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Figure A
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Figure B
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Figure C
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Figure D
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Figure E
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Figure D demonstrates an atypical subtrochanteric femur fracture, which has been found to occur in patients with a history of prolonged bisphosphonate use. When identified, contralateral hip and femur films should be obtained to evaluate for impending stress fracture which may necessitate prophylactic fixation. Bisphosphonate use has been associated with a variety of complications to include jaw osteonecrosis, atypical subtrochanteric femur fractures, and femoral stress fractures. In the evaluation of patients who have evidence of impending or completed atypical subtrochanteric femur fractures, it is important to evaluate for radiographic evidence of impending fracture on the contralateral side. If the patient has evidence of beaking or a stress fracture, they may require prophylactic fixation. Blood et al. reviewed the evaluation and treatment of atypical femur fractures. The authors support radiographic evaluation of patients with chronic bisphosphonate treatment and thigh pain. If an incomplete fracture is identified, they recommend prophylactic fixation. However, if no fracture is identified on plain film radiographs, the authors then recommend for MRI. They uphold that nonoperative treatment of painless, incomplete fractures includes protected weight-bearing, discontinuation of bisphosphonate therapy, and Vitamin D supplementation, while the treatment of complete atypical femur fractures is with intramedullary nailing and that delayed bone healing should be expected. Shane and the Task Force of the American Society of Bone and Mineral Research (ASBMR) in 2010 reported on bisphosphonate use and the association with atypical femur fractures. The authors discuss the definition of atypical fractures and the pathogenesis of atypical femur fractures. They report that 17-29% of subtrochanteric femur fractures have features of atypia. Furthermore, in patients with atypical fractures, 28% demonstrated bilateral involvement. Shane and the Task Force of the ASBMR reported a second time in 2014 on the use of bisphosphonates and included denosumab treatment in their analysis as well. The authors reported that atypical femur fractures behave as stress or insufficiency fractures, and that major features of atypia include periosteal reactions, an association with either no or minimal trauma, and a transverse fracture line laterally with oblique orientation medially. They calculated the risk of 3.2-50 cases per 100,000 person-years for patients on bisphosphonates, which increased up to 100 per 100,000 person-years with prolonged use. Figure A is a sagittal CT cut demonstrating an femoral head fracture. Figure B is an AP Xray of a reverse obliquity intertrochanteric hip fracture. Figure C shows an AP hip xray with a displaced left femoral neck fracture. Figure D shows an AP Xray of the hip with a transverse subtrochanteric hip fracture that is characteristic of extended bisphosphonate use. Figure E is a standard obliquity intertrochanteric hip fracture. Illustration A shows an AP of the hip with subtrochanteric beaking consistent with an impending fracture. Incorrect Answers: Answer 1-3 and 5: Workup for these fractures do not include contralateral imaging as part of the standard workup.
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