Imaging Features and Management of Stress, Atypical, and Pathologic Fractures

Radiographics. 2018 Nov-Dec;38(7):2173-2192. doi: 10.1148/rg.2018180073.


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, etiology, 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 remodeling 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 management 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 patients 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.

Publication types

  • Review
  • Video-Audio Media

MeSH terms

  • Bone Neoplasms / diagnostic imaging
  • Bone Neoplasms / pathology
  • Diagnosis, Differential
  • Fractures, Bone / diagnostic imaging*
  • Fractures, Bone / pathology
  • Fractures, Bone / therapy
  • Fractures, Spontaneous / diagnostic imaging
  • Fractures, Spontaneous / pathology
  • Fractures, Spontaneous / therapy
  • Fractures, Stress / diagnostic imaging
  • Fractures, Stress / pathology
  • Fractures, Stress / therapy
  • Humans
  • Risk Assessment