What's the Diagnosis? - Case 11

History 82 year old woman with diffuse pelvic pain.

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MRI dated 6/4/2007

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MRI dated 7/13/07

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Findings Initial radiographs demonstrate insufficiency fractures of the right superior and inferior pubic rami that become more conspicuous on the repeat radiographs with Judet views. On the views of 5/10, there is destruction about the right side of the pubis.

Note the difficulty in evaluating the sacrum secondary to osteopenia and overlying bowel.

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Findings • Bone Scan demonstrates increased uptake of the right side of the pubis and both sacral ala, left greater than right, indicating insufficiency fractures.

• MRI demonstrates marrow edema pattern of the sacral ala secondary to fractures and destruction of the right superior and to a lesser extent, inferior pubic ramus. The superior pubic ramus has been essentially replaced with a fluid filled cavity.

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Findings Follow up x-ray demonstrates destruction of the right superior and inferior pubic ramus but with residual cortices well formed. Lucent defects are seen of the sacral ala, left greater than right, indicating persistent fracture deformities.

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Diagnosis: Insufficency Fracture with postraumatic osteolysis Post traumatic osteolysis is commonly thought of as occurring in the distal clavicle secondary to trauma but is becoming more prominent in the pubis as the population ages. It most typically occurs, as in this case, in post menopausal women and typically with concommitant sacral insufficiency fractures. The differential diagnosis includes infection or tumor, although as in this case, a fluid collection can be present and not a soft tissue component, mitigating against tumor. Biopsy was performed with cultures obtained, both of which were negative.

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Resources • YYR Chan, YHH Huang et al . “Acute Osteolysis of the Pubic Bone and Sacral Insufficiency Fracture”. J HK Coll Raiolo. 2003; 6: 45-47.

• Albertsen AM, Egund N, Jurik AG, Jacobsen E. “Posttraumatic Osteolysis of the Pubic Bone Simulating Malignancy”. Acta Radiol. 1994; 35:40-44.

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http://emedicine.medscape.com/article/394406-overview

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