A Fragile Balance

A CLINICAL PROBLEM-SOLVING article by Asaf Bitton from Brigham and Women's Hospital, Harvard Medical School, Boston.
A 31-year-old man presented to the emergency department with pain in the left shoulder. He had tripped over the shoulder strap of his backpack earlier in the day and noted immediate severe pain around his left shoulder, without paresthesias or neck pain. Physical examination revealed bony point tenderness over the humeral head. Shoulder x-rays revealed an impacted fracture of the left humerus and evidence of osteopenia. His medical history was notable for multiple fractures of the femur, elbow, and wrist, without previous evaluation.
Plain x-rays are not sensitive for bone loss; the fact that osteopenia was detected on such imaging suggests considerable bone loss, and a formal assessment of bone mineral density is warranted. When osteopenia is suspected in a male patient who is younger than 50 years, a careful history taking is essential. The key components should include questions about fractures and the circumstances in which they occurred, growth and pubertal development in childhood, medication use, a thorough review of systems to screen for systemic diseases, and a family history of fractures or systemic diseases. The initial laboratory evaluation should include an assessment for secondary causes of bone loss in young men, with tests of thyroid, parathyroid, renal, and gonadal function, as well as vitamin D levels.