What You Need to Know About Insufficiency Fractures

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An insufficiency fracture is a type of stress fracture that can occur due to minor pressure in a bone that is weakened. This type of injury can happen anywhere in the body, and it most often affects the spine and pelvic bones.

The leading cause of insufficiency fractures is osteoporosis—a condition that commonly develops after age 50 that's characterized by bone loss and fragility. In fact, some studies show that as many as 32 percent to 72 percent of people with insufficiency fractures have osteoporosis.

Doctor explaining imaging of spine to a patient

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This article discusses the different types of insufficiency fractures, their causes, and who is most at risk. It also reviews symptoms and diagnosis, as well as treatment options and how to protect yourself from this type of injury.

In the United States, at least 10.2 million people over the age of 50 have osteoporosis. About 4.4 percent of men and 19.6 percent of women in this age range have the disease. Because of their high rate of osteoporosis, women have an increased risk of insufficiency fracture.

Types of Insufficiency Fractures

Insufficiency fractures are most likely to happen in areas of your body that carry a lot of your weight, particularly your pelvis, spine, and hips.

These bones can become especially weak, thin, and frail due to osteoporosis, vitamin D deficiency, or aging. As a result, a person can develop an insufficiency fracture from something as simple as a minor fall from a standing position.

Because they often aren't caused by serious trauma, many people can experience pain without remembering any specific traumatic event or fall.

The following types of insufficiency fractures are most common.

Pubic Ramus Fracture

The most common type of pelvic fracture is an injury to one or both of the pubic ramus bones—two ring-shaped bones located on each side of the lower pelvis.

In at least 80 percent of cases, the pubic ramus fractures in two places at once. This bone tends to break on the top and the bottom of the ring.

In people with osteoporosis, the pubic ramus bones often fracture during a low-impact fall. As many as two-thirds of pelvic ring insufficiency fractures in people with osteoporosis happen without any known traumatic event.

Sacral Fracture

The sacrum is a triangle-shaped bone made of five disks (vertebrae) that is located at the bottom of the lower (lumbar) spine. The sacrum connects to the tailbone and forms the back wall of the pelvis, helping to support and stabilize it.

Although sacral insufficiency fractures are common injuries, they are often undiagnosed because the sacral bones are difficult to see on regular X-rays. Typically, a computed tomography (CT) scan or magnetic resonance imaging (MRI) is needed to diagnose this type of fracture.

The sacrum bears much of your upper body weight when you walk, so a sacral injury can make it difficult to get around. The effects of a sacral fracture can increase the risk of additional falls, and sometimes it can cause a person to become bedridden.

For those with osteoporosis and untreated sacrum fractures, there's a 27 percent risk of death within five years of the fracture due to falls, pulmonary embolism, pneumonia, and other complications.

Femoral Neck Fracture

Your femur, better known as your thighbone, extends from your hip to your knee. At the top of your femur is the femoral head—a part of your hip joint that rotates like a ball in a socket, allowing you to move your leg around.

Supporting the femoral head is the femoral neck, the site where approximately 45 percent to 53 percent of hip fractures take place. This part of your hip carries much of your upper body weight, especially when you walk.

A femoral neck fracture can cut off blood supply to the femoral head, resulting in avascular necrosis. This is a potentially life-threatening condition in which the femoral head bone tissues die due to a lack of blood supply. Eventually, this can cause the femoral head to collapse.

Acetabular Fracture

The acetabulum is the socket of the hip joint that connects to the femoral head. Acetabular fractures usually happen alongside other pelvic fractures, which can have a severe impact on your ability to walk.

Due to the acetabulum's close proximity to the sciatic nerve and major blood vessels in the thigh, a fracture of this bone can lead to nerve damage and internal bleeding.

Like other insufficiency fractures, acetabular fractures commonly occur after a low-impact fall with osteoporosis.

Recap

Most insufficiency fractures affect the pelvis, specifically the pubic ramus and sacral bones. The femoral neck bones and the acetabular bones are the sites of most hip fractures. If you have osteoporosis, these bones can easily fracture due to minor accidents and falls.

Insufficiency Fracture Symptoms

Each of these fractures can significantly impact your quality of life due to pain and difficulty moving. And they also cause specific effects, depending on the location and size of the fracture.

Pelvic Fracture Symptoms

A fracture in your pubic ramus bones, sacral bone, or elsewhere in your pelvis can cause the following symptoms:

Pelvic fractures can result in life-threatening complications, especially when there are multiple fractures involved. This type of fracture can injure nearby organs within the pelvic ring, such as the intestines, kidneys, bladder, or genitals.

