Mysterious Femur Fracture in a Middle-Aged Man

George T. Griffing, MD; Naga Neelima Nallapaneni, MB BS


April 06, 2018

Physical Examination and Workup

Upon physical examination, his vital signs are normal. His height is about the same length as his arm span. The patient's physical appearance is remarkable for HIV-treatment–induced lipodystrophy and a Cushingoid habitus (Figure 1).

Figure 1.

The sclera and tympanic membranes are clear. Gonadal examination demonstrates bilaterally descended and normal-sized testicles. Upon laboratory investigations, the complete blood cell count, urinalysis, complete metabolic panel, vitamin D level, thyroid-stimulating hormone level, and testosterone level are normal. Urinary free cortisol and an overnight dexamethasone suppression test for Cushing syndrome are also normal. He has an undetectable HIV viral load and a normal CD4 count. He has normal plasma and urine calcium, serum phosphorus, alkaline phosphate, and parathyroid hormone levels.

The patient had been enrolled in an HIV alendronate study 7 years prior to injury. Bone mineral density (BMD) testing at that time showed osteopenia. The patient was then started on alendronate therapy. Repeat BMD testing 4 years before the injury showed normal density scores at both his hip and spine. Now, 8 months after his injury, his BMD is still normal although it is decreased from his levels 4 years previously (Table 1).

Table 1. Bone Mineral Density*

Time before or after fracture Spine (L1-L4)
Spine (L1-L4)
Femoral Neck
Femoral Neck
-7 years -1.08 -0.92 -1.23 -0.68
-4 years 0.1 0.4 -0.6 0.1
+8 months -0.6 -0.1 -0.3 -0.1

*Densities reported in g/cm2


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