Sacral insufficiency fractures: an unsuspected cause of low back pain

We describe 10 cases of sacral fractures diagnosed within the rheumatology department at Southend Hospital over the last 5 yr. All presented with sudden-onset low back pain. The majority were elderly, frail, with chronic inflammatory disease (six with rheumatoid arthritis, one with polymyalgia rheumatica, one with vasculitis) and had received steroids. Diagnosis was delayed by the inability of plain radiographs to show these fractures and was ultimately demonstrated by technetium scintigraphy/computed tomography scan. We feel that this diagnosis should be considered in elderly patients with rheumatoid arthritis or other risk factors for osteoporosis who present with low back pain and sacral tenderness. Further clues may be parasymphyseal tenderness (suggesting associated pubic ramus fracture), elevated alkaline phosphatase and plain radiograph showing pubic ramus fractures or parasymphyseal sclerosis. Patients with this complication generally have a poor prognosis and two of our patients have died. Seven required in-patient stay (mean 20 days; range 14-41). The mortality, morbidity and costs incurred in management may be comparable to those of femoral neck fractures.

Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes

OBJECTIVE

To demonstrate with radiographic imaging the association between pubic stress injury and sacroiliac abnormalities in athletes.

DESIGN AND PATIENTS

Eleven athletes (9 men and 2 women), comprising seven male long-distance runners, one male soccer player, one male and two female basketball players, were imaged with plain films for complaints of pubic symphysis pain, sciatica, groin pain, or a combination of these complaints. In addition to the plain films, four patients were imaged with CT, two patients had MR imaging, and a bone scan was performed in three patients. Anteroposterior plain films of the pelvis of 20 patients without back pain or pubic pain were evaluated for comparison as a control group (ages 18-72 years, average 49 years; 11 women and 9 men).

RESULTS

All athletes showed plain film evidence of either sclerosis, erosions or offset at the pubic symphysis. Four had avulsion of cortical bone at the site of insertion of the gracilis tendon. Four patients demonstrated sacroiliac joint abnormalities on plain films consisting of sclerosis, erosions and osteophytes, and in one of these athletes, bilateral sacroiliac changes are present. Two patients with normal sacroiliac joints on plain films had a bone scan showing increased radionuclide uptake bilaterally at the sacroiliac joints. One patient with both plain film and CT evidence of sacroiliac abnormalities had an MR examination showing abnormal signal at both sacroiliac joints and at the pubic symphysis. A sacral stress fracture was found on CT in one patient with complaints of sciatica. In the control group, six patients, all over the age of 55 years, had mild sclerosis of the symphysis, but no plain film evidence of sacroiliac abnormalities.

CONCLUSION

We have found a group of athletes in whom stress injuries to the pubic symphysis are associated with changes in the sacroiliac joint as demonstrated by degenerative changes or in the sacrum as manifested as a sacral stress fracture. These findings are probably due to abnormal stresses across the pelvic ring structure that lead to a second abnormality in the pelvic ring. The abnormality in the sacrum is not always well seen with conventional imaging. Recognition of the association of stress injury of the symphysis with back pain is important in that it can help avoid inappropriate studies and diagnostic confusion.

Hematogenous osteomyelitis of metaphyseal-equivalent locations

Flat and irregular bones have anatomic subdivisions comparable to long bones. This concept is useful in the radiograpic evaluation of solitary bone lesions. Areas adjacent to cartilage are metaphyseal-equivalent locations. Prior to skeletal maturation, metaphyseal-type vascular anatomy predisposes these sites to involvement by hematogenous osteomyelitis. Approximately 30% of cases of hematogenous osteomyelitis affect these metaphyseal-equivalent sites and often present difficult diagnostic challenges. Forty-nine patients with this condition are described.

Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes

OBJECTIVE

The purpose of this study was to describe the application, technique, and results of symphyseal cleft injection in athletes with osteitis pubis.

CONCLUSION

Symphyseal cleft injection is a useful technique for the diagnosis and treatment of osteitis pubis in athletes. The procedure is well tolerated and may facilitate early resumption of competitive duties.

Pubic rami fracture: a benign pelvic injury?

OBJECTIVE

To present a consecutive series of older patients with pubic rami fractures and evaluate their long term functional outcome.

STUDY DESIGN

Retrospective.

