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Z Orthop Unfall 2019; 157(02): 144-153
DOI: 10.1055/a-0640-8933
Review/Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Radiologische Diagnostik von Stress- und Insuffizienzfrakturen des Sakrums

Article in several languages: English | deutsch
Ulrich Josef Albert Spiegl
1   Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinik Leipzig
,
Klaus John Schnake
2   Zentrum für Wirbelsäulentherapie, Schön Kliniken, Fürth
,
Georg Osterhoff
3   Klinik für Traumatologie, Universitätsspital Zürich, Zürich, Schweiz
,
Max J. Scheyerer
4   Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinik Köln
,
Bernhard Ullrich
5   Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle
,
Philipp Bula
6   Klinik für Unfall- und Wiederherstellungschirurgie, Orthopädie, Plastische-, Hand- und Mikrochirurgie, Städtisches Klinikum Gütersloh gGmbH, Gütersloh
,
Holger Siekmann
7   Unfallchirurgie, Universität Halle
› Author Affiliations
Further Information

Publication History

Publication Date:
27 July 2018 (online)

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Zusammenfassung

Sakrumfrakturen, die ohne adäquates Trauma entstanden sind, werden in Insuffizienzfrakturen und Stressfrakturen eingeteilt. Während Insuffizienzfrakturen bei physiologischer Belastung meist auf dem Boden einer relevanten Osteoporose entstehen, beruhen Stressfrakturen auf einer mechanischen Überlastung. Der vordere Beckenring ist regelmäßig beteiligt. Aufgrund des fehlenden bzw. niederenergetischen Unfallhergangs wird die korrekte Diagnose oft verspätet gestellt. Demzufolge war es das Ziel der AG Osteoporotische Frakturen der Sektion Wirbelsäule der DGOU, die einzelnen bildgebenden Verfahren zur korrekten, schnellen und kosteneffektiven Diagnostik vorzustellen. Zur Diagnosesicherung sollte neben der konventionell radiologischen Diagnostik zeitnah eine Schnittbildgebung in die Wege geleitet werden. Mittels CT kann die Frakturmorphologie am besten beurteilt werden, wodurch potenzielle Instabilitätszeichen der Verletzung erkannt werden können. Die MRT kann aufgrund der hohen Sensitivität bei fehlendem Frakturnachweis im CT, bei jungen Patienten und unklaren Situationen zusätzliche wichtige Informationen liefern. Im Falle einer Kontraindikation für das MRT stellen nuklearmedizinische Untersuchungen eine gute Alternative dar.

