Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray,
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ORIGINAL ARTICLE
Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X‑ray, CT, and MRI datasets from 78 cases Thomas Mendel1,2 · Bernhard Wilhelm Ullrich1,2 · Gunther Olaf Hofmann1,2 · Philipp Schenk3 · Felix Goehre4 · Stefan Schwan5 · Friederike Klauke1,2 Received: 5 January 2020 / Accepted: 24 August 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
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 65 years with low back pain have a sacral fracture [5]. The standardized incidence rate
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of pelvic fractures derived from insurance data in a German population > 60 years was 22.4/10.000 person years and showed strong age and sex effects [6]. Numerous fracture patterns in the osteoporotic pelvis can be ascribed to the altered structure of osteoporotic bone. Such injuries have become increasingly important because of demographic changes in Western countries [7]. Affected individuals show increased mortality, with 1- and 3-year mortality rates of 17.5% and 25.5%, respectively, partially due to pain-related immobility [8]. Therefore, it is important to clarify the underlying causal mechanism. A better understanding of this injury is of fundamental importance to develop adequate conservative and surgical treatment options. In this study, we hypothesized that in contrast to the onestage, high-velocity bilateral sacral injuries that occur in good-quality bones, BFFSs follow sequential progression starting with a unilateral vertical sacral lesion. At this point, the overlying ligaments initially remain intact. With time, a contralateral lesion may follow and sometimes become completed by an interconnecting transverse sacral lesion. Subsequent bony avulsions of the L5 transverse process or a shelled iliac avulsion of
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