Atypical Fracture of Proximal Ulna Associated with Prolonged Bisphosphonate Therapy Managed with Nonoperative Treatment: A Case Report and Literature Review

Prolonged bisphosphonate (BP) treatment is associated with some complications, such as atypical femoral fractures (AFFs). Recent studies showed that atypical fractures also occurred in other bones, especially in the atypical fracture of the proximal ulna (AFPU). Although, AFPUs frequently share the same characteristics of atypical fractures as AFFs, such as fracture configuration and high risk of non-union, there is still limited evidence of the role of non-operative treatment in AFPU. The aim of the present study was to present an interesting case involving an 80-year-old female presented with non-displaced AFPU after receiving long-term BP medication and had been treated with a conservative method for 2.5 years, and to review the literature regarding the available AFPU treatment options. To the best of the authors’ knowledge, the present case report introduced new insight of the outcome of non-operative treatment for AFPU. Keywords: Non-displaced fracture; Ulna fracture; Long-term bisphosphonates; Conservative treatment; Nonunion; Osteoporosis

A Case of Teriparatide Use in Nonunion Atypical Ulnar Fracture

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.

Treatment strategy for atypical ulnar fracture due to severely suppressed bone turnover caused by long-term bisphosphonate therapy: a case report and literature review

Background Atypical fractures may occur due to the combined effect of severely suppressed bone turnover (SSBT) caused by long-term bisphosphonate treatment and chronic repetitive bone microdamage. Atypical fracture of the ulna due to SSBT is a rare entity; there is no standardized treatment strategy for this condition. We successfully treated a patient with atypical fracture of the ulna. Herein, we present this patient, review the relevant literature, and discuss the treatment strategy. Case presentation An 84-year-old woman presented with atypical fracture of the left ulnar shaft due to SSBT. She had a history of bisphosphonate therapy (ibandronate and alendronate) since more than 10 years; her bone turnover was severely suppressed. We performed open reduction and internal fixation (ORIF) using dual plate with some additional treatments. These included drilling and decortication, use of autogenous bone graft, low-intensity pulsed ultrasound (LIPUS) treatment, and administration of teriparatide. Finally, bone union was observed at 11 months after surgery. Conclusions Based on the literature review and our experience with this case, ORIF alone may not be adequate to achieve bone union; drilling, decortication, and use of cancellus bone graft is important to achieve favorable outcomes. Administration of teriparatide and LIPUS may facilitate early bone union, although further studies are required to provide more definitive evidence. Furthermore, ORIF using dual plate may help avoid implant failure owing to the long time required for bone union.

Long-term bisphosphonate treatment coupled with ovariectomy in mice provokes deleterious effects on femoral neck fracture pattern and modifies tibial shape

Aims The processes linking long-term bisphosphonate treatment to atypical fracture remain elusive. To establish a means of exploring this link, we have examined how long-term bisphosphonate treatment with prior ovariectomy modifies femur fracture behaviour and tibia mass and shape in murine bones. Methods Three groups (seven per group) of 12-week-old mice were: 1) ovariectomized and 20 weeks thereafter treated weekly for 24 weeks with 100 μm/kg subcutaneous ibandronate (OVX+IBN); 2) ovariectomized (OVX); or 3) sham-operated (SHAM). Quantitative fracture analysis generated biomechanical properties for the femoral neck. Tibiae were microCT scanned and trabecular (proximal metaphysis) and cortical parameters along almost its whole length measured. Results Fracture analyses revealed that OVX+IBN significantly reduced yield displacement (vs SHAM/OVX) and resilience, and increased stiffness (vs SHAM). OVX+IBN elevated tibial trabecular parameters and also increased cortical cross-sectional area and second moment of area around minor axis, and diminished ellipticity proximally. Conclusion These data indicate that combined ovariectomy and bisphosphonate generates cortical changes linked with greater bone brittleness and modified fracture characteristics, which may provide a basis in mice for interrogating the mechanisms and genetics of atypical fracture aetiology. Cite this article: Bone Joint Open 2020;1-9:512–519.

Actual features of express diagnostic of acetabular fractures. Part III. Atypical fractures diagnostic algorithm. Associated local injuries

Authors shows atypical fracture patterns and rational algorithm for express diagnostic of this fractures. Associated local injuries are described.

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

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.