Intertrochanteric Fracture in Young Woman Without Osteoporosis: A Case Study

Intertrochanteric Fracture in Young Woman Without Osteoporosis: A Case Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Intertrochanteric Fracture in Young Woman Without Osteoporosis: A Case Study Hazel Gray, Atticus Gray This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4782971/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This case presents a 42-year-old non-osteoporotic white female runner with an intertrochanteric stress fracture in the right hip which progressed to a displaced intertrochanteric fracture during a low-impact weighted hip exercise and required surgical intervention. X-rays revealed several previously untreated stress fractures throughout her lower body which had healed without intervention. This is an unusual case because nontraumatic stress fractures in the hip are quite rare in younger and non-osteoporotic patients. Additionally, the previous fractures in her lower body indicate that her injury was not acute, but part of a deeper, chronic issue. This study investigates and briefly discusses several inconspicuous factors present in this patient that could have contributed to this issue, including: Coeliac disease and other food intolerances, malnutrition, subclinical hypothyroidism, overexercise, and iron-deficiency anaemia. Herein are also identified and suggested relevant, potent areas for the consideration of further research. 1 Introduction Here is presented a study of a 42-year-old white female admitted to the orthopaedic surgical centre for an unusual case concerning an intertrochanteric fracture in her right hip. Investigation into the events preceding her admission reveals that this fracture occurred in an abnormal fashion. The patient had been routinely engaged in large volumes of low-intensity, steady-state exercise leading to the acute onset of localised pain in her anterior right hip six weeks prior to treatment. This is likely when the stress fracture occurred. She originally ignored this pain, thinking she pulled a muscle in her hip flexor, but it eventually progressed to a displaced intertrochanteric fracture during a weighted hip exercise 20 days before the operation. The patient was post-operatively tested for osteoporosis and found to have a sufficiently normal bone mass, with a bone mineral density (BMD) T-score of -0.4 in the left femoral neck bone and − 1.0 in the lumbar spine. Other testing revealed various indicators of malnutrition. X-rays and CT scans showed several other untreated fractures the patient had incurred over the previous three years including fractures in both the left pelvis and in two right metatarsals, all of which had significantly healed without intervention. The patient additionally showed symptoms of Coeliac disease and subclinical hypothyroidism, with a high thyroid-stimulating hormone (TSH) level of 6.120 mLU/L and a normal T4 level of 8.3 ug/dL. This study discusses the patient’s applicable medical history, focusing on her consecutive fractures, exercise levels, development of Coeliac disease, and history of anaemia. Given her young age, non-osteoporotic BMD, and the nontraumatic nature of her fracture, it appears that factors other than those commonly attributed as causative for hip fractures may have made significant contribution to her injuries. These factors, to be discussed in the following paragraphs, include Coeliac disease, other food intolerances, malnutrition, subclinical hypothyroidism, overexercise, and anaemia. 2 Case Presentation In the three years preceding her intertrochanteric fracture, the patient reported pain in various other locations throughout her lower body. This pain was later determined to be a result of various lower body fractures, specifically in the third and fourth metatarsals of her right foot, the lateral left inferior pubic ramus, and the lateral left superior pubic ramus. X-rays and CT scans verified the existence of these fractures, each of which had sufficiently healed without any medical intervention by the time of the intertrochanteric surgery. Additionally, both preceding and during her fractures, the patient reports having recognised negative physiological reactions such as hives, swelling, rashes, and gastrointestinal pain upon the consumption of glutenous foods, as well as other foods including salmon, eggs, and nuts. Eventually she chose to remove these foods from her diet, but this did not effectively occur until after her surgery. Further observations reveal that many of these intolerances developed during this same three-year time period preceding the surgery. Prior to the patient’s initial recognition of pain, she was an established endurance athlete, regularly participating in high levels of exercise. In the weeks prior to her stress fracture, the patient continued to be routinely involved in physical activity, averaging 60–80 minutes of daily exercise, consisting of 4–5 miles of running and at least an additional 30 minutes of weight lifting for four days each week. She also lived a generally active lifestyle, averaging 20 000–30 000 daily steps in addition to her exercise program. When the patient first started to experience pain, she assumed it was due to a pulled muscle and reduced her exercise load to casual weight lifting, during which she eventually exacerbated her stress fracture into a displaced fracture. The patient was engrossed with measuring her caloric consumption and exercise, frequently concerning herself with body image and physical fitness and often holding herself to levels of uncomfortable hunger to follow preset restrictions she had established for herself. She reports eating about 2600–2900 kcal/day and water consumption of at least 5 liters/day. Note that due to her various food intolerances, actual caloric and nutritional absorption was probably less than reported consumption. Furthermore, many years prior to this period, the patient had been experiencing a form of oligomenorrhea involving frequent and painful heavy menstrual bleeding with large clots, leading to anaemia. Ten years prior to her fractures, she began taking prescribed progesterone (norethindrone, 0.35 mg/day) to alleviate her pain and lessen her menstrual