An Atraumatic Symphysiolysis with a Unilateral Injured Sacroiliac Joint in a Patient with Cushing's Disease: A Loss of Pelvic Stability Related to Ligamentous Insufficiency?

Andreas Höch,Jörg Böhme,Philipp Pieroh,Faramarz Dehghani,Christoph Josten

doi:10.1155/2016/9250938

Andreas Höch, Jörg Böhme + Show 3 more

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https://doi.org/10.1155/2016/9250938

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Abstract

Glucocorticoids are well known for altering bone structure and elevating fracture risk. Nevertheless, there are very few reports on pelvic ring fractures, compared to other bones, especially with a predominantly ligamentous insufficiency, resulting in a rotationally unstable pelvic girdle. We report a 39-year-old premenopausal woman suffering from an atraumatic symphysiolysis and disruption of the left sacroiliac joint. She presented with external rotational pelvic instability and immobilization. Prior to the injury, she received high-dose glucocorticoids for a tentative diagnosis of rheumatoid arthritis over two months. This diagnosis was not confirmed. Other causes leading to the unstable pelvic girdle were excluded by several laboratory and radiological examinations. Elevated basal cortisol and adrenocorticotropic hormone levels were measured and subsequent corticotropin-releasing hormone stimulation, dexamethasone suppression test, and petrosal sinus sampling verified the diagnosis of adrenocorticotropic hormone-dependent Cushing's disease. The combination of adrenocorticotropic hormone-dependent Cushing's disease and the additional application of exogenous glucocorticoids is the most probable cause of a rare atraumatic rotational pelvic instability in a premenopausal patient. To the authors' knowledge, this case presents the first description of a rotationally unstable pelvic ring fracture involving a predominantly ligamentous insufficiency in the context of combined exogenous and endogenous glucocorticoid elevation.

Highlights

Besides their association with high-energy trauma, the majority (51%) of recent pelvic ring fractures are documented in patients older than 65 years after minor trauma, especially in female patients [1,2,3,4,5]
Considering the data, the patient suffered from a symphyseal diastasis leading to widening of the left sacroiliac joint with a rupture of the left anterior sacroiliac ligaments and by the hypermobility of the sacroiliac joint to a consecutively transiliac instability manifested as ventral ilium fracture
It seems to be more likely that ligamentous insufficiency contributed to the described ilium fracture as supported by finite element analysis [18]

Summary

Background

Besides their association with high-energy trauma, the majority (51%) of recent pelvic ring fractures are documented in patients older than 65 years after minor trauma, especially in female patients [1,2,3,4,5]. Other pathological conditions like rheumatoid arthritis with and without glucocorticoid (GC) therapy, malignancy, radiation, chemotherapy, drugs such as bisphosphonates, metabolic bone diseases, or pregnancy may contribute to pelvic ring fractures and a possible loss of stability [6,7,8,9,10,11,12]. These fractures may be present without adequate trauma or atraumatically and are often summarized as fragility fractures related to an impaired bone metabolism and composition [13]. After the exclusion of other causes leading to this injury the GC excess after two months of GC therapy and previously undiagnosed Cushing’s disease (CD) seem to be the most plausible reasons contributing to this predominantly ligamentous insufficiency presenting as a rotationally unstable pelvic ring fracture

Case Presentation

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Conclusion