Atypical Femoral Fracture

ANZONA Conference 2013 “Racing to the Challenge”

Anita Taylor, ONP, RAH

Cheryl Kimber, ONP, FMC

Overview

• Aetiology

• Case Series

• Case Study 1&2 - RAH

• Case Study 3&4 - FMC

• Patient Education

• Implications for Practice

Aetiology • Incidence

– Estimated to be 7̴8 cases in 100 000 patients taking oral bisphosphonates

(Yil 2013 quoting Dell et al 2010)

– 1 per 1000 per year (Rizzoli et al, 2010)

• Risk Benefit – Fracture prevention whilst on

bisphosphonates 1/100 (Rizzoli et al, 2010)

Aetiology • Clinical Features

– “stress fracture”

– Associated with no trauma or low

energy trauma

– Transverse fracture of proximal/subtrochanteric region of femur

– Complete fracture

– Unilateral/Medial “beaking” or spike

– Absence of comminution

– Cortical thickening

– Preceding ‘prodromal pain’

– Majority reported associated with long-term Bisphosphonate therapy

Why-Bisphosphonates?

• Increase bone strength and decrease fracture risk by suppressing excessive bone remodelling/turnover

• However - reduction remodelling associated with increased micro damage accumulation as cracks are not removed efficiently

• Similar age related reductions in bone turnover – increase micro damage accumulation

• BPs may exacerbate damage accumulation • Impair targeted remodelling → extent that remodelling not

targeted to damage repair • Allowing micro damage to persist for longer compared with

untreated bone

Case Series Design: • Retrospective review from January 2011 – June 2013: a

30 month period

Setting • 2 Level 1 Trauma Centres in Adelaide region

Sample • RAH n= 11; N= 88 (60+yrs) N=21 (50-60yrs)

0.5% of ALL SOF# • FMC n= 5; N= 31 (60+yrs) N=34 (50-60yrs)

0.14% of ALL SOF#

RAH Sample

Case Study 1 - RAH

• Demographics:71 yo woman, living

alone with community supports, mobile with w/frame

• PMHx: COPD, bronchiectasis, CCF,OA, OP, cataracts, HH etc

• HxPC: 10/7 ‘leg pain’→buckled & fell →transverse SOF#; Rx: (R) IM Nail

• Ix – BMD 2/2002; bisphosphonate therapy 7 years

Case Study 2 - RAH • Demographics: 88yo male living alone, 4WW,

drives car, MOW, cleaning & podiatry, ACAT-LLOC

• PMHx: prostate Ca(Androgen), HT, CCF, GORD, AF(Dabigatran), mild AR & MR, OP, glaucoma etc

• HxPC: Fell visiting wife in NH→(L)LGN. c/o (R)hip & thigh pain→distal femur →nil fall

• Ix – CT(R)hip; Bone tumour opinion; BoneBx

• Rx:(L)LGN & (R)LGN for contra-lateral, atypical subtrochanteric femoral # sustained in-hospital.

• Orthogeriatric opinion: “bisphosphonate related atypical #’s (seems likely) …”

FMC Sample

Case Study 3 - FMC • 68 yr lady, very mobile • PMHx – breast Ca + radiotherapy, NIDDM, HTN,

Osteoporosis • HxPC: bumped by friend and fell “heard crack” • Shortened leg, pain • Alendronate 14 yrs Management • Surgery: Long IM nail • Bone biopsy • Ceased Bisphosphonate, commenced strontium

Case Study 4 - FMC • 2013

• Trip fall - fracture

• Bone density -1.7 (2012)

• Back on alendronate as strontium caused reflux?

• Management - IM Nail, strontium ranelate and referral to endocrinologist

Patient Education In addition to usual discharge advice: post- operative care & follow up, bone health, falls risk minimisation etc. • Bisphosphonate use: dental care, ONJ • Immediate review of pain in hip, thigh or femur:

“typically sharp, well-localized to the mid or upper thigh, for several weeks to months prior to the fracture” (Yil 2013 quoting Giusti et al 2010)

• Discuss bisphosphonate cessation/‘drug holiday’ with medical officer/pharmacist

• Co-morbid conditions- Vitamin D deficiency, RA, hypophosphatasia, glucocorticoids

Implications for Practice

• Nurse awareness

• Identify risk factors amongst this in-patient population

• Standard definition of fracture type is required

• Research: Larger & longer studies to gather more information about this phenomenon

• International collaboration

Summary • Atypical femoral fractures are rare

• May be associated with long term bisphosphonate use

• Benefit of bisphosphonate for fracture prevention outweighs risk

• Subtrochanteric # is an expected finding in patients with osteoporosis

• Nursing awareness and knowledge is important

• Ongoing research is needed

References • Black,D., Kelly, M, Genant, M. et al, Bisphosphonates and Fractures of the

Subtrochanteric or Diaphyseal Femur, The New England Journal of Medicine 2010, May13, pp1761-71

• Neviaser, Lane, Lenart, Folorunsho Edobor-Osula, Lorich. Low-Energy Femoral Shaft Fractures Associated With Alendronate Use. Journal of Orthopaedic Trauma, 2008;22(5):346–350.

• Rizzoli, Akesson, Bouxsein, Kanis, Napoli, Papapoulos, Reginister, Cooper. Subtrochanteric fractures after long-term treatment with bisphosphonates: a European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, and International Osteoporosis Foundation Working Group Report. Osteoporosis International, 2010. DOI 10.1007/s00198-010-1453-5. Available from Source URL:

http://www.iofbonehealth.org/iof-and-esceo-issue-position-paper-atypical-femoral-fractures-and-long-term-bisphosphonate-use

• Yil Ryun Jo,Hye Won Kim,Seock Ho Moon,Young Jin Ko. A Case Report of Long-Term Bisphosphonate Therapy and Atypical Stress Fracture of Bilateral Femur. Annals of Rehabilitation Medicine, 2013;37(3):430-432. pISSN: 2234-0645. eISSN: 2234-0653. http://dx.doi.org/10.5535/arm.2013.37.3.430