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Bony Stress Injuries of the Pelvis and HipKennethG.Swan,Jr.,M.D.ClinicalAssistantProfessor
RutgersMedicalSchool
May23,2018
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• Nodisclosurestoreport
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STRESS FRACTURE SEMANTICS
• ”astressfractureisafatiguefractureofbonecausedbysubmaximalstress….”
• Maybedifferentthanastressreaction,whichisboneinflammation,seenonbonescanorMRI,showingreaction,oredema,butnocorticaldisruption.
• StressInjury termusedtoincludestressfracture,stressreaction,overuseinjuries,evengrowthenthesiopathies(OsgoodSchlatter’s,Sever’s)andtendonitis
• Bonystressinjury(BSI):newertermtoincludestressfractureandstressreactionspectrum
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STRESS FRACTURE SEMANTICS II• FATIGUEFRACTURE(akaStressFracture)
– Abnormalstressonnormal(?)bone• “RuleofToos”
– TooMuch,TooSoon,TooFar,TooOften,TooIntense,Toolittlerest/recovery/sleep
– StressTriad:Somethingnew/different,somethingstrenuous,somethingrepetitive
• StressFracturesdonotonlyoccurinyoungathletes….
• INSUFFICIENCYFRACTURE– Normalstressonabnormalbone– Typicallyelderly,osteoporotic
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INSUFFICIENCY FRACTURES• Normaleverydayactivitiescauseafracturein
mechanicallyweakbone– Lowbonequality,massorimpairedbonerepair
• Osteoporosismostcommon,butmanyadditionalcauses– Endocrineabnormalities(Cushing’sdisease,hyperPTH,renal
osteodystrophy)– VitaminDdeficiency– Nutrientmalabsorption(viaceliacdisease,lactose
intolerance,priorGIsurgery)– Medications(anti-seizuremeds,EtOH,chemotherapy,
Bisphosphonates)– RA,Diabetes– Post-radiationtherapy[topelvis]
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Stress fracture
• “SandontheBeach”– Dailychurnofoceanandsand=Normalboneturnover– HurricaneSandy=Fracture– Suddenstorm,hightide=bonebruise– Severalstormsoverthewinter=Stress[fatigue]fracture
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Stress fracture• Incidence:– Generalpopulation:1%– Runners:20%
– 90%ofstressFxs occurinthelowerextremities• Tibia>Foot>hip/pelvis>femur
– Morecommoninwomen– Morecommoninthepre-season– 21%seasonendinginjury(NCAA)
• Rizzone,JAthl Training2017
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Potential Risk Factors for Stress Fracture (LEs)
EXTRINSICFACTORS• TrainingRegimen– Distance– Intensity– Season
• Nutrition– Diet– Supplements
• OralContraceptives• OtherMeds(CTSDs)
INTRINSICFACTORS• Gender• PriorHx stressFx• MenstrualCharacteristics• BMD• Dz
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RISK FACTORS: LE Stress Fracture in Runners
• Wright,BrJrSportsMed,2015• SystematicReview,Meta-analysis
• OnlyConsistentlySignificantRiskFactors:–PreviousHx ofStressFx– Femalegender
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Female Athlete Triad
THEN:
• Osteoporosis
• Amenorrhea
• EatingDisorder
NOW:
• PoorBoneHealth
• MenstrualDysfunction
• DecreasedEnergyAvailability
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Fractures, Menstrual Status and Bone Health
• Ackerman,Medicine&ScienceinSports&Exercise,2015• 175femaleathletesandnon-athletes,ages14-25yrsstudied,Retrospective• DXA,HRpQCT,Fx Hx,MenstrualHx,DietHx
• Findings:– WBathleticactivityincreasedBMD,butnotinthosewithmenstrualdysfunction(whoweresameasnon-athletes)
– WBathleticactivityincreasedFx riskinthosewithmenstrualdysfunction(47%)vsnormalathletes(25%)andnon-athletes(12.5%)
– Ageofmenarche** waslater,andBMIlowerinthosewithmenstrualdysfunction
– 26%ofoligoamenorrheic athleteshadhistoryofdisorderedeating(comparedto6%eumenorrheic and0%non-athletes)
– DespiteVit Dlevelssignificantlyhigherinoligoamenorrheicathletes!
