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 Table of Contents  
IMAGES IN RHEUMATOLOGY
Year : 2017  |  Volume : 12  |  Issue : 2  |  Page : 110-111

Atraumatic bilateral subtrochanteric fracture in a young female with osteomalacia


Department of Rheumatology, King George Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication26-May-2017

Correspondence Address:
Rasmi Ranjan Sahoo
Department of Rheumatology, King George Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_19_17

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  Abstract 


Keywords: Osteomalacia, subtrochanteric fracture, Vitamin D deficiency


How to cite this article:
Dhakad U, Sahoo RR, Das SK, Bhadu D, Sharma M. Atraumatic bilateral subtrochanteric fracture in a young female with osteomalacia. Indian J Rheumatol 2017;12:110-1

How to cite this URL:
Dhakad U, Sahoo RR, Das SK, Bhadu D, Sharma M. Atraumatic bilateral subtrochanteric fracture in a young female with osteomalacia. Indian J Rheumatol [serial online] 2017 [cited 2020 Oct 31];12:110-1. Available from: https://www.indianjrheumatol.com/text.asp?2017/12/2/110/205160



A 22-year-old dark-skinned female presented with low back pain, bilateral knee and shoulder pain for the past 3 years. The pain was dull aching in nature, aggravated by weightbearing and physical activity. She also complained of difficulty in walking for the past 1 year. Past medical history and family history were unremarkable. The patient had reduced intake of dairy products. She had consulted local physicians and was on analgesics, multivitamins, and calcium supplements. On clinical examination, the patient was conscious and oriented. Neurological examination revealed decreased muscle tone in all the four limbs along with bilateral proximal muscle atrophy in the lower extremities. Muscle power was Grade 3/5 in both upper limbs and Grade 2/5 in both lower limbs. Deep tendon reflexes were normal in both upper and lower limbs with flexor plantar response. Cranial nerves and sensory examination were normal. There was no synovitis, however, range of movements were limited and painful at both hips. Rest of the systemic examination was unremarkable. Laboratory examination revealed hemoglobin: 9 g/dL, white blood cell count: 12,730/mm erythrocyte sedimentation rate: 30 mm/h, and C-reactive protein: 5 g/L. Her total serum calcium and ionic calcium were 7 mg/dl (normal: 8.1–10.4) and 4 mg/dl (normal: 4.8–5.7), respectively, serum phosphate: 2 mg/dl (normal: 2.5–4.5), serum alkaline phosphatase: 1180 IU/L (normal: 44–147), 25-(OH) Vitamin D3: 6 ng/ml (optimal level 30–50), and serum parathyroid hormone: 120 pg/ml (normal: 10–65). Total serum protein level was 7 g/dl with 3.9 g/dl albumin. Pelvis X-ray revealed fractures in the upper part of the bilateral femur and pubic bones [Figure 1]. Bone mineral density by dual-energy X-ray absorptiometry scan (DEXA) was suggestive of osteoporosis with Z-score of −3.7 at lumbar spine and −3.2 at the neck of femur. Tissue transglutaminase antibody test was negative. Liver, renal, and thyroid function tests and blood sugar levels were within normal limits.
Figure 1: Plain X-ray pelvis anteroposterior view showing bilateral subtrochanteric fractures of both femur and pubic bones

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The diagnosis of nutritional osteomalacia was made on the basis of low level of calcium and 25-(OH) Vitamin D3. The patient was treated with oral calcium and cholecalciferol 60,000 IU every week for 3 months followed by 800 IU daily. With this treatment, the patient showed significant increase in muscle power and pain subsided. Repeat 25-(OH) Vitamin D3 level at 3 months after initiating therapy was 40 ng/ml. The patient was able to walk pain free after 4 months of therapy. The pelvis X-ray after 6 months showed complete healing of fractures with some degree of deformity [Figure 2]. Repeat DEXA scan after 1 year revealed marked increase in bone mineral density (Z score −1.9 at lumbar spine and −1.7 at the neck of femur).
Figure 2: Plain X-ray pelvis anteroposterior view showing complete healing of fractures with some deformity, after 6 months of treatment

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  Discussion Top


Osteomalacia is a metabolic bone disease due to Vitamin D deficiency; characterized by mainly softening of bone, muscle and bone pain, proximal muscle weakness, osteoporosis, pseudofractures, and fractures. Pseudofractures also known as Looser's zones often are bilateral, symmetric, and lie perpendicular to the long axis of the bone. They represent either stress fractures, repaired by inadequately mineralized osteoid, or erosion of bone by arterial pulsations. Subtrochanteric region of hip is one of the strongest parts of the femur, and fractures in this area have been described occasionally in athletes, prolonged bisphosphonate therapy, or cases of hypophosphatemic osteomalacia.[1],[2] The patient had low bone mineral density for her chronological age with a Z score of −3.7 at lumbar spine which would have contributed to fracture.[3] Vitamin D related osteomalacia may be due to reduced sun exposure, poor dietary intake, decreased intestinal absorption, abnormal hepatic metabolism, reduced endogenous synthesis or vitamin D resistance at end organ level. Response to oral vitamin D supplementation is multifactorial with significant increments seen in patients with lower baseline 25-(OH) Vitamin D3 levels. Various studies have shown considerable difference in the dose-response relationship in Vitamin D supplementation. A well controlled study measured serum 25-(OH) Vitamin D3 levels after supplementation in subjects with low dietary intake of Vitamin D during the winter season. They predicted 400 IU/d supplementation of Vitamin D would elevate serum 25-(OH) Vitamin D3 by 7.0 nmol/L.[4]

Subtrochanteric pseudofractures of the femur due to osteomalacia often heal with calcium and Vitamin D supplements. Surgical intervention is not always required unless there is displaced fracture. Conservative management has been reported successful.[5] Our patient was given calcium, oral Vitamin D3, and had remarkable improvement in 2½ years of follow-up.

Nutritional osteomalacia is a reversible condition, and in the present case morbidity related to delayed management has been highlighted. Hence, patients presenting with pathological subtrochanteric fracture should also be evaluated for osteomalacia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Butler JE, Brown SL, McConnell BG. Subtrochanteric stress fractures in runners. Am J Sports Med 1982;10:228-32.  Back to cited text no. 1
    
2.
Cermak K, Shumelinsky F, Alexiou J, Gebhart MJ. Case reports: Subtrochanteric femoral stress fractures after prolonged alendronate therapy. Clin Orthop Relat Res 2010;468:1991-6.  Back to cited text no. 2
    
3.
Schousboe JT, Shepherd JA, Bilezikian JP, Baim S. Executive Summary of the 2013 ISCD Position Development Conference on Bone Densitometry. JCD 2013;16:455-67.  Back to cited text no. 3
    
4.
Heaney RP, Davies KM, Chen TC, Holick MF, Barger-Lux MJ. Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol. Am J Clin Nutr 2003;77:204-10.  Back to cited text no. 4
    
5.
Craig NJ, Maffulli N. Subtrochanteric fractures: Current management options. Disabil Rehabil [Internet]. Taylor and Francis 2005;27:1181-90.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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