METHODS

Sixty-three consecutive community-dwelling, ambulatory patients who sustained a public rami fracture and were treated at one hospital were reviewed. Fifty-two of sixty-three patients (83%) had radiographic evidence of pubic rami fracture at initial presentation; in the remaining eleven patients, the diagnosis of pubic rami fracture was made after additional imaging studies. Sixty patients (95%) required hospitalization for pain control and progressive mobilization.

RESULTS

The hospital length of stay for the sixty admitted patients averaged fourteen days; patients who had three or more associated medical comorbidities or required use of a cane or walker for ambulation prior to fracture were more likely to have been hospitalized greater than two weeks. Thirty-eight patients were available for one year minimum follow-up; thirty-five of thirty-eight patients (92%) were living at home, 84% had no or mild complaints of hip/groin pain, 92% had returned to their prefracture ambulatory status, and 95% had returned to their performance function in activities of daily living.

CONCLUSIONS

1) Elderly patients with pubic rami fractures utilize substantial healthcare resources based upon length of stay and need for home care services; and 2) those patients who survive have a good prognosis with regard to long term pain relief and functional outcome.

Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury

BACKGROUND

Little data exist on the results of treatment for sports-related chronic groin injury.

HYPOTHESIS

Sports-related chronic groin injury treated with a conservative (rest) program results in a satisfactory outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Professional Australian male football players, at the end of the playing season, had their groin injury diagnosed using specific clinical and magnetic resonance imaging (MRI) criteria. Those assessed as having a non-hip-related cause for their chronic groin injury were treated principally by 12 weeks of complete rest from active weightbearing activities. Response to treatment was assessed at different stages of rehabilitation by recording the number of athletes who had returned to playing football and the number of athletes without symptoms.

RESULTS

Twenty-seven athletes were considered to have chronic groin injury. Clinical and MRI (pubic bone marrow edema N = 26 [96%]), hyperintense line N = 25 [93%]) criteria suggested a pubic bone stress injury as diagnosis for the chronic groin injury. Eighty-nine percent of athletes returned to sport in the subsequent playing season, with 100% having returned by the second playing season after diagnosis. Forty-one percent of the athletes were without symptoms at the commencement of the following playing season, rising to 67% by the end of that playing season.

CONCLUSIONS

Conservative management of athletic chronic groin injury resulted in an excellent outcome when assessed by the return to sport criterion. However, the results were only satisfactory if the criterion of ongoing symptoms after treatment was used. More research is needed to compare the efficacy of all treatments that are used in this troublesome condition.

Evaluation of the bony pelvis in classic bladder exstrophy by using 3D-CT: further insights

OBJECTIVES

To provide a complete look at the bony pelvis in children with classic bladder exstrophy: dimensions, orientation, and relationships.

METHODS

Three-dimensional computed tomography was used in 6 boys and 1 girl, 5 of whom underwent primary closure and 2 who underwent reclosure at 4 and 8 months. These exstrophy pelves (intrapelvic angles and osseous dimensions) were compared with 26 age and sex-matched controls.

RESULTS

The iliac wing angle was 11.4 degrees larger in the classic bladder exstrophy cases. The sacroiliac joint angle was 9.9 degrees more externally rotated in the exstrophy cases. The pelvis was rotated 14.7 degrees in the superoinferior plane in the exstrophy cases. The mean pubic diastasis was 4.2 cm (0.6 cm in controls). The inter-triradiate distance in the patients with classic bladder exstrophy averaged 6.0 cm (4.2 cm in controls).

CONCLUSIONS

These new findings provide a better understanding of the bony pelvis, especially its posterior portion, in patients with classic bladder exstrophy. The results of this study revealed the orientation of the sacroiliac joints to be more externally oriented than previously thought and the pelvis to be rotated inferiorly, a previously unknown observation. Both of these factors will be important in the planning of newer osteotomies and pelvic reconstruction.

Parasymphyseal and associated insufficiency fractures of the pelvis and sacrum

Eleven post-menopausal women presenting with a parasymphyseal insufficiency fracture of the pubis are reported. The plain radiographs showed delayed healing with a mixed lytic and sclerotic area developed at the fracture site simulating a malignant lesion. Aetiological factors included post-menopausal osteoporosis, rheumatoid arthritis and steroid therapy, previous hip replacement and pelvic radiotherapy. Ten patients had concomitant fractures of the pelvis, including nine with sacral fractures. These were all initially missed on presentation because of the subtle radiographic signs of a longitudinal band of sclerosis, usually bilaterally, in the sacral ala. Bone scanning was shown to be the most sensitive technique in detecting the sacral fractures by demonstrating increased uptake in the sacral ala as well as the other fractures of the pelvis. Computed tomography in three cases was helpful in confirming the presence of fractures and excluding the possibility of malignancy.