Schlüsselwörter

Insuffizienzfraktur - Sakrum - Stressfraktur - MRT - CT
 

  • References/Literatur

  • 1 Peh WC, Khong PL, Ho WY. et al. Sacral insufficiency fractures. Spectrum of radiological features. Clin Imaging 1995; 19: 92-101
    CrossrefPubMedGoogle Scholar
  • 2 Finiels H, Finiels PJ, Jacquot JM. et al. [Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases]. Presse Med 1997; 26: 1568-1573
    PubMedGoogle Scholar
  • 3 Newhouse KE, el-Khoury GY, Buckwalter JA. Occult sacral fractures in osteopenic patients. J Bone Joint Surg Am 1992; 74: 1472-1477
    PubMedGoogle Scholar
  • 4 Kahanov L, Eberman L, Alvey T. et al. Sacral stress fracture in a distance runner. J Am Osteopath Assoc 2011; 111: 585-591
    PubMedGoogle Scholar
  • 5 Fredericson M, Jennings F, Beaulieu C. et al. Stress fractures in athletes. Top Magn Reson Imaging 2006; 17: 309-325
    CrossrefPubMedGoogle Scholar
  • 6 Nusselt T, Klinger HM, Schultz W. et al. Fatigue stress fractures of the pelvis: a rare cause of low back pain in female athletes. Acta Orthop Belg 2010; 76: 838-843
    PubMedGoogle Scholar
  • 7 Tins BJ, Garton M, Cassar-Pullicino VN. et al. Stress fracture of the pelvis and lower limbs including atypical femoral fractures-a review. Insights Imaging 2015; 6: 97-110
    CrossrefPubMedGoogle Scholar
  • 8 Yoder K, Bartsokas J, Averell K. et al. Risk factors associated with sacral stress fractures: a systematic review. J Man Manip Ther 2015; 23: 84-92
    CrossrefPubMedGoogle Scholar
  • 9 Nattiv A, Kennedy G, Barrack MT. et al. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am J Sports Med 2013; 41: 1930-1941
    CrossrefPubMedGoogle Scholar
  • 10 Bennell KL, Brukner PD. Epidemiology and site specificity of stress fractures. Clin Sports Med 1997; 16: 179-196
    CrossrefPubMedGoogle Scholar
  • 11 Gotis-Graham I, McGuigan L, Diamond T. et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 1994; 76: 882-886
    PubMedGoogle Scholar
  • 12 Klineberg E, McHenry T, Bellabarba C. et al. Sacral insufficiency fractures caudal to instrumented posterior lumbosacral arthrodesis. Spine (Phila Pa 1976) 2008; 33: 1806-1811
    CrossrefPubMedGoogle Scholar
  • 13 Lapina O, Tiskevicius S. Sacral insufficiency fracture after pelvic radiotherapy: a diagnostic challenge for a radiologist. Medicina 2014; 50: 249-254
    CrossrefPubMedGoogle Scholar
  • 14 Grangier C, Garcia J, Howarth NR. et al. Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skeletal Radiol 1997; 26: 517-524
    CrossrefPubMedGoogle Scholar
  • 15 Abe H, Nakamura M, Takahashi S. et al. Radiation-induced insufficiency fractures of the pelvis: evaluation with 99mTc-methylene diphosphonate scintigraphy. AJR Am J Roentgenol 1992; 158: 599-602
    CrossrefPubMedGoogle Scholar
  • 16 Gottfried ON, Daubs MD, Patel AA. et al. Spinopelvic parameters in postfusion flatback deformity patients. Spine J 2009; 9: 639-647
    CrossrefPubMedGoogle Scholar
  • 17 Dasgupta B, Shah N, Brown H. et al. Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 1998; 37: 789-793
    CrossrefPubMedGoogle Scholar
  • 18 Deschamps Perdomo A, Tome-Bermejo F, Pinera AR. et al. Misdiagnosis of sacral stress fracture: an underestimated cause of low back pain in pregnancy?. Am J Case Rep 2015; 16: 60-64
    CrossrefPubMedGoogle Scholar
  • 19 Major NM, Helms CA. Sacral stress fractures in long-distance runners. AJR Am J Roentgenol 2000; 174: 727-729
    CrossrefPubMedGoogle Scholar
  • 20 Connolly LP, dʼHemecourt PA, Connolly SA. et al. Skeletal scintigraphy of young patients with low-back pain and a lumbosacral transitional vertebra. J Nucl Med 2003; 44: 909-914
    PubMedGoogle Scholar
  • 21 Takahashi Y, Kobayashi T, Miyakoshi N. et al. Sacral stress fracture in an amateur rugby player: a case report. J Med Case Rep 2016; 10: 327
    CrossrefPubMedGoogle Scholar
  • 22 Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine (Phila Pa 1976) 1993; 18: 2507-2512
    CrossrefPubMedGoogle Scholar
