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| TEACHING IMAGES |
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| Year : 2016 | Volume
: 4
| Issue : 1 | Page : 151-152 |
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Monostotic Paget's disease of tibia with stress fracture
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
| Date of Web Publication | 2-Jun-2016 |
Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2321-4848.183353
Paget's disease of bone is a debilitating condition affecting the skeletal system and sometimes presents with mono-ostotic pattern. A deformed bone is potential site for stress related injuries notably stress fracture. Diagnostic workup includes clinic-radiological co-relation with biochemical parameters and sometimes use of advanced imaging modalities. A mono-ostotic deformity of bone with thickened, coarse structure may warrant ruling out of this differential diagnosis. Early diagnosis and treatment including use of bisphosphonates have proved beneficial in recovery and good functional outcome. Keywords: Bisphosphonates, management, Paget's disease, stress fracture, tibia
How to cite this article:
Dharmshaktu GS. Monostotic Paget's disease of tibia with stress fracture. Arch Med Health Sci 2016;4:151-2 |
A 65-year-old Indian woman presented with nontraumatic pain for last 4 weeks with a deformity in the form of anterolateral bowing of leg since last 7 years. The pain was increased on walking and weight bearing and relieved by rest or pain medications transiently. There was associated diabetes and hypothyroidism for which appropriate treatment was being taken. The radiograph of the leg showed a bowed tibia with an incomplete stress fracture at the apex of the deformity at tension side of the bone. The abnormal cortical thickening and sclerosis of the tibia were suggestive of underlying bone pathology [Figure 1]. Blood investigations showed a deficiency of 25-hydroxy Vitamin D and decreased calcium while the alkaline phosphatase level was normal. Bone specific alkaline phosphatase however, is the best investigation for the disease. Magnetic resonance imaging of the leg delineated stress fracture and ruled out any infection or neoplastic lesion [Figure 2]. As there was no clinically relevant, complain elsewhere, a diagnosis of monostotic Paget's disease of the tibia with stress fracture was made. The ultimate diagnosis, however, is based on histopathological correlation and may be necessary in cases of dubious presentation of the disease. The option for biopsy and further investigation was declined by family. A plaster cast was given as protection splint and functional brace. The calcium and Vitamin D preparations were started for 2 months followed by addition of a bisphosphonate (ibandronic acid 150 mg weekly) as an antiresorptive agent. The bone united well in 15 weeks of treatment and patient regained the preinjury level of activity [Figure 3]. Further follow-up with regard to recurrence or fresh problems is encouraged. Regular evaluation by serum levels of alkaline phosphatase is required in the follow-up to guide additional management. A future requirement of corrective osteotomy to restore mechanical axis of the lower limb is explained to the patient as per the requirement of it. | Figure 1: Radiograph showing fracture tibia with stress fracture of tibia at apex of bowing deformity in anterior-posterior (a) and lateral (b) views
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 | Figure 2: Magnetic resonance imaging of the leg delineating the fracture in frontal (a) and sagittal plane (b)
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Named after Sir James Paget as a disorder with abnormal bone remodeling as underlying pathology presents chiefly with pain, deformity, fractures, or neurological complaints.[1] The monostotic variant of Paget's disease has female preponderance with tibia as preferred site of involvement.[2] It has been a rare finding in Asians, Africans, and those belonging to Indian subcontinent.[3] Bone pain, deformity such as bowing, pseudofracture, or pathological fractures are common skeletal features of the disease. Focal osteolytic patches, coarse trabecular pattern, and cortical thickening are associated radiological features. The elevated alkaline phosphatase is found in most cases, but normal levels do not rule out the diagnosis.[4] The bisphosphonates have been used successfully to manage the condition even after pathological fractures and do not clinically hamper the fracture union.[5]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Paget J. On a form of chronic inflammation of bones (Osteitis Deformans). Med Chir Trans 1877;60:37-64.9.  |
| 2. | Kanis JA, editor. Pathophysiology and Treatment of Paget's Disease of Bone. Ch. 3. London, UK: Dunitz; 1991. |
| 3. | Joshi SR, Ambhore S, Butala N, Patwardhan M, Kulkarni M, Pai B, et al. Paget's disease from Western India. J Assoc Physicians India 2006;54:535-8. |
| 4. | Eekhoff ME, van der Klift M, Kroon HM, Cooper C, Hofman A, Pols HA, et al. Paget's disease of bone in The Netherlands: A population-based radiological and biochemical survey — The Rotterdam Study. J Bone Miner Res 2004;19:566-70. |
| 5. | Goldhahn J, Féron JM, Kanis J, Papapoulos S, Reginster JY, Rizzoli R, et al. Implications for fracture healing of current and new osteoporosis treatments: An ESCEO consensus paper. Calcif Tissue Int 2012;90:343-53. |
[Figure 1], [Figure 2], [Figure 3]
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