Анорексия у бегуньи привела к перелому плюсневой кости из-за истощения костной ткани

Slideshow - Figure. Radiograph demonstrates healing signs of a second metatarsal stress fracture. A 20-year-old woman presents with 3 weeks of progressively worsening right forefoot pain. Six weeks earlier, she increased her outdoor running mileage. However, the pain has progressed to the point that she now has discomfort while walking normally. Examination of the foot demonstrates focal tenderness over the plantar aspect of the second metatarsal neck. A radiograph demonstrates cortical thickening and callus formation consistent with a healing second metatarsal stress fracture (Figure). During the visit, she reports a history of anorexia nervosa for which she is currently receiving treatment. Anorexia nervosa increases the risk of low bone mineral density and stress fractures through the combined effects of chronic energy deficiency and endocrine dysfunction. Inadequate caloric intake suppresses the hypothalamic-pituitary-gonadal axis, leading to hypogonadotropic hypogonadism and reduced estrogen levels. Although... Submit your diagnosis to see full explanation. Anorexia nervosa increases the risk of low bone mineral density and stress fractures through the combined effects of chronic energy deficiency and endocrine dysfunction. Inadequate caloric intake suppresses the hypothalamic-pituitary-gonadal axis, leading to hypogonadotropic hypogonadism and reduced estrogen levels. Although estrogen deficiency contributes to increased bone resorption, the skeletal effects of anorexia are not caused by estrogen deficiency alone. Malnutrition also causes growth hormone resistance with decreased insulin-like growth factor-1 (IGF-1), an important promoter of osteoblast activity and bone formation.1,2 Other hormonal abnormalities, including relative hypercortisolemia and alterations in leptin and other regulators of energy metabolism, may further impair bone remodeling. The combination of increased bone resorption and decreased bone formation can result in significant reductions in bone mineral density and bone strength.1,2 These changes are particularly concerning in adolescents and young adults because anorexia can interfere with the attainment of normal peak bone mass. When weakened bone is exposed to repetitive loading, such as an increase in running mileage, microscopic bone damage may accumulate faster than it can be repaired, eventually resulting in a stress fracture.1,2 Management should address not only the fracture and temporary modification of impact activity but also the underlying energy deficiency. Nutritional rehabilitation and restoration of a healthy body weight are central to improving skeletal health, and recovery of normal hypothalamic-pituitary-gonadal function and menstruation is associated with improved bone mineral density.1,2 Because skeletal deficits may persist even after clinical recovery, prevention and early treatment of anorexia are particularly important for long-term bone health.1,2 Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of JBJS Journal of Orthopaedics for Physician Assistants. References - Misra M, Klibanski A. Bone health in anorexia nervosa. Curr Opin Endocrinol Diabetes Obes. 2011;18(6):376-382. doi:10.1097/MED.0b013e32834b4bdc - Misra M, Klibanski A. Anorexia nervosa and bone. J Endocrinol. 2014;221(3):R163-176. doi:10.1530/JOE-14-0039