Insufficiency and stress fractures of the long bones occurring in patients with rheumatoid arthritis

Insufficiency fractures of the knee, ankle, and foot in rheumatoid arthritis: A case series and case-control study

OBJECTIVE

To evaluate cases of insufficiency fractures verified by magnetic resonance imaging (MRI) of the knee, ankle, and foot in patients with rheumatoid arthritis (RA) cared for in our clinic over an 8-year period, to identify possible risk factors, and to test these in a case-control study.

METHODS

All patients in the rheumatology clinic with RA were registered prospectively in the database, DANBIO. All MRIs ordered from the clinic were registered and coded according to the anatomical region. We were thus able to retrieve all patients with RA and performed an MRI of the knee or ankle/foot. The patients with fractures constituted the case series, and the patients without fractures constituted the control group.

RESULTS

The RA clinic population comprised 1,624 patients who underwent a total of 70 MRIs.

CASE SERIES

39 insufficiency fractures were identified in 32 patients; 93% were women, and the median age was 68 years (range 33-89 years). Half of the patients had a T score >-2.5. The case control group without fractures comprised 38 patients; 74% were women, and the median age was 62 years (range 32-84 years). In the case series, 20 patients experienced later additional episodes of insufficiency fractures in the knee, ankle, or foot.

CONCLUSION

Insufficiency fractures of the knee, ankle, and foot are a significant cause of pain and long-lasting disability in RA. Recurrent fractures are common. Diagnosis is often delayed and confused with arthritic activity. Conventional radiography and DEXA scan are often normal. Older age, female gender, radiological erosions in hand/wrist, and treatment with methotrexate were all significantly associated with fractures.

An unusual cause of apareunia

A 49-year-old woman with history of rheumatoid arthritis presented with worsening pelvic pain. A pelvic computed tomography (CT) scan demonstrated a fracture and a lytic expansile lesion within the right superior and inferior pubic rami. The diagnosis of "insufficiency fractures secondary to rheumatoid arthritis" was established. Six months later, she started describing pain and fullness sensation in the vagina which eventually led to a complete apareunia. An x ray confirmed healing of the previous fractures, fracture of both left superior and inferior pubic rami, and an upwards shift of the right hemi-pelvis. Conservative management was chosen. Twelve months later, no improvement occurred and she was still apareunic. A "corrective osteotomy surgery" was performed and the displaced pubic rami and ischial tuberosities were remodelled bilaterally through a vertical incision over each labia majora. These bones were partially excised until an adequate vaginal opening was established. Her symptoms have impressively resolved with complete reverse of the apareunia.

Characteristics of fracture and related factors in patients with rheumatoid arthritis

To examine the clinical features of vertebral and non-vertebral fractures in patients with rheumatoid arthritis (RA), including insufficiency fractures, and to assess the risk factors for fracture, we prospectively studied 209 outpatients with rheumatoid arthritis for 1 year. The age, gender, Steinbrocker's functional class, glucocorticoid use, history of lower limb surgery, serum C-reactive protein (CRP), and use of bisphosphonates were evaluated. Examination for fractures was performed by radiography, computed tomography (CT), magnetic resonance imaging (MRI), and bone scanning. Thirty-three fractures occurred in 24 patients over the 1-year study period, and the incidence was 15.8 fractures per 100 patient-years. Fractures occurred at various sites. The majority (70%) was insufficiency fracture, and more than 50% caused ambulatory dysfunction. Radiographic findings were absent in 39% of the fractures at the onset of pain. The functional class and glucocorticoid dose were significantly associated with fracture development. This prospective study showed that the incidence of fractures, especially insufficiency fractures, was very high in patients with rheumatoid arthritis and that most of their fractures caused gait disturbance. Early intervention to prevent secondary osteoporosis is recommended to maintain the quality of life in patients with rheumatoid arthritis, especially those with functional impairment or undergoing glucocorticoid therapy.

Pelvic insufficiency fractures in postmenopausal woman with advanced cervical cancer treated by radiotherapy

PURPOSE

To assess the predisposing factors and clinical characteristics of pelvic insufficiency fractures (PIF) in postmenopausal women with pelvic irradiation.

