Calcitonin for multiple fractures in Paget's disease.

Paget's disease of bone-often causes pathological fracture,' though Paget made no mention of this complication in his original treatise. Multiple fractures may occur, and some measure of their incidence may be gauged from a series of femoral fractures secondary to Paget's disease described by Barry.-: Thirteen out of 73 patients had two femoral fractures, and four had at intervals sustained three fractures of the same femur. We describe here a particularly florrid case of Paget's disease with multiple fractures, for which calcitonin was prescribed. A 73-year-old woman presented with a week's history of a painful right hip and no history of injury. Radiographs showed Paget's disease of the pelvis and femora with a virtually undisplaced transverse fracture of the proximal right femoral shaft. Within the previous two years she had sustained a left subtrochanteric and a right intertrochanteric fracture secondary to Paget's disease. Both had been treated with internal fixation, with a subsequent incisional infection on the right. The underlying metal implant was removed late, after the fracture had united. The presenting right femoral shaft fracture was initially treated conservatively by immobilisation, but while lifting herself in bed the patient sustained a pathological mid-shaft fracture of the left clavicle. To improve the patient's mobility the femoral fracture was internally fixed with a compression plate, and at surgery the bone was found to be soft and vascular. A spontaneous supracondylar fracture of the same femur occurred soon after operation, this being the third pathological fracture within three weeks. The leg was immobilised in a plaster-of-Paris cylinder. Serum alkaline phosphatase concentration was raised (1750 IU/1), and because of this florrid clinical and biochemical presentation treatment of the Paget's disease was started with salmon calcitonin 100 MRC units daily. The alkaline phosphatase fell dramatically and the subsequent calcitonin dosage was titrated to its fluctuations (see figure). The serum calcium was normal and after a fall at the onset of treatment remained within the normal range. Seven weeks after the femoral fracture the knee was mobilised, and at 10 weeks the patient started full weight bearing. No further fractures occurred in the next two years, despite the fact that the patient once had a fall that caused an effusion into the right knee. The calcitonin was discontinued after 10 months of treatment, and since that time two further short courses have been given with benefit for pelvic girdle pain.