Undiagnosed bilevel tibial fracture in a bedridden rheumatoid arthritis patient: A case report emphasizing the diagnostic utility of scanogram

Rheumatoid arthritis (RA) patients are predisposed to fragility fractures due to a combination of chronic inflammation, prolonged corticosteroid use, and disuse osteoporosis. Fractures in such patients may remain undiagnosed, particularly in the absence of appropriate imaging, compounding disability and delaying definitive treatment. Here, we report a rare case of a 67-year-old female with seropositive RA bedridden for 6 months with progressive left knee pain, initially misdiagnosed as end-stage knee arthritis. Despite multiple evaluations at tertiary centers, essential long-leg radiological assessments were omitted. A scanogram revealed a rare bilevel tibial fracture involving the metaphyseal proximal tibia and mid-diaphyseal shaft. The patient was successfully treated with long-stem total knee arthroplasty, addressing both fracture stability and joint degeneration in a single-stage procedure. This case underscores the critical role of scanogram in the evaluation of nonambulatory RA patients presenting with unexplained lower limb pain. Early use of full-length imaging can unveil occult fractures, guide surgical planning, and prevent prolonged morbidity.