Hip or Spine Fracture Symptoms

You may experience the following if you have a fracture in your acetabular bone, sacral bone, femoral neck, or elsewhere in your hip:

  • Hip pain that can radiate to your knee
  • Low back pain
  • Pain or unsteadiness when standing or walking
  • Bruising and swelling in your hip

Hip fractures can also result in life-threatening complications due to the risk of injury to nearby blood vessels.

One major difference between pelvic fractures and hip fractures is that gentle leg motions are significantly more painful when you have a hip fracture compared to a pelvic fracture.

Diagnosis

Because insufficiency fractures can result in serious complications, it's important to see your doctor if you're having pain in your pelvis, hip, or lower back—even if you don't remember injuring yourself.

If you can recall a time when you fell, bumped into something, or landed too hard on yourself—no matter how insignificant the event was—let your doctor know.

Your doctor will likely begin by asking you about your pain. They will want to know where your pain is located, whether it is dull or stabbing, and what sorts of movements make it worse.

If you are up to it, they may ask you to walk across the room to assess your gait (walking pattern).

They may have you lie on your back while they move your leg at various angles. Doctors use these maneuvers to check how your hip moves and whether or not there is swelling.

Insufficiency fractures can sometimes be misdiagnosed or underdiagnosed. Don't hesitate to speak up or get a second opinion if your pain is persistent and unexplained.

Your doctor will likely order imaging tests. While X-rays can generally visualize some types of bone fractures and breaks, your doctor may need to order a CT scan or MRI to see hairline fractures.

Recap

Don’t ignore pain in the pelvis, hip, or lower back, even if you don't remember hurting yourself. In addition to asking about your pain and conducting a physical exam, your doctor may need to order imaging tests to diagnose a fracture.

Treatment

With certain types of fractures, your doctor or physical therapist may require you to limit how much weight you place on your injury. With others, you may be encouraged to place as much weight on the injured areas as you can tolerate, taking rests as needed. Slowly, this approach should improve your mobility and lead to recovery.

  • For sacral fractures, treatment is usually conservative and includes rest, pain relief medication, and physical therapy.
  • Pelvic injuries are also usually treated with rest and pain management until you're healed. In some instances, though, you may need a procedure known as sacroplasty. This is a type of surgery in which pins are placed in the bone.
  • Rest, pain medication, and hot and cold compresses are the first line of treatment for hairline hip fractures. However, these methods are sometimes not enough to help heal the hip bone. In those cases, a hip replacement may be necessary.

Depending on how severe your injury is, you may need inpatient hospitalization or nursing care to assist with your daily activities as you recover from your fracture.

Treating the Cause

Your doctor will try to identify the cause of your fracture. If your doctor determines that you have osteoporosis, you should begin making lifestyle changes right away. Follow a nutritious diet and incorporate exercises into your day.

Your doctor may also test you for a vitamin D deficiency, which is related to an increased risk of fractures. Depending on those test results, you may need to start taking calcium and vitamin D supplements to strengthen your bones.

Also, talk to your doctor about whether prescription medications are right for you. Treating osteoporosis is difficult, but it's important to prevent future insufficiency fractures. 

Recap

Taking care of the injury as soon as possible improves your chances for a full recovery. However, there can be complications. Fractures that get worse or don't improve may require surgery and a significantly longer recovery period.

Prevention

As you get older, your bones naturally lose bone mass and become weaker, which is why the majority of people who get insufficiency fractures are over age 60. That said, anyone can experience this type of fracture at any age if their bones are thinning.

For Everyone

Regardless of your age and whether or not you have known risk factors for an insufficiency fracture, it's never too late to start strengthening and protecting your bones with these steps:

  • Improve bone health with a diet that's rich in vitamin D and calcium.
  • Strengthen bones and prevent further bone loss by doing weight-bearing exercises regularly. This also builds muscle to lower the risk of falls.
  • Stop smoking. It can lower bone density.
  • Limit how much alcohol you drink. It gets in the way of calcium absorption and makes you more unsteady on your feet.

These steps are especially important for women who have a family history of bone loss.

For Those With Diagnosed Bone Disease

It's important to take additional steps to protect yourself if you have already been diagnosed with osteoporosis or osteomalacia, a condition in which the bones soften. Follow these recommendations to prevent falls and protect yourself from insufficiency fractures:

  • Improve your leg strength and balance with low-impact exercises like yoga, tai chi, and swimming⁠. Just be sure to get your doctor's approval before starting a new exercise routine.
  • Get your eyes checked at least once a year.
  • Make your home safer by clearing pathways, removing clutter that you could trip over, placing a rubber bathmat or nonslip seat in the shower, and moving more slowly through your home.

