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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01083-6
10.1016/j.ijscr.2024.110302
110302
Case Report
Bilateral femoral shaft fractures in osteomalacia: A case report and literature review
Khan Abdul Rehman rehmankhan@duhs.edu.pk

Rehan Fatima
Nasrumminallah Maryam
Kumar Harendra harend.kella@hotmail.com
⁎
Dow University of Health Sciences, Karachi, Pakistan
⁎ Corresponding author at: Medicine and Surgery, Dow University of Health Sciences, Karachi, Pakistan. harend.kella@hotmail.com
15 9 2024
10 2024
15 9 2024
123 1103022 8 2024
8 9 2024
13 9 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

When two non-traumatic femoral shaft fractures happen at the same time, they are usually not caused by high-energy trauma or medical conditions like osteomalacia caused by poor nutrition, long-term bisphosphonate medication use, or steroid use. Because this phenomenon is connected to inadequate bone mineralization and bone metabolism, it occurs when a bone is consistently under high stress.

Case presentation

A 40-year-old lady with a medical history of osteomalacia, including continuous vitamin D replacement therapy, showed up at the emergency room complaining of discomfort and swelling in her right thigh caused by a fall. During the emergency examination, X-rays showed a subtrochanteric fracture with a short oblique fracture line and a displaced oblique fracture in the right femoral shaft, but no fragmentation in the left femoral shaft. Osteomalacia caused the bilateral femoral shaft fracture in which the patient was identified as being displaced. We planned a surgical correction that included a closed reduction with intramedullary nailing and distal static screws on the right side, as well as intramedullary nailing followed by locking screw insertion on the left. Following the operation, the avoidance of bisphosphonate medications gained precedence.

Clinical discussion

Patients of any age who come with bone pain, non-traumatic fractures, and muscle weakness should have their blood vitamin D, ALP levels, and BMD evaluated for osteomalacia. If a conventional X-ray shows normal, an MRI or bone scan of both hips is recommended to rule out any underlying fatigue fractures. Finding and treating the underlying cause of osteomalacia can help improve the prediction.

Conclusion

Intramedullary nailing with screws is the most effective treatment for femoral shaft fractures. Improving patient outcomes relies on identifying and treating the underlying cause of osteomalacia. Given the patient's history and condition, avoiding bisphosphonate medicines following surgery was a primary priority in this case.

Highlights

• Bilateral femoral fractures in osteomalacia are rare and linked to poor bone mineralization.

• A 40-year-old woman with osteomalacia presented with bilateral femoral fractures.

• Use MRI or bone scans if X-rays appear normal to detect fatigue fractures.

• Intramedullary nailing with screws provides optimal biomechanical stability and allows for early mobilization, making it the best treatment for femoral shaft fractures.

• Avoid bisphosphonates and treat the underlying cause of osteomalacia for better outcomes.

Keywords

shaft femur
osteomalacia
bilateral
femoral diaphyseal fracture
insufficiency fracture
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pmc1 Introduction

Osteomalacia, which mostly affects the lower extremities, is a common cause of insufficient fractures [1]. Stress fractures, including insufficiency fractures, Because the femur is a frequently affected anatomical site, these fractures account for between 0.7 % and 20 % of all injuries of this kind [2]. Osteomalacia happens when the process of bone mineralization is interrupted [1,2]. This leads to the buildup of unmineralized matrix in places where the bone is under stress or where blood vessels bring nutrients to the bone [2]. Reduced absorption from the gastrointestinal tract and increased excretion via the kidneys may both contribute to inadequate mineralization caused by a calcium or phosphorous deficit in the circulation [2]. The illness is largely associated with altered bone metabolism, and its clinical manifestations often include tiny trauma-related fractures, muscle weakness, and bone soreness [1,2].

Osteomalacia has long been unappreciated and inadequately managed, owing to the fact that it is no longer widely seen as a lifestyle-related illness. Studies conducted between 1974 and 2020, using bone samples to assess the occurrence of osteomalacia in hip fractures, indicated prevalence ranges of 2 % to 37 % [3]. These numbers highlight osteomalacia's important, although generally unappreciated, impact on fracture risk [1,4]. The underdiagnosis of osteomalacia may be due to its general symptoms, which are readily associated with different disorders. Furthermore, its decreased identification as a widespread ailment has resulted in gaps in effective treatment and early diagnosis [5].

Though vitamin D deficiency plays a significant role, the etiology of osteomalacia is complicated [6]. Calcium and phosphorous balance are dependent on vitamin D; therefore, a lack of this vitamin may result in inadequate bone mineralization [7]. Other variables that may worsen this illness include gastrointestinal issues that limit nutrient absorption, certain medications, and chronic renal failure [1,5].

This case report discusses the case of a forty-year-old woman with osteomalacia who had stress fractures in both femoral shafts. Her experience underscores the need for improved osteomalacia awareness and diagnostic vigilance, especially in patients who approach with unusual fractures or prolonged bone pain. This article was written according to the SCARE guidelines [3].

2 Case presentation

A 40-year-old female housewife with a documented history of osteomalacia, including ongoing vitamin D replacement therapy, presented to the emergency department. She reported experiencing right thigh pain and swelling due to a fall that occurred one day prior. It is notable that she had previously suffered bilateral femur stress fractures approximately 3 to 4 months earlier. Upon a physical examination, the patient exhibited localized pain in the right thigh and experienced mild discomfort in the left thigh. No visible open wounds or injuries were observed. Additionally, her spinal structure appeared to display deformities. However, it is worth noting that her distal neurovascular bundle was fully intact.

In the emergency setting, X-rays in both lateral views (Fig. 1 A) and anteroposterior (A/P) (Fig. 1 B) revealed a displaced oblique fracture in the right femoral shaft. Simultaneously, the left femoral shaft displayed a subtrochanteric fracture with a short oblique fracture line, characterized by a lack of communication.Fig. 1 Initial radiograph (A) lateral view (B) anteroposterior view.

