A Case of Teriparatide Use in Nonunion Atypical Ulnar Fracture

Abstract Background: Atypical upper limb fracture is a rare complication of bisphosphonate use. The management of nonunion fractures is challenging, especially in patients who are not surgical candidates. Teriparatide, a novel anabolic drug for osteoporosis has been increasingly used off-label for treatment of nonunion fractures and bisphosphonate related atypical fractures of the lower extremity. The proposed mechanism of healing is by enhancement of callus formation and mechanical strength. Clinical Case: A 72 year-old woman with a history of bilateral lower extremity paralysis and bilateral upper extremity paresis, who mobilized short distances with Canadian crutches, had been treated for 15 years with alendronate, for osteopenia associated with multiple risk factors for osteoporosis. 11 months before referral, and a month after alendronate was discontinued, she sustained a muscle-spasm induced fracture of the mid-shaft of the right ulna. She was treated nonoperatively due to chronic osteomyelitis with recurrent bacteremia from a prior non-healing left ulnar fracture (with internal fixation). Bone density of the right forearm had been normal. Since the right ulna break was transverse with minimal comminution, located in the diaphysis, occurred after trivial force and exhibited delayed healing, it was thought to be an atypical fracture secondary to bisphosphonates. She was initiated on cyclical teriparatide injection 20 mcg subcutaneously daily, with 2 months on and 2 weeks off. In one year, patient responded with dramatic radiographic improvement by forming a large callus with almost complete healing of the fracture. Conclusion: Mid-forearm atypical fracture from long-term bisphosphonate use is rare and is at risk for nonunion. The management of atypical upper limb nonunion fracture in nonoperative patients is not well established. Case reports exist of patients with atypical upper limb fracture who are either treated conservatively, or surgically with fixation/bone grafting +/- teriparatide. Our case showed that teriparatide, when used cyclically, exerted positive osteogenic effect and improved healing of the nonunion of an atypical fracture of forearm in a patient who continued weight bearing activity on her only functional limb.

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A Suspicious Atypical Fracture of 5th Metatarsal Bone: A Case Report

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00331 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0033

Author(s):

Byeong-Seop Park ◽

Seungbum Koo ◽

Won-keun Park ◽

Ki-bum Kwon ◽

Kyoung Min Lee

Keyword(s):

Callus Formation ◽

Weight Bearing ◽

Femoral Fractures ◽

Metatarsal Bone ◽

Atypical Fracture ◽

Atypical Fractures ◽

Strenuous Activity ◽

History Of ◽

Surgical Fixation ◽

The Right

Category: Trauma Introduction/Purpose: Long-term usage of bisphosphonate can severely suppress bone turnover and alter bone mechanical properties, thereby resulting in atypical fractures that mainly occur at the femur.We present a rare case of suspicious atypical fracture of the metatarsal bone. Methods: A 63-year-old woman presented to our clinic with a primary complain of a one-week history of pain in her right foot. The patient had no history of trauma to the right foot and denied any strenuous activity. She experienced lateral foot pain while walking within her home. She was on alendronate therapy for osteoporosis for a decade. X ray and CT examination revealed a fifth metatarsal fracture whose features were compatible with those of atypical femoral fractures (Figure 1). Results: The patient was advised to discontinue alendronate and underwent percutaneous surgical fixation of the fracture via a proximal approach using a 4.0-mm half-threaded cannulated screw. Postoperatively, a short leg cast was created and the patients performed non-weight bearing ambulation until the cast was removed at the sixth postoperative week. Radiography in the sixth postoperative week revealed callus formation. Conclusion: Our findings suggest that physicians must keep in mind that atypical fractures could possibly occur at bones other than the femur.

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Bilateral Anatomical Variation in the Formation of Trunks of the Brachial Plexus - A Case Report

Journal of Morphological Sciences ◽

10.1055/s-0038-1660485 ◽

2018 ◽

Vol 35 (01) ◽

pp. 9-13

Author(s):

E. Lasch ◽

M. Nazer ◽

L. Bartholdy

Keyword(s):

Case Report ◽

Brachial Plexus ◽

Upper Limb ◽

Scientific Literature ◽

Case Reports ◽

Anatomical Variation ◽

Male Cadaver ◽

Motor Nerves ◽

The Right

AbstractThis study presents a bilateral variation in the formation of trunks of brachial plexus in a male cadaver. The right brachial plexus was composed of six roots (C4-T1) and the left brachial plexus of five roots (C5-T1). Both formed four trunks thus changing the contributions of the anterior divisions of the cervical nerves involved in the formation of the cords and the five main somatic motor nerves for the upper limb. There are very few case reports in the scientific literature on this topic; thus making the present study very relevant.

