Background Spontaneous fractures in patients with rheumatoid arthritis (RA) have only occasionally been reported in the literature1,2. However, rheumatologists at Vendsyssel Hospital have noticed several cases where new onset knee or ankle pain was misdiagnosed as arthritis activity but was later shown to be spontaneous fractures. An x-ray examination did not reveal the fracture, but it was identified on an MRI examination. The fractures are at risk of being overlooked, and this fact may lead to a delay in diagnosis and a risk of ineffective treatment with e.g. steroid injections.
Objectives The study was carried out in the Physio- and Occupational Therapist unit in Vendsyssel Hospital. The included patients were diagnosed with RA and spontaneous fractures. Fifteen patients, all women, were identified. Ten patients in the age of 57–88 years participated in the study. They had an average disease duration of 14.2 years and a MRI was performed at a median of eight months.
Methods The patients were divided into two age specific groups: 57–69 and 70–88 years. The focus groups data were subjected to thematic analysis to provide a sense of the important themes. Categorizing, coding and analysing the data from the focus groups identified the themes.
Results All patients identified the missing diagnosis as a significant burden. The patients were experiencing pain, but did not receive a diagnosis or an explanation for their symptoms. “I've never been as happy as when I was told my leg was broken …” Most of the patients experienced more pain than usual for their RA: ”You suddenly have a lot more pain, but you just don't know where it comes from”. All patients noticed a significant loss of function before the diagnosis was made and during immobilisation: ”I was so unhappy about not being able to do anything … even just getting up at night to go to the toilet …”. When the patients were immobilised they were offered crutches, but they were not able to use standard crutches due to their RA: ”I can't use crutches because I don't have enough strength to lift myself…”
Conclusions Patients with RA with spontaneous fractures experience the delayed diagnosis as a burden, and it is stressful for them to wait for an explanation for their pain. Due to the patients missing ability to use crutches or use a wheelchair, it is important to find other aids that patients with RA and spontaneous fractures can use. When the patients were immobilised they experienced loss of function. This calls for the need to focus on the diagnosis and guidance of these patients in relation to daily activities and aids.
Hauser B, Riches PL, Wilson JF, Horne AE, Ralston SH. Prevalence and clinical prediction of osteoporosis in a contemporary cohort of patients with rheumatoid arthritis. Rheumatology 2014; 53:1759–66
Spina A, Clemente A, Vancini C, Fejzo M, Campioni P. Musculoskeletal Radiology: Spontaneous talar and calcaneal fracture in rheumatoid arthritis: a case report. Radiology Case 2011; 5(7): 15–23
Disclosure of Interest None declared