Fracture / Sacral Fracture

Sacral Insufficiency Fractures

Pradeep Chockalingam Snr 2 Physio

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Definition  First described by Dr. Lourie in 1982  Sacral insufficiency fracture is a type of

stress fracture characterized by severe incapacitating hip, groin, pelvic, buttock and low back pain. It occur when normal or physiological stresses are placed on weakened bone that has a low elastic resistance. (Paker N & Tekdos D 2006)

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Anatomy and Classification Anatomy

Denis Classification

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Causes  Osteoporosis

 Paget's disease

 Radiation to the

 Hip joint replacement

pelvis  Steroid use  Rheumatoid arthritis  Hyperparathyroidism  Pregnancy

 Lumbosacral fusion  Anorexia nervosa  Liver diseases &

transplantation  Breastfeeding

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Signs & Symptoms Severe pain around

Tenderness around

 Buttock

 Buttock

 Low back

 Low back

 Sacroiliac

 Groin

 Hip

 Sacroiliac joint

 Groin

 Restricted hip

 Pelvis

movements

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Features         

Spontaneous or low velocity trauma Common in females with osteoporosis Associated with 60% of pubic ramus fractures Difficult to identify by normal X-ray Neurological deficit very rare Most of the fractures occur in zone-1 Mostly undiagnosed or misdiagnosed Less than 50% return to baseline mobility Length of stay unilateral: 2-4 weeks, bilateral: 8-36 weeks

Blake SP & Connors AM 2004, Graham G et al. 1994, Paker N & Tekdos D 2006 & Schindler OS et al 2007 www.pdfcoke.com/cpradheep

Diagnostic imaging a) No sign of # in normal b) a

b

c) d) c

d

e) f)

e

X-ray (early) Sclerotic changes in normal X-ray after 4 weeks Bone scan shows abnormal sign CT shows # R ala Bone scan in 8 months CT shows # R iliac in 8 months

f

Blake SP & Connors AM 2004 www.pdfcoke.com/cpradheep

Facts about Pubic Ramus #  25% suffered from dementia  Mean length of stay 9 to 25 days  All patients in this group needs some mobility aid    

at discharge 84% requires extra support at discharge Less than one third return to their baseline mobility within 90 days One year mortality rate is 27% High superior pubic ramus # have poor prognosis compared to the Low superior pubic ramus #

Hill RMF et al 2001, Morris RO et al 2000, Steinitz D et al 2004. www.pdfcoke.com/cpradheep

Management

 Adequate rest  Pain control  Encourage walking with appropriate aid

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Any Changes to Current Practice ?

 Feel for tenderness around sacroiliac joint

 If pain level high or persist for longer than the

normal time scale, consider to rule-out sacral insufficiency fracture

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Reference  Blake SP & Connors AM. Sacral insufficiency fracture:

Pictoral review. B.J.Radiology 2004;77: 891-96  Graham G et al. Sacral insufficiency fractures in the elderly. J.Bone Joint Surg 1994; 76-B: 882-06  Hill RMF et al. Fracture of the pubic rami. J. B&J Sur 2001; 83-B: 1141-44  Morris RO et al. Closed prlvic fractures: characteristics and outcomes in older patients admitted to medical and geriatric wards. Postgrad Med J 2000; 76: 646650

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Reference  Paker N & Tekdos D. Sacral insufficiency fracture: A

case report. Turk.P.M.Rehab 2006;52: 129-31  Schindler OS et al. Sacral insufficency fractures. J.Ortho.Sur 2007; 15(3):339-46  Steinitz D et al. All superior pubic ramus fractures are not created equal. Can J Surg 2004; 47-6: 422-25  www.eorthopod.com/public/patient_education/9207/sa cral_insufficiency_fractures.html (Date 07/03/2009)

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