ANZONA Conference 2013
Transcript of ANZONA Conference 2013
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#
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) …”
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