MATERIAL AND METHODS

A total 335 postmenopausal patients with cervical cancer of the intact uterus treated with radiation therapy between 1983 and 1998 were reviewed. Total external dose was delivered between 45 and 50.4 Gy with parallel opposed anteroposterior portals. Total brachytherapy dose at point A was delivered between 10 and 36 Gy. PIF were diagnosed by bone scintigraphy and confirmed by computed tomography. The cumulative incidence of symptomatic PIF was estimated by actuarial methods. Potential risk factors (age, weight, type II diabetes, delivery, menopause, total external dose, total brachytherapy dose) were assessed.

RESULTS

Fifty-seven (17.0%) of 335 patients were diagnosed as having PIF. Forty-seven patients were symptomatic and ten were asymptomatic. Parameters carrying a significant association with PIF were body weight 49 kg or below (P=0.044) in stepwise logistic regression analysis. The cumulative incidence of symptomatic PIF at 5 years was 17.9% calculated by the Kaplan-Meier method. A body weight of 49 kg or below and more than three deliveries were identified as having a significant effect on symptomatic PIF in univariate analysis (P=0.021, P=0.003, log-rank test) and Cox life table regression analysis (P=0.038, P=0.013). Five patients required narcotic agents and eight patients required hospital admission.

CONCLUSIONS

We should consider reducing the dose contribution to the sacrum and sacroilac joints, without underdosing the tumor, especially in postmenopausal women with many deliveries or low body weight.

Stress fractures of the ankle and forefoot in patients with inflammatory arthritides

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.

Insufficiency fractures of the distal tibiae

We describe two patients with uncommon types of insufficiency fractures that occurred at the distal tibiae. In case 1, a 71-year-old man with secondary osteoporosis due to hypogonadism fracture of his left distal tibia was overlooked because initial radiographs had seemed normal. However, bone scintigram obtained 2 months prior to the onset of fracture had already demonstrated abnormally high uptake at the site. In case 2, a 62-year-old woman with postmenopausal osteoporosis sustained an insufficiency fracture of the left distal tibia. Good clinical results were obtained with nonsurgical treatment. Based on the clinical course of case 1, we believe that bone scintigrams may be useful not only for the early diagnosis of insufficiency fracture but also for predicting such fractures.

Insufficiency fractures of the tibia and fibula

OBJECTIVE

Insufficiency fractures (IF) occur when normal or physiological muscular activity stresses a bone that is deficient in mineral or elastic resistance. IF of the tibia and fibula are probably less common than IF of the ribs, vertebrae, hip, pelvis, and distal ulna, and therefore they are frequently underrecognized and mistaken for other conditions. Our aim was to analyze the main features and outcome of IF of the tibia and fibula in patients attending our Rheumatology Service.

METHODS

IF was considered when occurring spontaneously or with minimal trauma. Between January 1984 and July 1997, 25 patients were diagnosed as having IF of the tibia and fibula. The main predisposing factors, clinical features, therapy, and outcome were retrospectively reviewed.

RESULTS

All the patients except four were women (mean age, 66+/-12 years). Three cases were diagnosed between 1984 and 1990 (0.42 cases/year) and 22 between 1991 and 1997 (three cases/year). Eighteen patients had an underlying condition: rheumatoid arthritis (RA, 13 cases), psoriatic arthritis (2), systemic lupus erythematosus (SLE) (1), kidney transplant (1), and Crohn's disease (1). Eleven patients had osteoporotic fractures in other locations. Risk factors for osteoporosis were corticosteroids (13 cases), prolonged immobilization (10), early menopause (2), and methotrexate therapy (10). All patients had pain on weight bearing and marked functional impairment, 16 had local inflammatory signs, and 10 had deformity. In only five patients the diagnosis of IF was considered at the first examination. The diagnostic delay was 76+/-117 days (median, 21). The initial radiograph was diagnostic in 20 patients, and in the remaining the diagnosis was made by computed tomography (CT) scan (three cases), magnetic resonance imaging (MRI) (1), and bone scan (1). IF were located as follows: tibia (10 cases), fibula (seven), tibia and fibula (eight). Nineteen patients were treated with conservative management, four received no specific treatment, and two required surgery. Sixteen patients were hospitalized for a mean period of 12+/-8 days. Most patients had complete recovery. The high frequency of IF seen in RA patients is probably due to the severe disease in patients treated by our Service and that such patients have a higher risk for osteoporosis and its complications.

