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Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases

European Journal of Trauma and Emergency Surgery volume 47, pages 11–19 (2021)Cite this article

Abstract

Purpose

The pathogenetic mechanism, progression, and instability in geriatric bilateral fragility fractures of the sacrum (BFFSs) remain poorly understood. This study investigated the hypothesis of sequential BFFS progression by analysing X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) datasets.

Methods

Imaging data from 78 cases were retrospectively analysed. Fractures were categorized using the CT-based Fragility Fractures of the Pelvis classification. MRI datasets were analysed to detect relevant fracture location information. The longitudinal sacral fracture was graded as stage 1 (bone oedema) on MRI, stage 2 (recent fracture), stage 3 (healing fracture), or stage 4 (non-union) on CT. Ligamentous avulsions at the L5 transverse process and iliac crest were also captured.

Results

Contralateral sacral lesions were only recognized by initial bone oedema on MRI in 17/78 (22%) cases. There were 22 cases without and 56 cases with an interconnecting transverse fracture component (TFC) [between S1/S2 (n = 39) or between S2/S3 (n = 17)]. With 30/78 patients showing bilateral fracture lines at different stages (1/2: n = 13, 2/3: n = 13, 1/3: n = 4) and 38 at similar stages, Wilcoxon tests showed a significant stage difference (p < 0.001). Forty cases had a coexistent L5 transverse process avulsion, consistent with a failing iliolumbar ligament. Analysis of variance revealed significant increases in ligamentous avulsions with higher fracture stages (p < 0.001).

Conclusion

Our results support the hypothesis of stagewise BFFS progression starting with unilateral sacral disruption followed by a contralateral lesion. Loss of sacral alar support leads to a TFC. Subsequent bone disruption causes iliolumbar ligament avulsion. MRI is recommended to detect bone oedema.

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Acknowledgements

The authors would like to thank Stephan Arlt for professional image preparation.

Funding

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Affiliations

  1. Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany

    Thomas Mendel, Bernhard Wilhelm Ullrich, Gunther Olaf Hofmann & Friederike Klauke

  2. Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany

    Thomas Mendel, Bernhard Wilhelm Ullrich, Gunther Olaf Hofmann & Friederike Klauke

  3. Research Executive Department, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany

    Philipp Schenk

  4. Department of Neurosurgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany

    Felix Goehre

  5. Department of Biological and Macromolecular Materials, Fraunhofer Institute for Microstructure of Materials and Systems IMWS, Halle (Saale), Germany

    Stefan Schwan

Authors
  1. Thomas Mendel
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  2. Bernhard Wilhelm Ullrich
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  3. Gunther Olaf Hofmann
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Correspondence to Thomas Mendel.

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Ethical approval

This article does not contain any studies with animals performed by any of the authors. The study was approved by the independent Medical Ethics Committee of the Medical Council of Saxony-Anhalt, Germany, and confirmed under approval no. 78/17.

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Mendel, T., Ullrich, B.W., Hofmann, G.O. et al. Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases. Eur J Trauma Emerg Surg 47, 11–19 (2021). https://doi.org/10.1007/s00068-020-01480-4

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  • DOI: https://doi.org/10.1007/s00068-020-01480-4

Keywords

  • Sacrum
  • Fragility fracture
  • Insufficiency fracture
  • Pelvis
  • Osteoporosis
  • Sequential progress