Mary’s broken leg – Part 1

I often say it’s never too late to build strong, healthy bones, but I could just as easily say it’s never too early! Here’s a case that illustrates that point.

Recently I did a consultation with a young woman from Maine who’d had a severe, and rather strange, leg fracture. Mary is 27, active, and mostly healthy, if a little overweight. In February of 2009, she was standing in line at a skating rink (wearing rollerskates) when someone behind her fell and knocked her down. She doesn’t recall falling particularly hard, yet a sudden, excruciating pain in her leg turned out to be a bone fracture. But this was not just a garden-variety fracture — her right tibia and fibula were shattered. Repairing them would require 16 screws and two metal plates inserted surgically to hold the bone together, followed by months of rehabilitation. I spoke to her by phone after the accident and encouraged her to use the 20 key bone-building nutrients to speed her healing along.

After she was healed, Mary came back to me for a consultation because the extensive damage to her leg had her worried. Why had such a simple fall caused her such serious damage? Friends of hers had had much less injury with similar falls, or even worse falls, than the one that shattered her leg bone. What was going on? Was she at risk of another serious fracture if she fell again?

When we first sat down to review her medical history, about 9 months after the initial accident when she was pretty well healed up, I asked if she’d had a bone scan or a vitamin D test when she was first evaluated by the bone specialist who’d repaired her leg. She hadn’t, so I suggested she go back to her own doctor and ask for both tests. When we looked at the results, there was one point that stood out: her DEXA showed that her bone density was normal for a woman her age, but her vitamin D was surprisingly low — only 24 ng/mL, and this was after she’d been taking close to 3000 IU daily for many months.

If you’ve been reading my blog posts, you already know that Vitamin D deficiency has a huge impact on bone strength. I felt certain that this was one piece of the puzzle. Unfortunately, Mary’s vitamin D status before the accident was unknown, because her doctor, like many others, doesn’t routinely test his patients’ vitamin D levels. But if Mary was this low after supplementing for many months, it’s realistic to think she was even lower last spring after going through a Maine winter with no extra vitamin D.

But there was more to her story. Mary also told me that she’d gone to her doctor not long before the break because of dysfunctional uterine bleeding and highly irregular periods. Estrogen-based birth control pills did nothing to change it — and at around the same time she broke her leg, her menstrual cycles stopped altogether. When they resumed, six months after the accident, she was prescribed progesterone-based birth control pills that seemed to address the issue — her menstrual cycles became regular again. These hormonal irregularities offered another clue: it was likely that added progesterone was what brought Mary’s menses into balance, and low progesterone might be linked to her leg fracture. Years ago, endocrinologist Dr. Jerilynn Prior reported that 25% of all young women in North America suffered from hidden ovulatory disturbances resulting in low progesterone levels and subsequent sub-optimal bone mass development.  So now I started wondering why she might experience progesterone deficiency and if there were other hidden endocrine disorders contributing to her menstrual irregularities. Could a thyroid, adrenal, or other sex hormone imbalance be affecting her bones? I asked if she’d had any hormone tests, and she said her thyroid was tested.  Her doctor had reported that she’d had a “normal” TSH at her last visit… but the records didn’t specify the exact TSH level. So that’s another place for us to look, since different physicians have different (and sometimes erroneous) ideas of what’s “normal.”  No other hormones were tested.

Mary is also working full time and attending graduate classes to obtain a Master’s degree in public policy. She told me that her irregular periods started about the time she moved out of her parents’ house (she has a big, close-knit family) and started living on her own. This raised a red flag for me that stress, and the stress hormone cortisol, could also be an issue here.

Right now, Mary is increasing her dose of vitamin D to around 7000 IU per day (the usual protocol when vitamin D is severely depleted is to take 50,000 IU a week for 8 weeks, then retest to see if it’s gone up). When she goes back for her vitamin D retest, she’s planning to request several of the other tests I recommend to look for signs of bone loss: ionized calcium, intact parathyroid, NTx bone resorption test, and if available, free cortisol and DHEA tests to see whether excess stress hormones are a piece of the puzzle. Mary is still in her bone-building years, so being proactive right now to find out why her bones are weak may save her a lot of trouble later.

This particular case is of interest to me because it’s not often that we see this kind of bone weakness in a young person — but I strongly suspect it’s becoming a lot more common than most of us might wish. We have a lot of bone-weakening factors in our modern lifestyles and diets, not to mention high levels of stress! I’ll be coming back to this case from time to time to talk about what we can learn from it, but for now, I think the take-away is this: bone health isn’t just a concern for older people. There are so many risk factors that can contribute to weak bones that it’s worth stopping to take a look at them and think about which ones you can change right now. Because every little bit helps!