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In the sacrum, stress fractures are associated with osteoporosis or prior radiation therapy to the pelvis (an insufficiency fracture). The osteoporotic sacrum develops a characteristic fracture with fracture lines running vertically through the left and right sides of the bone just medial to the SI joints, in conjunction with a transverse fracture just below the level of the SI joints. The fractures appear as a hot, geographic lesions confined to the sacrum and often have a characteristic “butterfly” or “Honda sign” appearance. Plain film are typically normal, but may show a sclerotic lesion.

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