blood loss, the latter of which eventually ceased. At the time of her intertrochanteric surgery, the patient was 165 cm tall and weighed 60 kg. She was a nonsmoker and never drank alcohol. The patient reported that she had initially been experiencing extreme lower back and hip flexor pain resulting in severely limited mobility. She thought she had pulled a muscle during a weighted hip exercise and had been seeing a chiropractor twice a week for three weeks in attempt to recuperate. After three weeks of no alleviation but only increased pain, she had visited a nearby clinic, received an X-ray, and found that her right pelvic bone was split along the border between the intertrochanteric region and the femoral neck (this X-ray also revealed the healed pubic ramus fractures). Because of the delay in receiving medical attention and the patient’s continued exercise (though greatly reduced), the originally unnoticed stress fracture was acutely exacerbated into a displaced fracture, signifying an urgent need for surgical intervention. The operation, which involved first the setting of the bone and then the insertion of a cephalomedullary nail, was successful, and the patient has experienced no significant resulting complications to date. Post-operative testing revealed a BMD with a T-score of -0.4 in the left femoral neck bone and − 1.0 in the lumbar spine, indicating an absence of osteoporosis, a notable finding given the prevalence of this low bone mineral density condition in similar cases. [ 1 ] However, these results barely bordered on a diagnosis of osteopenia/low bone mass (BMD T-score between − 1.0 and − 2.5 SD). Other testing administered at the time of surgery revealed other possibly consequential values, as shown in Table 1 . Table 1 Patient Data Patient Variables Results Normal Range (For Lab Results) Gender Female — Age 42 years — Height 165 cm — Weight 60 kg — Daily Consumption Variables Daily Caloric Consumption 2600–2900 kcal — Daily Water Consumption 5L — Alcohol or Tobacco Use None — Physical Activity Variables (Minimum; Prior to Stress Fracture) Miles Run 20 + per week — Minutes Weight Lifting 120 + per week — Additional Step Count 20 000–30 000 + per day — Lab Variables Vitamin D 27.30 ng/mL 30.00–100.00 ng/mL Calcium 9.3 mg/dL 8.5–10.1 mg/dL T4, Total 8.3 ug/dL 4.8–13.9 ug/dL Thyroid-Stimulating Hormone (TSH) 6.120 mlU/L 0.358–3.740 mlU/L Anion Gap 1.0 mmol/L 5.0–15.0 mmol/L Neutrophil Prevalence 73.1% 50% − 60% Absolute Neutrophil Count 3.6 K/uL 1.8–7.7 K/uL Lymphocyte Prevalence 17.8% 25.0% − 40.0% Absolute Lymphocyte Count 0.9 K/uL 1.0–4.8 K/uL Hemoglobin 14.0 g/dL 12.0–16.0 g/dL Hyaline Casts 0–2/LPF 0 LPF Bone Mineral Density (BMD), T-Scores Left Femoral Neck Bone -0.4 (-1.0) - (-2.5) SD for Osteopenia /Low Bone Mass Lumbar Spine -1.0 (-1.0) - (-2.5) SD for Osteopenia /Low Bone Mass 3 Discussion What sets this case apart from standard intertrochanteric fracture cases is the abnormal, unidentified cause of the patient’s injury. Some other hidden, nonobvious, or otherwise publicly undiscussed factors appear likely to have been the underlying cause of such a significant fracture. Although the patient is a white female, the demographic population amongst which hip fractures are most prevalent, [ 2 ] she also: is young (42 years), when hip fractures are generally rare; 2 lacks osteoporosis, which is prevalent in the majority of hip fracture cases among young patients; 1 and never underwent any trauma in causation of her injury (the injury occurred during a slow and methodical weighted exercise, not involving a fall or other traumatic accident). Hip fractures are rare and relatively unstudied in younger populations, and even amongst such populations are usually found to be due to falls and osteoporosis. [ 3 ] That this patient is such a notable exception gives reason to investigate what other probable factors may have caused her ultimate injury. One factor likely to have played a somewhat significant role in these events is a group of food intolerances the patient possesses, including Coeliac disease. There is some research on the possible correlation between this gluten intolerance and an increased risk of fractures or decrease in BMD. Some studies indicate that such a correlation does exist, [ 4 ] others argue otherwise, and still others conclude that more research must be done to reasonably settle the question. [ 5 ] Further investigation into this study and others like it could help provide valuable insight into this possible correlation. The patient’s blood and urinary tests revealed multiple indicators of possible malnutrition, including a low Vitamin D level (27.30 ng/mL), a low anion gap (1.0 mmol//L), a presence of hyaline casts (0–2/LPF), and TSH level (6.120 mlU/L, indicative of hyperthyroidism). These readings help shed light on other areas that might have contributed to the patient’s fracture. Low levels of Vitamin D, though common amongst Americans, do play an important role in bone health. However, as Vitamin D’s primary effect on bones is due indirectly through calcium absorption, and as the patient’s calcium levels read normal (9.3 mg/dL; normal range 8.5–10.1 mg/dL), it appears that this factor may not have significantly influenced this particular case. [ 6 ] Low anion gap readings are most often due to testing errors, [ 7 ] but readings remained low over three separate blood tests (ranging from 1–3 mmol/L; normal range 5–15 mmol/L). This low reading, then, could be due to a variety of reasons, including a decrease in albumin protein or an increase in some unmeasured cation such as lithium. [ 7 ] Hyaline casts are the most common type of urinary casts, and their presence in very low quantities is not abnormal. Composed of the protein uromodulin, they indicate dehydration, strenuous exercise, or any renal disease. Given the patient’s circumstances, reported water consumption (5 L/day) and other corresponding lab results, it appears that renal disease and dehydration are both unlikely and that these hyaline casts are most likely due to strenuous exercise, a finding confirming reported observations. [ 8 ] Finally, the patient’s TSH level (6.120 mlU/L) is somewhat high, indicative of subclinical hypothyroidism, a condition resulting