Skip to main content

Sacral insufficiency fractures: current concepts of management

Osteoporosis International volume 17, pages 1716–1725 (2006)Cite this article

Abstract

Background

Sacral insufficiency fractures (SIFs) are often overlooked in elderly patients presenting with low back and pelvic pain following no or minimal trauma.

Objective

The aim of this review is to raise awareness and outline the clinical presentation, methods of diagnosis and treatment of SIFs.

Discussion

Insufficiency fractures represent a special category of stress fractures that occur in bones with reduced mineral content and elastic resistance. SIFs, a well-defined subgroup of the latter group, are not uncommon, but lack of clinical suspicion results in many being undiagnosed. SIFs are set to become an important clinical entity of both social and economic significance as the Western population ages. Subtle clinical presentations and signs coupled with radiographic findings that can mimic other unrelated or overlapping conditions, such as sacroiliac joint infection, spinal stenosis and metastatic bone disease, often make SIF diagnosis a challenge. The aim of this review is to increase awareness among clinicians, highlighting SIFs as an important differential diagnosis to be considered when patients present with low back and pelvic pain and subsequently allow prompt management. The paper provides an overview of epidemiology, anatomical considerations, relevant pathophysiology and risk factors, presenting symptoms and signs, investigations and imaging techniques, differential diagnoses and current treatment methods available for the management of SIFs.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1

References

  1. Kannus P, Palvanen M, Niemi S et al (2000) Epidemiology of osteoporotic pelvic fractures in elderly people in Finland: sharp increase in 1970–1997 and alarming projections for the new millennium. Osteoporos Int 11:443–448

    Article  PubMed  CAS  Google Scholar 

  2. Kannus P, Palvanen M, Parkkari J et al (2005) Osteoporotic pelvic fractures in elderly women. Osteoporos Int 16:1304–1305

    Article  PubMed  Google Scholar 

  3. Lourie H (1982) Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA 248:715–717

    Article  PubMed  CAS  Google Scholar 

  4. Ries T (1983) Detection of osteoporotic sacral fractures with radionuclides. Radiology 146:783–785

    PubMed  CAS  Google Scholar 

  5. Gacetta DJ, Yandow DR (1984) Computed tomography of spontaneous osteoporotic sacral fractures. J Comput Assist Tomogr 8:1190–1191

    Article  PubMed  CAS  Google Scholar 

  6. De Smet AA, Neff JR (1985) Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 145:601–606

    PubMed  Google Scholar 

  7. Schneider R, Yacovone J, Ghelman B (1985) Unsuspected sacral fractures: detection by radionuclide bone scanning. AJR Am J Roentgenol 144:337–341

    PubMed  CAS  Google Scholar 

  8. Guilbeau JC, Arrive L, Maurice F et al (1986) Spontaneous fracture of the sacrum due to “insufficiency”. An overlooked cause of low lumbago in elderly women. J Radiol 67:741–744

    PubMed  CAS  Google Scholar 

  9. Balseiro J, Brower AC, Ziessman HA (1987) Scintigraphic diagnosis of sacral fractures. AJR Am J Roentgenol 148:111–113

    PubMed  CAS  Google Scholar 

  10. Carter SR (1987) Stress fracture of the sacrum: brief report. J Bone Joint Surg Br 69:843–844

    PubMed  CAS  Google Scholar 

  11. Gaucher A, Regent D, Paul JP et al (1987) Fractures caused by bony insufficiency of the sacrum. Clinical, radiographic, scintigraphic and x-ray computed tomographic symptomatology. J Radiol 68:433–440

    PubMed  CAS  Google Scholar 

  12. Pere P, Gaucher A, Pourel J (1987) Fractures caused by osseous insufficiency of the sacrum. Incidence, complications and pathogenesis. Rev Rhum Mal Osteoartic 54:311–313