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• FATIGUEFRACTURE(akaStressFracture)– Abnormalstressonnormal(?)bone
– OLIGOAMENORRHEICYOUNGATHLETESLACKBONEHEALTHBENEFITSOFWBEXERCISE
– BONEMICROARCHITECTURALANDSTRENGTHDIFFERENCESAREMOREPRONOUNCEDINAMENORRHEICATHLETESWHOEXPERIENCEDMULTIPLESTRESSFXS
• Ackerman,2015
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• Tenforde,AJSM,2018– “LowBMDinmaleathletesisassociatedwithbonestressinjuriesatanatomicsiteswithgreatertrabecularcomposition”
– LevelIII,Retrospectivereview
– ATHLETICSTRESSFRACTURESMAYNOTBEOCCURRINGABOUTNORMALBONE
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Vitamin D, Calcium Supplementation• Lappe J,JBoneMinerRes2008– RCT– FemaleNavyrecruits– 2000mgCalciumand800IUVit Dvsplacebo– 5201recruitsvolunteered;8weeksoftraining
• 309stressfractures(6%)• 20%fewerstressFxs insupplementgroup• Add’l findings:Amenorrhea,+Tobacco,Poorpre-Fitness,Progesterone-onlyOCPsotherRFs
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Femoral Neck Stress Fractures
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Femoral Neck Stress Fractures
• Seriousinjurythatmustnotbemissed• A“High-Risk”stressfracture• Typicallypresentswithgroinpain• Canpresentwithvagueanteriorthigh,evenisolatedkneepain!
• Completiontodisplacedfemoralneckfracturewillhaveseriousramificationsinayoungpatient
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AVASCULAR NECROSIS (AVN) HIP
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Hip AVN THR
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Femoral Neck Fracture Fixation
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Femoral Neck Stress Fx: Does Side Matter?
• TensionSide
• CompressionSide
• Transcervical
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Femoral Neck Stress Fx: Does Side Matter?
• TensionSide
• CompressionSide
• Transcervical
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Femoral Neck Stress Fx: Diagnosis
• History!!!• Physical– GroinpainwithPROM(Flex/IR)hip– Examinebothsides(b/l common)
• XRAYS– Oftennormal
• MRI– BetterthanbonescanorCT,butthoseareoptionsalso
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Femoral neck stress Fx: Treatment
• Transcervical fractureline:NWB,Wheelchair,ORtoday!
• Tensionsidefractureline:CanconsiderNWB,crutches,butrecommendOperativetreatment
• Compressionsidefractureline:ProtectedWB,closemonitoring
• StressRxn only:ProlongedActivityModificationmaybeenough
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Proposed MRI Grading System
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Rohena-Quinquilla,AJR, 2015
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• GradeI • GradeII
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• GradeIII
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MRI Classification System?• Rohena-Quinquilla,AJR,2018• Retrospectivereview• GradesIandII=“LowGrade”• GradesIIIandIV=“HighGrade”– HighGradesignificantlylongerReturntoDutyvsLow
• GradesI,II,andIIItreatedconservatively,nonewentontofracture
• GradeIVtreatedwithscrewfixation– 11.5%ofptsrequiredORfixation
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Stress fractures of the pelvis• Sacrum• Rami• Symphysispubis• Iliacwing
• TypicallyduetobonyInsufficiency,ratherthanFatiguefracture
• Etiologywork-upappropriateasindicated
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Risk Factors for Sacral Stress Fxs
INSUFFICIENCYFXs• Avg age>71• Osteoporosis• Hx ofpelvicradiationtx• RA• Long-termCTSDuse
Liong,BJR,2012Yoder, JMMT2015
FATIGUEFXs• Avg age25• Recentincreaseintraining
• Deficientdiet– Lowcaloricintake
• LowBMDseenin43%of“fatiguefxs”
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Stress Fx Sacrum• Lowbackpain,sometimesgroinpain• Tendernessaboutsacrum• +Patrick’stest(FABER)• Usuallynoneuro• Xrays typicallynegative• MRI+edemaorfractureline• SPECTcandetectsubtlestressreactions• Treatment:WBAT,meds,PT– Fatigue:Decreaseoffendingactivity– Insufficiency:Tx underlyingdisease(s)