CONCLUSIONS

IF of the tibia and fibula are probably more common than previously thought. They usually occur in patients with underlying rheumatic diseases, mainly RA, and are frequently mistaken for other joint and bone conditions. Despite a frequent delay in diagnosis, they have a good prognosis with conservative management. Nonetheless, a higher index of suspicion may avoid unnecessary investigations and treatments.

Longitudinal tibial stress fractures

The tibia is a fairly common site for stress fractures of both the fatigue and insufficiency types. The majority are transverse or, less frequently, oblique. The present report outlines four cases of vertical stress fractures, an orientation that is very uncommon and leads to bone scan findings which can be misleading.

Insufficiency and stress fractures of the long bones occurring in patients with rheumatoid arthritis and other inflammatory diseases, with a contribution on the possibilities of computed tomography

In patients with long standing rheumatoid arthritis and other rheumatoid disorders, stress fractures and insufficiency fractures are not uncommon. The cause may be osteoporosis due to rheumatoid arthritis, corticosteroid therapy, joint stiffness, and deformity of the joints caused by the inflammatory process. Also, unaccustomed exercise after reconstructive joint surgery may be a cause of fractures in these patients. Fractures can be documented on conventional X-ray-pictures and tomograms. Computed tomography can show the medullary extent of these fractures and gives, in several cases, additional information showing the combination of insufficiency fractures with fragmentations of parts of the involved bone. Reconstructive surgery with total joint replacement may be another cause of the development of these fractures. This unaccustomed increase in ambulation may lead to stress fractures in other joints of the same extremity or of contralateral extremity. Pain beginning in joint of the lower extremity in a patient with chronic rheumatoid arthritis should, besides arthritis, raise the possibility of a stress fracture. Also with cases of angular deformity of a joint and unaccustomed exercise after reconstructive surgery patients stress fractures may be seen and can be established by Plainfilm, Computed Tomography scintimetric bone scanning and MRI.

Stress fractures of the distal fibula presenting as monarticular flares in patients with rheumatoid arthritis

Monarticular flares occurring in patients with rheumatoid arthritis (RA) usually signify either a worsening of the underlying condition or a superimposed septic process. This report describes 2 patients with RA who had stress fractures of the fibular head, masquerading as monarticular flares of ankle arthritis.

Insufficiency stress fractures

Bones weakened by osteopenia have insufficient elastic resistance to withstand even the minimal mechanical stresses of normal daily activity. Repetitive subthreshold injury to these susceptible bones results in insufficiency-type stress fractures. The spine, pelvis, and lower extremities are commonly affected by these fractures. Insufficiency fractures create a diagnostic challenge for clinicians and radiologists alike. The radiographic evidence of the fracture is often so subtle that it escapes detection. Conversely, findings on other studies may be so striking that they suggest metastatic disease. Insufficiency fractures are often subjected to unnecessary biopsies, and they have been treated unwittingly with chemotherapy and radiation therapy. Radiologists are in a key position to prevent these errors. A thorough familiarity with the characteristic appearance and location of these fractures assures the correct diagnosis.

Difficult-to-Detect Osseous Injuries

In brief MRI can prove diagnostically brief useful for a number of osseous injuries that active patients may incur. The authors weigh the benefits of MRI, such as early injury detection and excellent contrast and spatial resolution, versus its shortcomings, such as high cost and sensitivity to motion. In addition, they describe in detail the MRI appearances of stress fractures, bone bruises, occult fractures, and osteochondral fractures.

