Case report
Asymmetrical multiple stress fractures
in an elderly lady due to secondary
hyperparathyroidism
Abstract
Multiple asymmetrical stress fractures occur very
rarely. We describe here an elderly lady with multiple
asymmetrical stress fractures including no weight
bearing bone . The fracture sites included were
bilateral neck of femur, bilateral tibial condyle ,
costochondral junction. The known causes of multiple
stress fractures including cushings 1 syndrome,
rheumatoid2 arthritis and epilepsy were absent in this
case. The patient underwent bilateral hemiarthroplasty
in staged manner .The patient is ambulant with walker
and knee brace to protect tibial condyle fracture.
Background
Stress fractures are usually seen in young individuals, in
weight bearing bones. Stress fractures occur commonly
following repeated trauma .Multiple asymmetrical
fractures occurs very rarely. The usual causes include
osteoporosis, either primary or secondary to cushing’s
syndrome or rheumatoid arthritis. It can also occur
following epileptiform convulsion, or in association with
irradiation. Stress fractures due to hyperparathyrodism
have been described in calacaneal 3stress fractures. Few
cases of femoral stress fracture have been described with
chronic renal failure4.
Case presentation
A 70 year old lady presented with history of pain both
hips for 2 years, which was increasing in severity
rendering patient immobile and bed ridden for last 2
months . There was no history of trauma. Patient is a
known case of DM, HTN, and CKD on treatment. There is
a history of CA cervix for which patient was given 6 cycles
of localized radiotherapy four years back, CA cervix
symptoms preceded the hip pain. On examination, left
hip joint line tenderness was present, movements of left
hip were painful and restricted. Patient was evaluated for
osteomalacia, cushings syndrome and other known
causes of stress fractures. Patient underwent left hip
hemiarthoplasty with AMP followed by hemiarthoplasty
right hip as staged procedure in view of her poor
anesthetic risk (ASA grade II ). Following surgery hip pain
was relieved and patient was mobilized in walker and
knee brace to protect tibial condyle fracture.pin fixation
was not considered as head fragment was avascular.
Biopsy was negative for malignancy, osteoporosis,
radiation necrosis, and osteomalacia. Harris hip score
improved from score of 25 to 50 following surgery
Bone scan showed
1. Increased uptake in skull bone (due to
hyperparathyroidism),in costochondral junction(due to
stress fracture),in B/L femoral neck (due to stress
fracture),B/L tibial condyle( due to stress fracture)
Conclusion
Stress fractures usually occur in young
individuals, in weight bearing bones due to
repeated activity and trauma. Multiple stress
fractures are rare. most cases of reported
multiple stress fractures are symmetrical .Here,
we report a case of multiple but asymmetric
stress fractures with involvement of non weight
bearing bone as well. There was a stress
fracture in the costochondral junction which is
a non weight bearing bone which is
uncommon. There was increased uptake in
skull in bone scan, due to hyperparathyroidism
.she was obese with weight 73 kg and BMI
35.26 .she is known case of CRF ,which has
resulted in secondary hyperparathyroidism,
which in turn resulted in multiple stress
fractures even though there was no trauma
REFERENCES
1 .multiple stress fractures-an unusual presentation of cushings
disease-FRANCESCAK, ONTELL, DAVID, sacramento, California- WJM,
april 1995,vol 162,no 4
2..multiple stress fractures in rheumatoid arthritis, by BARRY MILLER
,HERBERT, from department of physical medicine and rehabilitation,
orthopedic surgery, general rose memorial hospital, Denver-JBJS VOL
49 A,NO 7,OCTOBOR 1967
3. Atypical heel pain-hyperparathyroidism induced stress fracture of
calcaneus-by FISHCO WD et all-American college of foot and ankle
surgeons,flagstaff.
4. Bilateral stress fractures of femoral neck from renal osteomalacia-s
sengupta, dept of orthopaedics surgery, university Malaya medical
centre, kuala lumpur