Author: Bridget Caulkins, MD
Co Author #1: Carlton Covey, MD, CAQSM
Senior Editor: Siobhan Statuta, MD, FAMSSM
Editor: Brian Cervoni-Rosario, MD

Patient Presentation:
A 34 year old active duty United States Air Force male physician fell off a slow moving skateboard from floor height as it slipped out from underneath him. The skateboard was not moving at any appreciable speed prior to the incident and the patient fell directly onto his hands and then onto his right hip. He experienced immediate right hip pain after the fall and was unable to ambulate. He was subsequently brought to the emergency room for further evaluation.

History:
During evaluation in the emergency department, the patient was found to have a right-sided subcapital valgus impacted femoral neck fracture Case Photo #1 . No other bony injuries were sustained. He was admitted to the hospital and underwent an uncomplicated open reduction internal fixation of his femur the next day. He was discharged with primary care and orthopedic follow-up.

During his primary care provider follow up visit, concern for underlying low bone mineral density prompted further evaluation regarding associated risk factors. The patient revealed a history of decreased libido, lack of spontaneous erections, small testes, and more than 11 years of infertility with wife to include two years of active attempts at fertility. He endorsed intake of multiple dietary calcium and vitamin D sources, but due to his job, he did not get much exposure to direct sunlight.

He denied erectile dysfunction, breast discomfort, gynecomastia, or loss of axillary/pubic hair and reported normal history of pubertal development. He further denied history of obstructive sleep apnea symptoms or testicular pathology (trauma, torsion, infection, chemotherapy radiation or delayed descent). He had no history of a gastrointestinal malabsorption diagnosis but endorsed history of irritable bowel syndrome/constipation subtype (IBS-C) treated with linaclotide (Linzess). He denied history of intracranial tumors, head trauma, or pituitary surgery or radiation. He denied history of proximal muscle weakness, facial plethora, or red/purple abdominal striae.

On social history, he denied history of opioid use, tobacco use, corticosteroid use, anabolic steroid use, or marijuana use. He endorsed drinking one to two drinks of alcohol every month. He denied history of excessive exercise, low calorie intake, calorie restriction, calorie purging, or any dietary restrictions although he mostly ate a plant-based diet due to his history of IBS-C. He reports that he had always been thin with body mass index consistently around 19. Activity level prior to the fracture involved running between two and ten miles about four times per week.

After initial and follow-up interviews, a thorough osteoporosis evaluation was initiated.

Physical Exam:
Height: 188 cm
Weight: 68.2 kg
Body mass index: 19.3
BP: 116/77

General: Appears tall and thin. No ecchymosis, skin lesions, or striae.
Head: Normocephalic. Atraumatic.
Eyes: No gross proptosis. No abnormalities of conjunctiva.
Neck: No thyromegaly. No lymphadenopathy.
Respiratory: Normal respiration rhythm and depth.
Musculoskeletal: Right lower extremity with continued mild tenderness to palpation over the lateral aspect of right femur. Mildly antalgic gait.
Genitourinary: Normal phallus. Normal testicular texture. Low normal testicular size.

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