patients with idiopathic parkinson 's disease ( ipd ) are at a high risk for hip fractures . the causes may be multifactorial , including poor balance and other forms of neurological dysfunction . people with ipd also have a high frequency of osteopenia and osteoporosis leading to decreased bone mass compounding the risk of fracture . this short case report discusses various mechanisms and highlights the crucial need for prevention in these patients along with treatment . a 55-year - old caucasian male had a 14-year history of ipd with worsening dyskinesias alternating with spells of immobility , postural instability , and ' wearing off ' phenomenon . he was in this usual state of baseline neurologic health when he arose from his computer one morning , stumbled and fell . emergency medical services were activated and the patient was transported to the emergency department of our hospital where he was found to have a right hip fracture . the patient was seen by orthopedics and underwent a successful right hip arthroplasty without incident . the patient had worked as a warehouse manager for a number of years until progression of his disease forced him to retire ( about 5 years prior to his current presentation ) . the patient had been on high doses of carbidopa - levodopa ( 25250 mg , 1.5 tablets every 2 h while awake ) and a dopamine agonist ( ropinirole 2 mg , 1 tablet every 2 h while awake ) for his rigidity and amantadine ( 100 mg , 1 tablet every 5 h ) for his dyskinesias for a number of years . he had prominent dyskinetic movements involving his arms , neck and face with hypophonic speech . tone was increased in his bilateral upper extremities and finger - tapping amplitude was diminished . his mental status was quite intact , being able to recall objects and count backwards . reflexes were intact at 2/4 in the bilateral upper extremities and the left knee jerk . motor strength testing was 5/5 ( medical research council grade ) in the bilateral upper extremities and the left lower extremity . testing of the right lower extremity and gait was limited secondary to the post - operative hip immobilizer . there was no upper extremity dysmetria on finger - to - nose testing and sensation was intact to light touch , pain , and temperature throughout . parkinson 's disease and osteoporosis are 2 disorders that affect a significant portion of patients . the causes may be multifactorial , including poor balance and other forms of neurological dysfunction including bradykinesia and hypokinesis leading to falls . osteoporosis is more common in ipd patients than in age - matched controls . up to 91% of females with ipd one of the main factors causing increased osteoporosis in these patients is decreased mobility leading to decreased weight - bearing exercise which is critical to maintain bone mass during aging . in addition , these patients are unstable and have an increased risk of falls . besides bradykinesia and postural instability , both of which contribute to falls , autonomic instability further increases risk . it should be noted that autonomic instability may be a medication side effect  one that should be seriously considered before starting new medications in patients with ipd . one study has shown that dementia related to ipd increases fracture risk further , as these patients are less likely to be aware of their surroundings and physical limitations . a 2007 study showed that levodopa is associated with an increased fracture risk , and that the risk is dose dependent . some believe that the increased fracture risk is due to the fact that levodopa increases patient mobility without improving postural stability , providing increased opportunity for fall and fracture . it has also been shown that anti - ipd medications , specifically l - dopa , increase serum homocysteine levels . an elevated homocysteine level is an independent risk factor for fracture , regardless of the patient 's ipd status . although ipd is a serious , progressive illness , one must not forget other clinical factors applicable to each individual patient that may change their risk stratification for fractures . like all patients , increased age , female gender , low body mass , and vitamin d deficiency all increase fracture risk . any patient may have a variety of these risk factors along with the added factors associated with ipd . because of the often debilitating nature of hip fractures , clinicians should do whatever possible to prevent fractures in the first place . it has been shown that vitamin d supplementation and bisphosphonate treatment can decrease fracture risk . however , other studies show no statistically significant difference between those treated prophylactically with risedronate versus placebo . it is important to note that even in this trial , where fracture risk was not greatly affected , bone mineral density was significantly better in the bisphosphonate group . urine markers of bone resorption were also significantly improved , signifying a role for bisphosphonate prophylaxis in these patients . this study also included daily ergocalciferol treatment in both groups  which may help counter bone resorption in these patients . regardless of the cause of hip fracture in ipd patients , these fractures do occur and require vigilant management . many studies have postulated that these patients have an increased mortality when compared to controls without ipd ; however , these studies have had conflicting results . initial clinical parameters influence a patient 's clinical course , such as age , gender , mobility , etc . from the orthopedic prospective , it is difficult to compare outcomes of ipd patients with hip fractures from other patients with hip fractures . some studies suggest that 6-month mortality is similar for both groups , around 14% , where other studies suggest ipd mortality is closer to 50% at 6 months . internal fixation appears to be a good option for patients with ipd ; however , this is not always feasible when patients have a higher grade fracture . it is thought that endoprostheses for severe fractures are associated with poor outcomes in ipd because they delay mobility post - operatively . overall , this review of the literature illustrates that hip fractures are a large problem in the population of patients with ipd . it is important to counsel patients and family members about these risks , so they are aware of how they can prevent fractures in their home . in addition , it is an important issue for neurologists , orthopedists and primary care physicians to be aware of when seeing patients with ipd . it appears that controversy still exists regarding the best method of management for these fractures as well as long - term outcome . although it is crucial for orthopedists dealing with hip fractures to learn the best course of treatment , even more emphasis should be placed on prevention . r.a.r . serves as associate neurology editor for ' journal of medical case reports ' , ' case reports in neurology ' , ' grand rounds ' , and formerly ' cases journals ' .
patients with chronic idiopathic parkinson 's disease are at a high risk for fractures , particularly of the hip . 
 the causes may be multifactorial , including poor balance and other forms of neurological dysfunction . 
 osteopenia and osteoporosis leading to decreased bone mass are common in these patients . 
 we report a case of a male patient with a long - standing history of parkinson 's disease on chronic high - dose carbidopa - levodopa who suffered a hip fracture . 
 the relationship of parkinson 's disease and carbidopa - levodopa use with osteopenia and hip fractures is discussed , emphasizing the crucial need for prevention in this patient population along with medical and surgical treatment .