Skip to main content
NCBI home page
Annals of the Rheumatic Diseases logoLink to Annals of the Rheumatic Diseases
. 2004 Oct;63(10):1241–1243. doi: 10.1136/ard.2003.016105

Antiphospholipid antibodies, systemic lupus erythematosus, and non-traumatic metatarsal fractures

S Sangle 1, D D'Cruz 1, M Khamashta 1, G Hughes 1
PMCID: PMC1754745  PMID: 15361379

Abstract

Background: Stress fractures are common in military recruits and athletes and are thought to be secondary to stress and overuse. Less often they are associated with metabolic disorders such as osteoporosis, hypophosphataemia, and diabetes mellitus.

Objective: Analysis of 19 patients with systemic lupus erythematosus and antiphospholipid antibodies presenting consecutively with foot pain. All had metatarsal fractures (six bilateral) without any obvious history of trauma.

Results: 13 of the 19 patients had antiphospholipid syndrome. Among the whole group, 13 had normal bone mineral density, one had osteopenia, and five others had osteoporosis as defined by WHO criteria; 10 had received steroids, mostly in low dosage; 13 were receiving warfarin. There was no evidence that a metabolic bone abnormality was a unifying factor in the pathogenesis.

Conclusions: Atraumatic metatarsal stress fractures may occur in SLE, particularly in association with the antiphospholipid syndrome. The pathogenesis of these fractures remains uncertain but microinfarcts in the metatarsal bones are a possible cause.

Full Text

The Full Text of this article is available as a PDF (68.9 KB).

Figure 1.

Figure 1

Open in a new tab

 A radionuclide scan of the foot showing an area of increased uptake suggesting metatarsal fracture in a patient with primary antiphospholipid syndrome.

Figure 2.

Figure 2

Open in a new tab

 Foot x ray showing metatarsal fracture in a patient with secondary antiphospholipid syndrome.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alarcón-Segovia D., Delezé M., Oria C. V., Sánchez-Guerrero J., Gómez-Pacheco L., Cabiedes J., Fernández L., Ponce de León S. Antiphospholipid antibodies and the antiphospholipid syndrome in systemic lupus erythematosus. A prospective analysis of 500 consecutive patients. Medicine (Baltimore) 1989 Nov;68(6):353–365. doi: 10.1097/00005792-198911000-00003. [DOI] [PubMed] [Google Scholar]
  2. Asherson R. A., Lioté F., Page B., Meyer O., Buchanan N., Khamashta M. A., Jungers P., Hughes G. R. Avascular necrosis of bone and antiphospholipid antibodies in systemic lupus erythematosus. J Rheumatol. 1993 Feb;20(2):284–288. [PubMed] [Google Scholar]
  3. Asherson Ronald A., Cervera Ricard. Unusual manifestations of the antiphospholipid syndrome. Clin Rev Allergy Immunol. 2003 Aug;25(1):61–78. doi: 10.1385/CRIAI:25:1:61. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Boden B. P., Osbahr D. C. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000 Nov-Dec;8(6):344–353. doi: 10.5435/00124635-200011000-00002. [DOI] [PubMed] [Google Scholar]
  5. Donahue S. W., Sharkey N. A. Strains in the metatarsals during the stance phase of gait: implications for stress fractures. J Bone Joint Surg Am. 1999 Sep;81(9):1236–1244. doi: 10.2106/00004623-199909000-00005. [DOI] [PubMed] [Google Scholar]
  6. Elkayam O., Paran D., Flusser G., Wigler I., Yaron M., Caspi D. Insufficiency fractures in rheumatic patients: misdiagnosis and underlying characteristics. Clin Exp Rheumatol. 2000 May-Jun;18(3):369–374. [PubMed] [Google Scholar]
  7. Hochberg M. C. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997 Sep;40(9):1725–1725. doi: 10.1002/art.1780400928. [DOI] [PubMed] [Google Scholar]
  8. Houssiau F. A., N'Zeusseu Toukap A., Depresseux G., Maldague B. E., Malghem J., Devogelaer J. P., Vande Berg B. C. Magnetic resonance imaging-detected avascular osteonecrosis in systemic lupus erythematosus: lack of correlation with antiphospholipid antibodies. Br J Rheumatol. 1998 Apr;37(4):448–453. doi: 10.1093/rheumatology/37.4.448. [DOI] [PubMed] [Google Scholar]
  9. Jamal S. A., Browner W. S., Bauer D. C., Cummings S. R. Warfarin use and risk for osteoporosis in elderly women. Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1998 May 15;128(10):829–832. doi: 10.7326/0003-4819-128-10-199805150-00006. [DOI] [PubMed] [Google Scholar]
  10. Jones Lynne C., Mont Michael A., Le Tung B., Petri Michelle, Hungerford David S., Wang Ping, Glueck Charles J. Procoagulants and osteonecrosis. J Rheumatol. 2003 Apr;30(4):783–791. [PubMed] [Google Scholar]
  11. Philip W. J., Martin J. C., Richardson J. M., Reid D. M., Webster J., Douglas A. S. Decreased axial and peripheral bone density in patients taking long-term warfarin. QJM. 1995 Sep;88(9):635–640. [PubMed] [Google Scholar]
  12. Tektonidou Maria G., Malagari Katerina, Vlachoyiannopoulos Panayiotis G., Kelekis Dimitris A., Moutsopoulos Haralampos M. Asymptomatic avascular necrosis in patients with primary antiphospholipid syndrome in the absence of corticosteroid use: a prospective study by magnetic resonance imaging. Arthritis Rheum. 2003 Mar;48(3):732–736. doi: 10.1002/art.10835. [DOI] [PubMed] [Google Scholar]
  13. Tomczak R. L., VanCourt R. Metatarsal insufficiency fractures in previously undiagnosed osteoporosis patients. J Foot Ankle Surg. 2000 May-Jun;39(3):174–183. doi: 10.1016/s1067-2516(00)80019-8. [DOI] [PubMed] [Google Scholar]
  14. Wilson W. A., Gharavi A. E., Koike T., Lockshin M. D., Branch D. W., Piette J. C., Brey R., Derksen R., Harris E. N., Hughes G. R. International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome: report of an international workshop. Arthritis Rheum. 1999 Jul;42(7):1309–1311. doi: 10.1002/1529-0131(199907)42:7<1309::AID-ANR1>3.0.CO;2-F. [DOI] [PubMed] [Google Scholar]

Articles from Annals of the Rheumatic Diseases are provided here courtesy of BMJ Publishing Group

RESOURCES