Thomas Mendel1,2, Bernhard Wilhelm Ullrich3,4, Gunther Olaf Hofmann3,4, Philipp Schenk5, Felix Goehre6, Stefan Schwan7, Friederike Klauke3,4. 1. Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany. dr.th.mendel@gmail.com. 2. Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany. dr.th.mendel@gmail.com. 3. Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany. 4. Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany. 5. Research Executive Department, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany. 6. Department of Neurosurgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany. 7. Department of Biological and Macromolecular Materials, Fraunhofer Institute for Microstructure of Materials and Systems IMWS, Halle (Saale), Germany.
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.
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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