Femoral diaphyseal stress fracture as the initial presentation of acute leukaemia in an adolescent

Abstract

A 14-year-old boy was referred to the orthopaedic clinic by his general practitioner, reporting of a 6-week history of left thigh pain. Clinical examination was unremarkable. Radiographs demonstrated a periosteal reaction at the proximal femur. MRI scans demonstrated a stress fracture of the femur, with no associated sinister features and no evidence of a pathological lesion. As the fracture healed and symptoms improved, the patient became unwell with weight loss, lethargy, chest and jaw pain and fevers. After multiple blood tests over a 25-day period, including five full blood counts and two normal blood films, a third blood film finally demonstrated blasts in keeping with acute leukaemia. We discuss a literature review of musculoskeletal manifestations of leukaemia and the often atypical presentations found.

Childhood acute lymphoblastic leukaemia relapse with atypical localised presentation mimicking ankle trauma in a 28-year-old man

“…Musculoskeletal involvement was seen in less than half of patients, with symptoms including limb pain (incidence 43%), bone pain (26%), musculoskeletal impairment (23%), joint pain (15%) and limp (11%) 2. Of the patients who present with musculoskeletal symptoms, localised involvement is extremely rare,1 5 6 8 and when it does, often the occurrence is in the bone itself leading to a stress fracture 9. BM biopsy of this patient’s ilium, the preferred site of biopsy for BM studies, did not show evidence of disease, nor was there evidence of disease in the peripheral blood.…”