A 69-year-old man was injured after a fall at home on 20 December 2020, which resulted in pain and limited movement of the left hip joint. Following X-rays and computed tomography (CT) scans performed at a local hospital, a left femoral neck fracture was revealed (Figures 1 and 2). He was admitted to our hospital on 26 December 2020 for further diagnostic evaluation and treatment.
After admission, the patient was given bed rest, and a left leg traction was maintained. Physical examination on admission revealed pain and limited movement of the left hip joint, and the left lower extremity was shortened with external rotation deformity. The Harris score of left hip was 10.   The patient wanted hip surgery to relieve left hip pain. Therefore, on 26 December 2020, CT scan was used to evaluate the condition of the lungs before hip surgery, and it showed no coracoid process fracture (Figure 3).
Since the patient had a history of chronic renal failure and received resection for an esophageal tumor in 2011 without postoperative chemotherapy. And, the patient had no history of epilepsy and no history of medications that would cause osteoclast hyperactivation. Laboratory studies revealed serum creatinine level of 815.8 mumol/L (reference range: 53-110 micromol/L), and blood urea nitrogen (BUN) level of 28.68 mumol/L (reference range: 2.88-7.2 mumol/L).
After consulting the Nephrology Department and receiving eight cycles of hemodialysis to reduce levels of creatinine and BUN, the surgical requirements were finally met. However, a subsequent in-hospital CT scan done on 8 January 2021 to reevaluate the lung condition revealed bilateral coracoid process fracture, with no obvious bone lesion at the fracture end (Figure 4). Bilateral coracoid process fracture was still present when a CT scan was repeated for the third time on 13 January 2021 (Figure 5). The patient was treated in bed with traction because of a left femoral neck fracture, and the patient sustained no trauma since admission. We believe this could be attributed to a pathological fracture. Further examination revealed the following: serum alkaline phosphatase was 138.85 U/L (reference range: 30-130 U/L), bone mineral density assessment (lumbar spine) revealed T score of -2.8, while tumor markers and tuberculosis antibody were negative.
The patient insisted on hip replacement surgery for femoral neck fracture management.Thus, a left artificial double femoral head replacement was performed on the 20 January 2021, while conservative treatment was administered for the bilateral coracoid process fracture. The conservative treatment comprised reduction in shoulder motion and treatment of osteoporosis via injection of Elcatonin and oral administration of Carbonate D3 Granules. Histological examination of the broken end of the left femoral neck fracture through hematoxylin and eosin (H&E) staining revealed some new but very few bone tissues with massive fibrous structure and a thin and loose trabecular bone, but no tumor cells (Figure 6). A plain radiograph of the pelvis after surgery showed that the hip replacement arthroplasty was very successful (Figure 7).
On 7 February 2021, a CT scan was performed for the fourth time. The scan still indicated bilateral coracoid fracture (Figure 8). However, the patient did not feel local pain, and both upper limbs were functional enough to allow him to ambulate with a walker. There was no tenderness in bilateral coracoid processes, and bilateral shoulder joints could also be abducted upward (Figure 9). Therefore, conservative treatment for bilateral coracoid process fractures was continued.
We followed up the patient regularly after the hip surgery and he also underwent hemodialysis twice a week. However, due to financial difficulties, and the fact that he felt he had good functionality in both upper limbs, he refused to be subjected to further X-rays or CT scans for monitoring purposes. It was not until 20 October 2021 that he permitted a hip X-ray which indicated that the left femoral head prosthesis was still correctly positioned (Figure 10). Furthermore, a chest CT scan revealed that there was still a bilateral pleural effusion, in addition to presence of bilateral coracoid process fracture (Figure 11). However, the patient still felt no pain at the fracture site, and both upper limbs were functional (Figure 12). On the 20 December 2021, a reexamination of his shoulder function, as well as CT scan, showed similarity with the conditions in October (Figures 13 and 14).
On the 13 January 2022 (1 year later), a CT scan was performed for the last time. It was found that the bilateral pleural effusion persisted, and bilateral coracoid process fracture failed to heal (nonunion). Moreover, there was sclerosis at the broken ends, while bone destruction was absent (Figure 15). At this time, the patient developed dysphagia, which we suspected was caused by esophageal anastomosis in the original operation. Subsequent gastroscopy confirmed this and no recurrence was found (Figure 16).