from reduced thyroid hormone action. [ 9 ] Hypothyroidism is nearly ten times more common in females than in males, [ 9 ] and studies show a positive correlation between Coeliac and hypothyroidism [ 10 ] increasing the likelihood of the patient’s having this disease. Symptoms of subclinical hypothyroidism include weakness, depression, sleep disturbances, and menstrual irregularities such as menorrhagia—[ 10 ] Symptoms the patient has reported in varying degrees over the course of the three years preceding her fracture. Many of these values indicate the possible presence of malnutrition, another factor that may have led to the patient’s fractures. How could this have arisen? The patient had been eating adequate quantities of food in a healthy variety. However, the patient’s Coeliac disease would likely have reduced the amount of nutrients her body could have absorbed from these foods, as this pernicious disease can led to the damaging and deterioration of the lining of the GI tract. [ 11 ] The resulting condition, known as malabsorption, greatly hinders the body’s ability to absorb ingested nutrients. In particular, Coeliac disease can result in the body’s reduced capability to absorb vitamins and minerals such as Vitamin D and iron. Additionally, Coeliac disease’s damage to the GI tract can lead to low levels of other important nutrients such as the protein albumin (the protein commonly responsible for a low anion gap). [ 11 ] Seeing that there may exist a link between Coeliac disease, malabsorption, and fracture frequency, this possible correlation is highlighted here as another potentially fruitful area for further research. Another factor that may have played a role in the patient’s fracture is her level of exercise. Although the patient had exercised quite a lot (hours of various levels of activity each day with few recovery days and almost no days of complete rest), it is hard to tell if her level of exercise was enough to truly qualify as overexercise. The patient’s hyaline casts do indicate that this might have been the case to at least some degree, as discussed above, but there is no certainty of this. The only substantial thing that can be stated concerning this factor is that overexercise could have been present in this patient, especially given the nature of her fractures (each occurring while the patient was actively exercising). [ 12 ] That being said, further research is needed to determine the veracity of such a relationship. The last factor to be suggested in this study that may have contributed to the patient’s fracture concerns her menstrual history, particularly in regards to her oligomenorrheic menstrual condition. Many years before her fractures and her development of Coeliac disease, the patient was diagnosed with anaemia. This anaemia was likely due to chronic and non-resorptive blood loss, [ 13 ] resulting in a state of iron-deficiency anaemia. [ 14 ] Upon pre-operative testing, ten years after beginning to take her prescribed progesterone, the patient’s haemoglobin levels were found to be normal, signifying that she was no longer anaemic. However, over this time period, she simultaneously developed stronger symptoms of Coeliac disease. This course of events contradicts the typical positive correlation existing between Coeliac disease and iron-deficiency anaemia, a relationship in which the former usually causes the latter. [ 15 ] Determining whether this is a coincidence, an exception to the theoretical rule, or some other shrouded area of medicine requires further research and investigation. It is also possible that her menstrual bleeding desisted due to overexertion in strenuous exercise. However, this is unlikely, as her menstrual bleeding ceased before this postulated cause occurred and did not resume when she stopped exercising post-operation. Again, this is another relevant topic for future/further research. These, then, are some thoughts and speculations as to what appear to have had an impact on the patient’s fractures, especially in the culmination of her rare intertrochanteric fracture. As this study concerns only a single patient, our findings our naturally quite limited. However, the relationships that appear to have presented themselves in this study are promising areas for beneficial investigation. This case presents a host of research opportunities, especially those in the investigation of the influences and correlations between nonobvious or otherwise incompletely explored factors that could influence the likelihood of hip fractures. 4 Conclusion As has been shown, this case study presents an anomalous patient. She was lacking osteoporosis, was still at a young age, had not injured herself by means of falling or other trauma, yet had still suffered from a variety of lower body stress fractures and ultimately required surgery for a displaced and angulated intertrochanteric fracture. The causes of this patient’s fracture may help enlighten the current understanding of risk factors of intertrochanteric and other hip fractures. Possible factors discussed in this paper include Coeliac disease and other food intolerances, malnutrition, subclinical hypothyroidism, overexercise, and iron-deficiency anaemia. Declarations 5.2 Ethics approval This study successfully met the criteria for exemption under 45 CFR 46.104(d)(4)(iii). This study was conducted and carried out without discrimination based on any premises and without any ethical compromises in accordance with 1964 Declaration of Helsinki. Informed consent was properly obtained from the patient in accordance with the FDA Informed Consent Guidance Document. 5.3 Competing interests All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. 5.4 Consent to publish The participant has consented to the submission of the case report to the journal. 