  • 23 Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthop Surg 2007; 15: 339-346
    CrossrefPubMedGoogle Scholar
  • 24 Dalstra M, Huiskes R. Load transfer across the pelvic bone. J Biomech 1995; 28: 715-724
    CrossrefPubMedGoogle Scholar
  • 25 Burge R, Dawson-Hughes B, Solomon DH. et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007; 22: 465-475
    CrossrefPubMedGoogle Scholar
  • 26 Richards AM, Coleman NW, Knight TA. et al. Bone density and cortical thickness in normal, osteopenic, and osteoporotic sacra. J Osteoporos 2010; 2010 DOI: 10.4061/2010/504078.
    CrossrefPubMedGoogle Scholar
  • 27 Wagner D, Kamer L, Sawaguchi T. et al. Sacral Bone Mass Distribution Assessed by Averaged Three-Dimensional CT Models: Implications for Pathogenesis and Treatment of Fragility Fractures of the Sacrum. J Bone Joint Surg Am 2016; 98: 584-590
    CrossrefPubMedGoogle Scholar
  • 28 Wagner D, Kamer L, Sawaguchi T. et al. Morphometry of the sacrum and its implication on trans-sacral corridors using a computed tomography data-based three-dimensional statistical model. Spine J 2017; 17: 1141-1147
    CrossrefPubMedGoogle Scholar
  • 29 Linstrom NJ, Heiserman JE, Kortman KE. et al. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine (Phila Pa 1976) 2009; 34: 309-315
    CrossrefPubMedGoogle Scholar
  • 30 Cooper KL, Beabout JW, Swee RG. Insufficiency fractures of the sacrum. Radiology 1985; 156: 15-20
    CrossrefPubMedGoogle Scholar
  • 31 De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 1985; 145: 601-606
    CrossrefPubMedGoogle Scholar
  • 32 Lyders EM, Whitlow CT, Baker MD. et al. Imaging and treatment of sacral insufficiency fractures. AJNR Am J Neuroradiol 2010; 31: 201-210
    CrossrefPubMedGoogle Scholar
  • 33 Bohme J, Hoch A, Josten C. [Osteoporotic fractures of the pelvis]. Chirurg 2012; 83: 875-881
    CrossrefPubMedGoogle Scholar
  • 34 White JH, Hague C, Nicolaou S. et al. Imaging of sacral fractures. Clin Radiol 2003; 58: 914-921
    CrossrefPubMedGoogle Scholar
  • 35 Montana MA, Richardson ML, Kilcoyne RF. et al. CT of sacral injury. Radiology 1986; 161: 499-503
    CrossrefPubMedGoogle Scholar
  • 36 Resnik CS, Stackhouse DJ, Shanmuganathan K. et al. Diagnosis of pelvic fractures in patients with acute pelvic trauma: efficacy of plain radiographs. AJR Am J Roentgenol 1992; 158: 109-112
    CrossrefPubMedGoogle Scholar
  • 37 Cabarrus MC, Ambekar A, Lu Y. et al. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol 2008; 191: 995-1001
    CrossrefPubMedGoogle Scholar
  • 38 Schicho A, Schmidt SA, Seeber K. et al. Pelvic X-ray misses out on detecting sacral fractures in the elderly – Importance of CT imaging in blunt pelvic trauma. Injury 2016; 47: 707-710
    CrossrefPubMedGoogle Scholar
  • 39 Oberkircher L, Ruchholtz S, Rommens PM. et al. Osteoporotic Pelvic Fractures. Dtsch Arztebl Int 2018; 115: 70-80
    CrossrefPubMedGoogle Scholar
  • 40 Routt jr. ML, Simonian PT, Swiontkowski MF. Stabilization of pelvic ring disruptions. Orthop Clin North Am 1997; 28: 369-388
    CrossrefPubMedGoogle Scholar
  • 41 Nystrom LM, McKinley TO, Marsh JL. Radiographic Measurement of Rotational Deformity in Pelvic Fractures: A Novel Method With Validity and Reliability Testing. J Orthop Trauma 2015; 29: 365-369
    CrossrefPubMedGoogle Scholar
  • 42 Goetzen M, Ortner K, Lindtner RA. et al. A simple approach for the preoperative assessment of sacral morphology for percutaneous SI screw fixation. Arch Orthop Trauma Surg 2016; 136: 1251-1257
    CrossrefPubMedGoogle Scholar
  • 43 Nork SE, Jones CB, Harding SP. et al. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma 2001; 15: 238-246
    CrossrefPubMedGoogle Scholar
  • 44 Josten C, Heyde CE, Spiegl UJ. [Complex Pathologies of the Spine: Trauma meets Degeneration]. Z Orthop Unfall 2016; 154: 440-448
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Stover MD, Edelstein AI, Matta JM. Chronic Anterior Pelvic Instability: Diagnosis and Management. J Am Acad Orthop Surg 2017; 25: 509-517
    CrossrefPubMedGoogle Scholar