Fig. 1

In light of this unusual fracture pattern, a comprehensive preoperative evaluation was conducted, encompassing the assessment of tumor markers and bone series. Notably, these investigations did not reveal any pathological findings. The patient also reported having no prior medical history of diabetes mellitus or kidney disease. We planned surgical correction with open reduction and internal fixation, so the patient underwent a surgical procedure under aseptic conditions and general anesthesia. In the supine position, the patient was scrubbed and draped. An incision was made on the left side, and a guide wire was inserted to facilitate the placement of an intramedullary nail sized 10/36, followed by the securement of locking screws. On the right side, closed reduction was performed, with a 3 cm incision made for entry. A guide wire was inserted for the intramedullary nail, and distal static screws sized 45 were put in place, along with a 65-sized LAS screw. The wound was closed in an aseptic manner. It's important to note that bisphosphonate therapy was avoided post-surgery. Post-surgery, the patient made excellent progress and was able to bear weight immediately. Three months later, clinical and radiological assessments confirmed complete bone healing. (See Fig. 2.)Fig. 2 Post-operative radiograph showing intramedullary nails (A) Right (B) Left.

Fig. 2

3 Discussion

We described the case of a 40-year-old female who developed a bilateral femoral shaft fracture without any trauma. Bilateral femoral shaft fractures are unusual injuries, and there have been few articles discussing the conditions. Bilateral femoral shaft fractures have been observed to occur 4.6 % of the time worldwide [1,4]. Given that osteomalacia, for unknown reasons, caused this unusual fracture to occur bilaterally and simultaneously, this circumstance is both very instructive and significant.

A vitamin D shortage in adults can lead to osteomalacia, a disease of the mineralization of freshly formed organic matrix [5]. Diagnosing osteomalacia is crucial because it matches with the clinical picture of osteoporosis. Fukumoto suggested the osteomalacia diagnostic parameters [4]. A number of examinations are required for a conclusive finding of osteomalacia, including laboratory testing (including biopsy), imaging (such as X-ray and bone scintigraphy), and blood workup [5].

A patient's recent meal and the time of sample collection are two important variables that might affect the serum levels of calcium, phosphorus, and albumin, which are necessary for diagnosing osteomalacia [6]. Additionally, reports suggested that no abnormalities in biochemistry were seen in about 20 % of individuals with osteomalacia. All our patient's blood reports were normal. As a result, these values may not always be abnormal, which could cause osteomalacia to be misdiagnosed during standard biochemistry testing [7]. Osteomalacia can be misdiagnosed as osteoporosis, and its treatment with bisphohonates can further aggrevate osteomalacia because bisphohonates are contraindicated [8]. Previous research has found a strong association between prolonged bisphohonate therapy and femoral shaft fracture [7,8]. In our case, the patient was already diagnosed with osteomalacia, and there was no history of bisphohonate therapy.

A worldwide health concern, vitamin D insufficiency can be caused by insufficient sunshine exposure, poor dietary intake, or illnesses that affect the body's ability to absorb vitamin D, such as diseases of the liver or kidneys. Deficiency softens the bones by affecting bone mineralization. It is called a major reason for osteomalacia in adults. With a prevalence of 73 %, Pakistan has the highest rate of adult vitamin D insufficiency in South Asia [[8], [9], [10]]. Our patient was vitamin D deficient and was getting treated with vitamin D supplements before the fracture.

The mortality rate for simultaneous bilateral femoral shaft fractures has been shown to be as high as 16 %; that's why prompt diagnosis and management matter [11]. The aim of therapy is to maximize ultimate functionality by accurate reduction and firm fixation to restore articular and mechanical alignment [11,12]. Femoral fractures ought to be typically corrected; intramedullary nails, plates, or a mix of the two can be used as a choice of implants. Following the most recent recommendations from the American Society of Bone and Mineral Research (ASBMR), we performed intramedullary femur nailing in our patient and advised them to stop taking bisphosphonates and avoid exerting weight on their left lower leg [13].

IMN is currently the preferred technique for internal fixation of FSF, particularly in closed fractures [14]. Stabilization using IMN is said to have the following advantages: prompt mobilization, a high rate of union, a proper alignment, and fewer shortcomings [13,14]. When treating FSF, external fixation is rarely utilized, with the exception of patients who have open fractures with severe soft tissue damage [14].

4 Conclusion

In conclusion, for patients of any age presenting with bone pain, non-traumatic fractures, and muscular weakness, a comprehensive evaluation including serum vitamin D levels, alkaline phosphatase (ALP) levels, and bone mineral density (BMD) is essential to investigating suspected osteomalacia. If standard X-rays are inconclusive, MRIs or bone scans of both hips should be performed to detect potential underlying fatigue fractures. Timely identification and treatment of the underlying cause of osteomalacia are critical for enhancing patient outcomes. In cases of femoral shaft fractures, intramedullary nailing with screws remains the optimal treatment approach.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

No approval is required for the ethical committee for publication of this case report.

Funding

No source of funding available.

Author contribution

Dr. Abdul Rehman: for approving to write case report, operated this case.

Dr. Fatima Rehan: collecting data writing case and interpretation.

Dr. Maryam Nasrumminallah: collecting data, writing case and interpretation.

Dr. Harendra Kumar: for Interpretation, Validation, Reviewing and Writing.

Guarantor

Harendra Kumar.

Research registration number

N/A.

Declaration of competing interest

No conflict of interest.

Data availability

The data that support the findings of this study are available from the corresponding author, Harendra Kumar, upon reasonable request. The data are not publicly available since this could compromise the privacy of research participants.
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