5.1 Funding The authors did not receive support from any organization for the submitted work. Author Contribution All authors contributed equally across the various portions of this article. Data Availability The data collected for this study was obtained through access to the patient’s medical records and through interviews with the patient. This data is not publicly available and cannot be publicly accessed as this would be an infringement upon the patient’s privacy. References Boden, S.D., Labropoulos, P. & Saunders, R. Hip fractures in young patients: Is this early osteoporosis?. Calcif Tissue Int 46, 65–72 (1990). https://doi.org/10.1007/BF02556089 Benetos, I.S., Babis, G.C., Zoubos, A.B., Benetou, V. & Soucacos, P.N. Factors affecting the risk of hip fractures. Injury 38, 735-744 (2007). https://doi.org/10.1016/j.injury.2007.01.001 Ahn, J. & Bernstein, J. In Brief: Fractures in Brief: Intertrochanteric Hip Fractures. Clin Orthop Relate Res 468 , 1450-1452 (2010). https://doi.org/10.1007/s11999-010-1263-2 Zanchetta, M.B., Longobardi, V. & Bai, J.C. Bone and Celiac Disease. Curr Osteoporos Rep 14, 43–48 (2016). https://doi.org/10.1007/s11914-016-0304-5 Olmos, M., Antelo, M., Vazquez, H., Smecuol, E., Mauriño, E. & Bai, J.C. Systematic review and meta-analysis of observational studies on the prevalence of fractures in coeliac disease. Digestive and Liver Disease 40, 46-53 (2008). https://doi.org/10.1016/j.dld.2007.09.006 Khazai, N., Judd, S.E. & Tangpricha, V. Calcium and Vitamin D: Skeletal and Extraskeletal Health. Curt Rheumatol Rep 10, 110-117 (2008). https://doi.org/10.1007/s11926-008-0020-y Haber, L.A., Dhaliwal, G., Lo, L. & Rizzuto, G. Evaluating a low anion gap: A practical approach. Cleveland Clinic Journal of Medicine 90, 619-623 (2023). https://doi.org/10.3949/ccjm.90a.23035 Caleffi, A. & Lippi, G. Cylindruria. Clinical Chemistry and Laboratory Medicine (CCLM) 53, 1471-1477 (2015). https://doi.org/10.1515/cclm-2015-0480 Devdhar, M., Ousman, Y.H. & Burman, K.D. Hypothyroidism. Endocrinology and Metabolism Clinics of North America 36, 595-615 (2007). https://doi.org/10.1016/j.ecl.2007.04.008 Ch’ng, C.L., Jones, M.K., Kingham, J.G.C. Celiac Disease and Autoimmune Thyroid Disease. Clin Med Res 5, 184-192. https://doi.org/10.3121/cmr.2007.738 Clark, R. & Johnson, R. Malabsorption Syndromes. Nursing Clinics of North America 53, 361-374 (2018). https://doi.org/10.1016/j.cnur.2018.05.001 Korpelainen, R., Orava, S., Karpakka, J., Siira, P. & Hulkko, A. Risk Factors for Recurrent Stress Fractures in Athletes. The American Journal of Sports Medicine 29, 304-310 (2001). https://doi.org/10.1177/03635465010290030901 Munro, M.G., Mast, A.E., Powers, J.M., Kouides, P.A., O’Brien, S.H., Richards, T., Lavin, M. & Levy, B.S. The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia. American Journal of Obstetrics and Gynecology 229, 1-9 (2023). https://doi.org/10.1016/j.ajog.2023.01.017 Lopez, A., Cacoub, P., Macdougall, I.C. & Peyrin-Biroulet, L. Iron deficiency anaemia. The Lancet 387, 907-916 (2016). https://doi.org/10.1016/S0140-6736(15)60865-0 Freeman, H.J. Iron deficiency anemia in celiac disease. World J Gastroenterol 21, 9233-9238 (2015). https://doi.org/10.3748/wjg.v21.i31.9233 Additional Declarations No competing interests reported. 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Investigation into the events preceding her admission reveals that this fracture occurred in an abnormal fashion. The patient had been routinely engaged in large volumes of low-intensity, steady-state exercise leading to the acute onset of localised pain in her anterior right hip six weeks prior to treatment. This is likely when the stress fracture occurred. She originally ignored this pain, thinking she pulled a muscle in her hip flexor, but it eventually progressed to a displaced intertrochanteric fracture during a weighted hip exercise 20 days before the operation. The patient was post-operatively tested for osteoporosis and found to have a sufficiently normal bone mass, with a bone mineral density (BMD) T-score of -0.4 in the left femoral neck bone and \u0026minus;\u0026thinsp;1.0 in the lumbar spine. Other testing revealed various indicators of malnutrition. X-rays and CT scans showed several other untreated fractures the patient had incurred over the previous three years including fractures in both the left pelvis and in two right metatarsals, all of which had significantly healed without intervention. The patient additionally showed symptoms of Coeliac disease and subclinical hypothyroidism, with a high thyroid-stimulating hormone (TSH) level of 6.120 mLU/L and a normal T4 level of 8.3 ug/dL.\u003c/p\u003e \u003cp\u003eThis study discusses the patient\u0026rsquo;s applicable medical history, focusing on her consecutive fractures, exercise levels, development of Coeliac disease, and history of anaemia. Given her young age, non-osteoporotic BMD, and the nontraumatic nature of her fracture, it appears that factors other than those commonly attributed as causative for hip fractures may have made significant contribution to her injuries. These factors, to be discussed in the following paragraphs, include Coeliac disease, other food intolerances, malnutrition, subclinical hypothyroidism, overexercise, and anaemia.\u003c/p\u003e"},{"header":"2 Case Presentation","content":"\u003cp\u003eIn the three years preceding her intertrochanteric fracture, the patient reported pain in various other locations throughout her lower body. This pain was later determined to be a result of various lower body fractures, specifically in the third and fourth metatarsals of her right foot, the lateral left inferior pubic ramus, and the lateral left superior pubic ramus. X-rays and CT scans verified the existence of these fractures, each of which had sufficiently healed without any medical intervention by the time of the intertrochanteric surgery.\u003c/p\u003e \u003cp\u003eAdditionally, both preceding and during her fractures, the patient reports having recognised negative physiological reactions such as hives, swelling, rashes, and gastrointestinal pain upon the consumption of glutenous foods, as well as other foods including salmon, eggs, and nuts. Eventually she chose to remove these foods from her diet, but this did not effectively occur until after her surgery. Further observations reveal that many of these intolerances developed during this same three-year time period preceding the surgery.