Devastating Fracture In An Adolescent Runner: Nature Vs. Nurture? - Page #1

Author: Dena Florczyk, MD
Co Author #1: Michelle Barrack PhD
Co Author #2: Aurelia Nattiv, MD

Patient Presentation:
A 14 year-old Caucasian female cross-country runner with no significant past medical history was competing in a high-profile cross-country invitational in November 2009. 2.5 miles into the race she was running downhill and felt a “crack” in her left hip and collapsed, rendering her unable to finish the race. She denied any history of hip pain or prior injuries.

She started training for the JV cross-country team in June of 2009 and was running approximately 24-30 miles per week. In October of 2009, she was promoted to varsity during which her mileage doubled and the intensity of training increased.

She had no history of fractures, corticosteroid use or prior surgery. She takes no medications and has no allergies. She is in the 9th grade and lives with her parents and two siblings. She denied use of tobacco, alcohol or illicit drugs. There is a family history of osteoporosis in her mother, maternal grandmother, and paternal grandmother.

Within hours she was evaluated at an outside hospital and found to have a complete left femoral neck fracture with displacement and varus angulation A pathologic fracture was ruled out by a CT scan. The following day, she underwent open reduction/ internal fixation of the left hip with multiple screw fixation. Her post-operative course included 4 weeks of non-weight-bearing followed by gradual progression in weight-bearing status over 2-3 months. In May 2010, she had increased left hip pain and was found to have a non-union fracture, resumed non-weight-bearing status, and a bone stimulator was prescribed.

In August 2010, she presented to the UCLA Sports Medicine and Osteoporosis office for evaluation of poor fracture healing and non-union. Further history revealed no prior disordered eating or dietary restrictions; however, prior to the time of injury she did not increase her calorie intake as her training volume and intensity increased, resulting in an inadvertent energy deficit given her increased exercise energy expenditure. Additionally, she had a history of secondary amenorrhea for one year, with menses occurring every 6 months since menarche. Her reported weight in October of 2009 was 100lbs, height 5’1” and BMI 18.6.

Physical Exam:
Height 5’4”, weight 110lbs, BMI 18.9. General: Well nourished, well developed, without physical stigmata of anorexia or bulimia nervosa. Left Hip: Well healed surgical incision over lateral hip. Full range of motion without tenderness to palpation. There was generalized atrophy of the left hip and quadriceps with weakness of all hip resistance testing. Mildly antalgic gait with full weight-bearing.

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