Osteitis pubis

Osteitis pubis is a painful condition, usually caused by abnormal muscle forces acting on the symphysis pubis. The symptoms of osteitis pubis mimic many other injuries that affect the athlete's groin. To correctly diagnose this condition, the clinician must maintain a high index of suspicion. Reports suggest this condition is more common in men than women. Confirmatory radiographs, bone scans, and magnetic resonance imaging aid the diagnosis. Once diagnosed, the prognosis for full recovery is good, although lengthy. Typical treatments include physical therapy, involving strengthening the abdominal and hip muscles, and improving range of motion of the hip, particularly the muscles of internal rotation. Corticosteroid injections, wedge resection of the symphysis, curettage, and arthrodesis have all been used with variable success.

Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage

BACKGROUND

Angiography is the gold standard for the diagnosis and treatment of pelvic arterial hemorrhage associated with pelvic fractures. In most cases, a single angiogram with embolization is adequate to control pelvic arterial hemorrhage. However, a small subset of patients, require repeat pelvic angiogram to evaluate and treat recurrent hemorrhage. This study seeks to define this population and determine clinical predictors of recurrent hemorrhage.

METHODS

We conducted a retrospective case control study comparing patients with traumatic pelvic fracture undergoing repeated pelvic angiogram versus a single angiogram between the years 1995 and 2000. Stepwise logistic regression was used to identify the independent predictors of recurrent hemorrhage.

RESULTS

In the years studied, 556 patients underwent a pelvic angiogram to evaluate for pelvic arterial hemorrhage associated with pelvic fractures. Among these, 42 (7.5%) patients underwent a second angiogram for suspected recurrent hemorrhage. In comparison to the initial angiogram, the source of bleeding on the repeat angiogram occurred at a new bleeding site in 68%, at a previously embolized site in 18%, and both in 14%. Significant risk factors for recurrent pelvic arterial hemorrhage included hypotension or transfusion of >2 U of blood per hour before the initial angiogram, pubic symphysis widening, and more than two injured arteries requiring embolization (p < 0.05). Of these, more than two injured arteries requiring embolization (odds ratio, 16.0; 95% confidence interval, 2.9-88) and transfusion of >2 U of blood per hour (odds ratio, 6.9; 95% confidence interval,1.9-25) were independent predictors of recurrent hemorrhage.

CONCLUSION

Angiographic control of traumatic pelvic arterial hemorrhage is highly successful. However, recurrent pelvic arterial hemorrhage does occur. We identified a subgroup of patients with pelvic fractures who are at increased risk of recurrent pelvic arterial hemorrhage and should be considered for early repeat angiography for signs of ongoing hemorrhage.

Radiographic hallmarks of peripheral chondrosarcoma

Ten peripheral chondrosarcomas, nine arising in the cap of an osteochondroma and one developing as a primary periosteal tumor, are reported. The radiological and histological features of these tumors are compared with those of 203 benign osteochondromas and two soft-tissue chondrosarcomas. In 3 of the 10 cases, cytological evidence of malignancy could not be demonstrated, although the size of the tumors and the presence of extension into adjacent soft tissues indicated that they were low-grade chondrosarcomas. In all of the 10 cases there was radiological evidence of scattered calcifications in the cartilaginous part of the tumor, and this is regarded as an important radiological indication of malignancy. Histological studies indicate that calcification of tumor cartilage, followed by replacement of the calcified cartilage by endochrondral bone, is responsible for the opacities that, in clinical radiographs, are characteristic of chondrosarcoma.

Osteitis pubis after Marshall-Marchetti-Krantz urethropexy: a pubic osteomyelitis

OBJECTIVE

Our purpose was to review cases of osteitis pubis encountered at our institution after Marshall-Marchetti-Krantz retropubic urethropexy.

STUDY DESIGN

The charts of patients diagnosed with osteitis pubis subsequent to Marshall-Marchetti-Krantz retropubic urethropexy from 1980 to 1994 were reviewed.

