Subacute neck of femur fracture in severe renal osteodystrophy

Case contributed by Dr Jason Szczepanski

Presentation

Two weeks of right hip pain and difficulty weight-bearing after twisting in the bathroom. History of end-stage renal failure (ESRF) on dialysis. Previous left non-ossifying fibroma (NOF) fracture managed non-operatively, one year prior.

Patient Data

Age: 30 years
Gender: Male

Severe osteopenia reduces the diagnostic sensitivity of this study.

Within these limits, abrupt change in contour involving the right femoral head/neck junction is suggestive of an impacted fracture, the chronicity of which is uncertain.

Recent nondisplaced left superior pubic ramus fracture and segmental left inferior pubic ramus fracture, with likely evidence of early callus formation in the latter. No further acute fractures identified.

Presence of cortical thickening of bilateral proximal femoral heads and shepherd crook deformity. Multiple well-circumscribed cortically based lucent lesions most compatible with brown tumors in the context of renal osteodystrophy.

Moderate sized right hip joint effusion present. Segmental loss of normal intramedullary fat from subcapital to mid right femoral neck on T1W series, hardly visible on the T2W series, representing a fracture.

Adjacent muscle edema in the medial aspect of the right obturator externus and adjacent hip adductors, also present in the gluteal muscles laterally, with subcutaneous edema overlying the greater trochanter. No erosive arthropathy to suggest septic arthritis.

Conclusion:

Recent femoral neck fracture, in addition to known subacute left superior and inferior pubic rami fractures.

Case Discussion

This patient was managed conservatively for his previous contralateral neck of femur fracture 12 months prior, with an overall acceptable result.

A unit consensus was to manage conservatively again, with a short period of non-weight-bearing followed by protected weight-bearing for short distances.

Given the patient's severe tertiary hyperparathyroidism, he underwent a subtotal parathyroidectomy as an inpatient.

Overall, he recovered well from his right neck of femur fracture.

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