Vol.2, No.8, 457-459 (2013) Case Reports in Clinical Medicine
Large parathyroid adenoma presenting as a femoral
fracture in a young male
Duncan Light*, Chakri Munipalle, Vijay Kurup
General Surgery, North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK;
*Corresponding Author: duncan.light@hotmail.co.uk
Received 16 September 2013; revised 13 October 2013; accepted 2 November 2013
Copyright © 2013 Duncan Light et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Parathyr oid adenoma classical ly prese nt s symp-
toms of hypercalcaemia. Here, we present a
case of a rare presentation of a parathyroid ade-
noma in a young male patient with a pathologi-
cal fracture.
Keyw ords: Parathyroid Adenoma; Hypercalca emia;
Femoral Fracture
Osteoporosis secondary to hyperparathyroidism is a
rare presentatio n in young patients. Th e case study below
illustrates a case of a young male who presents a
pathological fracture secondary to giant parathyroid ade-
A 27-years-old male presented to the emergency de-
partment with femoral fracture following a fall onto his
left hip (Figure 1). He had been previously fit and well
though he had developed increasing thirst and lethargy in
the preceeding weeks. He was of normal build and nu-
tritional status. He underwent a femoral nail the fol-
lowing day. Initial investigations revealed a corrected
calcium of 3.32 and PTH of 2.7. Other biochemical tests
were normal. Sestamibi scan showed a likely parathyro id
adenoma in the right inferior pole of the thyroid gland
(Figure 2). An ultrasound of his neck confirmed the
finding. He was taken for neck exploration where the
diagnosis was confirmed and a large parathyroid ade-
noma weighing 4 grams was removed (Figures 3 and 4).
Histology did not reveal any evidence of malignancy and
subsequent phenotyping excluded the presence of MEN
syndrome. Over the subsequent weeks his calcium level
rose and at 6 months follow-up his calcium level had
returned to normal and he was asymptomatic.
Hyperparathyroidism commonly presents with
symptoms of hypercalcaemia such as abdominal pain,
bone pain, fatigue, depression and nephrolithiasis. It can
be classified into three main groups. Primary hyper-
parathyroidism is due to parathyroid adenoma in 85% of
patients, the remainder are due to multiple adenomas and
parathyroid cancers. It affects 1 in 2000 men annually.
Secondary hyperparathyroidism is due to chronic vitamin
D deficiency as a result of chronic renal failure. Tertiary
hyperparathyroidism is a result of autonomous parathy-
roid stimulation following a period of persistent parathy-
roid stimulation. Biochemical investigations reveal raised
calcium, raised PTH and decrease in phosphate levels in
the blood. Urinary calcium will be low in comparison to
Figure 1. Femoral fracture.
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D. Light et al. / Case Reports in Clinical Medicine 2 (2013) 4 57-459
Figure 2. Sestamibi scan.
Figure 3. Excision of a large parathyroid adenoma.
Figure 4. Excised parathyroid adenoma.
familial hypercalcaemia hypocalciuria.
Pathological fractures are rare in young adults. A
pathological fracture is defined as a fracture which oc-
curs without adequate trauma and is caused by a pre-
existent pathological bone lesion. Causes include resorp-
tion of bone mass (osteoporosis, hyperpara-thyroidism),
reduction of bone quality (osteomalacia, osteonecrosis),
insufficient bone production (osteogenesis imperfecta,
fibrous dysplasia), au gmented bone resorption (giant cell
granulomas, aneurysmal bone cyst), pathological bone
remodelling (Paget's disease) or local bone destruction
due to malignancy. It must be detected clinically as well
as radiologically and its cause diagnosed histologically in
order to ensure adequate therapy.
Pathological fracture in severe hyperparathyroidism
can be associated with osteitis fibrosa cystica. It can be
seen as a classical skeletal complication of hyperpara-
thyroidism in some patients, although it is rare in the
modern era. It occurs in approximately 2% of individuals
diagnosed with hyperparathyroidism [1]. It is associated
with a loss of bone mass due to increased osteoclast ac-
tivity in the matrix secondary to raised PTH. In additio n,
there is experimental evidence that elevated PTH secre-
tion may be implicated in the enhanced degradation of
25-hydroxy-vitamin D which could contribute to the for-
mation of osteoporosis. As a result there is a weakening
of the bones as their calcified supporting structures are
replaced with fibrous tissue and the formation of cyst-
like brown tumors in and around the bone increasing the
risk of fracture. A number of studies have confirmed that
there is a both an increased risk of fracture in patients
with primary hyperparathyroidism and a reduced risk of
fractures i n p atients who u nderg o pa ra thyroidecto my [2].
The use of preoperative localisation studies is contro-
versial. Main methods of imaging are ultrasound, com-
puted tomography and nuclear imaging. Technetium Tc
99 m sestamibi is the radio-pharmacological agent of
choice, with a sensitivity reported to be between 72% -
100% [3]. One reason for the controversy around sesta-
mibi is the variable quality and accuracy of scans be-
tween different units. This is also countered by the fact
that studies have shown that experienced surgeons have a
90% - 95% cure rate in patients who undergo neck
exploration for the first time. A recent study has shown
that sestamibi combined with ultrasound increases the
accuracy of detection for parathyroid adenomas [4].
Surgical management is the main modality of treat-
ment in parathyroid adenoma. It involves resection of the
parathyroid gland by traditional neck exploration or
minimally invasive parathyroidectomy. As yet there is no
definitive evidence for the benefit of either technique
over the other. There is however a growing trend towards
minimally invasive surgery either through preoperatively
localised single gland excision or intraoperative locali-
Copyright © 2013 SciRes. OPEN ACCESS
D. Light et al. / Case Reports in Clinical Medicine 2 (2013) 4 57-459
Copyright © 2013 SciRes. OPEN ACCESS
[2] VanderWalde, L.H., Liu, I.L. and Haigh, P.I. (2009) Ef-
fect of bone mineral density and parathyroidectomy on
fracture risk in primary hyperparathyroidism. World Jour-
nal of Surgery, 33, 406-411.
sation. Indeed, in a number of asian countries there is a
growing trend towards parathyroid surgery via remote
endoscopic access through the axilla and chest due to
patients reluctance to have incisions visible in the neck
[5]. [3] Shen, W., Sabanci, U., Morita , E.T., Si perstein, A.E., Duh,
Q.Y. and Clark, O.H. (1997) Sestamibi scanning is in-
adequate for directing unilateral neck exploration for
first-time parathyroidectomy. Archives of Surgery, 132,
Another facet of modern parathyroid surgery is intra-
operative monitoring of parathyroid hormone levels. Due
to the short half-life of parathyroid hormone in the blood
stream, it is possible to assess operative success with
serum PTH levels intra-operatively. It is also possible to
perform recurrent laryngeal monitoring intraoperatively
although this is still controversial and neither technique
has become standar d pr a ctice.
[4] Patel, C.N., Salahudeen, H.M., Lansdown, M. and Scars-
brook, A.F. (2010) Clinical utility of ultrasound and 99
mTc sestamibi SPECT/CT for preoperative localization of
parathyroid adenoma in patients with primary hyperpara-
thyroidism. Clinical Radiology, 65, 278-287.
[5] Lang, B. (2009) Minimally invasive thyroid and parathy-
roid surgery.
This case illustrates a rare presentation of a large para-
thyroid adenoma in a young patient and the successful
management of complications with surgery.
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