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Therapeutic Functional Bracing in Upper Limb Fracture-Dislocations

Journal of Orthopaedic Trauma ◽

10.1097/00005131-198802040-00007 ◽

1988 ◽

Vol 2 (4) ◽

pp. 308-313 ◽

Cited By ~ 6

Author(s):

K. S. Leung ◽

M. Kwan ◽

J. Wong ◽

W. Y. Shen ◽

A. Tsang

Keyword(s):

Upper Limb ◽

Limb Fracture ◽

Fracture Dislocations ◽

Upper Limb Fracture

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Neurological status documentation in upper limb fracture patients

Injury Extra ◽

10.1016/j.injury.2011.06.276 ◽

2011 ◽

Vol 42 (9) ◽

pp. 122

Author(s):

E.S. Uppin ◽

A. Khurana ◽

U.K. Choudhuri ◽

R. Trickett

Keyword(s):

Upper Limb ◽

Neurological Status ◽

Limb Fracture ◽

Upper Limb Fracture

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Coping with an upper limb fracture? A study of the elderly

Public Health ◽

10.1016/s0033-3506(05)80325-7 ◽

1992 ◽

Vol 106 (1) ◽

pp. 19-28 ◽

Cited By ~ 5

Author(s):

R. Madhok ◽

R.S. Bhopal

Keyword(s):

Upper Limb ◽

The Elderly ◽

Limb Fracture ◽

Upper Limb Fracture

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Low volumetric BMD is linked to upper-limb fracture in pubertal girls and persists into adulthood: A seven-year cohort study

Bone ◽

10.1016/j.bone.2009.05.016 ◽

2009 ◽

Vol 45 (3) ◽

pp. 480-486 ◽

Cited By ~ 32

Author(s):

Sulin Cheng ◽

Leiting Xu ◽

Patrick H.F. Nicholson ◽

Frances Tylavsky ◽

Arja Lyytikäinen ◽

...

Keyword(s):

Cohort Study ◽

Upper Limb ◽

Limb Fracture ◽

Volumetric Bmd ◽

Upper Limb Fracture

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Management of post-traumatic stiffness of the shoulder following upper limb trauma with manipulation under anaesthetic

Shoulder & Elbow ◽

10.1177/1758573217693974 ◽

2017 ◽

Vol 9 (4) ◽

pp. 258-265 ◽

Cited By ~ 3

Author(s):

Sarah T. Lancaster ◽

Thomas N. Grove ◽

David A. Woods

Keyword(s):

Upper Limb ◽

Frozen Shoulder ◽

Standard Technique ◽

Humeral Fracture ◽

Limb Fracture ◽

Significant Difference ◽

Shoulder Scores ◽

Post Traumatic ◽

Upper Limb Fracture ◽

Limb Fractures

Background A proportion of patients who sustain upper limb fractures develop post-traumatic stiffness (PTS), which may progress in a similar way to primary frozen shoulder (PFS). We have had success in treating PFS with manipulation under anaesthetic (MUA) and therefore treated PTS using MUA. Oxford Shoulder Scores (OSS), range of motion (ROM) data pre- and post-MUA, and the need for repeat procedure were compared. Methods Sixty-four patients with PTS following an upper limb fracture, unresponsive to conservative measures, were seen between 1 January 1999 and 1 November 2015. Thirty-two patients had sustained a proximal humeral fracture, six of whom had a concurrent shoulder dislocation. MUA was performed using a standard technique. The results were compared with 487 PFS patients undergoing the same procedure. Results There was no significant difference in ROM change between the groups. Improvement in OSS was slightly greater in the PFS group (17 versus 14, p = 0.005) but, upon subgroup analysis of the PTS group, no significant difference was found for patients presenting with humeral fractures alone. Conclusions MUA results for PTS following upper limb fracture are comparable to MUA for PFS. We therefore recommend MUA in PTS cases where conservative methods have failed.

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Atypical Insufficiency Fractures Associated with Long-Term Bisphosphonate Therapy: 3 Case Reports

Journal of Bone Biology and Osteoporosis ◽

10.18314/jbo.v1i1.45 ◽

2015 ◽

Vol 1 (1) ◽

Author(s):

Sandrine Malochet Guinamand

Keyword(s):

Case Reports ◽

Femoral Fractures ◽

Bisphosphonate Therapy ◽

Fracture Site ◽

Atypical Fracture ◽

Mineral Research ◽

The Third ◽

First Case ◽

The Right

Atypical femoral fractures as defined by the American Society for Bone and Mineral Research (ASBMR) are linked with long-term bisphosphonate therapy. We report the cases of 3 patients treated with bisphosphonates, and presenting non femoral atypical fracture. Our first patient presented with a series of fractures after being treated with risedronate: the left tibia, bilateral tibial plateau successively, the left femoral and tibial metaphysis, the right tibia and calcaneus, the left talus, and the left talar dome. The second patient had been taking alendronate and presented with a spontaneous fracture of the spine of the left scapula. The third patient had been treated with alendronate and presented with a fracture of the upper right tibial diaphysis with an unusual oblique orientation. These fractures could be suggestive of bisphosphonate therapy failure or stress fractures. However, the number of fractures in our first case, the fracture site in the second and the fracture line orientation in the third brings to mind the hypothesis of atypical non femoral fractures associated with bisphosphonate therapy. We therefore suggest the possibility of a new type of atypical fracture in patients treated with bisphosphonates, and whose causal relationship with bisphosphonates is even more difficult to demonstrate.

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