Cases reported "Fractures, Spontaneous"

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1/9. Neurological complications in insufficiency fractures of the sacrum. Three case-reports.

    Three cases of nerve root compromise in elderly women with insufficiency fractures of the sacrum are reported. Neurological compromise is generally felt to be exceedingly rare in this setting. A review of 493 cases of sacral insufficiency fractures reported in the literature suggested an incidence of about 2%. The true incidence is probably higher since many case-reports provided only scant information on symptoms; furthermore, sphincter dysfunction and lower limb paresthesia were the most common symptoms and can readily be overlooked or misinterpreted in elderly patients with multiple health problems. The neurological manifestations were delayed in some cases. A full recovery was the rule. The characteristics of the sacral fracture were not consistently related with the risk of neurological compromise. In most cases there was no displacement and in many the foramina were not involved. The pathophysiology of the neurological manifestations remains unclear. We suggest that patients with sacral insufficiency fractures should be carefully monitored for neurological manifestations.
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2/9. A case report of insufficiency fracture of the Fossa acetabuli in a patient with rheumatoid arthritis.

    Aside from vertebral compression fractures, the most common site of insufficiency fractures is the pelvis and lower extremities. In the pelvis, the fractures usually occur in the ilium, the pubis and the ischium, but rarely in the fossa acetabuli. We report a severe insufficiency fracture of the fossa acetabuli in a 78-year-old woman with rheumatoid arthritis (RA). She had associated insufficiency fractures of the rib, the thoracic spine and the sacrum. In our case, senile osteoporosis was present before the onset of the fracture was recognized on radiographs, and RA and corticosteroid therapy might have further aggravated the porosis, resulting in the destruction of the fossa acetabuli. Regarding treatment for the fracture, a cemented total hip replacement without bone graft was attempted for several reasons such as the patient's activities, postoperative rehabilitation and the bone mass of the acetabulum. The postoperative course was satisfactory during study period. However, further follow-up is needed to monitor carefully how the patient will be in the future.
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3/9. Sacral insufficiency fracture, an unsuspected cause of low-back pain in elderly women.

    Sacral insufficiency fractures (SIF) usually occur in elderly women and are secondary to various conditions, mainly postmenopausal or steroid-induced osteoporosis and radiation therapy. They are often overlooked or confused clinically and radiographically with metastatic disease. We report a case of a 72-year-old woman who presented to our department with severe low-back pain. She was thoroughly investigated for the cause of her back pain. Plain x-rays did not reveal any abnormality, but magnetic resonance (MR) scan revealed marked oedema within both sides of the sacrum, suggesting a neoplastic lesion. Bone scintigraphy did show a hyperfixation pattern forming an 'H' in the sacrum which is a characteristic sign of SIF. Computed tomography (CT) confirmed sclerotic changes interpreted as insufficiency fractures through both sacral alae. Increased awareness of these fractures may help to avoid unnecessary investigations and treatment. bed rest and analgesia followed by rehabilitation provide good relief of symptoms.
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4/9. Multiple insufficiency fractures with severe osteoporosis.

    Multiple insufficiency fracture is a rare injury. We report a 63-year-old woman who spontaneously developed insufficiency fractures at multiple sites including ribs, sacrum, pubis, ischium, acetabulum, metatarsal bone, and femoral neck. The patient had severe osteoporosis with a bone mineral density of 0.267 g/cm(2), although there was no evidence of bone metabolic disease or metastatic bone tumor. risk factors for osteoporosis in this case were her postmenopausal state and a history of gastrectomy. Interestingly, the serum level of insulin-like growth factor i, recognized as a growth factor that stimulates bone formation, was markedly decreased, and the patient had had viral hepatitis c. It was speculated that the synergistic effects of these disorders might have produced the osteoporosis, leading ultimately to the multiple insufficiency fractures.
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5/9. pentoxifylline in the treatment of radiation-related pelvic insufficiency fractures of bone.