RESULTS

Fifteen cases of osteitis pubis were diagnosed after 2030 Marshall-Marchetti-Krantz procedures (0.74%). Onset of symptoms related to osteitis pubis began a mean of 69.8 days postoperatively (range 10 to 459 days). Although initial plain films of the symphysis pubis were normal in 7 (54%), radiographic abnormality was eventually demonstrated in all a mean of 25.7 weeks after surgery (range 4 to 78 weeks). A variety of conservative treatments resulted in symptomatic relief in 47%. Seven of the remaining patients underwent operative therapy with partial or complete relief noted in all. Subsequent bone cultures were positive in 5 (71%). At follow-up a mean of 58 months after the Marshall-Marchetti-Krantz procedure complete resolution of symptoms was noted in 33% and continued pain or ambulatory difficulty in the remainder. There was no relationship between postoperative urinary tract infections, postoperative complications, presenting sign of fever, elevated leukocyte count or sedimentation rate, and subsequent operative intervention (P > .05).

CONCLUSIONS

Osteitis pubis after urogynecologic surgery is an uncommon event requiring aggressive surgical and antibiotic therapy. When bone cultures are performed, a microbial cause may be demonstrated in as many as 71% of patients.

CT and MRI of Gorham syndrome

Gorham syndrome, also known as massive osteolysis or vanishing bone, is a rare disorder (135 cases reported) leading to extensive loss of bony matrix, replaced by proliferating thin-walled vascular channels. Three histologically proven cases of the disease are reported, including the clinical presentation and modern imaging features with CT (with 3D reconstruction) as well as T1- and T2-weighted MRI. Two cases in young women were located in the pelvis with extensive osteolysis reaching to the acetabulum. The third case in a 2-month-old boy is the youngest case ever reported and involved the humerus. The radiological appearance of the disease is discussed and the importance of the modern imaging methods debated.

Computed tomography of the osseous pelvis

Computed tomography (CT) was used for study of the osseous pelvis in 43 patients with definitive pathological or clinical follow-up. CT accurately characterized and determined extent of bone and soft-tissue involvement; neoplasms and other disease processes, such as sacroiliac joint disease, were well localized. In cases of trauma, CT was able to identify, localize, and characterize fracture fragments and bone or joint displacement. CT was judged "useful" or "definitive" in 80% of all lesions and 96% of neoplasms studied.

High Risk of Mismatch Between Sanders and Risser Staging in Adolescent Idiopathic Scoliosis: Are We Guiding Treatment Using the Wrong Classification?

BACKGROUND

Despite known limitations, Risser staging has traditionally been the primary marker of skeletal maturity utilized in decision-making for treatment of adolescent idiopathic scoliosis (AIS). The purpose of this study is to assess the incidence and factors associated with mismatch between Risser Staging and Sanders classification, and determine interobserver reliability.

METHODS

We reviewed the medical records of consecutive patients aged 10 to 18 referred to our institution for evaluation of AIS from January to June 2016 with a closed triradiate cartilage. Data collected included sex, age, race, height, weight, body mass index percentile, menarchal status, Risser stage, Sanders classification, and major curve. Risser and Sanders stage was determined by 2 fellowship-trained pediatric spine surgeons and 1 pediatric orthopaedic nurse practitioner. Mismatch was defined as Risser stage 2 to 4 corresponding to Sanders 3 to 5, and Risser 0 to 1 corresponding to Sanders 6 to 7.

RESULTS

A total of 165 consecutive patients were identified (mean age: 13.9±1.7 y, major curve 28.2±15.4 degrees, 76% female). The risk of skeletal maturity mismatch, based on the criteria of Risser 2 to 5 (limited growth remaining) corresponding to Sanders 3 to 5 (significant growth remaining) was 21.8%, indicating that 1 of 5 patients would be undertreated if managed by Risser criteria. Conversely, the mismatch risk for Risser 0 to 1 corresponding to Sanders 6 to 7 was 3.6%, leading such patients to be treated conservatively longer than necessary. Males and those of Hispanic ethnicity were at a higher risk of mismatch (23.1% vs. 11.9%, P=0.08; 33.3% vs. 8.8%, P=0.04, respectively). Body mass index percentile, race, and major curve were not associated with mismatch. The unweighted and weighted interobserver κ for Risser staging was 0.74 and 0.82, respectively, and 0.86 and 0.91 for Sanders classification, respectively.

