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Abstract
Femoral neck fracture is a
serious complication of transient osteoporosis of the hip during
pregnancy. A case of spontaneous bilateral femoral neck fracture
is presented. The healing is observed on the right hip
spontaneously. On the left a femoral non union is observed,
surgery will be necessary.
Characteristics of transient osteoporosis of the hip during
pregnancy are reviewed and the mechanism is discussed.
Keys words: Transient osteoporosis;
Pregnancy; Femoral neck fracture
J.Orthopaedics 2006;3(3)e14
Introduction:
Transient osteoporosis during pregnancy is an uncommun
diagnosis. The hip is the most frequent localisation of this
disease and femoral neck fracture an exceptional critical
situation.
Case Report
A 41 years old
primigravida was admitted in Orthopaedics unit two months after
a succesful uncomplicated vaginal delivery.
She is crippled and presented with bilateral
pain of the hip. These symptoms started at 28 weeks of her
pregnancy, without hip trauma.
Physical examination showed lameness and external rotation of
the legs with no length disparity. The patient is walking with
the assistance of arthritic crutch.
X-ray showed bilateral fracture of the femoral neck (fig. 1).
Medical laboratory
investigations were normal (F.B.C., sedimentation rate, calcium,
phosphorus, total protein, albumin and hydroxyprolin).
The diagnosis of bilateral spontaneous
bilateral fracture of the femoral neck was done. It is a
complication of transient osteoporosis of the hip during
pregnancy. After two months rest and
medication (calcitonin) the healing was complete on the right
neck femoral (fig. 2). On the left,
non-union of the femoral neck was observed.
Discussion
About a hundred cases of
transient osteoporosis during pregnancy or post-partum has been
published with a preferencial localization to the hip [1].
However the real frequency of this disease is under estimated
[2] [3]. Most of the time, women present during pregnancy
various painfull syndroms, so called lumbago or sciatalgia and
are not well investigated. In fact, even the available
investigations allowing the diagnosis (X-Rays, Scintigraphy) are
limited during pregnancy. The biology is normal; only the
sedimentation rate and hydroxyproliuria are elevated and have no
pathological signification during pregnancy [4].
The pathogenesis is not
well known even though some risks factors were involved :
-
increase weight
-
microtrauma owe to
foetal movement
-
compression of the
pelvic sympathetic nerves by gravid uterus [5]
-
compression of the
pudental nerve [6]
-
compression of the
inferior vena cava leading to venus stasis [7]
-
hypertriglyceridemia
Transient osteoporosis
during pregnancy is a self-limiting disorder that resolves over
the course of six to eight months [8]. The femoral neck fracture
is an exceptional [9] and dangerous complication. The first
cases were reported by Curtiss et Kincaid [6]. This complication
is presenting insidiously. However a high suspicion should
permit the use of magnetic resonance imaging (MRI). MRI may an
early diagnosis and shows a diffuse bone – marrow – eodema –
pattern signal with an increased signal intensity on T2 –
weighted images and a decreased on T1 – weighted images [10,
11]. The neck femoral fracture find its explanation in the
weakening of the bones during pregnancy related to osteoporosis
and rarefiante osteopathy [12] ; most of calcium from the mother
for the benefit of the foetus is also involved [13].
Our observation is
peculiar :
-
the neck femoral
fracture is spontaneous (there is no trauma)
-
the discovery of the
fracture is fortuitous
-
the fracture is
bilateral. A review of the literature found three observations
concerning spontaneous bilateral femoral fracture of the neck
during transient osteoporosis of the hip [14] [15] [16]
-
the healing is observed
in one side after few weeks rest, without surgery. In the
other side, osteosynthesis with bone graft or arthroplastic
will be necessary.
Conclusion:
The
transient osteoporosis of the hip during pregnancy is a disease
that should not be under estimated.
The occurence of the fracture of femoral neck is the most
serious complication. In non displaced
case the outcome is good without surgery: rest and some
medication (calcitonine). Surgery is advocated in displaced
cases.
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