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Sacral insufficiency fracture

¹ Department of Radiology, South Infirmary-Victoria Hospital, Old Blackrock Road, Cork, Ireland and ² Department of Radiology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK

View larger version (121K): [in a new window]   Figure 1. A 79-year-old female presenting with recurrent minor falls and right hip pain. Plain film of pelvis demonstrating fractures of superior and inferior pubic rami on the left side. The sacrum shows generalized sclerosis. Note is also made of sclerosis at the left L5/S1 facet joint secondary to degenerative change. CT (not shown) confirmed bilateral sacral fractures and healing fractures of the left pubic rami.

View larger version (99K): [in a new window]   Figure 2. A 73-year-old female with severe low back and left leg pain referred with suspected sacral and pelvic metastases. (a) Plain radiograph at presentation shows no significant abnormality, although a follow-up film 4 weeks later (b) shows sclerosis in the right sacral ala (arrows). (c) Posterior view of isotope bone scan shows marked abnormal uptake at right side of sacrum (arrow). (d) CT confirms unilateral sacral fracture (arrow). (e) Posterior view of isotope bone scan 8 months later showing avid uptake in the right side of sacrum and right ilium (arrow) and uptake in the left side of sacrum (arrowhead). (f) CT scan at this time showing right iliac fracture (arrow) and sclerosis due to healing of the right sacral insufficiency fracture (arrowhead), with less marked sclerosis at the left sacral ala from healing of left side insufficiency fracture.

View larger version (104K): [in a new window]   Figure 3. A 76-year-old female with rheumatoid arthritis and new onset of severe low back pain. She also had weight loss, anorexia and possible left iliac fossa mass and malignancy was strongly suspected. (a) Plain radiograph fails to demonstrate significant abnormality. (b) Axial T1 weighted MR image (repetition time 700/echo time 20) demonstrating low signal intensity in both sacral alae. Because of the suspicion of malignancy, intravenous gadolinium chelate was given. (c) The post-contrast T1 weighted axial MR image (repetition time 700/echo time 20) shows enhancement through the sacral ala, with linear defects representing fracture lines. (d) Posterior view of isotope bone scan shows an asymmetric H-shaped appearance of bilateral sacral insufficiency fracture, the uptake being more marked in the right sacral ala (arrow). (e) CT scan through the sacrum shows no space-occupying lesion and confirms the bilateral insufficiency fracture (arrows).

View larger version (106K): [in a new window]   Figure 4. A 76-year-old female with recent onset of increasingly severe low back pain and a history of surgery and radiotherapy for endometrial carcinoma underwent a routine lumbar spine MR examination. (a) Sagittal T2 weighted images through right and left sacral alae showing abnormal high signal at multiple sacral levels (arrows). Slight low signal was seen in these areas on the corresponding T1 weighted images (not shown). (b) Coronal oblique T1 weighted image through sacrum showing low signal in the left sacral ala (open arrows) with a central linear signal defect crossing the sacral body to the right ala (black arrows). There is also minor low signal seen in the right ala (small arrows). (c) Coronal oblique fast spin echo fat suppressed T2 weighted image through sacrum demonstrates a low signal fracture line in the left sacral ala and across the body of the sacrum surrounded by oedema (white arrows). There is also oedema seen within the right ala (black arrow). (d) Posterior view of isotope bone scan shows uptake in the sacral ala (arrowheads) and sacral body (arrows), with an asymmetric H-shaped pattern. (e) CT study confirms bilateral sacral insufficiency fractures (arrows) and shows no destructive mass lesion.

View larger version (118K): [in a new window]   Figure 5. A 74-year-old female on long-term oral corticosteroid therapy, with documented osteoporosis, with rapid onset of severe low back pain was referred for lumbar spine MRI. (a) Axial T1 weighted MR image (repetition time 700/echo time 20) through sacrum shows an area of low signal in the right sacral ala (arrow) that demonstrated enhancement after intravenous gadolinium chelate (b). There were similar less marked appearances in the left sacral ala. (c) CT scan through the sacrum confirmed right sacral fracture (arrow). (d) Posterior view of isotope bone scan shows uptake in the sacral ala (solid arrows) and across sacral body (open arrow) with the classic "H-sign" of bilateral sacral insufficiency fracture. There was also increased uptake throughout much of the lumbar spine, correlating with marked degenerative changes on plain film.