Spontaneous Fractures in Rheumatoid Arthritis

Abstract

Spontaneous fractures in rheumatoid arthritis are said to be rare (Baer, 1941 ; Rosenberg, 1958) apart from steroid therapy. This is surprising, since rheumatoid arthritis occurs particularly in women of the age-group when spontaneous fractures might be expected (Albright et at., 1941). The fractures which occur during steroid therapy bave been extensively studied (Boland, 1951 ; Demartini et al., 1952 ; Rosenberg, 1958), particularly when this therapy is prolonged (Gascon and Grignon, 1960), but apart from this the subject has received little attention. Den Oudsten and Speyer (1959) found little difference between the number of fractures in a group of rheuma toid patients and those in a control group. However, Fineschi (1957) has drawn attention to spontaneous fractures in rheumatoid arthritis and describes many of their features. Spontaneous fractures have also been described in Still's disease (Badley and Ansell, 1960). This paper reports five cases of rheumatoid arthritis where spontaneous fractures occurred in the absence of any other known cause. All five patients were typical rheumatoid arthritics and fulfil the criteria of definite rheumatoid arthritis laid down by the American Rheumatism Association (Ropes et al., 1957). Case 1 A woman of 65 had suffered from rheumatoid arthritis for 16 years and had been treated with salicylates, phenyl butazone, and gold. She was admitted to hospital in 1958 because of an exacerbation of her arthritis affecting the shoulders, hands, and lower limbs. She improved with bed rest, analgesics, and physiotherapy. During convalescence while walking she experienced pain in the right ankle, and a radiograph showed a fracture through the right fibula (Fig. 1). This healed with bed rest and strapping. Investigations.?Hb, 67%. White blood count, 6,400/ cmm., differential count normal. Plasma proteins, 7.5 g./ 100 ml. (albumin, 5.6 g., globulin 1.9 g.). Rose, test positive. No lupus erythematosus cells in peripheral blood. Sedimentation rate, 60 mm. in one hour. Serum alkaline phosphatase, 12.2 K.A. units. Serum inorganic phosphorus, 3.4 mg./100 ml. Serum calcium, 10 mg./100 ml. Urine normal She improved and was discharged from hospital. Five months later, however, she returned with pain in the left ankle; this followed a stumble while walking. On June 16, 1959, radiography showed a crack fracture through the left fibula and a commencing fracture in the left tibia (Fig. 2). She was treated with bed rest, and on July 24 a radiograph showed union of the fibula, while the tibial fracture was more obvious and involved the whole shaft (Fig. 3). Union again occurred after bed rest.