Rheumatoid arthritis (RA) can lead to insufficiency fractures due to bone weakness associated with the disease and its pharmacologic management. We report a 56 year old female with three weeks history of progressive non-traumatic pain and swelling in her right leg with inability to bear weight. X ray revealed a healing fracture of the lower third of right tibia and fibula. She had been using steroids for two years and currently was on methotrexate (MTX). Her serum vitamin D levels were sub-optimal. She was managed with POP back slab and immobilization for four weeks, vitamin D replacement therapy and rehabilitation. She was asymptomatic on follow up visit. Insufficiency fractures should be suspected in RA as they are often missed, leading to increased morbidity since the symptoms mimic disease relapse. Bone scan, CT scan, Magnetic resonance imaging can help in early diagnosis as X rays may appear normal initially.
Kay LJ, Holland TM, Platt PN. Stress fractures in rheumatoid arthritis: A case series and case-control study. Ann Rheum Dis 2004; 63: 1690-2.
Hooyman JR, Melton LJ 3rd, Nelson AM, O’Fallon WM, Riggs BL. Fractures after rheumatoid arthritis, A population-based study. Arthritis Rheum 1984; 27(12): 1353-61.
Dreher R, Buttgereit F, Demary W, Görtz B, Hein G, Kern P et al. Insufficiency fractures in rheumatology: Case report and overview. Z Rheumatol 2006; 65(5): 417-23.
Ha YJ, Lee SW, Lee SK, Park YB. Osteo¬porotic calcaneal stress fractures mistaken for aggravation of rheumatoid arthritis. Arthritis Rheum 2013; 65(11): 2983.
Spina A, Clemente A, Vancini C, Fejzo M, Campioni P. Spontaneous talar and calcaneal fracture in rheumatoid arthritis: A case report. J Radiol Case Rep 2011; 5(7): 15-23.
Michel BA, Bloch DA, Wolfe F, Fries JF. Fractures in rheumatoid arthritis: an evaluation of associated risk factors. J Rheumatol 1993; 20(10): 1666-9.
Elkayam O, Paran D, Flusser G, Wigler I, Yaron M, Caspi D. Insufficiency fractures in rheumatic patients: misdiagnosis and underlying characteristics. Clin Exp Rheu¬matol 2000; 18: 369-74.
Pauser J, Carl HD, Swoboda B, Jendrissek KA. Insufficiency fractures of the feet and lower limbs in rheumatoid arthritis. Z Rheumatol 2011; 70(10): 866-73.
Huusko TM, Korpela M, Karppi P, Avika¬inen V, Kautiainen H, Sulkava R. Three fold increased risk of hip fractures with rheumatoid arthritis in Central Finland. Ann Rheum Dis 2001; 60(5): 521-2.
Wijnands M, Burgers A. Stress fracture in long term methotrexate treatment for psoriatic arthritis. Ann Rheum Dis 2001; 60: 736-8.
Convey R, Bergin D, Carey JJ, Coughlan RJ. Tibial insufficiency fractures in rheumatoid arthritis: A new clinical sign. J Rheumatol 2012; 39(9): 1893-4.
Jolles BM, Bogoch ER. Current consensus recommendations for rheumatoid arthritis therapy: A blind spot for osteoporosis prevention and treatment. J Rheumatol 2002; 29(9): 1814-17.
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