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Imaging Features and Manage-
ment of Stress, Atypical, and
Pathologic Fractures
Richard A. Marshall, MD
Jacob C. Mandell, MD
Michael J.Weaver, MD
Marco Ferrone, MD
Aaron Sodickson, MD, PhD
Bharti Khurana, MD
Abbreviations: AP = anteroposterior, ASBMR =
American Society for Bone and Mineral Research
RadioGraphics 2018; 38:2173–2192
https://doi.org/10.1148/rg.2018180073
Content Codes:
From the Departments of Radiology (R.A.M.,
J.C.M., A.S., B.K.) and Orthopedic Surgery
(M.J.W., M.F.), Brigham and Women’s Hospital,
75 Francis St, Boston, MA 02115. Presented as
an education exhibit at the 2017 RSNA Annual
Meeting. Received March 11, 2018; revision re-
quested April 26 and received May 21; accepted
June 1. For this journal-based SA-CME activity,
the author M.J.W. has provided disclosures (see
end of article); all other authors, the editor, and
the reviewers have disclosed no relevant relation-
ships. Address correspondence to B.K. (e-
mail: BKhurana@bwh.harvard.edu).
©
RSNA, 2018
SA-CME Learning Objectives
After completing this journal-based SA-CME
activity, participants will be able to:
■■Describe the radiographic appearance
of stress, atypical, and pathologic frac-
tures in the appendicular skeleton, with
an emphasis on the imaging features that
a multidisciplinary team uses to guide
treatment.
■■Identifythe imaging features that best
allow discrimination of stress fractures
from pathologic fractures.
■■Discuss the application of the Mirels
criteria for risk stratification of impend-
ing fracture of a bony neoplasm.
See rsna.org/learning-center-rg.
2173
Trauma/Emergency Radiology
Traumatic and atraumatic fractures are entities with distinct but
often overlapping clinical manifestations, imaging findings, and
management protocols. This article is a review of terminology, etiol-
ogy, and key imaging features that affect management of atraumatic
fractures including stress fractures, atypical femoral fractures, and
pathologic fractures. The terminology of atraumatic fractures is
reviewed, with an emphasis on the distinctions and similarities of
stress, atypical, and pathologic fractures. The basic biomechanics of
normal bone is described, with an emphasis on the bone remodel-
ing pathway. This framework is used to better convey the shared
etiologies, key differences, and important imaging findings of these
types of fractures. Next, the characteristic imaging findings of this
diverse family of fractures is discussed. For each type of fracture,
the most clinically relevant imaging features that guide manage-
ment by the multidisciplinary treatment team, including orthopedic
surgeons, are reviewed. In addition, imaging features are reviewed
to help discriminate stress fractures from pathologic fractures in pa-
tients with challenging cases. Finally, imaging criteria to risk stratify
an impending pathologic fracture at the site of an osseous neoplasm
are discussed. Special attention is paid to fractures occurring in
the proximal femur because the osseous macrostructure and mix
of trabecular and cortical bone of the proximal femur can function
as a convenient framework to understanding atraumatic fractures
throughout the skeleton. Atraumatic fractures elsewhere in the
body also are used to illustrate key imaging features and treatment
concepts.
©
RSNA, 2018 • radiographics.rsna.org
Introduction
Atraumatic fractures including stress fractures, atypical femoral
fractures, and pathologic fractures are encountered frequently in
the emergency department. An atraumatic or minimally traumatic
fracture is defined as a fracture caused by a relatively low-energy
mechanism that normally would not be expected to cause a fracture.
Although these diverse types of fractures (caused by repetitive stress,
alteration in bone metabolism, and focal neoplasms, respectively)
may at first glance appear to be unrelated, they actually share a
common mechanism at the microstructural level. Bone is a living,
dynamic organ, and these types of fractures are all caused by focal
failure of the bone due to imbalances in the bone remodeling cycle.
2174 November-December 2018 radiographics.rsna.org
Teaching Points
■■ Atypical femoral fractures are explicitly defined, and terminol-
ogy should follow the established guidelines of the American
Society for Bone and Mineral Research (ASBMR).
■■ Stress fractures can be stratified as either low or high risk,
which helps to guide optimal treatment and prediction of the
time it will take for the patient to return to activity (return to
play). Stress fractures arising under compressive forces gener-
ally are considered low risk and can be managed with activity
modification and continued weight bearing. The most com-
mon types of stress fractures are low-risk fractures, including
those of the posteromedial tibia, the calcaneus, the third and
fourth metatarsals, and the medial femoral neck. In compari-
son, fractures that arise under tensile stress and/or in areas of
poor vascularity are considered to be high-risk fractures and
are more likely to require extended rehabilitation, to result
in delayed union, or even to progress to complete fracture.
High-risk fractures include those of the superolateral femoral
neck, the patella, the anterior tibial cortex, the medial mal-
leolus, the talar neck, the dorsal navicular cortex, the proximal
metaphysis of the fifth metatarsal, and the sesamoids of the
great toe. These fractures may require more aggressive man-
agement, with cessation of the offending activity, protected
weight bearing, and in some cases, surgery.
■■ When an atypical femoral fracture injury is identified, screen-
ing of the contralateral hip and entire femur is recommended
with AP and lateral radiographs because up to 44% of patients
demonstrate a fracture in the contralateral femur either at the
time of the fracture or in subsequent years. Contralateral ra-
diography should be performed during the patient’s initial
hospital stay because the presence of contralateral injury may
alter potential surgical treatment for both the ipsilateral and
contralateral injuries. If no fracture is identified, recommen-
dations can include close clinical and radiographic follow-up
or immediate bone scanning or MRI. Bone scanning or MRI
should be favored whenever the patient presents with clini-
cal features associated with atypical femoral fracture, such as
thigh or groin pain.
■■ The most important marrow signal intensity characteristic to
differentiate benign from pathologic fractures is the margin
and homogeneity of the T1-weighted signal intensity abnor-
mality around the fracture.
■■ In the presence of a newly identified osseous neoplasm, im-
aging has an important role in prediction of the risk of the
patient developing a pathologic fracture. The Mirels scor-
ing system is the most commonly used scoring system and
has proven valid and reproducible for predicting impending
pathologic fractures of the appendicular skeleton on the basis
of the radiographic appearance of a bone lesion.
The terminology, imaging findings, and treat-
ment options of atraumatic fractures often over-
lap and are sometimes confusing. This can result
in interpretive challenges for the radiologist and
the potential for inadvertent miscommunication
with the multidisciplinary treatment team. Ac-
curate discrimination of the cause of the fracture
