Insufficiency Fracture in Rheumatoid Arthritis

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Patients receiving corticosteroid therapy often suffer from insufficiency fractures (trabecular disruption in nonlesional bones) of, for example, the spine, hip, and knee. Pathologically, osteopenia and osteonecrosis precede the fractures because they begin earlier as a result of microvascular occlusion and infraction. Radiographic manifestations include osteopenia, crescent or patchy lucency, and bone collapse and condensation due to impaction. In the spine, the vertebral bodies show condensation of the endplates with compressions of various grades (Fig. 10.46A). The femoral head and the tibial head are notorious sites for insufficiency fractures, showing a mixed pattern of mottled or patchy sclerosis and lucencies with volume loss of bone (Fig. 10.47A).

Pinhole scintigraphically, vertebral fractures are represented by extremely intense tracer uptake in endplates, which are depressed (Fig. 10.46B). Indeed, the depression is an essential feature of compression fractures. In uncomplicated cases, the disk space is either preserved or widened. On the other hand, insufficiency fractures in the femoral head and the tibial head are indicated by irregularly increased or decreased tracer uptake within the metaphyseal cancellous bones, reflecting fractures and avascular bone necrosis, respectively (Fig. 10.47B).

Fig. 10.46A, B Insufficiency spinal fracture in rheumatoid arthritis treated with corticosteroid. A Posterior pinhole scintigraph of the midlumbar spine in a 54-year-old woman shows minimally arcuate, very intense tracer uptake in the lower endplate of the L2 vertebra and the upper endplate of the L3 vertebra (arrowheads). B Anteroposterior radiograph reveals compression fracture with eburnation in the upper endplate of the L3 vertebra (arrows). The L2 vertebral fracture is not indicated radio-graphically

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