CONCLUSION

Given the limited sensitivity of Risser staging during peak growth velocity, high mismatch risk, and lower interobserver reliability, the Sanders classification should be utilized to guide treatment options in patients with AIS. Compared with Sanders, utilizing Risser staging results in mistreatment in a total of 1 of 4 patients, with the vast majority being undertreated.

LEVEL OF EVIDENCE

Level II.

Osteochondroma and secondary synovial osteochondromatosis

Secondary synovial osteochondromatosis (SOC) is a rare disorder caused by a variety of joint disorders. Two unusual cases of secondary SOC are presented. The first patient is a 43-year-old man with extensive SOC developing within a bursa surrounding an osteochondroma of the pubic bone. The second patient is a 23-year-old man who developed florid and progressive SOC of his hip joint following excision of a femoral neck osteochondroma. SOC recurred despite three excisions over a 15-month period. Imaging was useful in pre-operative diagnosis of bursal SOC in the first patient and in detecting multiple recurrences in the second patient. Both cases illustrate prominent SOC developing secondary to osteochondroma. The different hypotheses regarding bursal and secondary SOC are reviewed.

Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature

An athletic 23 year old man presented with suprapubic tenderness, fever, and raised inflammatory blood variables. A diagnostic laparoscopy was performed, with a presumed diagnosis of retrocaecal appendicitis, but no abnormalities were found, apart from free fluid in the pouch of Douglas. Imaging of the pubic area suggested bony infection and inflammation. Biopsy and culture confirmed the presence of Staphylococcus aureus, a very common pathogen. The final diagnosis was osteomyelitis pubis, an infectious disease, and osteitis pubis, an inflammatory disease.

Pelvic ramus fractures in the elderly: 50 patients studied with MRI

BACKGROUND

Whilst it is well known that fractures of the pelvic rami in the elderly are frequently associated with posterior ring injuries, the extent of this second injury is less well known. We evaluated this question by MRI scanning a group of elderly patients presenting at our unit with pelvic rami fractures.

PATIENTS AND METHODS

We investigated 50 consecutive elderly patients (45 women) with fractures of the pelvic rami using an MRI scan of the pelvis in order to assess the competency of the pelvic ring.

RESULTS

On MRI, 45 (95% CI 42-48) patients had a sacral fracture. At 5-month follow-up, 39 (of 41 reviewed) still complained of posterior sacral tenderness.

INTERPRETATION

Pelvic rami fractures in the elderly are nearly always associated with posterior ring injuries. This probably explains why these patients take longer to rehabilitate than might be expected if only the anterior injury is considered, and it also explains why they experience long-term back pain.

Post-traumatic abnormalities of the pubic bone simulating malignancy

Three cases are presented in which unusual healing patterns of pubic features simulated malignant processes. Consideration of trauma as an etiologic factor in such cases may obviate the need for extensive clinical and histologic evaluation.

The incidence and significance of fluid-fluid levels on computed tomography of osseous lesions

The demonstration of a fluid-fluid level (FFL) within an osseous lesion on computed tomography (CT) has been reported as suggestive of an aneurysmal bone cyst (ABC) although FFLS have also been rarely found in association with other lesions. This study was conducted to determine the frequency of FFLS on CT in a group of ABCs and a series of patients presenting to a major tertiary referral centre for the treatment of bone tumours. An FFL was present on CT in 21 (84%) of the 25 ABCs and in 17 was multiple. FFLs are typical of the mid ("blow-out") or late phase of development of an ABC and not the incipient ("permeative") stage or where the internal architecture of the tumour has been disrupted by biopsy or previous surgery. In a 3-year period, 16 ABCs were found in 491 bone lesions referred to a bone tumour treatment centre. CT of the ABCs revealed FFLs in 14 (87.5%) cases. Within the same period, 728 CTs of these and other bone lesions were performed and FFLs were identified in two further cases: a massive telangiectatic osteosarcoma and a conventional osteosarcoma following chemotherapy. The diagnostic significance of an FFL on CT for ABC is: sensitivity = 87.5%, specificity = 99.7%, positive predictive value = 87.5%, negative predictive value = 99.7%, accuracy = 99.4%. An FFL within a bone lesion on CT remains strongly suggestive of an ABC although the radiologist should be wary of a rare telangiectatic osteosarcoma.