is of particular importance when the differential
diagnosis includes both pathologic and atypical
femoral fractures, because the treatment of these
fracture types is often very different from that of
acute traumatic fractures. Misdiagnosis can result
in delayed diagnosis of malignancy, failure to
correct a metabolic derangement, or suboptimal
surgical treatment and potential implant failure.
Optimal management of an atraumatic fracture,
whether conservative or surgical, often requires
a multidisciplinary approach that depends on
timely identification, characterization, and report-
ing of the clinically relevant imaging features.
In this article we review the terminology,
pathophysiology, imaging features, and manage-
ment of stress fractures, atypical femoral frac-
tures, and pathologic fractures. The proximal
femur is emphasized as a template for long bones
throughout the skeleton because it is a common
site for all three types of atraumatic fractures,
but the general principles discussed are broadly
applicable throughout the skeleton. In addition,
we emphasize key imaging features that help to
expedite appropriate management, to differen-
tiate among the fracture types, and to stratify
impending fractures according to risk in patients
with bony neoplasms.
Definitions and Terminology
The variety of overlapping terminology used to
describe atraumatic fractures, including stress,
fatigue, insufficiency, fragility, atypical, and
pathologic fractures, can be an impediment to
understanding, reporting, and grading these in-
juries (1,2). Stress fractures, in the broadest sense
of the term, can be divided into fatigue fractures
and insufficiency fractures. In clinical practice,
fatigue fractures and insufficiency fractures lie
along a spectrum, and in some cases, it can be
difficult to differentiate between the two. How-
ever, understanding the biologic and radiographic
differences can lead to a better understanding of
the underlying pathophysiology.
A fatigue fracture is a focal failure of normal
bone caused by repetitive applied stress (1,3,4).
Fatigue fractures commonly occur when the
patient engages in increased frequency, duration,
or intensity of activity, such as when military re-
cruits sustain “march fractures” of the metatarsal
bones (5).
In comparison, an insufficiency fracture is a fo-
cal failure of abnormally weakened bone caused
by repetitive applied stress (1–4). The term
fragility fracture likewise signifies a fracture in
abnormally weakened bone; however, the term is
often used in the setting of an isolated mechani-
cal loading event rather than repetitive applied
stress, and it applies most commonly in a patient
with osteoporosis (6–8). In clinical practice, the
terms fragility and insufficiency are often used
interchangeably with reference to osteoporotic
fractures because, in many cases, it is not possible
to distinguish the chronicity and magnitude of
RG  •  Volume 38  Number 7 Marshall et al  2175
Figure 1.  Illustration of the macrostructure of a long bone.
loading resulting in fracture in diffusely weakened
osteoporotic bone.
Although osteoporosis is by far the most com-
mon underlying metabolic disturbance resulting
in fracture (2,9), insufficiency fractures may arise
from a variety of disorders that influence the abil-
ity of bone to withstand normal loading forces,
including disorders of bone mineral homeostasis
(eg, osteoporosis, hyperparathyroidism, diabe-
tes mellitus, osteomalacia), bone remodeling
(eg, Paget disease, osteopetrosis, other scleros-
ing bone dysplasias), collagen formation (eg,
osteogenesis imperfecta, Marfan syndrome), the
adverse effects of pharmaceuticals (eg, gluco-
corticoid drugs, chemotherapeutic agents), and
prior radiation therapy (4,9–14). However, in
the absence of a known history of metabolic
bone disease, differentiation between fatigue and
insufficiency fractures is often arbitrary, and it is
not always clear how to distinguish normal from
abnormal bone.
In addition, similar fracture patterns can be
seen in both traumatic and insufficiency frac-
tures, including fractures of the distal radius,
tibial plateau, and femoral neck, although higher-
energy trauma generally is required to fracture
healthy bone. Furthermore, there may be a com-
ponent of both mechanisms in the same patient,
such as the relatively common clinical scenario
of the “female athlete triad,” in which disordered
eating, amenorrhea, and osteoporosis are pres-
ent simultaneously, often in high-level endurance
athletes (15). Possibly because of this ambiguity,
the term stress fracture is used widely to refer to
fatigue fracture both in clinical practice and in the
orthopedic and sports medicine literature (16).
For these reasons, this review is focused on fa-
tigue fractures, and to maintain consistency with
the orthopedic literature, the term stress fracture is
used synonymously with fatigue fracture and insuf-
ficiency fracture to refer to a fracture in weakened
bone.
Atypical femoral fractures occur in the lateral
cortex of the femoral diaphysis and can be seen
in patients undergoing long-term therapy with
bisphosphonate medications. In distinction to
stress and insufficiency fractures, where the ter-
minology is somewhat imprecise, atypical femoral
fractures are explicitly defined, and terminology
should follow the established guidelines of the
American Society for Bone and Mineral Research
(ASBMR) (10,12). The imaging appearance of
these fractures is similar to that of stress (fatigue)
fractures; however, they should be considered as
a form of insufficiency fracture because the bone
can be excessively brittle and weakened.
The term pathologic fracture generally is
reserved for fractures through a focal neo-
plasm, which may be either benign or malignant
(4,17,18), although this definition is also incon-
sistently applied, and pathologic fracture through
osteomyelitis has been described in the literature
(19,20). This is in contradistinction to a fracture
of a region of metabolic bone disease—whether
diffuse, such as with osteopetrosis, or focal, such
as with Paget disease—which generally should be
referred to as an insufficiency fracture, as previ-
ously discussed.
Bone Structure and Pathophysiology
These apparently diverse types of atraumatic
fractures have more in common than may be
evident at first glance. To best understand the
shared etiology and imaging features of these
fractures, it is helpful to review the basic prin-
ciples of bone anatomy, biomechanics, and the
bone remodeling cycle.
Bone is the strongest and stiffest material in
the body. It is organized into two predominat-
ing macrostructures: cortical (or compact) bone
and trabecular (spongy, medullary, or cancellous)
bone (Fig 1). The relative proportion of each type
of bone depends on the shape of the bone, the
specific location within the bone, and the vari-
ety of directional forces that must be supported
(2,13,21). Cortical bone predominates in the di-
aphyses of the long bones. The microstructure of
2176 November-December 2018 radiographics.rsna.org
Figure 2.  Graph shows the theoretical
stress-strain curve. The yield point rep-
resents the mechanical load required to
cause irreversible plastic deformation of a
material. In bone, multidirectional forces
above the yield point result in microcracks
that initiate the bone remodeling and
repair cascade. A stress fracture occurs
