: Discussionmentioning

confidence: 99%

Symmetrical Synchronous Stress Fractures of Bilateral Tibial Medial Condyles

Kaur¹,

Garg²

2019

JCR

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“…(2) fracture originating at the lateral cortex and primarily transverse in pattern (with or without a medial spike) [4,5]; (3) evidence of localized periosteal or endosteal thickening of the lateral cortex at the site of fracture origin [1,4,15]; and (4) fracture occurring with minimal to no trauma. These radiographic features were first reported more than 10 years ago [3,16,17] and comprise the well-established criteria for AFF used by experts, especially the finding of focal periosteal or endosteal thickening at the transverse fracture origin [4,18,19].…”

Section: Bisphosphonate (Bp) Exposure Assessmentmentioning

confidence: 99%

“…These radiographic features were first reported more than 10 years ago [3,16,17] and comprise the well-established criteria for AFF used by experts, especially the finding of focal periosteal or endosteal thickening at the transverse fracture origin [4,18,19]. The original ASBMR criteria for AFF [20] were revised in 2013 [1] to include periosteal callous formation as a major feature of AFF, with recognition that the initially transverse fracture originating in the lateral cortex can propagate medially at an oblique angle, with or without a medial spike [1,15,21]. It has also been noted that these atypical fractures can present initially with focal cortical hypertrophy that progresses to partial or complete AFF [1,15,16,22].…”

Section: Bisphosphonate (Bp) Exposure Assessmentmentioning

confidence: 99%

“…The original ASBMR criteria for AFF [20] were revised in 2013 [1] to include periosteal callous formation as a major feature of AFF, with recognition that the initially transverse fracture originating in the lateral cortex can propagate medially at an oblique angle, with or without a medial spike [1,15,21]. It has also been noted that these atypical fractures can present initially with focal cortical hypertrophy that progresses to partial or complete AFF [1,15,16,22]. Figure 1 shows a radiographic example of complete AFF [22], demonstrating the transverse fracture that develops in the lateral cortex at the site of periosteal hypertrophy, with the fracture becoming oblique as it propagates medially.…”

Section: Bisphosphonate (Bp) Exposure Assessmentmentioning

confidence: 99%

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Risk of complete atypical femur fracture with Oral bisphosphonate exposure beyond three years

Neugebauer

Ettinger

et al. 2020

BMC Musculoskelet Disord

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Background Bisphosphonate (BP) therapy has been associated with atypical femur fracture (AFF). However, the threshold of treatment duration leading to increased AFF risk is unclear. In a retrospective cohort of older women initiating BP, we compared the AFF risk associated with treatment for at least three years to the risk associated with treatment less than three years. Methods We used observational data from a large population of female members of an integrated healthcare system who initiated oral BP during 2002–2014. Women were retrospectively followed for incident AFF confirmed by radiologic adjudication. Demographic data, pharmacologic exposures, comorbidity, bone density, and fracture history were ascertained from electronic health records. Inverse probability weighting was used to estimate risk differences comparing the cumulative incidence (risk) of AFF if women discontinued BP within three years to the cumulative incidence of AFF if women continued BP for three or more years, adjusting for potential time-dependent confounding by the aforementioned factors. Results Among 87,820 women age 45–84 years who initiated BP (mean age 68.6, median T-score − 2.6, 14% with prior major osteoporotic fracture), 16,180 continued BP for three or more years. Forty-six confirmed AFFs occurred during follow-up in the two groups. AFF-free survival was greater for BP treatment < 3 years compared to treatment ≥3 years (p = 0.004 comparing areas under survival curves). At five years, the risk of AFF was 27 per 100,000 (95% confidence interval, CI: 8–46) if women received BP treatment < 3 years and 120 per 100,000 (95% CI: 56–183) if women received BP treatment ≥3 years (risk difference 93 per 100,000, 95% CI: 30–160). By ten years, the risks were 27 (95% CI: 8–46) and 363 (95% CI: 132–593) per 100,000 for BP treatment < 3 and ≥ 3 years, respectively (risk difference 336 per 100,000, 95% CI: 110–570). Conclusions Bisphosphonate treatment for 3 or more years was associated with greater risk of AFF than treatment for less than 3 years. Although AFFs are uncommon among BP-treated women, this increased risk should be considered when counseling women about long-term BP use. Future studies should further characterize the dose-response relationship between BP duration and incident AFF and identify patients at highest risk.

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“…Less common causes are osteogenesis imperfecta, radiation osteonecrosis, renal osteodystrophy, and osteomalacia. 2,3 When necessary, a clinical history can usually isolate these much less common nonosteoporotic causes of insufficiency fracture.…”

Section: Tip 1: Know the Significance Of An Insufficiency Fracturementioning

confidence: 99%