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subtrochanteric stress fracture

Etiology: - bisphosphonate therapy for > 5 years Clinical manifestations: - sudden right hip snapping sound - inability to bear weight [12] - pain in the groin & the proximal thigh - range of motion of hip is normal - deep tendon reflexes are normal - hip extension in the prone position is painless - pain localized to the proximal thigh on palpation - no rash Radiology: - increased femoral cortical width on the previous plain radiograph Differential diagnosis: - osteoporotic fracture (insufficiency fracture, minimal trauma fracture) - osteoarthritis of the hip - range of motion of hip is not normal - trochanteric bursitis - pain over trochanteric bursa - L3 radiculopathy (hyporeflexia) Management: - stop bisphosphonate

General

stress fracture (fatigue fracture) subtrochanteric fracture

References

  1. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  2. Giusti A, Hamdy NA, Dekkers OM et al Atypical fractures and bisphosphonate therapy: a cohort study of patients with femoral fracture with radiographic adjudication of fracture site and features. Bone. 2011 May 1;48(5):966-71. PMID: 21195812
  3. Nieves JW, Cosman F. Atypical subtrochanteric and femoral shaft fractures and possible association with bisphosphonates. Curr Osteoporos Rep. 2010 Mar;8(1):34-9. Review. PMID: 20425089
  4. Schilcher J et al. Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 2011 May 5; 364:1728. PMID: 21542743
  5. FDA Medwatch Oral Bisphosphonates: Ongoing Safety Review of Atypical Subtrochanteric Femur Fractures http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm204127.htm
  6. Shane E, Burr D, Abrahamsen B, Adler RA et al Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2014 Jan;29(1):1-23. Review. PMID: 23712442 Free Article
  7. Tyler W, Bukata S, O'Keefe R. Atypical femur fractures. Clin Geriatr Med. 2014 May;30(2):349-59. Review. PMID: 24721373
  8. Park-Wyllie LY, Mamdani MM, Juurlink DN Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA. 2011 Feb 23;305(8):783-9 PMID: 21343577
  9. Kayali C, Altay T, Ozan F et al. Atypical femoral shaft fractures secondary to long-term bisphosphonate therapy. J Orthop. 2017;14(2):226-230 PMID: 28203048 PMCID: PMC5293726 Free PMC article https://doi.org/10.1016/j.jor.2017.01.002
  10. Starr J, Tay YKD, Shane E. Current understanding of epidemiology, pathophysiology, and management of atypical femur fractures. Curr Osteoporos Rep. 2018;16(4):519-529 PMID: 29951870 PMCID: PMC6061199 Free PMC article https://link.springer.com/article/10.1007/s11914-018-0464-6
  11. Dell R, Greene D. A Proposal for an Atypical Femur Fracture Treatment and Prevention Clinical Practice Guideline. Osteoporos Int. 2018;29(6)1277-1283 PMID: 29675745 https://link.springer.com/article/10.1007/s00198-018-4506-9
  12. Black DM et al. Atypical femur fracture risk versus fragility fracture prevention with bisphosphonates. N Engl J Med 2020 Aug 20; 383:743. PMID: 32813950 https://www.nejm.org/doi/10.1056/NEJMoa1916525