Citation, DOI & article data
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:
- disrupted bone mineral homeostasis: hyperparathyroidism, diabetes mellitus, osteomalacia
- bone remodeling: Paget disease, osteopetrosis
- collagen formation: Marfan syndrome, fibrous dysplasia
- medications: glucocorticoids, chemotherapy
- radiation therapy
vertebral (crush or wedge) fractures: very common
- marrow edema is limited to the vertebral body; extension of abnormal signal into the pedicles suggests an underlying lesion
- sacrum: Honda sign
- neck of femur
- proximal third femur (see article: bisphosphonate-related proximal femur fractures) 5
- pubic rami
- sternum 3
- fibula 6
- tibia 6
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 and prognosis
Treatment of the underlying cause of bone weakness is also essential.
- 1. Kaplan P. Musculoskeletal MRI. W B Saunders Co. (2001) ISBN:0721690270. Read it at Google Books - Find it at Amazon
- 2. Burnet S, Mahadevan G, Lee A et-al. Sacral insufficiency fracture--a case of post-coital back pain. Rheumatology (Oxford). 2001;40 (9): 1065-6. doi:10.1093/rheumatology/40.9.1065 - Pubmed citation
- 3. Chen C, Chandnani V, Kang HS et-al. Insufficiency fracture of the sternum caused by osteopenia: plain film findings in seven patients. AJR Am J Roentgenol. 1990;154 (5): 1025-7. AJR Am J Roentgenol (abstract) - Pubmed citation
- 4. Burgener FA, Kormano M, Pudas T. Bone and Joint Disorders. Thieme Medical Pub. (2005) ISBN:1588904458. Read it at Google Books - Find it at Amazon
- 5. Porrino JA, Kohl CA, Taljanovic M et-al. Diagnosis of proximal femoral insufficiency fractures in patients receiving bisphosphonate therapy. AJR Am J Roentgenol. 2010;194 (4): 1061-4. doi:10.2214/AJR.09.3383 - Pubmed citation
- 6. Alonso-Bartolomé P, Martínez-Taboada VM, Blanco R, et al. Insufficiency fractures of the tibia and fibula. (1999) Seminars in arthritis and rheumatism. 28 (6): 413-20. Pubmed
- 7. Papanna MC, Tafazal S, Bell MJ, et al. Femoral neck fractures in osteogenesis imperfecta treated with bisphosphonates. (2017) Journal of children's orthopaedics. 11 (3): 191-194. doi:10.1302/1863-2548.11.160212 - Pubmed
- 8. Wolfgang Dähnert. Radiology Review Manual. (2011) ISBN: 9781609139438
- 9. Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (7): 2173-2192. doi:10.1148/rg.2018180073 - Pubmed