when the rate of microcrack formation ex-
ceeds the repair capacity of the bone. The
failure point represents the mechanical
load required for gross failure of the mate-
rial. In bones, this is the force required to
produce an acute traumatic fracture.
cortical bone consists of parallel cylindrically
shaped osteons composed of lamellar sheets of
mineralized collagen (2,22) that are reinforced
by intervening cement lines (23). Trabecular
bone, on the other hand, is considerably more
porous and is organized in a dynamic meshwork
of plates and struts oriented in relation to the
stresses applied to the bone over time. Trabecu-
lar bone predominates in the metaphyses and
subchondral regions of the long bones, the verte-
bral bodies, the flat bones of the pelvis, the tarsal
bones, and the sesamoid bones, among others
(2,13,21). Cortical bone and trabecular bone
have different imaging appearances and different
levels of resistance to applied stress and response
to injury.
Bones are exposed to a variety of mechanical
forces, including compressive, tensile, bending,
shearing, and torsional forces (24). The imme-
diate response of bone or any other structural
material to mechanical forces is determined
according to the interplay of two primary fac-
tors—the ability of the material to absorb a
mechanical load (stress) and the ability to deform
under those forces without failure (strain) (Fig 2)
(2,25). At low load levels, a bone readily deforms
within its elastic range, and the bone returns to
its original shape and structure when the load is
released. As mechanical load increases, the bone
deforms beyond its elastic range (into the plastic
range) and microcracks are formed. A fracture
occurs when there is accumulation of micro-
cracks outpacing the body’s capacity for repair
(eg, stress, fatigue, or insufficiency fracture),
when there is a single force exceeding the failure
load of the bone (eg, traumatic fracture), or when
there is a combination of these two (2).
Wolff’s law describes how bone adapts to
mechanical stress by continuously remodeling,
resulting in increased strength and increased
resistance to the applied stress (1). The complete
bone remodeling pathway can take 2–8 months
and involves three discrete steps: (a) microcrack
creation due to the initial plastic deformation,
(b) resorption cavity formation by osteoclasts at
the site of the microcrack, and (c) osteoblast acti-
vation with new bone deposition at the resorption
cavities (Fig 3) (26). This remodeling process is
similar throughout the skeleton; however, there
are key differences between cortical and trabecu-
lar bone. Only cortical remodeling is associated
with inflammation of the adjacent periosteum
(27). Remodeling of trabecular bone, on the
other hand, is associated with reorientation of
the trabeculae to better withstand applied forces.
Imbalance of any component of the remodeling
pathway impairs microcrack repair and limits the
body’s adaptive response to stresses. This ulti-
mately results in abnormally weakened bone and
predisposes the bone to atraumatic fractures.
In stress fractures, the imbalance in the bone
remodeling pathway is an excess of severity, dura-
tion, or frequency of the applied stress, where the
bone does not have enough time to repair micro-
cracks adequately before a new round of stress is
applied. In atypical femoral fractures, the imbal-
ance results from a deficiency in intracortical
bone remodeling and repair of microcracks in the
lateral femoral cortex, which is at least partially
mediated by suppression of osteoclast function
(10). In pathologic fractures, a focal lesion dis-
rupts the bone microstructure, macrostructure,
and the associated remodeling pathway. In the
case of some focal lytic neoplasms, the remodel-
RG  •  Volume 38  Number 7 Marshall et al  2177
Figure 3.  Illustration shows bone remodeling failure in fatigue stress fractures, atypical femoral fractures, and pathologic fractures.
ing cascade imbalance can result from tumor-
induced upregulation of osteoclast differentiation
and local bone resorption (Fig 3) (28).
Stress (Fatigue) Fractures
Stress fractures occur as the summative result of
repetitive cyclical loading, when the rate of accu-
mulated microdamage outpaces the ability of the
bone to regenerate through the normal remodeling
process. They occur most commonly in young ac-
tive individuals as a result of increased frequency,
duration, or intensity of activity. Both intrinsic and
extrinsic factors contribute to the etiology of stress
fractures. Intrinsic factors are directly related to
the athlete’s anatomic and metabolic characteris-
tics, including sex, hormonal status, bone quality,
muscular strength, and gait. Extrinsic factors in-
clude the training regimen and equipment-related
factors such as footwear and running surfaces.
Stress fractures most often manifest in the weight-
bearing lower extremities, including, in descending
order of frequency, the tibia, calcaneus, metatarsal
bones, and proximal femur (29,30). Although
stress fractures may be seen in the upper extremi-
ties, these injuries are considerably less common
(31) and usually are the result of athletic activities
involving repetitive throwing.
Imaging Findings.—Imaging features of stress
fractures are determined predominantly accord-
ing to two factors: the relative proportion of
cortical to trabecular bone and the chronicity of
the injury (Fig 4). In locations with a higher pro-
portion of cortical bone, such as the long bone
diaphyses, the earliest radiographic sign of bone
fatigue is the “grey cortex” sign, which refers to
subtle cortical lucency at the site of microcrack
formation and osteoclast resorption (32,33). A
periosteal reaction and endosteal callous forma-
tion with cortical thickening follow as the injury
propagates to the periosteal and endosteal sur-
faces and the healing cascade initiates. Finally, in
higher-grade injuries, a cortical break with a lu-
cent fracture line becomes evident (24). This is in
contradistinction to stress fractures in bones with
a higher proportion of trabecular bone, such as
the long bone metaphyses, where the initial sign
is subtle blurring and faint sclerosis of the tra-
beculae (1). This progresses to linear intramedul-
lary sclerosis, which results from bone deposition
and microcallus formation along the remodeled
trabecular struts (1,34) (Fig 4). Comminution
and displacement are uncommon manifestations
of stress fractures.
MRI has higher sensitivity than does radi-
ography in evaluation of early stress fractures.
Sensitivity for stress fractures with radiography
has been reported as 15%–35% for early-stage
injuries and 30%–70% for late-stage injuries
(35). MRI, on the other hand, is considered to
have near 100% sensitivity (13,36,37). Early
MRI features including periosteal edema and
marrow edema are best demonstrated on images
from fluid-sensitive sequences. As the severity
of the injury progresses, a hypointense linear
fracture line may be seen (38,39). Periosteal and
endosteal new bone formation are hypointense
on images from all sequences (40).
Presently, CT is not considered to be a first-
or second-line imaging modality for the diagnos-
tic evaluation of suspected stress injury; however,
CT may have a role in cases where the MRI
results are equivocal, owing to high specificity for
stress fractures (36,37).
2178 November-December 2018 radiographics.rsna.org

