Case Author(s): Sam Wang, M.D. and Jerold Wallis M.D. , 7/18/95 . Rating: #D2, #Q4

Diagnosis: Sacral fracture, rib fractures

Brief history:

Elderly woman with pelvic pain.


Anterior and posterior images are shown

View main image(bs) in a separate image viewer

View second image(bs). Spot views of the ribs.

View third image(mr). T1 weighted image of the sacrum.

View fourth image(ct). CT of sacrum.

Full history/Diagnosis is available below

Diagnosis: Sacral fracture, rib fractures

Full history:

81-year old woman with history of multiple spontaneous rib fractures and presents now with low back and sacral pain. Plain films of the pelvis obtained revealed healing left inferior and superior pubic rami fractures. MRI of the pelvis obtained before bone scintigraphy demonstrated a broad area of marrow replacement in the S1 and S2 segments of the sacrum with the differential diagnosis lying between sacral insufficiency fracture and neoplastic marrow infiltrative processes.


The delayed whole body images from bone scintigraphy demonstrate intense uptake of the radiotracer in the sacral region involving both wings of the sacrum as well as the interposed sacrum. This finding, also known as the ³Honda² sign (named for the automakerıs emblem), is characteristic for sacral insufficiency fracture. There is also focally increased uptake in the region of the left superior and inferior pubic rami correlating with the radiographic findings of healing fractures. Also noted are multiple foci of increased uptake in the left anterior ribs connecting as two curved lines and are entirely consistent with rib fractures.


Sacral insufficiency or stress fractures occur commonly in patients who are osteoporotic or who have undergone radiation therapy. On bone scintigraphy, they commonly appear as an ³H² with vertical uptake in the sacral ala and horizontal uptake in the sacrum. Fractures may also be unilateral involving just one side of the sacrum or may appear as a transverse band of increased activity across the body of the sacrum.


Shortly after bone scintigraphy, the patient also had CT myelogram performed. Scans through the sacrum confirmed the presence of bilateral sacral insufficiency fractures.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Effect of Trauma)

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Case number: bs028

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