Insufficiency fracture

Last revised by Liz Silverstone on 18 Jul 2023

Insufficiency fractures are a type of stress fracture, which are the result of normal stresses on abnormal bone. Looser zones are also a type of insufficiency fracture. They should not be confused with fatigue fractures which are due to abnormal stresses on normal bone, or with pathological fractures, the result of diseased, weakened bone due to focal pathology such as tumors (both malignant and benign).

In general, they are seen in the elderly, more frequently in women 2.

They are most often seen in the setting of osteoporosis, although any process which weakens bone is a risk factor. Long-term bisphosphonate use has also been associated with insufficiency fractures 5.

Osteoporosis is the most common cause of insufficiency fractures, although there are many causes 7-9:

Early diagnosis is best made with a bone scan or MRI, as plain films may initially appear normal.

  • initially normal

  • periosteal reaction progressing to callus formation in diaphyseal fractures

  • linear sclerosis and cortical thickening more frequent in metaphyseal and epiphyseal fractures 2

MRI is as sensitive as bone scanning, with the added benefit of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumors or infection.

  • T1: low marrow signal

  • T2: high marrow signal with extension into adjacent soft tissues

  • T1 C+ (Gd): enhancement can be intense

On bone scan, there is increased activity at the site of the fracture.

Treatment depends on the location and whether the fracture is complete or incomplete. Options, therefore, include:

Treatment of the underlying cause of bone weakness is also essential.

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Cases and figures

  • Figure 1: pelvic insufficiency fractures
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  • Case 1
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  • Case 2: calcaneal insufficiency fracture
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  • Case 3
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  • Case 4: osteoporotic lumbar fractures
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  • Case 5
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  • Case 6: tibial plateau
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  • Case 7: bilateral on SPECT
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  • Case 8
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  • Case 9: sacral insufficiency fracture
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  • Case 10: Insufficiency fractures due to vitamin D deficiency
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