Figure 4.  Imaging features of fatigue stress fractures in locations with variable proportions
of cortical and trabecular bone. (a, b) Anteroposterior (AP) radiographs of the ankle and foot
show bone with a higher proportion of cortical bone, such as the anterior tibial diaphysis (a)
and the second metatarsal (b), and may demonstrate a subtle transverse or obliquely oriented
lucency (black arrow) with adjacent smooth periosteal reaction (white arrows). (c, d) AP ra-
diographs of the ankle show bones with a greater proportion of trabecular bone, such as the
distal tibial metaphysis (c) and the calcaneus (d), and may show subtle trabecular blurring and
vague sclerosis (arrowheads in c) or linear sclerosis along the fracture line (arrowheads in d).
If the trabecular fracture extends to the cortex, periosteal reaction may be seen (arrow in c).

Role of Imaging in Managing Stress Frac-
tures.—Stress fractures can be stratified as either
low or high risk, which helps to guide optimal
treatment and prediction of the time it will take
for the patient to return to activity (return to
play) (Fig 5). Stress fractures arising under com-
pressive forces generally are considered low risk
and can be managed with activity modification
and continued weight bearing (41). The most
common types of stress fractures are low-risk
fractures, including those of the posteromedial
tibia, the calcaneus, the third and fourth metatar-
sals, and the medial femoral neck. In comparison,
fractures that arise under tensile stress and/or
in areas of poor vascularity are considered to be
high-risk fractures and are more likely to require
extended rehabilitation, to result in delayed
union, or even to progress to complete fracture
RG  •  Volume 38  Number 7 Marshall et al  2179