Summary

Insufficiency fractures are a type of stress fracture that are most common in people with osteoporosis. This type of fracture can occur in any weight-bearing bone, but they're most common in the pelvis, hips, and sacrum.

Fractures in each of these areas can cause similar symptoms, and they can also result in potentially life-threatening complications.

If you experience pain, it's important to visit your doctor—even if you don't recall injuring yourself.

A Word From Verywell

The fear of falling and injuring yourself can have a negative impact on your physical and psychological health when you have osteoporosis.

Understanding osteoporosis, learning how to prevent injury, and joining a support group may help you cope. In addition, many people find that wearing a medical alert bracelet or necklace provides them and their loved ones peace of mind.

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20 Sources
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  1. Vaishya R, Agarwal AK, Banka PK, Vijay V, Vaish A. Insufficiency fractures at unusual sites: a case seriesJ Orthop Case Rep. 2017 Aug;7(4):76-79. doi:10.13107/jocr.2250-0685.862

  2. Tile M, Helfet D, Kellam J, et al. Insufficiency fractures of the pelvis: metabolic and nonoperative workup. In: Fractures of the Pelvis and Acetabulum.

  3. Centers for Disease Control and Prevention. Osteoporosis or low bone mass in older adults: United States.

  4. Studer P, Suhm N, Zappe B, Bless N, Jakob M. Pubic rami fractures in the elderly—a neglected injury?. Swiss Med Wkly. 2013 Aug;143(1):1-7. doi:10.4414/smw.2013.13859

  5. Rommens PM, Hopf JC, Herteleer M, Devlieger B, Hofmann A, Wagner D. Isolated pubic ramus fractures are serious adverse events for elderly persons: an observational study on 138 patients with fragility fractures of the pelvis type I (FFP type I)J Clin Med. 2020 Aug;9(8):2498. doi:10.3390/jcm9082498

  6. O'Connor TJ, Cole PA. Pelvic insufficiency fracturesGeriatr Orthop Surg Rehabil. 2014 Sep;5(4):178-190. doi:10.1177/2151458514548895

  7. Schicho A, Schmidt S, Seeber K, Olivier A, Richter P, Gebhard F. Pelvic X-ray misses out on detecting sacral fractures in the elderly - importance of CT imaging in blunt pelvic trauma. Injury. 2016 Mar;47(3):707-710. doi:10.1016/j.injury.2016.01.027

  8. Haberal B, Şimşek EK, Işik M. Incidence and mortality of osteoporotic sacral insufficiency fractures: a retrospective single-centre study. J Turk Spinal Surg. 2020 Jan;31(1):36-40. doi:10.4274/jtss.galenos.2020.62

  9. Johns Hopkins Medicine. Fixing hip fractures.

  10. Han S, Oh M, Yoon S, et al. Risk stratification for avascular necrosis of the femoral head after internal fixation of femoral neck fractures by post-operative bone SPECT/CTNucl Med Mol Imaging. 2017 Aug;51(1):49-57. doi:10.1007/s13139-016-0443-8

  11. Hospital for Special Surgery. Pelvic fractures/acetabular fractures.

  12. Cedars Sinai. Pelvic fracture.

  13. Cedars Sinai. Hip fracture.

  14. Kao F-C, Hsu Y-C, Liu P-H, Yeh L-R, Wang J-T, Tu Y-K. Osteoporotic sacral insufficiency fracture: An easily neglected disease in elderly patients. Medicine. 2017;96(51):e9100.

  15. Patel H, Kamath AF. Subchondral insufficiency fracture of the femoral head treated with core decompression and bone void filler support. Arch Bone Jt Surg. 2016;4(3):264-268.

  16. Lips P, van Schoor N. The effect of vitamin D on bone and osteoporosis. Best Pract Res Clin Endocrinol Metab. 2011 Aug;25(4):585-591. doi:10.1016/j.beem.2011.05.002

  17. Acevedo C, Stadelmann V, Pioletti D, Alliston T, Ritchie R. Fatigue as the missing link between bone fragility and fracture. Nat Biomed Eng. 2018 Jan;2(1):62-71. doi:10.1038/s41551-017-0183-9

  18. Centers for Disease Control and Prevention. Does osteoporosis run in your family?.

  19. Shanb AA, Youssef EF. The impact of adding weight-bearing exercise versus nonweight bearing programs to the medical treatment of elderly patients with osteoporosisJ Family Community Med. 2014;21(3):176-81. doi:10.4103/2230-8229.142972

  20. Hernigou J, Schuind F. Tobacco and bone fracturesBone Joint Res. 2019;8(6):255-265. doi:10.1302/2046-3758.86.BJR-2018-0344.R1