Page 24 - Delaware Medical Journal - November/December 2020

Figure 5 Normal histological evaluation of small intestine mucosa.1 Figure 6 Abnormal histological evaluation of celiac disease.2
problems that developed. Fortunately for this patient, she did not develop complete calcium or iron deficiency anemia, but her laboratory findings were in the low normal range.
In addition to the work-up for nutritional deficiencies as a cause of her atraumatic fractures, additional causes were investigated and
ruled out along the course of her treatment. When evaluating the
cause of atraumatic fractures and futher trying to place them into the insufficiency or stress type, it can be helpful to look at any intrinsic and/
or extrinsic contributing factors. Intrinsic factors include biomechanics (malalignment, gait abnormality, muscle imbalance, and small bone diameter) and biochemical issues (hormone imbalance, low bone mineral density, pathologic bone diseases, and nutritional deficits).5 Extrinsic factors include training errors (overuse, lack of cross training, lack of conditioning, sudden increases in training intensity
and duration, and poor technique), enviromental challenges (nonabsorbing training surface and banked tracks), and improper equipment (inappropriate footwear, prolonged use of footwear, and non-gender-specific training equipment).5
It should be noted that there are instances where both intrinsic and extrinsic factors may contribute to the same fracture, making definitive diagnosis difficult. It has also been found that women are 3.5 times more likely to sustain stress fractures than men, and are more prone to femoral stress fractures.5 One study found that most atraumatic fractures due to intrinsic factors are due to underlying nutritional deficits, such as vitamin
D deficiency.6 Furthermore, it has been shown that the cause of vitamin D deficiency in such patients is most commonly inadequate sun exposure, ETOH abuse, or smoking.6 All three of these factors were noncontributory to our patient’s condition. In the elderly
population, medication toxicity, such as corticosterid use, has also been associated with calcium and vitamin D deficiency resulting in atraumatic fractures.5
The patient presented here was diagnosed with osteomalacia, but had
a normal DEXA scan performed six weeks after treatment of her fracture. It should be noted that a positive DEXA scan is not required for the diagnosis
of osteomalacia. Osteomalacia and osteoporosis are two distinct disease processes. While osteoporosis
results in brittle and weak bone due
to decreased bone mineral density, osteomalacia results in soft bone
due to a decreased ratio of mineral
to matrix or demineralization. One study showed that 70% of patients with osteomalacia will have osteoporosis
on DEXA, which in turn highlights the fact (supported by another study) that an individual can have osteomalacia with normal BMD on DEXA.7,8 In fact, subjective assessment of BMD alone
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Del Med J | November/December 2020 | Vol. 92 | No. 6