Figure 5.  Management of compressive (low risk) or tensile (high risk) stress fractures. (a) Sagittal T1-
weighted MR image shows a fatigue stress fracture (arrow) extending to the compressive posterior cortex
of the tibia. Because compressive fatigue fractures are considered low risk, this patient could be treated
with activity modification only (short-interval cessation of the repetitive stressor—in this case, running).
(b) Lateral radiograph shows a fatigue stress fracture (arrow) of the anterior cortex of the tibia. Because
tensile fatigue fractures are considered high risk, this patient was treated with cessation of the repetitive
stressor (running) and prolonged protected weight bearing.

Figure 6.  Displaced fracture in a 33-year-old woman with a history of a high-risk tensile side stress
fracture of the femoral neck who did not adhere to recommendations for cessation of running and pro-
tected weight bearing. AP radiograph (a) and coronal T1-weighted fat-saturated MR image (b) show a
displaced fracture (arrows) of the femoral neck with varus angulation and impaction of the medial cortex.

(Fig 6). High-risk fractures include those of the
superolateral femoral neck, the patella, the ante-
rior tibial cortex, the medial malleolus, the talar
neck, the dorsal navicular cortex, the proximal
metaphysis of the fifth metatarsal, and the sesa-
moids of the great toe (42). These fractures may
require more aggressive management, with ces-
sation of the offending activity, protected weight
bearing, and in some cases, surgery (41). A
surgical or sports medicine consultation is often
recommended when high-risk stress fractures are
identified. In addition, proximal femur fractures,
fractures with a fatigue line greater than 50% of
the width of the femoral neck, or fractures with
any evidence of displacement should be consid-
ered high risk (43).
Likewise, MRI findings are used to guide re-
turn-to-play decisions for athletes. Fractures can
2180 November-December 2018 radiographics.rsna.org
Figure 7. Illustration
shows the Fredericson
classification grades for
medial tibial stress syn-
drome at MRI.
be graded on the basis of the classification system
proposed by Fredericson et al (38), which allows
classification of medial tibial fatigue fractures on
the basis of patterns of periosteal, marrow, and
cortical edema apparent on images from fat-sup-
pressed T2-weighted and non–fat-saturated T1-
weighted MRI sequences (Fig 7). In the Freder-
icson classification system, grade 1 is periosteal
edema only, grade 2 is mild bone marrow edema
evident only on T2-weighted MR images, grade
3 is more severe bone marrow edema evident on
both fluid-sensitive and T1-weighted MR images,
and grade 4 is an intracortical linear fracture
line. This system was modified by Kijowski et
al (39), who suggested dividing grade 4 into 4a
(intracortical signal intensity change without a
linear shape) and 4b (linear intracortical cortical
fracture line) (Fig 7).
Although this classification system was devel-
oped for posteromedial-tibial stress injuries, the
Fredericson system often is employed for grad-
ing of stress fractures in other areas. However,
one important limitation of MRI (and therefore
of the Fredericson classification) is that physi-
ologically, cortical injury (microcrack forma-
tion) is one of the earliest manifestations of
stress fracture; however, conventional MRI does
not allow visualization of cortical changes until
late in the progression of the stress fracture.
Multimodality imaging also may have a supple-
mentary role in assessment of stress fractures,
because authors of some studies (37,44) have
shown improved prediction of time to return to
play by combining MRI grading, fracture loca-
tion, and bone mineral density scores with dual-
energy x-ray absorptiometry; however, more
research is needed in this area.
Atypical Femoral Fractures
Atypical femoral fractures are substantially trans-
versely oriented fractures of the lateral cortex
of the femur that arise, resulting from deficien-
cies in normal bone turnover and the coupled
osteoclast-osteoblast bone remodeling pathway
(10,45). Atypical femoral fractures have been
reported in patients who have taken long-term
medications that suppress osteoclast-mediated
bone turnover, such as bisphosphonate drugs and
denosumab (a monoclonal antibody RANKL
[receptor activator of nuclear factor κB ligand]
inhibitor that inhibits maturation of osteoclasts);
however, these fractures also can be seen in
patients without exposure to these drugs (46).
Because bone formation that is not coupled to
osteoclast-mediated resorption cavity creation
is not suppressed, atypical femoral fractures
demonstrate endosteal and periosteal bone cal-
lus formation that is typical of repetitive stress
injuries (ie, fatigue stress fractures) elsewhere in
the skeleton (10,47). Although these fractures
may look like fatigue stress fractures, they are
classified more accurately as a form of insuffi-
ciency fracture, because the bone is weakened by
a disturbance in the bone remodeling cycle.
With atypical femoral fractures, the repetitive
stresses predisposing the patient to injury are
tensile stresses, which are most pronounced in
the lateral cortex of the femur (48). In fact, stud-
RG  •  Volume 38  Number 7 Marshall et al  2181
Figure 8.  Illustration shows femoral morphology in
some atypical femoral fractures. Studies suggest in-
creased incidence in patients with a femoral morphol-
ogy that exacerbates tensile stresses on the lateral cor-
tex of the femur, including femoral bowing.
ies (49,50) have shown increased risk of atypical
fractures in patients with abnormalities of gait or
limb geometry that accentuates tensile stresses
along the lateral femur, including those with
an increased tibiofemoral angle and those with
increased femoral bowing (Fig 8).
Imaging Features.—In 2013, the ASBMR re-
leased a revised set of clinical and imaging criteria
for the definition of an atypical femoral fracture
(Table 1). These criteria were crafted to highlight
the imaging appearance of atypical femoral frac-
tures while excluding clinical and imaging features
that raised the possibility of alternate causes for
the fracture, such as osteoporosis and trauma.
Comorbid conditions and medications associated
with atypical fractures are not included as compo-
nents of the definition (10).
To meet the definition for an atypical femoral
fracture, the fracture is required to be located
within the femoral diaphysis (distal to the lesser
trochanter and proximal to the supracondylar
flare) (10). Fractures originating in the femoral
neck and in the intertrochanteric femur are spe-
cifically excluded from the definition, because
these fractures are more likely to be associated
with other causes such as trauma or osteoporo-
sis (51,52).
The fracture should originate in the lateral
tensile cortex of the femur (Fig 9). By definition,
incomplete fractures are located only in the lat-
eral cortex of the femoral diaphysis. With com-
plete fractures, localized periosteal or endosteal
thickening that suggests repetitive stress injury
is seen in the lateral cortex (10), and there may
be a characteristic spiking of the medial cortex
(Fig 10). Results of one study (53) showed that
this focal lateral cortical thickening was the most
accurate finding (84.2%–94.7%) for differentia-
tion of atypical fractures from fractures of other
causes, including trauma and bone fatigue. Focal
lateral cortical thickening also has proven useful
in differentiating atypical fractures from other
types of insufficiency fractures, including those
associated with Paget disease and those in pa-
tients with osteopetrosis (53–56).
A final morphologic feature considered
integral to the diagnosis of an atypical fracture
is the substantially transverse orientation of the
noncomminuted fracture at the origin in the
lateral cortex (Fig 10). In complete fractures, the
fracture line may become more oblique in ori-
entation as the fracture extends medially across
the remainder of the femur. This may lead to the
characteristic “medial spike” appearance, which
may be caused by the acute medial propagation
of an incomplete transversely oriented fracture
of the lateral cortex (10). In one study (53), the
substantially transverse fracture orientation was
highly accurate (84.2%–86.8%) for discrimina-
tion of atypical femoral fractures from those with
other causes, while a lack of comminution and
the presence of a medial spike were considered
slightly less useful diagnostically.
Clinical and imaging features that raise the pos-
sibility of alternative fracture causes are excluded
from the definition of atypical fractures. Atypical
fractures occur in patients without a history of
trauma or with minimal trauma, such as a fall from
standing. In addition, the fracture should be non-
comminuted or minimally comminuted, suggestive
of “brittle” failure. Comminution is more com-
monly seen in traumatic fractures, with or without
osteoporosis. Although noncomminuted traumatic
femoral diaphyseal fractures sometimes occur,
they typically lack lateral cortical thickening or the
medial spike (Fig 11). Other conditions specifically
excluded from the definition include periprosthetic
fractures, pathologic fractures (associated with a
neoplasm), and insufficiency fractures related to
miscellaneous metabolic and other bone diseases
(eg, Paget disease and fibrous dysplasia, among
others) (Fig 12).
Treatment.—Treatment of patients with atypi-
cal femoral fractures may include cessation of
antiresorptive treatment, assessment and possible
supplementation with calcium and vitamin D,
consideration of bone forming agents (including
teriparatide, a recombinant parathyroid hormone),
2182 November-December 2018 radiographics.rsna.org
Table 1: Atypical Femoral Fracture: Summary
of the ASBMR Task Force Revised Definition
(2013)
Location in the femoral diaphysis
  Distal to the lesser trochanter
  Proximal to the supracondylar flare
Major features (four of five required)*
  Atraumatic or minimal trauma
  Substantially transverse (at origin in lateral cor-
tex); complete fractures may become oblique
more medially
  Must involve lateral cortex; complete fractures
extend to medial cortex and may demonstrate
a “medial spike”
  Noncomminuted or minimally comminuted
  Endosteal or periosteal thickening (beaking or
flaring)
Minor features†
  Generalized diaphyseal thickening
  Bilateral femoral diaphyseal fractures
  Prodromal symptoms (eg, groin pain)
  Delayed healing
Exclusion criteria
  Fractures of the femoral neck or intertrochanter-
ic region with spiral subtrochanteric extension
  Periprosthetic fractures
  Fractures associated with tumors and miscella-
neous bone diseases (eg, Paget disease, fibrous
dysplasia)
Source.—Reference 10.
*Four of the five major criteria must be met with-
out violation of the exclusion criteria. Although
each of the five criteria is highly suggestive of an
atypical fracture, only four are required to permit
clinical judgment in cases with high suspicion or
when information is missing.
†Minor features have been associated with atypical
fractures but are not required for diagnosis.
radiographic screening of the contralateral femur,
and possible surgical fixation (10,57). In this
article, we focus on detailing the treatment most
pertinent to the radiologist: contralateral femoral
screening, and imaging features that guide surgical
treatment by the orthopedic surgeon.
When an atypical femoral fracture is identi-
fied, screening of the contralateral hip and entire
femur is recommended with AP and lateral ra-
diographs (Fig 13) because up to 44% of patients
demonstrate a fracture in the contralateral femur
either at the time of the fracture or in subsequent
years (10,58). Contralateral radiography should
be performed during the patient’s initial hospital
stay because the presence of contralateral injury
may alter potential surgical treatment for both
the ipsilateral and contralateral injuries (10,57).
If no fracture is identified, recommendations can
Figure 9.  Illustration shows the locations of fatigue stress frac-
tures and atypical fractures in the femur.
include close clinical and radiographic follow-
up or immediate bone scanning or MRI. Bone
scanning or MRI should be favored whenever the
patient presents with clinical features associated
with atypical femoral fracture, such as thigh or
groin pain (57,59).
Surgical treatment of atypical femoral fractures
depends on a combination of clinical and imaging
factors. Displaced or complete fractures should
be treated surgically. Conservative treatment can
be considered in patients with incomplete atypical
fractures with minimal or absent groin or thigh
pain (10). Other imaging features that may raise
the risk of progression and suggest the need for
possible surgical treatment are (a) the presence of
a radiolucent line in the cortex, (b) fracture in the
subtrochanteric location, (c) deformity or bowing
of the femur, (d) the presence of a current or prior
contralateral atypical fracture, and (e) the absence
of healing at short-interval follow-up imaging (57).
Clinical features that may increase risk include
long-term patient use of and high adherence to
bisphosphonate therapy; glucocorticoid medica-
tion or proton pump inhibitor use; and thigh or
groin pain (57).
When surgery is indicated, intramedullary
nailing is the preferred treatment (Fig 14) and is,
in fact, considered by some to be the standard of
care for all transverse or obliquely oriented mini-
mally comminuted fractures of the lower extrem-
ity long bone diaphysis, regardless of cause (60).
Deformity, stenosis, or obstruction of the
intramedullary canal may affect device selection,
may even preclude treatment with an intra-
medullary device, and are important to note
to the orthopedic surgeon (60). For example,
excessive anterolateral femoral bowing may be
seen in atypical femoral fractures (49,50) and
requires an intramedullary nailing system with
an appropriate curvature and diameter to fit the
RG  •  Volume 38  Number 7 Marshall et al  2183

