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Home , Osteopenia, Stress fracture

Scaphoid in a 65-year-old Man with Low Bone Mineral Density: A Case Report

Dean W. Smith, MD* *Department of Plastic and Reconstructive , Hand & Upper Extremity, University of Texas Health Sci- ence Center at Houston, Clinical Instructor (Private practice in Houstin, Texas)

Correspondance: Orthopaedic Hand and Upper Extremity Surgery, 6400 Fannin, Suite 2080, Houston, TX 77030 (phone: 713-524-0580; [email protected]).

Abstract of an endocrinologist for treatment of type 2 diabetes mel- litus and hypothyroidism when the pain began. This case Although commonly reported in women and less common- highlights the importance and management of a nontrau- ly in younger athletes, no studies have reported stress frac- matic scaphoid stress fracture and its probable indication tures of the scaphoid in older, sedentary men. Because of its of . rarity, in older men is often unrecognized and only diagnosed after the fracture. I describe a previously Case Report sedentary 65-year-old man who presented to my clinic with pain in the right wrist after his first day of intense physical A male attorney aged 65 presented to my clinic with pain activity and underwent 8 weeks of splinting and bracing in the right wrist. At the advice of his primary care physi- for treatment of a fracture of the waist of the scaphoid. Ten cian, he resumed physical aerobic exercise and tennis after weeks after the pain began, a computed tomography image 20 years of a sedentary lifestyle. The patient drank alco- revealed healing of the fracture with mild deformity and hol on occasion and never used tobacco. On the first day the results of a bone densitometry test met the criteria for of exercise, he participated in intense striking drills with a osteopenia. Nontraumatic wrist pain in older male patients tennis ball for an hour. The next day, he noticed pain, lim- may be a clinical sign of fragility stress fracture, which can ited range of motion, and mild swelling in his right wrist. indicate low bone mineral density and subsequent risk of No direct to the wrist was reported, and the patient metabolic . did not have a history of wrist trauma. Initial radiographs obtained by his previous orthopaedic surgeon were read Introduction as “mild wrist arthritis,” but the symptoms did not resolve with rest, splinting, or nonsteroidal . His per- Stress fractures are often associated with repetitive im- tinent medical history included seasonal allergic airway pact loading and have been reported in athletes, laborers, disease, hypothyroidism controlled with oral , military recruits, and patients with underlying metabol- hypertension, type 2 diabetes mellitus, and kidney stones. ic disease. This type of fracture mainly affects pre- and Two weeks after the onset of wrist pain, he was referred to post-menopausal women in the lower extremities. Stress my clinic for evaluation. fractures of the wrist are much less common but have been On physical examination, the patient had a body mass described in younger athletes (associated with competitive index of 24.8 kg/m2. His right wrist was mildly swollen and gymnastics, badminton, cricket, soccer goaltending, and painful to palpation in the area of the anatomical snuff- platform high diving).1-5 box. The range of motion of his wrist was limited in radial However, no studies have reported stress fractures of the and ulnar deviation and extension. Results of a neurovas- scaphoid in sedentary older men. In the current case, a pre- cular examination were normal, and pain was felt over the viously sedentary 65-year-old man developed acute wrist scaphoid during the Watson shift test. pain after a repetitive stress event. He was under the care Radiographs of the wrist obtained 2 weeks after the pain began revealed a possible fracture of the waist of

