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  • Atypical fractures of the lower extremities in two patients with rheumatoid arthritis: clinical presentations of presumed methotrexate osteopathy

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Endocrinology
Atypical fractures of the lower extremities in two patients with rheumatoid arthritis: clinical presentations of presumed methotrexate osteopathy
  1. Christian Lund Petersen1,
  2. Marc David2,
  3. Lis Stilgren2 and
  4. Zandra Nymand Ennis3
  1. 1 Department of Radiology, Sygehus Lillebælt Vejle Sygehus, Vejle, Denmark
  2. 2 Odense University Hospital, Svendborg, Syddanmark, Denmark
  3. 3 Department of Clinical Pharmacology, Odense University Hospital, Odense C, Denmark
  1. Correspondence to Dr Zandra Nymand Ennis; zne{at}rsyd.dk

Abstract

We present two patients who developed multiple lower limb stress fractures. Potential causes, such as osteoporosis, malignancies and disturbances in calcium metabolism were investigated. This led the physicians to consider whether methotrexate (MTX) exposure posed a risk of atypical fractures.

The association between MTX and lower limb fractures has been described in at least 80 cases in the literature. Stress fractures associated with MTX treatment are atypical of osteoporosis and located in the lower extremities, most often the tibia. The limited data suggest that discontinuation of MTX may improve symptoms and chances of fracture healing, while antiresorptive or osteoanabolic therapies have not proven clinically efficient. It seems evident, however, that the benefits of MTX treatment in rheumatological disease clearly outweigh the risk of MTX osteopathy and related fractures.

  • Calcium and bone
  • Unwanted effects / adverse reactions
  • Drugs: musculoskeletal and joint diseases

https://doi.org/10.1136/bcr-2023-256567

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    Footnotes

    • Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms and critical revision for important intellectual content: CLP, MD and ZNE. The following authors gave final approval of the manuscript: CLP, MD, LS and ZNE.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.