Use of pelvic CT scanning to evaluate pubic arch interference of transperineal prostate brachytherapy

PURPOSE

To determine the necessity of preoperative evaluation of pubic arch interference in patients with small prostate volumes.

METHODS AND MATERIALS

CT scans from 97 consecutive, unselected patients with stage T1 or T2 prostatic carcinoma who had transperineal I-125 or Pd-103 implants at the University of Washington in 1997 were analyzed for pubic arch interference. Transrectal ultrasound (TRUS) was performed with 6.0-MHz transducer with the patient in the lithotomy position and the patient's thighs vertical, similar to that used during the implant procedure. CT scans were obtained with the patient in the supine position, with 0.5-cm images taken at every 0.5 cm. To check for potential arch interference, the largest prostate cross-section was overlaid on the narrowest portion of the pubic arch. The overlap of the pubic arch and the prostate margin is measured at right angles to the inner pubic surface. The prostate volume obtained from the TRUS images was compared with the degree of pubic arch interference in order to determine whether TRUS volume predicted for interference.

RESULTS

There was considerable variability in pubic arch interference between patients. The mm of pubic arch overlap with the prostatic margin varied from -11 mm to 20 mm. Patients with larger prostate volumes generally had more pubic arch interference, but the degree of interference was only loosely related to the prostate volume (r = 0.46).

CONCLUSIONS

The degree of pubic arch interference is highly variable from one patient to the next and the TRUS volume cannot reliably predict patients who do or do not need a pelvic CT to detect potential arch interference.

Parasymphyseal insufficiency fractures of the os pubis

Twelve parasymphyseal insufficiency fractures of the os pubis are described in eight osteopenic postmenopausal women, three of whom had rheumatoid arthritis. The fractures involved both right and left pubic bones in three women. Radiographically lesions often appear deceptively destructive and malignant. In six patients, biopsy was performed and showed no tumor. Biopsy can be avoided in an osteopenic woman with recent increased activity, pubic pain, and the characteristic pubic lesion.

Pelvic stress fractures in long distance runners

We describe five cases of radiographically proven stress fracture of the pubic ramus in serious runners, three of whom were elite female marathoners. In a further two cases in which radiography failed to support the clinical diagnosis, there was bone scintigraphic evidence of stress fracture. Another five cases had the identical clinical presentation, but the diagnosis was not confirmed radiologically and bone scanning was not performed. Most patients experienced persistent groin discomfort during any activity for the first 4 weeks after injury, but all recovered completely after 8 to 12 weeks of rest, in particular, avoidance of running. In common with other studies, we found that the injury occurred in competitive runners, especially females, and was likely to develop during competitive races or intensive training sessions. We suggest that a diagnosis of pelvic stress fracture or stress fracture syndrome can be made with confidence, even in the absence of radiographic evidence, if the following three features are present in a long distance runner presenting with groin pain: First, activity causes such severe discomfort in the groin that running is impossible. Second, the athlete develops discomfort in the groin when standing unsupported on the leg corresponding to the injured side (positive standing test). In some cases the pain is so severe that standing on one leg is impossible. Third, deep palpation reveals extreme, exquisite nauseating tenderness localized to the pubic ramus and not to the overlying soft tissues. The diagnosis can be confirmed by bone scintigraphy where such facilities exist.

Insufficiency fractures of the pubic ramus

Seven elderly women with insufficiency fractures of the pubic ramus are described. The predisposing factors for this condition were osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery. The clinical presentation included progressive inguinal pain, limping, and inability to walk. Because initial radiographs were diagnostic only in four cases, bone scintigraphy and computed tomography were necessary to confirm the diagnosis and detect additional fractures. In most patients, bed rest, non-weight-bearing ambulation, symptomatic treatment, and therapy for osteoporosis resulted in rapid improvement, and long-term follow-up showed complete or partial recovery. In one case, no recovery was achieved because of noncompliance with treatment. Insufficiency fracture of the pubic ramus should be suspected in cases of unexplained inguinal or hip-area pain and inability to walk in the elderly. The clinical suspicion should be supplemented by radiological investigation. Bone scintigraphy and computed tomography are useful means for early and accurate diagnosis. The risk factors for this condition should be identified and treated. If therapy is initiated early and pursued, this type of fracture has a benign outcome.