Why we need to investigate stress fractures carefully.
My clinical practice somehow attracts lots of people with overloaded bones. I see several hip stress fractures each week.
It’s no doubt outside the ‘norm’ for my profession, but it’s simply because I see a lot of athletes and active folk with hip problems. In other words, it’s ‘bread and butter’ clinical work for me.
Every now and then I meet a particularity surprising case, and one such patient had a very interesting story to tell; she kindly agreed for me to share it with you.
Most patients with bone stress injuries will be able to give you a pretty good account of how they came to be in trouble.
‘I guess I compressed sixteen weeks of marathon training into eight weeks, because the boss kept sending me to New York’.
‘I really got into five-times-a-week boot camp, because my wedding was coming up’.
‘Some mates and I went on the lash, and thought it was a wise move to do a Tough Mudder’.
My patient had another tale to tell.
The only thing different she had done, was to birth a baby in a water bath. As she was giving her final push to bring junior into the world, she lunged forward and felt an almighty crunch in her right groin.
Because she is a stoical sort of lass, she ‘got on with things’. Despite the fact that she couldn’t weight bear on her leg for two weeks, she decided that this was part and parcel of having a baby.
(Midwives everywhere, please let me know if you have had other cases of such brave patients?)
Eventually after seven weeks of limping around in misery, she came into clinic. Her bone stressed right hip was glowing in the dark on the MRI – I literally had to do a double take and check the name of the patient.
So, she’s been off loaded onto crutches.
I’m guessing that like me, you felt her story seemed, well, dodgy.
As with all patients, I sent her for a DEXA scan and bloods. Lots of bloods. Her DEXA showed that she had just crept into the osteopenic range in her lumbar spine, but nothing more.
Her biochemistry results were a little more exciting.
Atypically for smoke shrouded Londoners, she actually had a heathy vitamin D.
Her prolactin level however was somewhat unhealthy. Breast feeding might push prolactin levels into the high hundreds, but our new mum had a prolactin level that topped out over thirty thousand.
She’s now off for an MRI scan of her head, and we will find out if she has been growing a pituitary adenoma as well as a baby.
So… the moral is:
If the clinical picture doesn’t fit the story, you’ve gotta dig deeper.