  • 46 Scheyerer MJ, Osterhoff G, Wehrle S. et al. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury 2012; 43: 1326-1329
    CrossrefPubMedGoogle Scholar
  • 47 Blake SP, Connors AM. Sacral insufficiency fracture. Br J Radiol 2004; 77: 891-896
    CrossrefPubMedGoogle Scholar
  • 48 Longhino V, Bonora C, Sansone V. The management of sacral stress fractures: current concepts. Clin Cases Miner Bone Metab 2011; 8: 19-23
    PubMedGoogle Scholar
  • 49 Murthy NS. Imaging of stress fractures of the spine. Radiol Clin North Am 2012; 50: 799-821
    CrossrefPubMedGoogle Scholar
  • 50 Sun H, Xue HD, Jin ZY. et al. Non-enhanced low-tube-voltage high-pitch dual-source computed tomography with sinogram affirmed iterative reconstruction algorithm of the abdomen and pelvis. Chin Med Sci 2014; 29: 214-220
    PubMedGoogle Scholar
  • 51 Hackenbroch C, Riesner HJ, Lang P. et al. Dual Energy Computed Tomography in Musculoskeletal Imaging, with Focus on Fragility Fractures of the Pelvis. Z Orthop Unfall 2017; 155: 708-715
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Memetoglu OG, Ozkan FU, Boy NS. et al. Sacroiliitis or insufficiency fracture?. Osteoporos Int 2016; 27: 1265-1268
    CrossrefPubMedGoogle Scholar
  • 53 Ugurluer G, Akbas T, Arpaci T. et al. Bone complications after pelvic radiation therapy: evaluation with MRI. J Med Imaging Radiat Oncol 2014; 58: 334-340
    CrossrefPubMedGoogle Scholar
  • 54 Byun WM, Jang HW, Kim SW. et al. Diffusion-weighted magnetic resonance imaging of sacral insufficiency fractures: comparison with metastases of the sacrum. Spine (Phila Pa 1976) 2007; 32: E820-E824
    CrossrefPubMedGoogle Scholar
  • 55 Mammone JF, Schweitzer ME. MRI of occult sacral insufficiency fractures following radiotherapy. Skeletal Radiol 1995; 24: 101-104
    PubMedGoogle Scholar
  • 56 König MA, Jehan S, Boszczyk AA. et al. Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies. Eur Spine J 2012; 21: 829-836
    CrossrefPubMedGoogle Scholar
  • 57 Roy-Camille R, Saillant G, Gagna G. et al. Transverse fracture of the upper sacrum. Suicidal jumperʼs fracture. Spine (Phila Pa 1976) 1985; 10: 838-845
    CrossrefPubMedGoogle Scholar
  • 58 Thiryayi WA, Thiryayi SA, Freemont AJ. Histopathological perspective on bone marrow oedema, reactive bone change and haemorrhage. Eur J Radiol 2008; 67: 62-67
    CrossrefPubMedGoogle Scholar
  • 59 Rangger C, Kathrein A, Freund MC. et al. Bone bruise of the knee: histology and cryosections in 5 cases. Acta Orthop Scand 1998; 69: 291-294
    CrossrefPubMedGoogle Scholar
  • 60 Ishibashi Y, Okamura Y, Otsuka H. et al. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med 2002; 12: 79-84
    CrossrefPubMedGoogle Scholar
  • 61 Scheyerer MJ, Hullner M, Pietsch C. et al. Evaluation of pelvic ring injuries using SPECT/CT. Skeletal Radiol 2015; 44: 217-222
    CrossrefPubMedGoogle Scholar
  • 62 Scheyerer MJ, Pietsch C, Zimmermann SM. et al. SPECT/CT for imaging of the spine and pelvis in clinical routine: a physicianʼs perspective of the adoption of SPECT/CT in a clinical setting with a focus on trauma surgery. Eur J Nucl Med Mol Imaging 2014; 41 (Suppl. 01) S59-S66
    PubMedGoogle Scholar
  • 63 Lau TW, Leung F. Occult posterior pelvic ring fractures in elderly patients with osteoporotic pubic rami fractures. J Orthop Surg 2010; 18: 153-157
    CrossrefPubMedGoogle Scholar
  • 64 Fujii M, Abe K, Hayashi K. et al. Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 2005; 30: 165-169
    CrossrefPubMedGoogle Scholar
  • 65 Salavati A, Shah V, Wang ZJ. et al. F-18 FDG PET/CT findings in postradiation pelvic insufficiency fracture. Clin Imaging 2011; 35: 139-142
    CrossrefPubMedGoogle Scholar
  • 66 Dachverband Osteologie e.V.. Prophylaxe, Diagnostik und Therapie der OSTEOPOROSE bei Männern ab dem 60. Lebensjahr und bei postmenopausalen Frauen. Im Internet: http://www.dv-osteologie.org/uploads/Leitlinie 2014/DVO-Leitlinie Osteoporose 2014 Kurzfassung und Langfassung Version 1a 12 01 2016.pdf Stand: 13.01.2018
    PubMedGoogle Scholar