    PubMed  CAS  Google Scholar 

  13. Davies AM, Evans NS, Struthers GR (1988) Parasymphyseal and associated insufficiency fractures of the pelvis and sacrum. Br J Radiol 61:103–108

    Article  PubMed  CAS  Google Scholar 

  14. Hauge MD, Cooper KL, Litin SC (1988) Insufficiency fractures of the pelvis that simulate metastatic disease. Mayo Clin Proc 63:807–812

    PubMed  CAS  Google Scholar 

  15. Rawlings CE 3rd, Wilkins RH, Martinez S et al (1988) Osteoporotic sacral fractures: a clinical study. Neurosurgery 22:72–76

    PubMed  Google Scholar 

  16. Brahme SK, Cervilla V, Vint V et al (1990) Magnetic resonance appearance of sacral insufficiency fractures. Skeletal Radiol 19:489–493

    Article  PubMed  CAS  Google Scholar 

  17. Guttner B, Freyschmidt J, Hohlweg-Majert P (1990) Stress fracture of the sacral bone. Rofo 152:236–237

    PubMed  CAS  Google Scholar 

  18. Jones JW (1991) Insufficiency fracture of the sacrum with displacement and neurologic damage: a case report and review of the literature. J Am Geriatr Soc 39:280–283

    PubMed  CAS  Google Scholar 

  19. Kayes K, Coscia M, Braunstein E (1991) Radiologic case study. Sacral insufficiency fracture. Orthopedics 14:817–818

    PubMed  CAS  Google Scholar 

  20. Khorasani R, Nagel JS, Tumeh SS (1991) Radiologic vignette. Sacral insufficiency fracture. Arthritis Rheum 34:1387–1390

    Article  PubMed  CAS  Google Scholar 

  21. Nokes SR, Boyd CM, Kovaleski TM (1991) Radiological case of the month. Insufficiency fractures of the sacrum and left pubis. J Ark Med Soc 87:345–346

    PubMed  CAS  Google Scholar 

  22. Stroebel RJ, Ginsburg WW, McLeod RA (1991) Sacral insufficiency fractures: an often-unsuspected cause of low back pain. J Rheumatol 18:117–119

    PubMed  CAS  Google Scholar 

  23. Abe H, Nakamura M, Takahashi S et al (1992) Radiation-induced insufficiency fractures of the pelvis: evaluation with 99mTc-methylene diphosphonate scintigraphy. AJR Am J Roentgenol 158:599–602

    PubMed  CAS  Google Scholar 

  24. Newhouse KE, el-Khoury GY, Buckwalter JA (1992) Occult sacral fractures in osteopenic patients. J Bone Joint Surg Am 74:1472–1477

    PubMed  CAS  Google Scholar 

  25. Lien HH, Blomlie V, Talle K et al (1992) Radiation-induced fracture of the sacrum: findings on MR. AJR Am J Roentgenol 159:227

    PubMed  CAS  Google Scholar 

  26. Weber M, Hasler P, Gerber H (1993) Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine 18:2507–2512

    Article  PubMed  CAS  Google Scholar 

  27. Peris P, Guanabens N, Pons F et al (1993) Clinical evolution of sacral stress fractures: influence of additional pelvic fractures. Ann Rheum Dis 52:545–547

    PubMed  CAS  Google Scholar 

  28. Blomlie V, Lien HH, Iversen T et al (1993) Radiation-induced insufficiency fractures of the sacrum: evaluation with MR imaging. Radiology 188:241–244

    PubMed  CAS  Google Scholar 

  29. Peh WC, Gough AK, Sheeran T et al (1993) Pelvic insufficiency fractures in rheumatoid arthritis. Br J Rheumatol 32:319–324

    PubMed  CAS  Google Scholar 

  30. Leroux JL, Denat B, Thomas E et al (1993) Sacral insufficiency fractures presenting as acute low-back pain. Biomechanical aspects. Spine 18:2502–2506