Figure 10.  Spectrum of radiographic abnormalities seen with atypical femoral fractures in three patients. (a) AP radiograph of the
right hip in a 64-year-old woman with periosteal and endosteal thickening (arrow) of the lateral cortex of the femoral diaphysis, which
is consistent with an atypical femoral stress reaction or a subtle fracture. (b) AP radiograph of the left hip in a 67-year-old woman
shows a transversely oriented fracture (white arrow) of the lateral cortex of the femoral diaphysis with associated endosteal beaking
(black arrow) and adjacent cortical thickening (arrowheads), findings that are consistent with incomplete atypical femoral fracture.
(c) AP radiograph of the right hip in a 59-year-old woman shows a noncomminuted fracture of the femoral diaphysis consistent with
a complete atypical fracture. The fracture is substantially transverse (white arrow) in the lateral cortex but becomes more oblique with
a medial spike as the fracture propagates medially (black arrow). Associated endosteal and periosteal beaking with thickening of the
lateral cortex suggest that this complete fracture originated in the lateral cortex.

Figure 11.  Traumatic fracture in a 38-year-old woman who

was involved in a high-speed motor vehicle collision. Sagittal (a)
and coronal (b) average intensity projection CT images show
a transversely oriented noncomminuted femoral fracture (ar-
row). Although the transverse noncomminuted fracture is
similar to that seen in an atypical fracture, features suggesting
that this is not an atypical femoral fracture include a history of
trauma, absence of lateral cortical thickening and beaking, and
absence of a medial spike.

between the stresses placed on the bone and the

deformed femur (57,61,62). In addition, the in-
tramedullary canal may be narrowed focally be-
cause of endosteal beaking in atypical fractures
or diffusely as a result of cortical thickening in
patients with insufficiency fractures related to
osteopetrosis (63,64). Regardless of the cause,
substantial intramedullary canal narrowing or
deformity may result in intraprocedural difficul-
ties with reaming of the medullary canal and
implanting the nail through the medullary canal,
particularly in brittle or insufficient bone (Fig
12) (62,65). For these reasons, severe deformity
or substantial narrowing of the medullary canal
is a relative contraindication to placement of an
intramedullary device.
Pathologic Fractures
Just as with stress and atypical fractures, patho-
logic fractures arise because of an imbalance
ability of the bone to withstand those stresses
without failure. With pathologic fractures,
diminished resistance to loading occurs owing
to erosion and replacement of the normal bone
architecture with a focal benign or malignant
neoplasm or osteomyelitis. With many lytic
neoplasms, the imbalance arises because of the
upregulation of osteoclast differentiation and the
resorption of bone outpacing new bone deposi-
tion (28). Some tumors lead to well-defined
bone destruction with clear borders, while other
tumors permeate through the bone, producing a
much less well-defined lesion.
Accurate discrimination of stress fractures
from pathologic fractures can be challenging for
the interpreting radiologist owing to overlap-
ping injury locations and imaging features. For
example, developing stress fractures may be
associated with aggressive radiographic features
such as irregular periosteal reaction or exu-
berant osteolysis and can be confused with a
pathologic fracture or lytic neoplasm (3,66,67).
In these scenarios, biopsy of a developing stress
fracture can further confound the true diagno-
sis because the immature osteoid formed in the
healing process can be interpreted as a finding
2184 November-December 2018 radiographics.rsna.org

Figure 12.  Osteogenesis imperfecta and a minimally traumatic humeral fracture in a

23-year-old man. (a) AP radiograph shows a minimally comminuted transverse fracture
of the right humerus (white arrow) resulting from minimal trauma. An oblique fracture
of the medial condyle also is seen (black arrow). Although the minimally traumatic
transverse noncomminuted fracture is similar in shape to an atypical fracture, it is not
an atypical fracture because of the humeral location, the presence of underlying bone
disease (osteogenesis imperfecta), the absence of cortical stress changes (endosteal
beaking, cortical thickening), and the absence of a medial spike. Therefore, this is best
referred to as an insufficiency (or fragility) fracture. (b) AP radiograph shows subse-
quent fixation of the fractures (black and white arrows) with intramedullary rods and
a cortical plate. Difficulties fitting the stiff intramedullary rod into the brittle humerus
resulted in an intraoperative oblique fracture of the proximal humeral diaphysis (arrow-
head), highlighting the surgical challenges encountered in patients with brittle bone
diseases and with narrow intramedullary canals.

of a neoplasm at histopathologic evaluation (9).
Conversely, a pathologic fracture may likewise
be misinterpreted as a benign fracture, resulting
in delay in the diagnosis of malignancy (3,68).
The clinical history of the patient and the loca-
tion of the injury can be important in differenti-
ating stress from pathologic injuries. Diagnoses
of stress fractures should be favored in young
healthy patients with a history of repetitive activ-
ity. Pathologic fractures, on the other hand, should
be considered particularly in elderly patients with
metastatic disease and without a history of repeti-
tive activities. As a note of caution, however, Ew-
ing sarcoma and primary lymphoma of the bone
in young patients may be challenging to differenti-
ate from the much more common diagnosis of
stress fracture (3,68). In addition, the location of
the injury can be useful for discriminating between
stress and pathologic fractures. Stress injuries
commonly occur in characteristic locations associ-
ated with specific activities (Table 2). Pathologic
fractures, on the other hand, occur most com-
monly in three locations: (a) the subtrochanteric
femur, (b) the junction of the humeral head and
metaphysis, and (c) in the vertebral bodies (3).
Avulsion injuries of the lesser trochanter of the
femur in adults should be considered pathologic
until proven otherwise (Fig 15) (70). Although the
clinical history and location of injury can be help-
ful, they are nonspecific, and in many scenarios,
they are insufficient to discriminate confidently
between benign and malignant causes.
RG  •  Volume 38  Number 7 Marshall et al  2185

Figure 13.  Screening of the entirety of the contralateral femur in two patients. (a) AP radiograph of the left hip in a 58-year-old
woman with hip pain and a new atypical femoral fracture who was taking bisphosphonate medication shows a transversely oriented
fracture (arrow) of the lateral cortex of the femur with endosteal and periosteal beaking, consistent with an incomplete atypical femoral
fracture. (b) Screening AP radiograph of the contralateral (right) hip performed during the same admission shows no contralateral
fracture; however, the entirety of the femur was not imaged, as is typically recommended. (c) A low-resolution scout radiograph of
the pelvis from a concurrently performed abdominal-pelvic CT examination shows the left-sided atypical fracture (black arrow) and an
atypical femoral stress reaction or subtle incomplete fracture in the right femoral diaphysis (white arrow), which was outside of the field
of view on the hip radiograph. (d, e) Cropped AP radiograph of the left hip (d) and stitched AP radiograph of the entire right femur (e)
in a 70-year-old woman show appropriate screening of the entire contralateral femur when an atypical fracture (arrow in d) is identified.