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Avulsion Injuries Around the Pelvis
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• Apophysis:Secondarycenterofossificationthatcontributestosizeandshapeofabone,butnotlength– Usuallyfuseslaterthanphyses oflongbones– Siteofattachmentororiginofmuscles– Commonsiteofacuteandchronicinjuries(weaklink)
• Acuteinjuriesmayresultindisplacementofapophysisfragment– “…rapid,forcefuleccentriclateralflexionorrotationoftorsocausingexcessivestrainofabdominalmusculature”
– 13Xmorecommoninmalesthanfemales!• Chronicinjuriesassociatedwithongoingreparativeinflammation(apophysitis)
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Apophyses - Pelvis• Iliaccrest– Externaland
Internalobliques,Transverseabdominus,Gluteusmuscles,TFL
• ASIS– Sartorius• AIIS– Rectus(direct
head)• Ischium– Hamstrings• Lessertuberosity--
Iliopsoas
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Apophyseal Injuries-- Pelvis• Presentation– Typicallysudden,severepaininadolescentathlete– Non-contactinjury– Mayhear/feela“pop”– Ambulationmaybeverydifficult– [butnotallpresentacutely---canpresentlikestressfracture]
– Exam:focaltenderness;difficultywithAROMaffectedmuscle
– Workupincludesxrays;Mayneedobliqueviewstoseetheinjury(ERfilmsmaybereadasNormal)
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ASIS AIIS
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Iliac Crest Apophyseal Fracture
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Iliac Crest Apophyseal Fracture
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Iliac Crest Stress Fracture
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Apophyseal Avulsion Injuries -- Pelvis
• Treatment– UsuallyNon-operative(foracuteorsubacute/stress)– Rest,PT,slowRTP,typically4-6weekslater– Operativetreatmentrarelyconsideredina)significantlydisplacedfractureavulsionsand/orb)chronicallysymptomaticavulsions
– NostrongEvidenceBasedGuidelines
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Take Home Points
• Insufficiencyfracturescommonlyoccuraroundthepelvis,inabnormalbone
• BonyStressInjuriesareaspectrumofoveruseconditionsinathletes,fromstressreactionstostressfractures.Bonemaybenormalorabnormal
• Femoralneckstressfracturescanbeanorthopaedic emergency
• MRIimagingmodalityofchoice
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ReferencesAckermanK,SokoloffN,Maffazioli G,etal.Fracturesinrelationtomenstural statusandboneparametersinyoungathletesMedicine& ScienceinSports&Exercise;2015:1577-1586
BehrensS,Deren M,MatsonA.Stressfracturesofthepelvisandlegsinathletes:areviewSportsHealth2012;165:165-174
Fernbach S,WilkinsonR. AvulsioninjuriesofthepelvisandproximalfemurAJR 1981;137:581-584
HerbertK,Laor T,EmeryK.MRIappearanceofchronicstressinjuryoftheiliaccrestapophysis inadolescentathletesAJR2008;1487-1492
KongC,InY,KimS,etal.Avulsionfractureoftheiliaccrestapophysis treatedwithopenreductionandinternalfixationJOrthop Trauma2011;25(6):e56-e58
Liong S,WhitehouseR.LowerextremityandpelvicstressfracturesinathletesBritishJournalofRadiology;2012:1148-1156
Rohena-Quinquilla I,Rohena-Quinquilla F,ScullyW,etal.Femoralneckstressinjuries:Analysisof156casesinaUSmilitarypopulationandproposalofanewMRIclassificationsystemAJR 2018;210:601-607
Tenforde A,Parziale A,PoppK,etal.Lowbonemineraldensityinmaleatheltes isassociatedwithbonestressinjuriesatanatomicsiteswithgreatertrabecularcompositionAmJSportsMed2018;46:30-36
YoderK,Bartsokas J,AverellK,etal.Riskfactorsassociatedwithsacralstressfractures:AsystematicreviewJManualandManipulativeTherapy2015;23(2):84-92
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THANK YOU!
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