    Article  PubMed  CAS  Google Scholar 

  31. West SG, Troutner JL, Baker MR et al (1994) Sacral insufficiency fractures in rheumatoid arthritis. Spine 15:2117–2121

    Google Scholar 

  32. Gotis-Graham I, McGuigan L, Diamond T et al (1994) Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 76:882–886

    PubMed  CAS  Google Scholar 

  33. Stabler A, Beck R, Bartl R et al (1995) Vacuum phenomena in insufficiency fractures of the sacrum. Skeletal Radiol 24:31–35

    Article  PubMed  CAS  Google Scholar 

  34. Peh WC, Khong PL, Ho WY (1996) Insufficiency fractures of the sacrum and os pubis. Br J Hosp Med 54:15–19

    Google Scholar 

  35. Grasland A, Pouchot J, Mathieu A et al (1996) Sacral insufficiency fractures: an easily overlooked cause of back pain in elderly women. Arch Intern Med 156:668–674

    Article  PubMed  CAS  Google Scholar 

  36. Peh WC, Khong PL, Ho WY (1997) Case report: sacral insufficiency fractures masking malignancy. Clin Radiol 52:71–72

    Article  PubMed  CAS  Google Scholar 

  37. Breuil V, Brocq O, Euller-Ziegler L et al (1997) Insufficiency fracture of the sacrum revealing a pregnancy associated osteoporosis. First case report. Ann Rheum Dis 56:278–279

    PubMed  CAS  Google Scholar 

  38. Grimaud A, Oddo F, Thibaud I et al (1997) Fracture of the sacrum caused by bone insufficiency in a pregnant woman. J Radiol 78:511–512

    PubMed  CAS  Google Scholar 

  39. Schulman LL, Addesso V, Staron RB et al (1997) Insufficiency fractures of the sacrum: a cause of low back pain after lung transplantation. J Heart Lung Transplant 16:1081–1085

    PubMed  CAS  Google Scholar 

  40. Parikh VA, Edlund JW (1998) Sacral insufficiency fractures-rare complication of pelvic radiation for rectal carcinoma: report of a case. Dis Colon Rectum 41:254–257

    Article  PubMed  CAS  Google Scholar 

  41. Verhaegen MJ, Sauter AJ (1999) Insufficiency fractures, an often unrecognized diagnosis. Arch Orthop Trauma Surg 119:115–116

    Article  PubMed  CAS  Google Scholar 

  42. Weber M, Hasler P, Gerber H (1999) Sacral insufficiency fractures as an unsuspected cause of low back pain. Rheumatology 38:90–91

    Article  PubMed  CAS  Google Scholar 

  43. Schmid L, Pfirrmann C, Hess T et al (1999) Bilateral fracture of the sacrum associated with pregnancy: a case report. Osteoporos Int 10:91–93

    Article  PubMed  CAS  Google Scholar 

  44. Peh WC (2000) Intrafracture fluid: a new diagnostic sign of insufficiency fractures of the sacrum and ilium. Br J Radiol 73:895–898

    PubMed  CAS  Google Scholar 

  45. Aretxabala I, Fraiz E, Perez-Ruiz F et al (2000) Sacral insufficiency fractures. High association with pubic rami fractures. Clin Rheumatol 19:399–401

    Article  PubMed  CAS  Google Scholar 

  46. Peh WC (2001) Clinics in diagnostic imaging (60). Insufficiency fractures of the pelvis. Singapore Med J 42:183–186

    PubMed  CAS  Google Scholar 

  47. Wild A, Jaeger M, Haak H et al (2002) Sacral insufficiency fracture, an unsuspected cause of low-back pain in elderly women. Arch Orthop Trauma Surg 122:58–60