\u003c/p\u003e \u003cp\u003ePrior to the patient\u0026rsquo;s initial recognition of pain, she was an established endurance athlete, regularly participating in high levels of exercise. In the weeks prior to her stress fracture, the patient continued to be routinely involved in physical activity, averaging 60\u0026ndash;80 minutes of daily exercise, consisting of 4\u0026ndash;5 miles of running and at least an additional 30 minutes of weight lifting for four days each week. She also lived a generally active lifestyle, averaging 20 000\u0026ndash;30 000 daily steps in addition to her exercise program. When the patient first started to experience pain, she assumed it was due to a pulled muscle and reduced her exercise load to casual weight lifting, during which she eventually exacerbated her stress fracture into a displaced fracture.\u003c/p\u003e \u003cp\u003eThe patient was engrossed with measuring her caloric consumption and exercise, frequently concerning herself with body image and physical fitness and often holding herself to levels of uncomfortable hunger to follow preset restrictions she had established for herself. She reports eating about 2600\u0026ndash;2900 kcal/day and water consumption of at least 5 liters/day. Note that due to her various food intolerances, actual caloric and nutritional absorption was probably less than reported consumption.\u003c/p\u003e \u003cp\u003eFurthermore, many years prior to this period, the patient had been experiencing a form of oligomenorrhea involving frequent and painful heavy menstrual bleeding with large clots, leading to anaemia. Ten years prior to her fractures, she began taking prescribed progesterone (norethindrone, 0.35 mg/day) to alleviate her pain and lessen her menstrual blood loss, the latter of which eventually ceased.\u003c/p\u003e \u003cp\u003eAt the time of her intertrochanteric surgery, the patient was 165 cm tall and weighed 60 kg. She was a nonsmoker and never drank alcohol.\u003c/p\u003e \u003cp\u003eThe patient reported that she had initially been experiencing extreme lower back and hip flexor pain resulting in severely limited mobility. She thought she had pulled a muscle during a weighted hip exercise and had been seeing a chiropractor twice a week for three weeks in attempt to recuperate. After three weeks of no alleviation but only increased pain, she had visited a nearby clinic, received an X-ray, and found that her right pelvic bone was split along the border between the intertrochanteric region and the femoral neck (this X-ray also revealed the healed pubic ramus fractures). Because of the delay in receiving medical attention and the patient\u0026rsquo;s continued exercise (though greatly reduced), the originally unnoticed stress fracture was acutely exacerbated into a displaced fracture, signifying an urgent need for surgical intervention.\u003c/p\u003e \u003cp\u003eThe operation, which involved first the setting of the bone and then the insertion of a cephalomedullary nail, was successful, and the patient has experienced no significant resulting complications to date.\u003c/p\u003e \u003cp\u003ePost-operative testing revealed a BMD with a T-score of -0.4 in the left femoral neck bone and \u0026minus;\u0026thinsp;1.0 in the lumbar spine, indicating an absence of osteoporosis, a notable finding given the prevalence of this low bone mineral density condition in similar cases. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] However, these results barely bordered on a diagnosis of osteopenia/low bone mass (BMD T-score between \u0026minus;\u0026thinsp;1.0 and \u0026minus;\u0026thinsp;2.5 SD).\u003c/p\u003e \u003cp\u003eOther testing administered at the time of surgery revealed other possibly consequential values, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePatient Data\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal Range (For Lab Results)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDaily Consumption Variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDaily Caloric Consumption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2600\u0026ndash;2900 kcal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDaily Water Consumption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol or Tobacco Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical Activity Variables (Minimum; Prior to Stress Fracture)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMiles Run\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026thinsp;+\u0026thinsp;per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMinutes Weight Lifting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u0026thinsp;+\u0026thinsp;per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdditional Step Count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 000\u0026ndash;30 000\u0026thinsp;+\u0026thinsp;per day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLab Variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVitamin D\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.30 ng/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.00\u0026ndash;100.00 ng/mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCalcium\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.3 mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5\u0026ndash;10.1 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eT4, Total\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.3 ug/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u0026ndash;13.9 ug/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThyroid-Stimulating Hormone (TSH)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.120 mlU/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.358\u0026ndash;3.740 mlU/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnion Gap\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0 mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026ndash;15.0 mmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeutrophil Prevalence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50% \u0026minus;\u0026thinsp;60%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbsolute Neutrophil Count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6 K/uL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u0026ndash;7.7 K/uL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLymphocyte Prevalence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0% \u0026minus;\u0026thinsp;40.