Introduction: Nutritional osteomalacia is a metabolic bone disorder common among the Asian female immigrant population in the United Kingdom. It is often under diagnosed in the United Kingdom, although it has been highlighted in the literature since the 1960s.1 Patient may be asymptomatic in the early stages although signs of osteomalacia may be apparent on X-ray pictures or other diagnostic tests. As osteomalacia worsens, symptoms may include bone pain, decreased muscle tone and muscle weakness. Pathological fractures such as bilateral subtrochanteric pseudofractures of the femur are an uncommon complication of osteomalacia. This has been rarely reported. Case presentation: This case presents an interesting and unusual case of a 38-year-old female of Asian origin with bilateral subtrochanteric pseudofractures of the femur secondary to osteomalacia. The patient was treated successfully with calcium and vitamin D supplement therapy without surgical intervention. The bone pain subsided and she was able to bear full weight within 2 weeks of treatment. Conclusion: There should be a high index of suspicion of this disease, particularly among Asian female immigrant population presenting with persistent and non-specific musculoskeletal pain and on strict vegetarian diet. This case reiterates the importance of considering insufficiency or stress fractures in this group of patient. Management of the underlying cause, osteomalacia proves vital to prevent further complications. Morbidity related to delayed treatment has been well documented, so a high level of clinical suspicion is imperative. Introduction Nutritional osteomalacia is a metabolic bone disorder common among the Asian female immigrant population in the United Kingdom. It is often under diagnosed in the United Kingdom, although it has been highlighted in the literature since the 1960s.1 Patient may be asymptomatic in the early stages although signs of osteomalacia may be apparent on X-ray pictures or other diagnostic tests. As osteomalacia worsens, symptoms may include bone pain, decreased muscle tone and muscle weakness. Pathological fractures such as bilateral subtrochanteric pseudofractures of the femur are an uncommon complication of osteomalacia. Early recognition of this type of pathological fractures leads to the appropriate treatment, including medical and surgical treatment to avoid serious complications. Case presentation A 38-year-old female of Asian origin who was a vegetarian presented with a six-month history of intermittent bilateral hip pain. She had experienced generalised malaise, some discomfort in the groin for the past few months on walking and recalled losing her balance. There was no history of direct trauma. Her past medical history included hypothyroidism and she was on 125 mcg levothyroxine daily. She did not drink alcohol or smoke. Since moving to the United Kingdom from India two years earlier, she had stayed indoors most of the time and had very little exposure to the sun. On examination, she was slim and walked with a waddling gait. Movements of both hips were mildly painful on abduction and internal rotation. No other obvious abnormality was found. The kidney, liver, bone profile and thyroid function tests were all normal. The anteroposterior radiograph of the pelvis showed bilateral undisplaced subtrochanteric pseudofractures of the femur. The radiograph changes were suggestive of pseudofracture secondary to osteomalacia. She was treated with therapeutic doses of calcium and vitamin D supplements but had no surgical intervention. She was advised to increase her calcium intake by consuming dairy and poultry products, especially eggs and milk. She was discharged 2 weeks later when the bone pain subsided and able to bear full weight.
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