Skeletal fragility in type 1 diabetes mellitus: A rare case of avascular necrosis of talus

A divergent fracture pattern is seen in patients living with type 1 diabetes (T1D). These patients are at risk for fractures at unusual distal sites over and above the fractures occurring at major osteoporotic sites. Avascular necrosis (AVN) involving the talus has not been reported previously in T1D. We hereby report an exceptional case of a 24-year old patient of T1D, who reported to us 3 months post-partum with swelling and pain over her right ankle. In the third trimester of her pregnancy, she encountered trivial trauma to her right ankle. One month after delivery, she developed fragility fractures over her left 2nd to 4th metatarsal heads. On further workup, she was found to have low bone mass and avascular necrosis of right talus on magnetic resonance imaging. On follow up 1 year later, she continued to have low bone mass although her bone mineral density (BMD) increased at the lumbar spine and hip. She was diagnosed with right talar AVN due to fragility fracture sustained in the third trimester with low bone mass consequent to T1D. A possible role of pregnancy- and lactation-related osteoporosis was considered in view of the chronological association with pregnancy. Our case highlights the fragile skeletal health of patients living with T1D making a case for greater scrutiny of declining bone health in these patients.