Break a Leg: A Woman with Recurrent Fractures

Imaging confirmed a stress fracture of the fourth metatarsal (Figure 1) with left hip osteopenia. Oral ibandronate was prescribed, but 4 years later, the patient experienced an osteoporotic femoral fracture. The patient switched from ibandronate to intravenous zoledronic acid, but she continued to experience fractures, including an atypical femoral fracture. A picture started to emerge: Low alkaline phosphatase (ALP); elevated serum vitamin B6 levels; and a history of frequent dental caries, delayed ambulation, short stature, and scoliosis suggested an inherited mineralization disorder.