    The reported incidence of bone complications after radiation therapy is quite low. The most commonly seen bone complication is insufficiency fractures of the pubis and sacrum. Treatment of insufficiency fractures consists of conservative care, and mineral replacement may be useful. The resolution of symptoms takes at least one year with these treatments. Vascular damage has an important role in the etiology of late radiation injury in normal tissues. Progressive ischemic changes further weaken the bone structure, which can cause fractures, and healing is also delayed. pentoxifylline is a methylxanthine derivative that is shown to increase tissue blood flow. Here, we present a 63-year-old male patient with pelvic insufficiency fractures due to postoperative pelvic irradiation for rectal adenocarcinoma. The patient received pelvic radiotherapy to a total dose of 50.4 Gy with concomitant 5-FU. Six months after the completion of radiotherapy, the patient presented with severe pelvic pain. Pelvic magnetic resonance imaging (MRI) demonstrated abnormal signal intensity with insufficiency fractures at the sacrum and bone marrow edema near the fractures, but not an abnormal intensity that revealed bone metastases. Neither distant nor locoregional recurrence was observed at his work-up. The final diagnosis was insufficiency fractures of the pelvic bones owing to irradiation, and pentoxifylline (400 mg, 3 times daily, peroral, 1,200 mg/day) was used for eight months as treatment. Dramatic clinical improvement was obtained in six months, and objective healing was revealed with MRI. We concluded that pentoxifylline is a cost-effective drug with minimal adverse effects in treating radiation damage of bone.
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6/9. Balloon kyphoplasty for treatment of sacral insufficiency fractures. Report of three cases.

    Sacral insufficiency fracture is a painful injury, for which no effective treatment currently exists. The objective of this study was to report on the clinical outcomes and technical aspects of balloon kyphoplasty, which was used in three patients with this injury. Three elderly women with intractable pain from sacral insufficiency fractures were treated with polymethyl methacrylate (PMMA) injections into the sacrum by using a modified balloon kyphoplasty procedure. The visual analog scale pain score improved by four points in each case. Functional status was improved and analgesic medication requirements were decreased in all three patients. There were no complications associated with the procedure. Because of the unique anatomy of the sacrum, it was difficult to monitor instrument placement and PMMA injection by using conventional fluoroscopy. BrainLAB image guidance was used in one case, and was helpful in guiding instrument placement and assuring accurate PMMA deposition at the fracture site. Balloon kyphoplasty may be a treatment alternative in selected patients with sacral insufficiency fractures. BrainLAB image guidance may offer some advantages over conventional fluoroscopy with regard to the monitoring of instrument placement and PMMA injection.
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7/9. Insufficiency fractures of the pelvis that simulate metastatic disease.

    Insufficiency fractures of the pelvis, which almost always occur in elderly women with osteoporosis, are often misinterpreted as metastatic disease. The initial symptom of such fractures is severe pain unassociated with an obvious history of trauma. The typical sites of involvement are the sacrum, the iliac bones, and the pubis. The plain film appearance of the sacral and iliac fractures is usually subtle and easily overlooked, and bone scans will show the abnormal areas more readily. The existence of multiple fractures not only in the pelvis but also in the vertebrae and ribs should suggest the diagnosis of insufficiency-type stress fractures. Computed tomography can exclude the presence of a destructive process and an associated soft tissue mass, as would be seen in metastatic disease. If insufficiency fractures are identified in the typical anatomic locations, bone biopsy is unnecessary.
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8/9. Unsuspected sacral fractures: detection by radionuclide bone scanning.

    Unsuspected sacral fractures may present with confusing clinical, radiographic, and scintigraphic findings. Sacral fractures were diagnosed by radionuclide bone scans in 23 patients, most of whom were osteopenic and had only minor or no trauma. Symptoms usually consisted of low back pain, sometimes with radiculopathy, but some of the patients were asymptomatic and the fractures discovered coincidentally. Abnormalities on bone scanning consisted of increased uptake in the body of the sacrum and one or both sacral alae or only in a single sacral ala. A retrospective review showed abnormalities on radiographs in 11 of the 23 patients and in all four of the CT scans obtained, but the abnormalities were often overlooked or misinterpreted on the original reading. Bone biopsies of the sacrum, done in two patients to rule out metastatic disease, showed reactive bone formation consistent with fracture. Recognition of the characteristic scintigraphic patterns in sacral fractures and the frequency of these fractures in osteopenic patients can avoid mistaken diagnoses and unnecessary tests or treatment.
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9/9. Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly.

    Three elderly patients with incapacitating back and leg pain were found to have spontaneous osteoporotic fractures of the sacrum. The clinical picture in these three patients suggests a distinct clinical entity of spontaneous osteoporotic fracture of the sacrum (SOFS). This is characterized by severe low back, hip, and leg pain that suggests initially lumbosacral radicular compression, either from disk disease, spinal stenosis, tumor. However, objective mechanical signs more typical of those entities may be absent or minimal in SOFS. Symptoms suggestive of a cauda equina syndrome may be present, but there is minimal or no neurological deficit on examination. Marked sacral tenderness is a hallmark of SOFS.
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