Bilateral femoral insuffiency fractures treated with inflatable intramedullary nails: a case report

Abstract

Stress fractures could be classified as fatigue fractures and insufficiency fractures (IF). Fatigue fractures occur when abnormal mechanical stress is applied to a normal bone, on the other hand insufficiency fractures occur when normal to moderate pressure is applied to a bone that has decreased resistance (Daffner and Pavlov in Am J Radiol 159:242-245, 1992). IF have been observed mainly in patients with postmenopausal osteoporosis, and are becoming more common with the increase of elderly population (Daffner and Pavlov in Am J Radiol 159:242-245, 1992). Other systemic and metabolic conditions that can result in osteopenia and IF include osteomalacia, hyperparathyroidism, hyperthyroidism, rheumatoid arthritis, fluoride treatment, diabetes mellitus, fibrous dysplasia, Paget's disease, irradiation and mechanical factors (Daffner and Pavlov in Am J Radiol 159:242-245, 1992; Soubrier et al. in Joint Bone Spine 70:209-218, 2003; Epps et al. in Am J Orthop 33:457-460, 2004; Austin and Chrissos in Orthopedics 28:795-797, 2005). In this case report, the authors present an osteoporotic woman who developed bilateral insufficiency fracture of the femoral shaft after longstanding steroid, thyroxine replacement and alendronate therapy due to partial empty sella syndrome and osteoporosis, resulting in the treatment of the fracture by inflatable intramedullary nailing.

Atypical Subtrochanteric and Femoral Shaft Fractures and Possible Association with Bisphosphonates

“…All of the individual case reports of atypical femoral fractures that have been published [12][13][14][15][16][17][18][19][20] illustrate one or more features suggestive of a fracture distinct from the common osteoporosis-related, prosthesis-related, or major traumarelated fracture described above. These include prodromal pain in the thigh or leg for weeks or months prior to the fracture [14,17,18]; use of another antiresorptive or steroid therapy, in addition to the bisphosphonate [12,15,18]; lack of trauma precipitating a fracture [13,14,17,18]; bilaterality (either simultaneous or sequential) [13,15,18,20]; transverse fractures [17]; cortical hypertrophy or thickness [18]; stress reaction on the affected and/or unaffected side [12,14,17,18,20]; poor fracture healing [18,19]; and normal or low bone mass but not osteoporosis in the hip region [11,15,21].…”

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

“…Several unique radiographic and clinical features have emerged from these case reports and series. All the individual case reports of atypical femoral fractures (118,119,122,(125)(126)(127)(128)(129) illustrate one or more radiographic features suggestive of a fracture distinct from the common osteoporosis-, prosthesis-, or major trauma-related fractures.…”

“…These include lack of precipitating trauma, (118,122,127) (118,119,122,129) transverse fractures, (127) cortical hypertrophy or thickness, (118) stress reaction on the affected and/or unaffected side, (118,122,125,127,129) and poor fracture healing. (118,128) Other features include prodromal pain in the thigh or groin for weeks or months prior to the fracture, (118,122,127) use of an additional antiresorptive agent (eg, estrogen, raloxifene, or calcitonin), use of GCs or PPIs in addition to the BP, (118,119,125) presence of RA or DM, serum 25(OH)D concentrations less than 20 ng/mL, and normal or low BMD but not osteoporosis in the hip region.…”

“…(118,128) Other features include prodromal pain in the thigh or groin for weeks or months prior to the fracture, (118,122,127) use of an additional antiresorptive agent (eg, estrogen, raloxifene, or calcitonin), use of GCs or PPIs in addition to the BP, (118,119,125) presence of RA or DM, serum 25(OH)D concentrations less than 20 ng/mL, and normal or low BMD but not osteoporosis in the hip region. (13,115,119) Several reports describe iliac crest biopsies with very low bone turnover rates (Table 6); however, this is not a distinguishing feature of patients with atypical fractures on BPs because even short-term use of a BP results in dramatic reductions in rates of bone turnover.…”

Epidemiology, radiology and histology of atypical femoral fractures

“…Several case reports established an association with other antiresorptive drugs in addition to bisphosphonates (estrogen, raloxifene, calcitonin) (Schneider 2006, Demiralp et al 2007, Somford et al 2009). …”