Sacral Insufficiency

Fractures

Pradeep Chockalingam
Snr 2 Physio

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Definition
 First described by Dr. Lourie in 1982

 Sacral insufficiency fracture is a type of

stress fracture characterized by severe
incapacitating hip, groin, pelvic, buttock and
low back pain. It occur when normal or
physiological stresses are placed on
weakened bone that has a low elastic
resistance. (Paker N & Tekdos D 2006)

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 Anatomy and Classification
Anatomy Denis Classification

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 Causes

 Osteoporosis  Paget's disease

 Radiation to the  Hip joint replacement
pelvis  Lumbosacral fusion
 Steroid use  Anorexia nervosa
 Rheumatoid arthritis  Liver diseases &
 Hyperparathyroidism transplantation
 Pregnancy  Breastfeeding

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 Signs & Symptoms
Severe pain around Tenderness around

 Buttock  Buttock
 Low back  Low back
 Sacroiliac  Groin
 Hip  Sacroiliac joint
 Groin  Restricted hip
 Pelvis movements

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 Features
 Spontaneous or low velocity trauma
 Common in females with osteoporosis
 Associated with 60% of pubic ramus fractures
 Difficult to identify by normal X-ray
 Neurological deficit very rare
 Most of the fractures occur in zone-1
 Mostly undiagnosed or misdiagnosed
 Less than 50% return to baseline mobility
 Length of stay unilateral: 2-4 weeks,
bilateral: 8-36 weeks
Blake SP & Connors AM 2004, Graham G et al. 1994, Paker N & Tekdos D 2006 & Schindler OS et al 2007

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 Diagnostic imaging
a) No sign of # in normal
X-ray (early)
b) Sclerotic changes in
a b
normal X-ray after
4 weeks
c) Bone scan shows
abnormal sign
c d
d) CT shows # R ala
e) Bone scan in 8 months
f) CT shows # R iliac in 8
months

e f

Blake SP & Connors AM 2004

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 Facts about Pubic Ramus #
 25% suffered from dementia
 Mean length of stay 9 to 25 days
 All patients in this group needs some mobility aid
at discharge
 84% requires extra support at discharge
 Less than one third return to their baseline
mobility within 90 days
 One year mortality rate is 27%
 High superior pubic ramus # have poor
prognosis compared to the Low superior pubic
ramus #

Hill RMF et al 2001, Morris RO et al 2000, Steinitz D et al 2004.

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Management

 Adequate rest

 Pain control

 Encourage walking with appropriate aid

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Any Changes to Current Practice ?

 Feel for tenderness around sacroiliac joint

 If pain level high or persist for longer than the

normal time scale, consider to rule-out sacral
insufficiency fracture

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Reference

 Blake SP & Connors AM. Sacral insufficiency fracture:

Pictoral review. B.J.Radiology 2004;77: 891-96
 Graham G et al. Sacral insufficiency fractures in the
elderly. J.Bone Joint Surg 1994; 76-B: 882-06
 Hill RMF et al. Fracture of the pubic rami. J. B&J Sur
2001; 83-B: 1141-44
 Morris RO et al. Closed prlvic fractures: characteristics
and outcomes in older patients admitted to medical
and geriatric wards. Postgrad Med J 2000; 76: 646-
650

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Reference

 Paker N & Tekdos D. Sacral insufficiency fracture: A

case report. Turk.P.M.Rehab 2006;52: 129-31
 Schindler OS et al. Sacral insufficency fractures.
J.Ortho.Sur 2007; 15(3):339-46
 Steinitz D et al. All superior pubic ramus fractures are
not created equal. Can J Surg 2004; 47-6: 422-25
 www.eorthopod.com/public/patient_education/9207/sa
cral_insufficiency_fractures.html (Date 07/03/2009)

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