  • 67 Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int 1994; 4: 368-381
    CrossrefPubMedGoogle Scholar
  • 68 Neuerburg C, Schmidmaier R, Schilling S. et al. Identifikation, Diagnostik und leitliniengerechte Osteoporosetherapie (DVO) unfallchirurgischer Patienten. Unfallchirurg 2015; 118: 913-924
    CrossrefPubMedGoogle Scholar
  • 69 Neuerburg C, Stumpf U, Schmidmaier R. et al. Neue Osteoporose-Leitlinie DVO 2014 und ihre Bedeutung für den Unfallchirurgen. Unfallchirurg 2015; 118: 905-912
    CrossrefPubMedGoogle Scholar
  • 70 Pickhardt PJ, Pooler BD, Lauder T. et al. Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med 2013; 158: 588-595
    CrossrefPubMedGoogle Scholar
  • 71 Pompe E, Willemink MJ, Dijkhuis GR. et al. Intravenous contrast injection significantly affects bone mineral density measured on CT. Eur Radiol 2015; 25: 283-289
    CrossrefPubMedGoogle Scholar
  • 72 Bauer JS, Henning TD, Mueller D. et al. Volumetric quantitative CT of the spine and hip derived from contrast-enhanced MDCT: conversion factors. AJR Am J Roentgenol 2007; 188: 1294-1301
    CrossrefPubMedGoogle Scholar
  • 73 Schonenberg D, Guggenberger R, Frey D. et al. CT-based evaluation of volumetric bone density in fragility fractures of the pelvis-a matched case-control analysis. Osteoporos Int 2018; 29: 459-465
    CrossrefPubMedGoogle Scholar
  • 74 Wagner D, Kamer L, Sawaguchi T. et al. Sacral bone mass distribution assessed by averaged three-dimensional CT models: implications for pathogenesis and treatment of fragility fractures of the sacrum. J Bone Joint Surg Am 2016; 98: 584-590
    CrossrefPubMedGoogle Scholar
  • 75 Schwaiger BJ, Gersing AS, Baum T. et al. Bone mineral density values derived from routine lumbar spine multidetector row CT predict osteoporotic vertebral fractures and screw loosening. AJNR Am J Neuroradiol 2014; 35: 1628-1633
    CrossrefPubMedGoogle Scholar
  • 76 Bredow J, Boese CK, Werner CM. et al. Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg 2016; 136: 1063-1067
    CrossrefPubMedGoogle Scholar
  • 77 Tile M. Pelvic ring fractures: should they be fixed?. J Bone Joint Surg Br 1988; 70: 1-12
    CrossrefPubMedGoogle Scholar
  • 78 Young JW, Burgess AR, Brumback RJ. et al. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986; 160: 445-451
    CrossrefPubMedGoogle Scholar
  • 79 Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: Recommendations for surgical treatment. Injury 2013; 44: 1733-1744
    CrossrefPubMedGoogle Scholar
  • 80 Rommens PM, Vanderschot PM, Broos PL. Conventional radiography and CT examination of pelvic ring fractures. A comparative study of 90 patients. Unfallchirurg 1992; 95: 387-392
    PubMedGoogle Scholar
  • 81 Mattila VM, Niva M, Kiuru M. et al. Risk factors for bone stress injuries: a follow-up study of 102,515 person-years. Med Sci Sports Exerc 2007; 39: 1061-1066
    CrossrefPubMedGoogle Scholar
  • 82 Fredericson M, Moore W, Biswal S. Sacral stress fractures: magnetic resonance imaging not always definitive for early stage injuries: a report of 2 cases. Am J Sports Med 2007; 35: 835-839
    CrossrefPubMedGoogle Scholar
  • 83 Giannoulis DK, Koulouvaris P, Zilakou E. et al. Atraumatic Sacral Fracture in Late Pregnancy: A Case Report. Global Spine J 2015; 5: 248-251
    Article in Thieme ConnectPubMedGoogle Scholar
  • 84 Rommens PM, Wagner D, Hofmann A. Fragility Fractures of the Pelvis. JBJS Rev 2017; 5: 101-112
    PubMedGoogle Scholar
  • 85 Hoch A, Ozkurtul O, Pieroh P. et al. Outcome and 2-Year Survival Rate in Elderly Patients With Lateral Compression Fractures of the Pelvis. Geriatr Orthop Surg Rehabil 2017; 8: 3-9
    CrossrefPubMedGoogle Scholar
  • 86 Rommens PM, Wagner D, Hofmann A. Minimal Invasive Surgical Treatment of Fragility Fractures of the Pelvis. Chirurgia (Bucur) 2017; 112: 524-537
    PubMedGoogle Scholar
  • 87 Schreiber JJ, Anderson PA, Rosas HG. et al. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am 2011; 93: 1057-1063
    CrossrefPubMedGoogle Scholar