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbsolute Lymphocyte Count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9 K/uL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026ndash;4.8 K/uL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemoglobin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.0 g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u0026ndash;16.0 g/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHyaline Casts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;2/LPF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 LPF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBone Mineral Density (BMD), T-Scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeft Femoral Neck Bone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-1.0) - (-2.5) SD for Osteopenia /Low Bone Mass\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLumbar Spine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-1.0) - (-2.5) SD for Osteopenia /Low Bone Mass\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"3 Discussion","content":"\u003cp\u003eWhat sets this case apart from standard intertrochanteric fracture cases is the abnormal, unidentified cause of the patient\u0026rsquo;s injury. Some other hidden, nonobvious, or otherwise publicly undiscussed factors appear likely to have been the underlying cause of such a significant fracture. Although the patient is a white female, the demographic population amongst which hip fractures are most prevalent, [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] she also: is young (42 years), when hip fractures are generally rare;\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e lacks osteoporosis, which is prevalent in the majority of hip fracture cases among young patients;\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e1\u003c/span\u003e\u003c/sup\u003e and never underwent any trauma in causation of her injury (the injury occurred during a slow and methodical weighted exercise, not involving a fall or other traumatic accident). Hip fractures are rare and relatively unstudied in younger populations, and even amongst such populations are usually found to be due to falls and osteoporosis. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] That this patient is such a notable exception gives reason to investigate what other probable factors may have caused her ultimate injury.\u003c/p\u003e \u003cp\u003eOne factor likely to have played a somewhat significant role in these events is a group of food intolerances the patient possesses, including Coeliac disease. There is some research on the possible correlation between this gluten intolerance and an increased risk of fractures or decrease in BMD. Some studies indicate that such a correlation does exist, [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] others argue otherwise, and still others conclude that more research must be done to reasonably settle the question. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Further investigation into this study and others like it could help provide valuable insight into this possible correlation.\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s blood and urinary tests revealed multiple indicators of possible malnutrition, including a low Vitamin D level (27.30 ng/mL), a low anion gap (1.0 mmol//L), a presence of hyaline casts (0\u0026ndash;2/LPF), and TSH level (6.120 mlU/L, indicative of hyperthyroidism). These readings help shed light on other areas that might have contributed to the patient\u0026rsquo;s fracture.\u003c/p\u003e \u003cp\u003eLow levels of Vitamin D, though common amongst Americans, do play an important role in bone health. However, as Vitamin D\u0026rsquo;s primary effect on bones is due indirectly through calcium absorption, and as the patient\u0026rsquo;s calcium levels read normal (9.3 mg/dL; normal range 8.5\u0026ndash;10.1 mg/dL), it appears that this factor may not have significantly influenced this particular case. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLow anion gap readings are most often due to testing errors, [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] but readings remained low over three separate blood tests (ranging from 1\u0026ndash;3 mmol/L; normal range 5\u0026ndash;15 mmol/L). This low reading, then, could be due to a variety of reasons, including a decrease in albumin protein or an increase in some unmeasured cation such as lithium. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHyaline casts are the most common type of urinary casts, and their presence in very low quantities is not abnormal. Composed of the protein uromodulin, they indicate dehydration, strenuous exercise, or any renal disease. Given the patient\u0026rsquo;s circumstances, reported water consumption (5 L/day) and other corresponding lab results, it appears that renal disease and dehydration are both unlikely and that these hyaline casts are most likely due to strenuous exercise, a finding confirming reported observations. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFinally, the patient\u0026rsquo;s TSH level (6.120 mlU/L) is somewhat high, indicative of subclinical hypothyroidism, a condition resulting from reduced thyroid hormone action. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Hypothyroidism is nearly ten times more common in females than in males, [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and studies show a positive correlation between Coeliac and hypothyroidism [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] increasing the likelihood of the patient\u0026rsquo;s having this disease. Symptoms of subclinical hypothyroidism include weakness, depression, sleep disturbances, and menstrual irregularities such as menorrhagia\u0026mdash;[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Symptoms the patient has reported in varying degrees over the course of the three years preceding her fracture.\u003c/p\u003e \u003cp\u003eMany of these values indicate the possible presence of malnutrition, another factor that may have led to the patient\u0026rsquo;s fractures. How could this have arisen? The patient had been eating adequate quantities of food in a healthy variety. However, the patient\u0026rsquo;s Coeliac disease would likely have reduced the amount of nutrients her body could have absorbed from these foods, as this pernicious disease can led to the damaging and deterioration of the lining of the GI tract. