Dhaniwala Nareshkumar Satyanarayan, Dhaniwala Mukund Naresh
Department of Orthopedics, Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.
Department of Orthopedics, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India.
J Orthop Case Rep. 2020 Sep;10(6):49-53. doi: 10.13107/jocr.2020.v10.i06.1872.
Pathological fractures in long bones are commonly caused by simple bone cyst or Osteogenesis imperfecta in children and by metastatic tumors from primary carcinoma, multiple myeloma, osteoporosis, and bone tumors in adults. Hyperparathyroidism causing pathological fractures, though a well-known entity, is seen infrequently in clinical practice. The fractures occur in the expansile fibro-cystic bone lesions called as "Brown tumor." The reported case describes a patient with classical features of primary hyperparathyroidism (PHPT) having multiple lytic lesions in pelvis and bilateral femur with pathological fracture. It is being reported due to its rarity.
A 28-year-old young married lady presented with chronic dull aching pain in both thighs and difficulty in walking for 2 years. Examination revealed tenderness in both thighs, with antalgic gait. X-ray pelvis with both thighs showed multiple lytic lesions of variable size in both femora and pelvis. Blood investigations showed raised levels of serum calcium, with highly raised levels of serum parathyroid hormone (PTH). Contrast-enhanced computerized tomography (CT) scan of neck demonstrated parathyroid adenoma. The patient admitted for prophylactic nailing for right femur, developed a fracture while indoor and was managed by right proximal femoral nailing, followed by parathyroid adenoma excision. Follow-up showed dramatic clinical and radiological improvement with good healing of fracture. Lytic lesions healed gradually and blood parameters returned to normal. The patient remains asymptomatic at 2 years follow-up.
Advanced case of symptomatic PHPT affecting bones is rare and it should be considered as a differential diagnosis in cases of a solitary and or multiple osteolytic lesions. Serum calcium and PTH level estimation at an early stage prevents missing the diagnosis and progression of disease. Early diagnosis and appropriate treatment help in rapid clinical improvement with almost total reversal of bony changes, thus avoiding devastating complications.
儿童长骨病理性骨折通常由单纯性骨囊肿或成骨不全引起，而成人则由原发性癌转移瘤、多发性骨髓瘤、骨质疏松症和骨肿瘤引起。甲状旁腺功能亢进导致病理性骨折，虽然是一个众所周知的病症，但在临床实践中很少见。骨折发生在被称为“棕色瘤”的膨胀性纤维囊性骨病变中。本文报道的病例描述了一名具有原发性甲状旁腺功能亢进（PHPT）典型特征的患者，其骨盆和双侧股骨有多个溶骨性病变并伴有病理性骨折。因其罕见性而予以报道。
一名28岁已婚年轻女性，双大腿慢性钝痛伴行走困难2年。检查发现双大腿压痛，有跛行步态。骨盆及双大腿X线检查显示双侧股骨和骨盆有多个大小不一的溶骨性病变。血液检查显示血清钙水平升高，血清甲状旁腺激素（PTH）水平显著升高。颈部增强计算机断层扫描（CT）显示甲状旁腺腺瘤。患者因右股骨预防性钉固定入院，在住院期间发生骨折，随后行右股骨近端钉固定，接着切除甲状旁腺腺瘤。随访显示临床和影像学有显著改善，骨折愈合良好。溶骨性病变逐渐愈合，血液参数恢复正常。在2年随访时患者仍无症状。
有症状的晚期PHPT累及骨骼的病例罕见，在出现孤立性和/或多发性溶骨性病变的病例中应将其作为鉴别诊断。早期测定血清钙和PTH水平可防止漏诊和疾病进展。早期诊断和适当治疗有助于临床快速改善，几乎完全逆转骨改变，从而避免严重并发症。