Imaging Findings.—MRI is best suited for
discrimination between benign and malignant
fractures owing to its ability to characterize mar-
row signal intensity abnormalities (3,68,71). The
most important marrow signal intensity charac-
teristic to differentiate benign from pathologic
fractures is the margin and homogeneity of the
T1-weighted signal intensity abnormality around
the fracture (Fig 16) (17,68). In benign fractures,
the T1-hypointense signal abnormality represents
acute edema and hemorrhage. Therefore, it may
demonstrate indistinct margins, patchy interven-
ing normal fatty marrow, and a gradual bandlike
transition to normal marrow signal intensity more
distant to the fracture (17,68,72). In many patho-
logic fractures, however, the T1-weighted signal
intensity abnormality is at least partially caused by
the infiltrative tumor. This often results in a more
homogeneously T1-hypointense signal abnormal-
ity with well-defined convex margins (17,68,72).
T2-weighted signal intensity abnormalities are
less specific, given the abundant marrow edema,
hemorrhage, and adjacent inflammation that can
be seen in acute fractures of any cause (17). Of
note, the MRI appearance of many pathologic
fractures—where a lesion is present with well-
defined margins—can be counterintuitive to less
experienced radiologists because the radiographic
appearance of many aggressive-appearing lesions
is classically one with a wide zone of transition.
2186 November-December 2018 radiographics.rsna.org

Figure 14.  Atypical femoral fracture in a 65-year-old woman who presented with left hip pain and insta-
bility after a fall from standing. (a) AP radiograph shows a fracture (arrow) with a transverse orientation in
the lateral cortex, medial spike, and lateral cortical endosteal beaking, findings consistent with a complete
atypical femoral fracture. (b) AP radiograph shows fixation with an intramedullary nail (arrow), which
is considered the standard of care for atypical femoral fractures and other noncomminuted transverse
fractures of the long bones.

A second feature that is helpful to differenti-
ate stress from pathologic fractures at CT and
MRI is the presence or absence of a well-defined
fracture line (Fig 16) (68,73). When present, a
fracture line extending from the cortical bone
into the cancellous bone may be suggestive of
a stress fracture (68,73). In many pathologic
fractures, the tumor may erode the trabecular
bone and infiltrate the fracture space, reduc-
ing the conspicuity of a distinct fracture line
(68,74). Other features that are more suggestive
of pathologic fracture at CT or MRI include an
aggressive periosteal reaction, cortical erosion,
endosteal scalloping, hypoenhancing (necrotic)
areas in the adjacent soft tissue, and the presence
of an enhancing soft-tissue mass (3,17,68).
Signal intensity and morphologic features have
been studied more extensively for discrimina-
tion of osteoporotic compression (insufficiency)
fractures from pathologic fractures in the vertebral
bodies. Although imaging protocols and manage-
ment are often different for spinal abnormalities,
imaging features useful for differentiating insuf-
ficiency and pathologic fractures in the spine may
share similarities to those of bones with similar
trabecular-predominant macrostructure. Just as
in the appendicular skeleton, both the pattern
of T1-hypointense signal and the absence of a
defined fracture line have demonstrated utility for
discrimination of the cause of fracture in the spine
(72,74,75). In addition, osteoporotic vertebral
compression fractures may be associated with a
band of sclerosis or trabecular impaction parallel
to the fracture line (76). This may be analogous
to the microcallus and linear sclerosis seen along
early trabecular stress fractures (1,34). Pathologic
fractures are more likely to erode the trabeculae
and are therefore less likely to demonstrate linear
sclerosis parallel to the fracture. Other features
that may suggest pathologic vertebral compres-
sion fracture include (a) destruction of cortical or
cancellous bone (72,74), (b) absence of a vacuum
or fluid cleft (74), (c) convexity or bulging of the
posterior vertebral body wall (75), (d) pedicle
involvement (75), a focal paravertebral mass mea-
suring greater than 10 mm (72,74,75), and (e) a
T1 signal intensity abnormality that persists at 3–6
month follow-up MRI (75–77) (Table 3). Ad-
vanced imaging techniques for evaluation of mar-
row signal intensity alterations, including dynamic
contrast material–enhanced MRI, chemical shift
MRI, and diffusion-weighted MRI, have shown
promise for discrimination of benign from malig-
nant fractures in the vertebral bodies (76,77).
Table 3 summarizes imaging findings with
multiple modalities that may be useful to
discriminate stress from pathologic fractures
(3,17,68,72,74,76–78). If definitive diagnosis
remains uncertain after initial imaging, diagnos-
tic options include immediate biopsy or short-
interval follow-up radiography and MRI (9,79).
In benign fractures, short-interval follow-up
imaging should demonstrate signs of healing
and improvement in marrow signal intensity
abnormalities by 2–3 months.
In the presence of a newly identified osse-
ous neoplasm, imaging has an important role in
prediction of the risk of the patient developing a
pathologic fracture. The Mirels scoring system
is the most commonly used scoring system and
RG  •  Volume 38  Number 7 Marshall et al  2187

Table 2: Common Stress Fracture Locations by Activity

Location Activity
Hamate (hook) Golf, tennis, baseball
Ulna (coronoid/olecranon) Throwing (eg, pitching), using a
wheelchair
Humerus (distal diaphysis) Throwing (eg, pitching)
Ribs Golf, rowing, heavy lifting
Lumbar spine (spondylolysis) Heavy lifting, ballet
Obturator ring/pubic bone Gymnastics, track and field, bowling
Femur (diaphysis, neck) Running, ballet, gymnastics
Tibia Running, basketball, ballet
Fibula Running, jumping (eg, acrobatics)
Calcaneus Jumping (eg, acrobatics), standing
Tarsal navicular Running
Metatarsal diaphysis Running, standing, basketball, ballet
Sesamoids of metatarsals Standing
Source.—Reference 69.