    PubMed  CAS  Google Scholar 

  48. Garant M (2002) Sacroplasty: a new treatment for sacral insufficiency fracture. J Vasc Interv Radiol 13:1265–1267

    PubMed  Google Scholar 

  49. Pommersheim W, Huang-Hellinger F, Baker M et al (2003) Sacroplasty: a treatment for sacral insufficiency fractures. AJNR Am J Neuroradiol 24:1003–1007

    PubMed  Google Scholar 

  50. Hoshino Y, Doita M, Yoshikawa M et al (2004) Unstable pelvic insufficiency fracture in a patient with rheumatoid arthritis. Rheumatol Int 24:46–49

    Article  PubMed  Google Scholar 

  51. Khanna AJ, Kebaish KM, Ozdemir HM et al (2004) Sacral insufficiency fracture surgically treated by fibular allograft. J Spinal Disord Tech 17:167–173

    Article  PubMed  Google Scholar 

  52. Fujii M, Abe K, Hayashi K et al (2005) Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 30:165–169

    Article  PubMed  Google Scholar 

  53. Butler CL, Given CA 2nd, Michel SJ et al (2005) Percutaneous sacroplasty for the treatment of sacral insufficiency fractures. AJR Am J Roentgenol 184:1956–1959

    PubMed  Google Scholar 

  54. Brook AL, Mirsky DM, Bello JA (2005) Computerized tomography guided sacroplasty: a practical treatment for sacral insufficiency fracture: case report. Spine 30:E450–E454

    Article  PubMed  Google Scholar 

  55. Dasgupta B, Shah N, Brown H et al (1998) Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 37:789–793

    Article  PubMed  CAS  Google Scholar 

  56. Denis F, Davis S, Comfort T (1988) Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 227:67–81

    PubMed  CAS  Google Scholar 

  57. Lin J, Lane JM (2003) Sacral stress fractures. J Womens Health 12:879–888

    Article  Google Scholar 

  58. White JH, Hague C, Nicolau S et al (2003) Imaging sacral fractures. Clin Radiol 58:914–921

    Article  PubMed  CAS  Google Scholar 

  59. Finiels H, Finiels PJ, Jacquot JM et al (1997) Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases. Presse Med 26:1568–1573

    PubMed  CAS  Google Scholar 

  60. Negishi H, Kobayashi M, Nishida R et al (2002) Primary hyperparathyroidism and simultaneous bilateral fracture of the femoral neck during pregnancy. J Trauma 52:367–369

    Article  PubMed  Google Scholar 

  61. Henry AP, Lachmann E, Tunkel RS et al (1996) Pelvic insufficiency fractures after irradiation: diagnosis, management, and rehabilitation. Arch Phys Med Rehabil 77:414–416

    Article  PubMed  CAS  Google Scholar 

  62. Eastell R, Dickson ER, Hodgson SF et al (1991) Rates of vertebral bone loss before and after liver transplantation in women with primary biliary cirrhosis. Hepatology 14:296–300

    Article  PubMed  CAS  Google Scholar 

  63. Peris P, Navasa M, Guanabens N et al (1993) Sacral stress fracture after liver transplantation. Br J Rheumal 32:702–704

    CAS  Google Scholar 

  64. Lips P (2001) Vitamin D deficiency and secondary hyperthyroidism in the elderly: concequences for bone loss and fractures and therapeutic implications. Endocr Rev 22:477–501

    Article  PubMed  CAS  Google Scholar 

  65. Lips P, Obrant KJ (1991) The pathogenesis and treatment of hip fractures. Osteoporosis Int 1:218–231

    Article  CAS  Google Scholar 

  66. Thienpont E, Simon JP, Fabry G (1999) Sacral stress fracture during pregnancy-a case report. Acta Orthop Scand 70:525–526

    PubMed  CAS  Google Scholar 

  67. Schmid L, Pfirrmann C, Hess T et al (1999) Bilateral fracture of the sacrum associated with pregnancy: a case report. Osteoporos Int 10:91–93