Investigation of joint disease

The role of nuclear medicine in the diagnosis and management of the major arthropathies is critically reviewed, with particular reference to osteoarthritis, rheumatoid and similar forms of arthritis, ankylosing spondylitis, non-specific back pain, gout, the neuropathic joint, avascular necrosis, infection and the consequences of prosthetic joint insertion. Attention is drawn both to practical applications and deficiencies in current techniques and knowledge.

Insufficiency fractures of the distal tibia misdiagnosed as cellulitis in three patients with rheumatoid arthritis

We describe 3 patients with rheumatoid arthritis who presented with diffuse pain, swelling, and erythema of the distal aspect of the lower extremity, suggestive of either cellulitis or thrombophlebitis, but were found to have insufficiency fractures of the distal tibia. The value of technetium-99m diphosphonate bone scintigraphy in the early recognition of these fractures and a possible explanation for the associated inflammatory symptoms are discussed.

Stress fractures of the legs and swelling of the ankles in a patient with lupus: a diagnostic dilemma

A patient with systemic lupus erythematosus (lupus) is described, in whom stress fractures of both legs developed, accompanied by swelling of both ankles. The swelling of the right ankle associated with fracture mimicked lupus synovitis, but resolved with healing of the fracture. On the left side the swelling represented true lupus synovitis coexistent with the tibial stress fracture. This presentation posed a diagnostic dilemma. It is necessary to maintain vigilance in the diagnosis of these fractures in lupus.

Hip fracture in rheumatoid arthritis

All patients with rheumatoid arthritis, admitted for hip fracture to a regional hospital during a 5-year period, were studied in retrospect. Of 1092 hip fractures, 16 cervical and nine trochanteric fractures occurred in rheumatics. Four cervical fractures were stress fractures. The mean patient age was lower than in a normal hip fracture material and the female predominance more pronounced. Of 14 surviving patients with cervical fractures, three had an uncomplicated 2-year healing, while 11 developed redisplacement, non-union or segmental collapse, in eight cases necessitating hip arthroplasty. Of eight surviving patients with trochanteric fractures, serious complications developed in two: non-union in one and septicaemia in one, necessitating nail extraction 1 week after the primary operation. The complication rate was higher than in an unselected femoral neck fracture material.

Stress fractures of the femoral neck: a scintigraphic sign for early diagnosis

Two patients with hip pain are presented; both patients were on steroid therapy. The diagnosis of a stress fracture was initially missed because the patients were not exceedingly active and the plain roentgenograms were essentially normal. The bone scan demonstrated a discretely localized area of increased radionuclide uptake in the femoral neck, which alerted us to the correct diagnosis. This scintigraphic sign is helpful in arriving at an early diagnosis and preventing prolonged disability.

Subcapital fractures of the femur in rheumatoid arthritis

A review of 40 subcapital fractures of the femur in 37 patients with rheumatoid arthritis has shown that no displaced fracture treated by reduction and fixation united, even when it had been acceptably reduced and fixed. Primary prosthetic replacement of the femoral head gave significantly better results, at least in the short term. A postoperative deep infection rate for prosthetic replacement of one in five was reduced to zero by prophylactic antibiotics: current treatment with oral corticosteroids did not increase the risk of infection. The possibility of a stress fracture of the femoral neck should be considered if a patient with chronic rheumatoid arthritis presents with increasing hip pain after minimal trauma.

Cyclic loading in knee ligament injuries

The effect of cyclic loading on knee ligaments was studied both in vivo and in vitro. The compliance of the medial collateral ligaments of athletes participating in hockey, basketball, soccer, and downhill skiing was determined by using a specially built machine. Tests were conducted before and after participation in the various sports. Most subjects tested showed an increased compliance after their respective sporting activities. This observation was confirmed in the laboratory by imparting cyclic loading to 10 people under controlled conditions. The in vitro studies were conducted on the medial collateral ligaments of rats. These were tested to determine the effect of cyclic loading on the strength and stiffness of the ligaments. Results show a clear relationship between decreased stiffness or softening and a reduction in strength of the ligament. The amount of softening was related to the cyclic stress in the ligament.