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The resulting condition, known as malabsorption, greatly hinders the body\u0026rsquo;s ability to absorb ingested nutrients. In particular, Coeliac disease can result in the body\u0026rsquo;s reduced capability to absorb vitamins and minerals such as Vitamin D and iron. Additionally, Coeliac disease\u0026rsquo;s damage to the GI tract can lead to low levels of other important nutrients such as the protein albumin (the protein commonly responsible for a low anion gap). [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Seeing that there may exist a link between Coeliac disease, malabsorption, and fracture frequency, this possible correlation is highlighted here as another potentially fruitful area for further research.\u003c/p\u003e \u003cp\u003eAnother factor that may have played a role in the patient\u0026rsquo;s fracture is her level of exercise. Although the patient had exercised quite a lot (hours of various levels of activity each day with few recovery days and almost no days of complete rest), it is hard to tell if her level of exercise was enough to truly qualify as overexercise. The patient\u0026rsquo;s hyaline casts do indicate that this might have been the case to at least some degree, as discussed above, but there is no certainty of this. The only substantial thing that can be stated concerning this factor is that overexercise could have been present in this patient, especially given the nature of her fractures (each occurring while the patient was actively exercising). [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] That being said, further research is needed to determine the veracity of such a relationship.\u003c/p\u003e \u003cp\u003eThe last factor to be suggested in this study that may have contributed to the patient\u0026rsquo;s fracture concerns her menstrual history, particularly in regards to her oligomenorrheic menstrual condition. Many years before her fractures and her development of Coeliac disease, the patient was diagnosed with anaemia. This anaemia was likely due to chronic and non-resorptive blood loss, [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] resulting in a state of iron-deficiency anaemia. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Upon pre-operative testing, ten years after beginning to take her prescribed progesterone, the patient\u0026rsquo;s haemoglobin levels were found to be normal, signifying that she was no longer anaemic. However, over this time period, she simultaneously developed stronger symptoms of Coeliac disease. This course of events contradicts the typical positive correlation existing between Coeliac disease and iron-deficiency anaemia, a relationship in which the former usually causes the latter. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Determining whether this is a coincidence, an exception to the theoretical rule, or some other shrouded area of medicine requires further research and investigation.\u003c/p\u003e \u003cp\u003eIt is also possible that her menstrual bleeding desisted due to overexertion in strenuous exercise. However, this is unlikely, as her menstrual bleeding ceased before this postulated cause occurred and did not resume when she stopped exercising post-operation. Again, this is another relevant topic for future/further research.\u003c/p\u003e \u003cp\u003eThese, then, are some thoughts and speculations as to what appear to have had an impact on the patient\u0026rsquo;s fractures, especially in the culmination of her rare intertrochanteric fracture. As this study concerns only a single patient, our findings our naturally quite limited. However, the relationships that appear to have presented themselves in this study are promising areas for beneficial investigation. This case presents a host of research opportunities, especially those in the investigation of the influences and correlations between nonobvious or otherwise incompletely explored factors that could influence the likelihood of hip fractures.\u003c/p\u003e"},{"header":"4 Conclusion","content":"\u003cp\u003eAs has been shown, this case study presents an anomalous patient. She was lacking osteoporosis, was still at a young age, had not injured herself by means of falling or other trauma, yet had still suffered from a variety of lower body stress fractures and ultimately required surgery for a displaced and angulated intertrochanteric fracture. The causes of this patient\u0026rsquo;s fracture may help enlighten the current understanding of risk factors of intertrochanteric and other hip fractures. Possible factors discussed in this paper include Coeliac disease and other food intolerances, malnutrition, subclinical hypothyroidism, overexercise, and iron-deficiency anaemia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003e5.2 Ethics approval\u003c/h2\u003e \u003cp\u003eThis study successfully met the criteria for exemption under 45 CFR 46.104(d)(4)(iii). This study was conducted and carried out without discrimination based on any premises and without any ethical compromises in accordance with 1964 Declaration of Helsinki. Informed consent was properly obtained from the patient in accordance with the FDA \u003cem\u003eInformed Consent\u003c/em\u003e Guidance Document.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e5.3 Competing interests\u003c/strong\u003e \u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e5.4 Consent to publish\u003c/strong\u003e \u003cp\u003e The participant has consented to the submission of the case report to the journal.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003e5.1 Funding\u003c/h2\u003e \u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed equally across the various portions of this article.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data collected for this study was obtained through access to the patient\u0026rsquo;s medical records and through interviews with the patient. This data is not publicly available and cannot be publicly accessed as this would be an infringement upon the patient\u0026rsquo;s privacy.