    Article  PubMed  CAS  Google Scholar 

  68. Rousiere M, Kahan A, Job-Deslandre C (2001) Postpartal sacral fracture without osteoporosis. Joint Bone Spine 68:71–73

    Article  PubMed  CAS  Google Scholar 

  69. Kohlmeier L, Marcus R (1995) Calcium disorders of pregnancy. Review. Endocrinol Metab Clin North Am 24:15–39

    PubMed  CAS  Google Scholar 

  70. Black AJ, Topping J, Durham B (2000) A detailed assessment of alterations in bone turnover, calcium homeostasis, and bone density in normal pregnancy. J Bone Miner Res 15:557–563

    Article  PubMed  CAS  Google Scholar 

  71. Kent GN, Price RI, Gutteridge DH et al (1990) Human lactation: forearm trabecular bone loss, increased bone turnover, and renal conservation of calcium and inorganic phosphate with recovery of bone mass following weaning. J Bone Miner Res 5:361–369

    Article  PubMed  CAS  Google Scholar 

  72. McFarland EG, Giangarra C (1996) Sacral stress fractures in athletes. Clin Orthop Relat Res 329:240–243

    Article  PubMed  Google Scholar 

  73. Thienpont E, Simon JP, Fabry G (1999) Sacral stress fracture during pregnancy-a case report. Acta Orthop Scand 70:525–526

    Article  PubMed  CAS  Google Scholar 

  74. Di Gregorio S, Danilowicz K, Rubin Z et al (2000) Osteoporosis with vertebral fractures associated with pregnancy and lactation. Nutrition 16:1052–1055

    Article  PubMed  Google Scholar 

  75. Magee DJ (eds) (1997) Orthopedic physical assessment, 3rd ed. W.B. Saunders, Philadelphia

  76. Jacquot JM, Finiels H, Fardjad S et al (1999) Neurological complications in insufficiency fractures of the sacrum. Three case-reports. Rev Rhum Engl Ed 66:109–114

    PubMed  CAS  Google Scholar 

  77. Mathers DM, Major GA, Allen L et al (1993) Insufficiency fractures of the sacrum. Ann Rheum Dis 52:621–623

    PubMed  CAS  Google Scholar 

  78. Peh WC, Ooi GC (1997) Vacuum phenomena in the sacroiliac joints and in association with sacral insufficiency fractures: incidence and significance. Spine 22:2005–2008

    Article  PubMed  CAS  Google Scholar 

  79. Peh WC, Khong PL, Yin Y et al (1996) Imaging of pelvic insufficiency fractures. Radiographics 16:335–348

    PubMed  CAS  Google Scholar 

  80. Grangier C, Garcia J, Howarth NR et al (1997) Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skeletal Radiol 26:517–524

    Article  PubMed  CAS  Google Scholar 

  81. Blake SP, Connors AM (2004) Sacral insufficiency fracture. Br J Radiol 77:891–896

    Article  PubMed  CAS  Google Scholar 

  82. Lin J, Lachmann E, Nagler W (2001) Sacral insufficiency fractures: a report of two cases and a review of the literature. J Womens Health Gend Based Med 10:699–705

    Article  PubMed  CAS  Google Scholar 

  83. Black DM, Cummings SR, Karpf DB et al (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention trial Research Group. Lancet 248:1535–1541

    Article  Google Scholar 

  84. McClung MR, Geusens P, Miller PD et al (2001) Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 344:333–340

    Article  PubMed  CAS  Google Scholar 

  85. Odvina CV, Zerwekh JE, Rao DS et al (2005) Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab 90:1294–1301

    Article  PubMed  CAS  Google Scholar 

  86. Mashiba T, Turner CH, Hirano T et al (2001) Effects of suppressed bone turnover by bisphosphonates on microdamage accumulation and biomechanical properties in clinically relevant skeletal sites in beagles. Bone 28:524–531

