Category: Calcium/Bone Disorders

Monitor: 5

5 - BISPHOSPHONATE RELATED ATYPICAL FEMORAL FRACTURES: NEED FOR HEIGHTENED AWARENESS REGARDING DIAGNOSIS AND THERAPY

Thursday, Apr 25
11:00 AM – 11:30 AM

Objective : To describe the clinical presentation, diagnosis and management challenges of an elderly lady who developed sequential bilateral bisphosphonate related atypical femoral fractures.


Methods :

Age 45:  female; Treated [for polymyositis] with Tab Prednisolone 80mg BD tapered over 6 months.


Age 46: She was treated with alendronate for 6 years for “bilateral thigh pain” [Metabolic workup/ BMD: Never done !!!!].


Age 49: 3 years after starting alendronate she had fracture of a right femur shaft and hairline fracture of left femur sub trochanteric, while standing in moving bus – slumped on road hump. Surgery: Therapeutic rodding of right femur done; “left femur hairline fracture was not attended to” !!


Age 55: 6 years later she slipped and fell in a temple and fractured her left femur shaft. Surgery: Therapeutic rodding of left femur done.


Age 61:  Presented to Endocrine Clinic for metabolic work up- past history of multiple fractures of bilateral femur shaft. She had also received SGLT2 inhibitors for diabetes.


Results :

Imaging =


Age 49: X-Ray Right femur: Fracture femur shaft non-comminuted; Left femur: Fracture hair line sub trochanteric, with focally thickened cortex.


Age 55: X-Ray left femur: Fracture subtrochanteric.


Age 61:  BMD T Score:  L1 - L4= +3    ...!!


Discussion :

Multiple causes of osteoporosis in this case: Postmenopausal, glucocorticoid related, polymyositis related, SGLT2 inhibitor associated (?).


Atypical Femur Fractures: Sequential - Bilateral - Bisphosphonate related. If left femur “prophylactic rodding” was done [at age 49] for the sub trochanteric hairline fracture (reported along with the fracture of the right femur shaft), the subsequent fracture [at age 55] of left femur could have been avoided.


Conclusion :

Rare type of femoral stress fractures are recently described as potentially associated with prolonged bisphosphonate therapy. Long-term use of these drugs may suppress bone remodelling, leading to bone fragility and unusual fractures. Patients on bisphosphonates should be informed of these, so that they are aware and cautious to avoid these types of fractures due to minimal trauma. Also, endocrinologists and orthopaedic surgeons should be aware of such atypical fractures, as these are associated with minimal trauma and are noncomminuted or minimally comminuted fractures.  The ‘beaking’ or ‘flaring’ concept [PBD: Prodromal Bone Deterioration], which is “asymptomatic” localized periosteal or endosteal thickening of the lateral cortex at the potential fracture site, is also important, so that prophylactic treatment [“rodding”] can be done at this stage.

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Nidhi Garg

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
bangalore, Karnataka, India

Designation: Senior Consultant and Faculty
Specialties: Diabetes and Metabolism
Clinical Interests: Comprehensive diabetes care, In-patient diabetes and metabolic care, Perioperative diabetes management, Diabetes and endocrine emergencies – Metabolic Intensive Care, Obesity management, Lipids and preventive cardiology, Gestational diabetes, Thyroid disorders, Type 1 diabetes across ages

Kavitha Muniraj

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty; Director Medical ; Director Research; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction; Diabetes Pharmacotherapy; Clinical Pharmacology; Pharmacovigilance; Clinical research Safety and Audits

Reshma B. Vijay

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes and Metabolism
Clinical Interests: Pediatric Endocrinology; Diabetes mellitus; Insulin Pumps, Continuous Glucose Monitoring and Artificial Pancreas; Growth and Puberty; Thyroid; Pituitary Adrenal disorders

Vasanthi Nath

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes, Internal Medicine, Geriatrics
Clinical Interests: Neuroendocrinology and Neurometabolism, Metabolic Myopathies; Thyroid tumors, Geriatric Endocrinology, Inpatient Diabetes Care and Endocrine Emergencies; Type 1 diabetes across ages

Chandraprabha S

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes Metabolism
Clinical Interests: Pregnancy Diabetes, Pregnancy Thyroid Dysfunction, Women Health, Geriatric Endocrinology, Diabetes mellitus and Mental Health, Spiritual Medicine

Babitha D. T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes
Clinical Interests: Endocrine disorders of pregnancy, Pregnancy Diabetes, Cardiovascular Health, Thyroid, Inpatient diabetes care and endocrine metabolic emergencies

Muralidhara Krishna

Consultant Faculty Endocrinology Diabetes Biochemistry
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty: Endocrinology Diabetes Metabolism; Associate Professor: Clinical Biochemistry and Laboratory Medicine
Specialties: Endocrinology Diabetes Metabolism; Clinical Biochemistry
Clinical Interests: Diabetes mellitus; Thyroid Disorders; Obesity; Dyslipidemia.

Jayalakshmi T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty

Specialties: Endocrinology, Diabetes, Internal Medicine,
Clinical Interests: Diabetes mellitus, Cardiovascular Health, Thyroid, In Patient Diabetes Care, Endocrinology Metabolic emergencies and critical care

Apoorva Govind

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, India

Designation: (a) Fellow: Endocrinology Diabetes Medicine, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital ; (b) Co Investigator – Clinical Research, Samatvam Science and Research Center

Specialties: Endocrinology, Diabetes, Internal Medicine

Siddartha Dinesha

Resident, Medicine Diabetes Endocrinology
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Resident: Medicine; Endocrinology Diabetes, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital
Specialties: Endocrinology, Diabetes, Internal Medicine

MD Chitra

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Consultant and Faculty; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Diabetes, Obesity, Dyslipidemia, Osteoporosis, Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction;

Vasudha Srikanth


India

Nalini Rayas

Keerthana Haridas

Monica Narayanaswamy

Resident doctor
Samatvam jnana sanjeevini diabetes hospital and medical centre
Chintamani, India

Sathvik Reddy Chinna Bainagari

Resident Doctor
Samatvam jnana sanjeevini Diabetes hospital and medical center
Chittoor, Andhra Pradesh, India

Sri Srikanta