Can we predict fracture in pathologic altered bone of the

proximal femur using only plain radiographs?

Poster No.: C-2194

Congress: ECR 2016
Type: Scientific Exhibit
Authors: M. Simunovic; Zagreb/HR
Keywords: Musculoskeletal bone, Conventional radiography, Outcomes
analysis
DOI: 10.1594/ecr2016/C-2194

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Aims and objectives

Simple bone cyst (SBC) is the most common benign lytic bone lesion in childhood, mainly
affecting the proximal femur and proximal humerus.

SBC located in a biomechanically unfavourable area such as the proximal femur

significantly raises risk of pathological fracture (PF). Various radiological criteria (bone
cyst index-BCI, bone cyst diameter-BCD; minimal cortical thickness-MCT) have been
suggested to help predict which cysts will lead to PF. Aim of this abstract is to evaluate
these criteria.

Methods and materials

Twenty-six patients treated at our Department from 1981 to 2008 for proximal femoral
SBC were divided into two groups. The first group included patients who had fracture in
pathologic altered bone and the second group included patients without fracture.

Significant radiological criteria were measured (BCI, BCD-longitudinal and transversal,

MCT-medial and lateral) on plain radiographs. (Fig.1-3)

Images for this section:

Page 2 of 9
Fig. 1: The BCI is obtained by multiplying the cyst area (a x b) and diaphyseal diameter
squared. Diaphysis diameter is measured in the middle third of thigh or below SBC.

© Dept. of radiology, Zagreb, Croatia, Clinical Hospital Centre Zagreb, Zagreb, Croatia
- Zagreb/HR

Page 3 of 9
Fig. 2: In case of a pathological fracture through the SBC, the cyst diameter was
calculated as shown.

© Dept. of radiology, Zagreb, Croatia, Clinical Hospital Centre Zagreb, Zagreb, Croatia
- Zagreb/HR

Page 4 of 9
Page 5 of 9
Fig. 3: Cortical thickness was calculated on at least 3 levels, and an average was
calculated.

© Dept. of radiology, Zagreb, Croatia, Clinical Hospital Centre Zagreb, Zagreb, Croatia
- Zagreb/HR

Page 6 of 9
Results

Average age of the patients was 10.6 years (range, 3 to 20). Diagnosis of proximal
femoral SBC was confirmed in all patients. Group A consisted of 12 (9 male, 3 female)
patients who presented with PF through the proximal femoral SBC. Median BCI was 4.19
(IQR 3.08, Q1 2.96, Q3 6.04). Median BCD (mm) longitudinally was 48.15 (IQR 34.2,
Q1 37.8, Q3 72), transversely 27 (IQR 15.75, Q1 23.4, Q3 39.15). Median MCT (mm)
medially was 1.9 (IQR 1.4, Q1 0.9, Q3 2.3), laterally 1.8 (IQR 1.8, Q1 0.9, Q3 2.7). Group
B counted 14 (12 male, 2 female) patients without PF through proximal femoral SBC at
presentation. Median BCI was 4.26 (IQR 2.85, Q1 2.83, Q3 5.68). Median BCD (mm)
longitudinally was 54.9 (IQR 34.2, Q1 42.3, Q3 76.5), transversely 29.2 (IQR 14.4, Q1
21.6, Q3 36). Median MCT (mm) medially was 1.8 (IQR 1.8, Q1 0.9, Q3 2.7), laterally
1.8 (IQR 0.9, Q1 0.9, Q3 1.8) (Table 1).

Images for this section:

Table 1: Group A - consisted of 12 (9 male, 3 female) patients who presented with PF

through the proximal femoral SBC. Group B - counted 14 (12 male, 2 female) patients
without PF. Average age of the patients was 10.6 years (range, 3 to 20).

© Dept. of radiology, Zagreb, Croatia, Clinical Hospital Centre Zagreb, Zagreb, Croatia
- Zagreb/HR

Page 7 of 9
Conclusion

No significant differences of measured values were found between the two groups. The
proposed radiological criteria are not reliable to anticipate occurrence of PF through SBC.
Other factors, like biological nature of the lesion, remodelling properties and structural
rigidity of the remaining bone should be taken into consideration.

Further evaluation on a larger number of patients is required.

Significance: Ability to predict PFs using simple radiological criteria would help lower
complications they cause.

Personal information

Marko Šimunovi# - Department of Radiology, Clinical Hospital Centre Zagreb, University

of Zagreb Medical School.

Silvana Mir#eta - Health Center, KZŽ.

Ozren Kubat - Department of Orthopaedic Surgery, Clinical Hospital Centre Zagreb,

University of Zagreb Medical School.

Kristina Poto#ki - Department of Radiology, Clinical Hospital Centre Zagreb, University

of Zagreb Medical School.

References

1. Vasconcellos DA, Yandow SM, Grace AM et al. Cyst index. A non predictor of simple
bone cyst fracture. J Pediatr Orthop. 2007;27:307-310.

2. Pireau N, De Gheldere A, Mainard-Simard L et al. Fracture risk in unicameral bone cyst.

Is magnetic resonance imaging a better predictor than plain radiography? Acta Orthop
Belg. 2011;77:230-238.

3. Snyder BD, Hauser-Kara DA, Hipp JA et al. Predicting fracture through benign skeletal
lesions with quantitative computed tomography. J Bone Joint Surg Am. 2006;88:55-80.

4. Ulici A, Balanescu R, Topor L, Barbu M, The modern treatment of the simple bone
cysts, J.Med.Life, 2012,5: 469-473

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