    Article  PubMed  CAS  Google Scholar 

  87. Ott SM (2005) Editorial: Long term safety of bisphosphonates. J Clin Endocrinol Metab 90:1897–1899

    Article  PubMed  CAS  Google Scholar 

  88. Vogelvang TE, van der Mooren MJ, Mijatovic V (2004) Hormone replacement therapy, selective estrogen receptor modulators, and tissue-specific compounds: cardiovascular effects and clinical implications. Treat Endocrinol 3:105–115

    Article  PubMed  CAS  Google Scholar 

  89. Body JJ, Gaich GA, Scheele WH et al (2002) A randomized double-blind trial to compare the efficacy of teriparatide [recombinant human parathyroid hormone (1–34)] with alendronate in postmenopausal women with osteoporosis. J Clin Endocrinol Metab 87:4528–4535

    Article  PubMed  CAS  Google Scholar 

  90. Neer RM, Arnaud CD, Zanchetta JR et al (2001) Effect of parathyroid hormone (1–34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344:1434–1441

    Article  PubMed  CAS  Google Scholar 

  91. Dempster DW, Cosman F, Kurland ES et al (2001) Effects of daily treatment with parathyroid hormone on bone microarchitecture and turnover in patients with osteoporosis: a paired biopsy study. J Bone Miner Res 16:1846–1853

    Article  PubMed  CAS  Google Scholar 

  92. Jilka RL, Weinstein RS, Bellido T et al (1999) Increased bone formation by prevention of osteoblast apoptosis with parathyroid hormone. J Clin Invest 104:439–446

    Article  PubMed  CAS  Google Scholar 

  93. Simon AM, Manigrasso MB, O’Connor JP (2002) Cyclo-oxygenase 2 function is essential for bone fracture healing. J Bone Miner Re 17:963–976

    Article  CAS  Google Scholar 

  94. Altman RD, Latta LL, Keer R et al Effect of non-steroidal anti-inflammatory drugs on fracture healing: a laboratory study in rats. J Orthop Trauma 9:392–400

  95. Giannoudis PV, MacDonald DA, Matthews SJ et al (2000) Non-union of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br 82:655–658

    Article  PubMed  CAS  Google Scholar 

  96. Chao EY, Inoue N, Koo TK et al (2004) Biomechanical considerations of fracture treatment and bone quality maintenance in elderly patients and patients with osteoporosis. Clin Orthop Relat Res 425:12–25

    Article  PubMed  Google Scholar 

  97. Fishmann AJ, Greeno RA, Brooks LR et al (1994) Prevention of deep veil thrombosis and pulmonary embolism in acetabular and pelvic fracture. Clin Orthop Rel Res 305:133–137

    Google Scholar 

  98. Buerger PM, Peoples JB, Lemman GW et al (1993) Risk of pulmonary emboli in patients with pelvic fractures. Am Surg 59:505–508

    PubMed  CAS  Google Scholar 

  99. Chobanian AV, Lillie RD, Tercyak A et al (1974) The metabolic effects and hemodynamic effects of prolonged bed rest in normal subjects. Circulation 49:551–559

    PubMed  CAS  Google Scholar 

  100. Babayev M, Lachmann E, Nagler W (2000) The controversy surrounding sacral insufficiency fractures: to ambulate or notto ambulate? Review. Am J Phys Med Rehabil 79:404–409

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Academic Department of Trauma and Orthopedics, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK

    E. Tsiridis, N. Upadhyay & P. V. Giannoudis

Authors
  1. E. Tsiridis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. N. Upadhyay
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. P. V. Giannoudis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. V. Giannoudis.

Additional information

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Tsiridis, E., Upadhyay, N. & Giannoudis, P.V. Sacral insufficiency fractures: current concepts of management. Osteoporos Int 17, 1716–1725 (2006). https://doi.org/10.1007/s00198-006-0175-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-006-0175-1

Keywords

  • Minimal trauma
  • Sacral insufficiency fractures
  • Stress fractures