60 UNM Orthopaedics Journal 2015 Case Report 61 the scaphoid with mild osteoarthritic changes in the sca- thyroid hormone. uncouples the normal process of bone formation and References photrapezoid-trapezial joint. Osteopenia in the proximal Ten weeks after the pain started, a computed tomography resorption, which leads to net loss of and pole of the scaphoid was also noted (Figure 1). Images ob- image showed a healed scaphoid waist fracture with increased risk of fracture. Primary osteoporosis is more 1. Matzkin E, Singer DI. Scaphoid stress fracture in a tained by magnetic resonance imaging revealed a complete mild humpback deformity (Figure 3). Results of a bone common, accounting for about 80% of osteoporosis in 13-year-old gymnast: a case report. J Hand Surg Am 9 scaphoid waist fracture with mixed signal changes in the densitometry test revealed abnormal bone density, met women and 50% in men. Secondary osteoporosis accounts 2000;25(4):710-3. proximal pole, which was suggestive of evolving avascular the criteria for osteopenia established by the World Health for 50% of the cases in men, is typically multifactorial, 2. Brutus JP, Chahidi N. Could this unusual scaphoid frac- 6 necrosis (Figure 2). No signs of carpal collapse or fragmen- Organization, and indicated a medium risk for fracture. and can arise as a consequence of lifestyle factors, diet, ture occurring in a badminton player be a stress fracture? tation were detected, and the scapholunate and lunotrique- Six months after the pain began, his wrist range of motion eating disorders, endocrinopathies, systemic disease, Chir Main 2004;23(1):52-4. tral ligaments were intact. had improved and he was free of pain with all activities of organ dysfunction, , and as the result of treating 3. Rethnam U, Yesupalan RS, Kumar TM. Non union of 11 daily living. these conditions. Indirect and direct loss of bone density scaphoid fracture in a cricketer - possibility of a stress frac- is ultimately related to altered osteoclast and ture: a case report. J Med Case Rep 2007;1:37. function. 4. Pidemunt G, Torres-Claramunt R, Ginés A, de Zaba- It is estimated that more than 2 million men in the la S, Cebamanos J. Bilateral stress fracture of the carpal 12 United States have osteoporosis. Most of the cases of scaphoid: report in a child and review of the literature. Clin osteoporosis are unrecognized and diagnosed only after the J Sport Med 2012;22(6):511-3. fracture. As many as 85% of all hip fractures and 90% of all 5. Hosey RG, Hauk JM, Boland MR. Scaphoid stress frac- vertebral fractures in older-aged men are associated with ture: an unusual cause of wrist pain in a competitive diver. 10 osteoporosis. Men have a 13% to 25% risk of developing Orthopedics 2006;29(6):503-5. osteoporosis in their lifetime and a 33% to 47% risk of Figure 3. Obtained 10 weeks after the pain started, a computed 6. World Health Organization. Assessment of Fracture Risk tomography image of fine-cut sagital bone window in line with developing osteopenia after age 50, compared with a 50% and Its Application to Screening for Postmenopausal Oste- 13,14 the long axis of the scaphoid shows a healed fracture with minimal risk for women in both cases. oporosis. Geneva: Word Health Organization; 1994. WHO humpback deformity. Nontraumatic wrist pain in middle- to older-aged men Technical Report Series 843. should alert clinicians to a possible fragility stress fracture 7. Wright VJ. Osteoporosis in men. J Am Acad Orthop Surg and orthopaedic surgeons to potentially diminished bone 2006;14(6):347-53. Discussion density, as described in this case. Workup should include 8. Hannan MT, Felson DT, Anderson JJ. Bone mineral den- evaluation of underlying disease processes that may Figure 1. Radiographs of the right wrist obtained 2 weeks after sity in elderly men and women: results from the Framing- pain started show possible osteopenia in the proximal pole of the Stress fractures of the wrist are uncommon but have been contribute to decreased bone mass suggestive of secondary ham osteoporosis study. J Bone Miner Res 1992;7(5):547-53. scaphoid and a subtle line of a fracture in the waist of the scaphoid reported in cases of repetitive stress and younger athletes. osteoporosis. In addition to managing the fracture, the 9. Templeton K. Secondary osteoporosis. J Am Acad Or- consistent with a stress fracture. Mild osteoarthritic changes in the However, relative to normal aging, the risk of osteopenia goal of treatment is to lower the risk of additional fractures thop Surg 2005;13(7):475-86. scaphotrapezoid-trapezial joint are also noted. and osteoporosis increases, resulting in secondary fragility and preserve quality of life, and interventions should limit 10. Melton LJ 3rd, Thamer M, Ray NF, et al. Fractures at- and insufficiency fractures that are directly associated future bone loss. tributable to osteoporosis: report from the National Osteo- Figure 2. Coronal magnetic with decreasing bone mineral density. Metabolic bone porosis Foundation. J Bone Miner Res 1997;12(1):16-23. resonance imaging T1- weighted image obtained 2 disease such as osteoporosis has been linked to fragility 11. Bilezikian JP. Osteoporosis in men. J Clin Endocrinol 7 weeks after pain started shows fractures in both men and women, although no scaphoid Metab 1999;84(10):3431-4. the nondisplaced fracture stress fractures were reported in middle- to older-aged of the waist of the scaphoid sedentary men. In the current case, underlying secondary and proximal pole changes suggestive of . osteopenia may have caused a stress fracture of the waist of the scaphoid. Although osteoporosis has been associated mostly with older women, results of the Framingham study in 1992 revealed that loss of bone density in the femoral neck was linear with age and equivalent in men and women.8 The Treatment included 6 weeks of the patient wearing prevalence rates of osteoporosis in men are lower than a short-arm thumb spica splint with clamshell design women because of three main factors: men have increased followed by 2 weeks of intermittent supportive bracing with accumulation of bone mass during development, slower a durable medical equipment device. During treatment, declines in hormonal function with age, and shorter life his endocrinologist recommended daily use of low-dose spans.9 The higher peak in bone mineral density with men supplements for , , and multivitamins. compared to women results in a 10-year age gap of fragility Results of laboratory tests on serum concentration fractures of the hip, vertebrae, and distal radius (ie, an indicated normal levels of parathyroid hormone, follicle 85-year-old man would have about the same absolute bone stimulating hormone, prolactin, testosterone, vitamin mineral density as a 75-year-old woman).10 D, 1,25-dihydroxyvitamin D, luteinizing hormone, and A patient with primary or secondary osteoporosis

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