hyperparathyroidism ( hpt ) occurs when there is an abnormal increase in parathyroid hormone ( pth ) production by the parathyroid gland [ 13 ] .
primary hpt ( phpt ) is caused by parathyroid adenomas in 85% of cases , leading to hyperplasia and over - secretion of pth . in most individuals in western society , it is diagnosed at an asymptomatic stage , without signs or symptoms of ( pth ) calcium excess .
initial symptoms are nonspecific , such as weakness , malaise , fatigue and possible mood disturbances . if not diagnosed and left untreated , it leads to devastating consequences including nephrolithiasis , nephrocalcinosis , renal failure , osteopenia and osteoporosis .
a 22-year - old male student presented to our hospital with a 2-year history of progressive lower extremity weakness .
one year prior to the admission , he had been seen at another medical clinic because of fatigue and difficulty walking .
his radiographs showed no fractures , and he was referred to physiotherapy for muscle strengthening .
further questioning revealed that , despite physiotherapy , his weakness had progressed and he had to quit school as he was having considerable difficulty walking up a flight of stairs .
a thorough investigation was performed and showed a serum calcium level of 3.46 mmol / l ( normal : 2.12.6 mmol / l ) and a pth level of 138 pmol / l ( normal : 1.69.3 pmol / l ) .
he was referred to our general surgery service where he was admitted for excision of the parathyroid adenoma . upon admission ,
one day prior to the scheduled parathyroidectomy , he had a simple , low - energy fall while he was walking on his own to the hospital .
radiographs revealed a displaced subcapital fracture of his left hip , a segmental fracture of his right humerus and extreme osteopenia ( fig .  1 ) . 

figure  1:(a ) left femoral neck displaced subcapital fracture and ( b ) right humeral shaft segmental fracture .
( a ) left femoral neck displaced subcapital fracture and ( b ) right humeral shaft segmental fracture .
one day after sustaining this injury , the patient underwent an uncemented left total hip arthroplasty ( tha ) ( fig . 
2 ) , and acetabular fixation was supplemented with multiple screws , and he maintained touch - down weight bearing for 6 weeks postoperatively .
postoperatively , the pth level had decreased to 4.9 pmol / l , and the calcium level had returned to normal at 2.42 mmol / l .
the calcium level continued to fall , and 2 weeks after the parathyroidectomy , it had reached 1.70 mmol / l . after a further 20 days , it started to normalize and then continued to remain stable , as shown in fig .  3 . 

figure  2:(a ) left thr and ( b ) right humerus in a brace . 

( a ) left thr and ( b ) right humerus in a brace . a graph for calcium level from admission to 7 weeks after surgery
we report this case to illustrate the importance of early detection and diagnosis of phpt , which was possible in this young and presumed healthy individual if proper assessment and management were done .
furthermore , sending him for physiotherapy without a clear diagnosis increased the likelihood of missing the diagnosis and progression of the disease .
solitary parathyroid adenoma is the most common cause of phpt , representing 8590% of cases .
symptomatic phpt with skeletal , renal , abdominal and neuro - psychiatric manifestations has become exceedingly rare in developed countries .
our patient was unusual in that he was not diagnosed early and presented with skeletal manifestations resulting in multiple fractures including femoral neck fracture ( fnf ) , which was treated with total hip replacement ( thr ) . at this young age , thr would affect his lifestyle and put him at risk of revision surgery early in his life .
the literature clearly shows that the earlier hpt is detected , the more reversible the disease .
we believe that , despite the young age of our patient , thr was still the preferred treatment in this situation owing to his poor bone quality , which could have led to failure of fixation ; in addition , severe fracture displacement carries a high risk of femoral head avascular necrosis .
yang et al . found that salvage tha for failed internal fixation following fnf is a more technically demanding procedure with prolonged operative time and larger amounts of postoperative drainage ( within 24 h ) and that patients are at increased risk of developing hip complications compared with primary thr for acute displaced fnf .
french et al .   reported a case of a 21-year - old male with parathyroid adenoma who had presented with a left femoral shaft fracture and right fnfs .
although these were treated with fixations , the right side required conversion to thr within a year of his presentation .
 we present the case of a 22-year - old male with longstanding progressive fatigue , weakness and pain around his hips due to an undiagnosed parathyroid adenoma . 
 the resultant primary hyperparathyroidism ultimately caused pathologic fractures . 
 he was admitted to the hospital for further assessment and excision of the parathyroid adenoma . 
 a few days after admission , he fell down while walking and was referred to our team . 
 x - rays showed a displaced left femoral neck fracture ( fnf ) and right humeral shaft fracture with poor bone quality . 
 his humeral fracture was treated conservatively , and the fnf was treated with total hip replacement . 
 three days later , he underwent parathyroidectomy . 
 this case demonstrates the importance of a thorough investigation of progressive weakness even in a young individual and illustrates the importance of early diagnosis of parathyroid adenoma to avoid the devastating end results of this condition . 