Postpartum Sacral Stress Fracture
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Karataş M, Başaran C, Özgül E, Tarhan Ç, Ağildere AM: Postpartum sacral stress fracture: an unusual case of low-back and buttock pain. Am J Phys Med Rehabil 2008;87:418–422. Low-back and buttock pain is a common complaint during pregnancy and the postpartum period and is usually attributable to mechanical lesions of the pelvis. Sacral stress fractures are unusual but important causes that should be considered in differential diagnosis. To date, only eight postpartum sacral stress fractures have been reported in the literature. A 32-yr-old woman presented with low-back and right buttock pain that started 15 days after uneventful cesarean section delivery. Imaging studies revealed a right sacral stress fracture. Lumbar spine and femoral neck bone mineral density were normal and, except for pregnancy and lactation, no risk factors for osteoporosis were identified. There was no history of trauma, excessive weight gain, strenuous physical activity, or contribution of mechanical factors. The question remains whether this is an insufficiency fracture or a fatigue fracture. Clinicians should consider sacral fracture during pregnancy and the postpartum period as a diagnostic possibility in patients with low-back and/or buttock pain.Keywords:
Insufficiency fracture
Stress Fractures
Back Pain
Insufficiency fracture
Stress Fractures
Groin
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Pars interarticularis
Stress Fractures
Insufficiency fracture
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Iliac wing fractures are under-diagnosed fractures often associated with sacral insufficiency fractures in osteoporotic patients. They are rarely seen alone. Insufficiency fractures of the iliac bone can often be missed on computerized tomography (CT) and magnetic resonance imaging (MRI) yet identified on radioisotope bone scans. Symptomatic iliac fractures present with more lateralized pain in the hip and groin compared to patients with only sacral insufficiency fractures. Since the acetabulum is the key weight-bearing articulation between the sacrum and pelvis and the femoral head and leg, worsening of iliac stress fractures can have major effects on weight bearing and should be a consideration in patients with persistent pain in this area. The anatomy of the ilium and relationship to other pelvic insufficiency fractures is reviewed as well as treatment options. Typical cases are presented where the iliac fractures were found on bone scan either in addition to the more common sacral fracture or due to the persistence of symptoms of hip and thigh pain.
Insufficiency fracture
Groin
Stress Fractures
Hip bone
Iliac bone
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In Brief Study Design. Correlation of locations of sacral insufficiency fractures is made to regions of stress depicted by finite element analysis derived from biomechanical models of patient activities. Objective. Sacral insufficiency fractures occur at consistent locations. It was postulated that sacral anatomy and sites of stress within the sacrum with routine activities in the setting of osteoporosis are foundations for determining patterns for the majority of sacral insufficiency fractures. Summary of Background Data. The predominant vertical components of sacral insufficiency fractures most frequently occur bilaterally through the alar regions of the sacrum, which are the thickest and most robust appearing portions of the sacrum instead of subjacent to the central sacrum, which bears the downward force of the spine. Methods. First, the exact locations of 108 cases of sacral insufficiency fractures were catalogued and compared to sacral anatomy. Second, different routine activities were simulated by pelvic models from CT scans of the pelvis and finite element analysis. Analyses were done to correlate sites of stress with activities within the sacrum and pelvis compared to patterns of sacral insufficiency fractures from 108 cases. Results. The sites of stress depicted by the finite element analysis walking model strongly correlated with identical locations for most sacral and pelvic insufficiency fractures. Consistent patterns of sacral insufficiency fractures emerged from the 108 cases and a biomechanical classification system is introduced. Additionally, alteration of walking mechanics and asymmetric sacral stress may alter the pattern of sacral insufficiency fractures noted with hip pathology (P = 0.002). Conclusion. Locations of sacral insufficiency fractures are nearly congruous with stress depicted by walking biomechanical models. Knowledge of stress locations with activities, cortical bone transmission of stress, usual fracture patterns, intensity of sacral stress with different activities, and modifiers of walking mechanics may aid medical management, interventional, or surgical efforts. Sacral insufficiency fractures occur at consistent locations congruous with stress depicted by biomechanical models. Consistent patterns emerge allowing a biomechanical classification system. Knowledge of biomechanics, locations and intensity of sacral stress, cortical bone transmission of sacral stress, and biomechanical modifiers may aid medical, interventional, or surgical management.
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Seven instances of insufficiency fractures of the sacrum due to metabolic bone disease or secondary to pelvis radiation therapy were retrospectively reviewed. The contribution of the different investigation procedures was compared. Identification of stress fractures during clinical investigation or in the assessment of metabolic disease should enable early and adequate response and possibly prevent unnecessary biopsies.
Insufficiency fracture
Stress Fractures
Metabolic bone disease
Bone disease
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Three military recruits developed stress fractures in the sacral wing during rigorous elite basic training. Stress fractures in the sacrum have previously not been reported in a healthy population. Sacrum, like every bone of the pelvis and the lower limb that participates in weight bearing, may be susceptible to stress fracture following sustained excessive physical activity.
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Stress Fractures
Insufficiency fracture
Neuroradiology
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Low back pain is a common finding in an athletically active premenopausal female population. We describe an unusual cause of persistent low back/sacroiliac pain: a fatigue-type sacral stress fracture. Plain radiographs, bone scans, computed tomography, and magnetic resonance imaging studies were obtained in the female athletes to determine the nature of the pathologic abnormality. The most significant risk factor for fatigue-type sacral stress fractures was an increase in impact activity due to a more vigorous exercise program. Potential risk factors such as abnormal menstrual history, dietary deficiencies, and low bone mineral density were examined. The clinical course was protracted, with an average 6.6 months of prolonged low back pain before resolution of symptoms. Sacral fatigue-type stress fractures did not preclude the athletes from returning to their previous level of participation once healing had occurred.
Stress Fractures
Insufficiency fracture
Abnormality
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