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBoden, S.D., Labropoulos, P. \u0026amp; Saunders, R. Hip fractures in young patients: Is this early osteoporosis?. \u003cem\u003eCalcif Tissue Int\u003c/em\u003e \u003cstrong\u003e46,\u003c/strong\u003e 65\u0026ndash;72 (1990). https://doi.org/10.1007/BF02556089\u003c/li\u003e\n\u003cli\u003eBenetos, I.S., Babis, G.C., Zoubos, A.B., Benetou, V. \u0026amp; Soucacos, P.N. Factors affecting the risk of hip fractures. \u003cem\u003eInjury\u003c/em\u003e \u003cstrong\u003e38,\u003c/strong\u003e 735-744 (2007). https://doi.org/10.1016/j.injury.2007.01.001\u003c/li\u003e\n\u003cli\u003eAhn, J. \u0026amp; Bernstein, J. In Brief: Fractures in Brief: Intertrochanteric Hip Fractures. \u003cem\u003eClin Orthop Relate Res\u003c/em\u003e \u003cstrong\u003e468\u003c/strong\u003e, 1450-1452 (2010). https://doi.org/10.1007/s11999-010-1263-2\u003c/li\u003e\n\u003cli\u003eZanchetta, M.B., Longobardi, V. \u0026amp; Bai, J.C. Bone and Celiac Disease. \u003cem\u003eCurr Osteoporos Rep\u003c/em\u003e \u003cstrong\u003e14,\u003c/strong\u003e 43\u0026ndash;48 (2016). https://doi.org/10.1007/s11914-016-0304-5\u003c/li\u003e\n\u003cli\u003eOlmos, M., Antelo, M., Vazquez, H., Smecuol, E., Mauri\u0026ntilde;o, E. \u0026amp; Bai, J.C. Systematic review and meta-analysis of observational studies on the prevalence of fractures in coeliac disease. \u003cem\u003eDigestive and Liver Disease\u003c/em\u003e \u003cstrong\u003e40,\u003c/strong\u003e 46-53 (2008). https://doi.org/10.1016/j.dld.2007.09.006\u003c/li\u003e\n\u003cli\u003eKhazai, N., Judd, S.E. \u0026amp; Tangpricha, V. Calcium and Vitamin D: Skeletal and Extraskeletal Health. \u003cem\u003eCurt Rheumatol Rep \u003c/em\u003e\u003cstrong\u003e10,\u003c/strong\u003e 110-117 (2008). https://doi.org/10.1007/s11926-008-0020-y\u003c/li\u003e\n\u003cli\u003eHaber, L.A., Dhaliwal, G., Lo, L. \u0026amp; Rizzuto, G. Evaluating a low anion gap: A practical approach. \u003cem\u003eCleveland Clinic Journal of Medicine\u003c/em\u003e \u003cstrong\u003e90,\u003c/strong\u003e 619-623 (2023). https://doi.org/10.3949/ccjm.90a.23035\u003c/li\u003e\n\u003cli\u003eCaleffi, A. \u0026amp; Lippi, G. Cylindruria. \u003cem\u003eClinical Chemistry and Laboratory Medicine (CCLM)\u003c/em\u003e \u003cstrong\u003e53,\u003c/strong\u003e 1471-1477 (2015). https://doi.org/10.1515/cclm-2015-0480\u003c/li\u003e\n\u003cli\u003eDevdhar, M., Ousman, Y.H. \u0026amp; Burman, K.D. Hypothyroidism. \u003cem\u003eEndocrinology and Metabolism Clinics of North America\u003c/em\u003e \u003cstrong\u003e36,\u003c/strong\u003e 595-615 (2007). https://doi.org/10.1016/j.ecl.2007.04.008\u003c/li\u003e\n\u003cli\u003eCh\u0026rsquo;ng, C.L., Jones, M.K., Kingham, J.G.C. Celiac Disease and Autoimmune Thyroid Disease. \u003cem\u003eClin Med Res\u003c/em\u003e \u003cstrong\u003e5,\u003c/strong\u003e 184-192. https://doi.org/10.3121/cmr.2007.738\u003c/li\u003e\n\u003cli\u003eClark, R. \u0026amp; Johnson, R. Malabsorption Syndromes. \u003cem\u003eNursing Clinics of North America\u003c/em\u003e \u003cstrong\u003e53,\u003c/strong\u003e 361-374 (2018). https://doi.org/10.1016/j.cnur.2018.05.001\u003c/li\u003e\n\u003cli\u003eKorpelainen, R., Orava, S., Karpakka, J., Siira, P. \u0026amp; Hulkko, A. Risk Factors for Recurrent Stress Fractures in Athletes. \u003cem\u003eThe American Journal of Sports Medicine \u003c/em\u003e\u003cstrong\u003e29,\u003c/strong\u003e 304-310 (2001). https://doi.org/10.1177/03635465010290030901\u003c/li\u003e\n\u003cli\u003eMunro, M.G., Mast, A.E., Powers, J.M., Kouides, P.A., O\u0026rsquo;Brien, S.H., Richards, T., Lavin, M. \u0026amp; Levy, B.S. The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia. \u003cem\u003eAmerican Journal of Obstetrics and Gynecology\u003c/em\u003e \u003cstrong\u003e229,\u003c/strong\u003e 1-9 (2023). https://doi.org/10.1016/j.ajog.2023.01.017\u003c/li\u003e\n\u003cli\u003eLopez, A., Cacoub, P., Macdougall, I.C. \u0026amp; Peyrin-Biroulet, L. Iron deficiency anaemia. \u003cem\u003eThe Lancet\u003c/em\u003e \u003cstrong\u003e387,\u003c/strong\u003e 907-916 (2016). https://doi.org/10.1016/S0140-6736(15)60865-0\u003c/li\u003e\n\u003cli\u003eFreeman, H.J. Iron deficiency anemia in celiac disease. \u003cem\u003eWorld J Gastroenterol \u003c/em\u003e\u003cstrong\u003e21,\u003c/strong\u003e 9233-9238 (2015). https://doi.org/10.3748/wjg.v21.i31.9233\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4782971/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4782971/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis case presents a 42-year-old non-osteoporotic white female runner with an intertrochanteric stress fracture in the right hip which progressed to a displaced intertrochanteric fracture during a low-impact weighted hip exercise and required surgical intervention. X-rays revealed several previously untreated stress fractures throughout her lower body which had healed without intervention. This is an unusual case because nontraumatic stress fractures in the hip are quite rare in younger and non-osteoporotic patients. Additionally, the previous fractures in her lower body indicate that her injury was not acute, but part of a deeper, chronic issue. This study investigates and briefly discusses several inconspicuous factors present in this patient that could have contributed to this issue, including: Coeliac disease and other food intolerances, malnutrition, subclinical hypothyroidism, overexercise, and iron-deficiency anaemia. Herein are also identified and suggested relevant, potent areas for the consideration of further research.\u003c/p\u003e","manuscriptTitle":"Intertrochanteric Fracture in Young Woman Without Osteoporosis: A Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-23 17:49:21","doi":"10.21203/rs.3.rs-4782971/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac60e5c7-8f17-425c-98c8-03202d946676","owner":[],"postedDate":"August 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-20T11:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-23 17:49:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4782971","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4782971","identity":"rs-4782971","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}