Figure 15.  Lesser trochanter avulsion in a 59-year-old man with a history of melanoma who presented with left hip
pain. (a) AP radiograph shows an avulsion fracture (arrows) of the lesser trochanter. (b) Coronal CT image shows the
underlying lytic lesion (arrow) in this patient with metastatic melanoma. Lesser trochanteric avulsion fractures in adults
should be considered pathologic until proven otherwise.

has proven valid and reproducible for predicting
impending pathologic fractures of the appen-
dicular skeleton on the basis of the radiographic
appearance of a bone lesion (Table 4) (80–82).
It is important for the radiologist to be familiar
with the Mirels scoring system and other risk
factors for fracture in a patient with a neoplasm
to provide the orthopedic surgeon with the most
clinically relevant features of osseous tumors
that guide surgical treatment. The system is
based on four primary characteristics: (a) the
site of the lesion, (b) the size of the lesion, (c) the
matrix of the lesion, and (d) the presence of pain.
These imaging features are scored as described
in Table 4 and a total score is calculated. Per the
original recommendation, prophylactic fixa-
tion is recommended for lesions with a score
greater than or equal to 9 (Fig 17); lesions with
a score of 8 are equivocal, and clinical judg-
ment is required; and lesions with a score of less
than 7 often can be treated medically (80). For
instance, a peritrochanteric (3 points) lytic (3
points) lesion that is less than one-third of the
diameter of the bone (1 point) with mild pain
(1 point) has a total score of 8 points. If the
lesion were any larger or pain were more severe,
prophylactic fixation would be recommended
according to the Mirels criteria. Outside of the
2188 November-December 2018 radiographics.rsna.org

Figure 16.  Fracture line and T1-weighted marrow signal intensity for differentiation of pathologic from stress frac-
tures. (a) Coronal T1-weighted MR image of the left femoral neck shows a stress fracture with a well-defined T1-
hypointense fracture line extending from the cortex into the trabecular bone (white arrow). Associated T1-weighted
signal intensity abnormality is poorly defined, with patchy intervening areas of normal fatty marrow (black arrows).
(b) Sagittal T1-weighted MR image of the right humerus demonstrates a subtle cortical disruption suggestive of
pathologic fracture (white arrow), without evidence of a well-defined T1-hypointense fracture line penetrating the
trabecular bone in the marrow cavity. Associated T1-hypointense signal abnormality is homogeneous and well de-
fined (black arrows), with minimal intervening normal T1-weighted fatty marrow.

Table 3: Features Suggesting Pathologic versus Stress Fractures

Modality Pathologic Fractures Stress Fractures: Fatigue and Atypical

Radiography Cortical destruction or endosteal scal- Endosteal and periosteal thickening
and CT loping Benign periosteal reaction
Aggressive periosteal reaction Intact sclerotic trabecula
Lytic or permeative marrow pattern Absent soft-tissue mass
Soft-tissue mass
Mineralized matrix
MRI Absent or infiltrated fracture line Well-defined fracture line extending
Well-defined T1-hypointense signal through trabecular bone
abnormality Poorly defined T1-hypointense signal
Homogeneously low T1-weighted signal abnormality
intensity without normal intervening Heterogeneous T1-weighted signal
marrow intensity with patchy normal interven-
Substantial adjacent muscle edema ing fatty marrow
Trace poorly defined adjacent muscle
edema
Scintigraphy/ Diffuse uptake Focal or linear uptake
PET
Sources.—References 3 and 17.

Mirels criteria, others have suggested prophylac- cm in diameter, when the fracture includes the
tic fixation when greater than 50% of the bone lesser trochanter, and in patients with pain after
width is destroyed, with lesions larger than 2.5 radiation of a lesion (85–87).
RG  •  Volume 38  Number 7 Marshall et al  2189

Table 4: Pathologic Fracture Risk (Mirels Criteria)

Score Location Pain Lesion Matrix Lesion Size*

1 Upper extremity Mild Blastic <1/3
2 Lower extremity Moderate Mixed 1/3–2/3
3 Peritrochanteric femur Functional† Lytic >2/3
*Lesion size refers to the fraction of the bone diameter as per the initial article by Mirels (80); how-
ever, more recent sources (83,84) refer to lesion size as a fraction of cortical involvement.
†Functional pain is defined as pain when the extremity is used (eg, leg pain when walking).

Figure 17.  Application of the Mirels criteria for im-

pending pathologic fracture in two patients. (a) AP ra-
diograph in a 66-year-old man with a history of renal cell
carcinoma and functional thigh pain (3 points) shows a
permeative lytic lesion (arrows; 3 points) of the lower
limb (2 points), which involves more than two-thirds of
the diameter of the cortex (3 points). (b) The Mirels cri-
teria score for this lytic lesion was 11 points, and there-
fore, it was fixated prophylactically before complete
fracture. (c) AP radiograph in 57-year-old man with
metastatic squamous cell carcinoma and mild left-sided
leg and groin pain (1 point) shows a lytic lesion (arrows;
3 points) of the lower limb (2 points), which spans more
than two-thirds of the diameter of the cortex (3 points).
This lesion scored 9 points and was therefore at risk for
impending fracture. (d) The patient declined fixation
at the time of radiography and presented 4 months
later with a pathologic fracture. Although this fracture
is noncomminuted, it shows a substantially transverse
orientation in the lateral cortex (arrow) and shows a
medial spike (arrowhead). It is not considered an atypi-
cal femoral fracture because of the absence of lateral
cortical beaking or thickening and the presence of an
underlying neoplasm (an exclusion criterion).

Additional Treatment Considerations.— De- the scope of this article. Factors influencing the
tailed treatment considerations for patients with optimal treatment strategy of pathologic fractures
pathologic fractures are complicated and beyond include an evaluation of the origin of the lesion,
2190  November-December 2018 radiographics.rsna.org
disease dissemination status, patient prognosis,
the overall health of the patient, fracture mor-
phology, and the local status of the involved
bone, among many other considerations (88). In
patients undergoing palliative treatment, surgi-
cal intervention may be offered for prophylactic
fixation of impending fractures or for mechani-
cal stabilization of pathologic fractures. In these
situations, the purpose of surgery is not curative;
surgery is offered for pain relief, restoration of
function, and improvement in quality of life (89).
Conclusion
Atraumatic fractures including stress, atypical, and
pathologic fractures are encountered commonly in
the emergency department and in clinical practice.
Radiologists should understand the terminology
and clinically relevant imaging features of atrau-
matic fractures to ensure timely identification,
characterization, and appropriate communication
of critical findings that affect treatment.
Disclosures of Conflicts of Interest.—M.J.W. Activities related to
the present article: disclosed no relevant relationships. Activities
not related to the present article: stipend for educational lectures
from the AO Foundation. Other activities: disclosed no relevant
relationships.
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TM
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