PMC2684998_01
Bilateral fatigue fractures of the inferior pubic rami in a 22-year-old male recruit.
kjr-6-47-g001.jpg
PMC2684998_01_kjr-6-47-g001.jpg
F1
The plain radiograph showed no evidence of complications from the previous surgery for a fracture of the right femoral neck, but revealed bilateral non-displaced fractures with callus formation at the junction between the inferior pubic ramus and the ischial ramus (Fig. 1A), which were overlooked by an orthopedic surgeon. In order to exclude any surgery-related complications such as osteonecrosis, MR imaging (Signa Excite, GE Medical Systems, Milwaukee, Wis.) of the pelvis was performed, which showed transverse fracture lines through the overlying callus formation and high signal intensity around the adductor magnus muscles bilaterally (Fig. 1B). A bone scan (E.CAM, Siemens, Erlangen, Germany) with 99mTc-MDP revealed symmetric focal areas of increased uptake at the same regions as the plain radiograph and MR imaging (Fig. 1C). The follow-up MR images demonstrated discrete callus formation with a resolution of the abnormal signal intensity around adjacent soft tissues (Fig. 1D). In the follow-up bone scan, the focal tracer activities still remained but were much improved (Fig. 1E) compared with the initial images, and there were no clinical symptoms.
PMC2684998_02
Bilateral fatigue fractures of the inferior pubic rami in a 20-year-old male recruit.
kjr-6-47-g002.jpg
PMC2684998_02_kjr-6-47-g002.jpg
F2
The plain radiograph showed bilateral non-displaced fractures with callus formation at the junction between the inferior pubic ramus and the ischial ramus (Fig. 2A), which were similar to those observed in case 1. A bone scan with 99mTc-MDP also demonstrated symmetric bilateral focal areas of intensely increased tracer accumulation at the same regions as the plain radiograph (Fig. 2B), suggesting bilateral fatigue fractures.
PMC2684998_03
A 19-year-old female military cadet with a fatigue fracture of the left inferior pubic ramus.
kjr-6-47-g003.jpg
PMC2684998_03_kjr-6-47-g003.jpg
F3
Clinically, a fatigue fracture was suspected, but the initial radiograph only showed a subtle fracture line in the left inferior pubic ramus (Fig. 3A). A bone scan with 99mTc-MDP revealed a focal area of increased tracer activity in the left inferior pubic ramus (Fig. 3B), suggesting a fatigue fracture, which was disclosed definitely on the caudal view of the pelvis by separating it from the urinary bladder activity. The follow-up plain radiograph revealed discrete callus formation in the left inferior pubic ramus (Fig. 3C). The axial T1-weighted MR image demonstrated a fracture line and a minimally displaced small bony fragment with callus formation in the anterior portion of the left inferior pubic ramus (Fig. 3D), suggesting an avulsion type of fatigue fracture, and the Gd-DTPA (Gadolinium-diethyltriaminepentaacetic acid) enhanced MR image showed soft tissue enhancement around the callus formation (Fig. 3E).