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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 4  |  Page : 283-285

Multiple insufficiency fractures related to Vitamin D deficiency in a young lady


Department Of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission10-Aug-2020
Date of Decision26-Oct-2020
Date of Acceptance28-Oct-2020
Date of Web Publication24-Nov-2020

Correspondence Address:
Dr. Abhishek Vaish
Indraprastha Apollo Hospital, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_103_20

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  Abstract 


A young girl presented with increasing bilateral groin pain for the past 3 months (visual analog scale score 8/10) and inability to weight bear for the last 1 month. Plain X-rays showed bilateral fractures of the femoral neck, extending in the intertrochanteric and subtrochanteric regions on both sides. Laboratory investigations revealed severe Vitamin D deficiency with secondary hyperparathyroidism. The insufficiency fractures are subtypes of stress fractures with decreased mineralization and weakened zone calcification of the bone. Clinical awareness about the insufficiency fractures and a high index of suspicion is required to make an early diagnosis. The majority of insufficiency fractures due to Vitamin D deficiency can be managed conservatively with timely diagnosis, adequate supplementation of Vitamin D, and calcium.

Keywords: Femur, insufficiency fractures, osteomalacia, osteoporosis, pelvis, Vitamin D


How to cite this article:
Vaish A, Vaishya R. Multiple insufficiency fractures related to Vitamin D deficiency in a young lady. Apollo Med 2020;17:283-5

How to cite this URL:
Vaish A, Vaishya R. Multiple insufficiency fractures related to Vitamin D deficiency in a young lady. Apollo Med [serial online] 2020 [cited 2021 Jan 17];17:283-5. Available from: https://www.apollomedicine.org/text.asp?2020/17/4/283/301470




  Introduction Top


Insufficiency fractures are common. These are subtypes of stress fractures with decreased mineralization and weakened zone calcification of the bone.[1] The most common sites of the insufficiency fractures include the pelvis, long bones of the lower extremity, and the vertebrae. We present a 22 year old female with increasing bilateral groin pain for the past 3 months and inability to weight bear for the last 1 month. Xrays showed bilateral fractures of the femoral neck, extending in the intertrochanteric and subtrochanteric regions on both sides. Laboratory investigations revealed severe Vitamin D deficiency with secondary hyperparathyroidism. She was treated with high dosage of Vitamin D, calcium, and phosphate. All of her insufficiency fractures had united without any further displacement, at 3-month follow-up. Hence, The majority of insufficiency fractures due to Vitamin D deficiency can be managed conservatively with timely diagnosis, adequate supplementation of Vitamin D, and calcium. Hence, the majority of insufficiency fractures due to Vitamin D deficiency can be managed conservatively with timely diagnosis, adequate supplementation of Vitamin D, and calcium.


  Case Report Top


A 22-year-old young female presented with increasing bilateral groin pain for the past 3 months (visual analog scale [VAS] score 8/10) and inability to weight bear for the last 1 month. Both hip movements were painful and restricted in all directions. There was no history of trauma.

Plain radiographs of the pelvis, on anteroposterior view, showed bilateral fractures of the femoral neck, extending in the intertrochanteric and subtrochanteric regions on both sides [Figure 1]. There was also an associated coxa vara deformity and severe osteoporosis around the hip joints. The computed tomography scan confirmed the presence of fractures involving the proximal femora bilaterally. In addition, there were fractures involving the ilium and both public rami on both sides [Figure 2].
Figure 1: Bilateral insufficiency fractures in proximal femora (with coxa vara) and pubic rami with juxta-articular osteoporosis

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Figure 2: A three-dimensional reconstructed image of a computed tomogram scan, showing bilateral proximal femoral, iliac blades, and public rami fractures

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Laboratory investigations revealed severe Vitamin D deficiency with secondary hyperparathyroidism [Table 1]. Complete blood counts and other kidney and liver function tests were within normal limits.
Table 1: Comparative laboratory reports

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The patient was put on a high dosage of Vitamin D, calcium, and phosphate. Initially, she was given an intramuscular injection of Vitamin D3 (600,000 units) and cholecalciferol (nanosuspension) 60,000 units twice a week for 4 weeks, followed by once a week for a further 5 months. She did not agree with the surgical fixation of these fractures. She responded adequately to medical treatment and rest. Her pain reduced significantly (VAS score 1/10), at 1 month follow-up. She could start walking with a walking frame after 2 months and without any support at 3-month follow-up. All of her insufficiency fractures had united without any further displacement, at 3-month follow-up [Figure 3], and the deranged laboratory investigations have returned back to normal range [Table 1] and remained within the normal range at 6-month follow-up. She was however left with an abductor lurch gait due to residual coxa vara and was advised corrective subtrochanteric valgus osteotomy of both femora, with plate fixation. However, she did not agree with the surgery, at present.
Figure 3: Healed pathological fractures with residual coxa vara

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  Discussion Top


The insufficiency fractures are subtypes of stress fractures with decreased mineralization and weakened zone calcification of the bone.[1] The most common sites of the insufficiency fractures include the pelvis, long bones of the lower extremity, and the vertebrae. The clinical presentation of these pathological fractures is variable. These may present with nonspecific low-grade chronic pain or with a spontaneous fracture. Vitamin D deficiency due to any cause may result in insufficiency fractures. Vitamin D deficiency causes a rise in PTH: Parathormone (Parathyroid hormone) as a secondary response to hypocalcemia or hypophosphatemia.[2] This results in altered mineral homeostasis in the bones, leading to weakened zones in the bones, which become prone to develop pathological fractures, like in this case. The other risk factors for such fractures include osteoporosis, chronic kidney and liver disease, prolonged bisphosphonate, and high-dose corticosteroid therapy.[3]

Clinical awareness about the insufficiency fractures and a high index of suspicion is required to make an early diagnosis. The femoral neck is at high risk for these fractures, being a zone of excess force transmission.

The majority of insufficiency fractures due to Vitamin D deficiency can be managed conservatively with timely diagnosis, adequate supplementation of Vitamin D, and calcium. The PTH and minerals such as calcium, phosphorus, and fluoride play a major role in the bone remodeling process. Surgical intervention is only required in major and displaced fractures of the weight-bearing bones and in those fractures which do not respond adequately to the conservative treatment.

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.
Vaishya R, Agarwal AK, Banka PK, Vijay V, Vaish A. Insufficiency fractures at unusual sites: A case series. J Orthop Case Rep 2017;7:76-9.  Back to cited text no. 1
    
2.
Ishimaru D, Sumi H. A case of an insufficiency fracture of the medial proximal tibia secondary to osteomalacia associated with long-term saccharated ferric oxide administration. Case Rep Orthop 2017;2017:1675654.  Back to cited text no. 2
    
3.
Hameed K, Packe GE, Legge JS, Friend JA. Spontaneous sternal fractures in four patients with chronic airflow obstruction taking corticosteroids. Thorax 1993;48:1183-4.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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