Incomplete atypical femoral fracture after bisphosphonate use in a patient with post menopausal osteoporosis

Dr Rukshini Puvanendran1, Ms Mei Tuan Chua1

1KKH, Singhealth, Singapore

Background: Atypical femoral fractures (AFF) are an uncommon side-effect of anti-osteoporotic treatment with bisphosphonates (BP) and Denosumab.

Objectives: We report a case of incomplete AFF after bisphosphonate use.

Methods: 68-year-old woman with post-menopausal osteoporosis was treated with oral alendronate weekly with calcium and Vitamin D for 4 years. She complained of right thigh pain, aggravated by weight bearing. Xray revealed bilateral incomplete AFF. Advised rest. Alendronate was discontinued. Calcium and Vitamin D were continued. Patient was treated with teriperatide

Results: We discuss diagnosis and management of AFF.

Risk factors: Long term BP, corticosteroid and proton pump inhibitor (PPI) use, genu varus, bowed femur, contralateral AFF, collagen disease.

Prodromal symptoms: Persistent thigh or groin pain. Fracture occurs with minimal or no trauma.

Radiological findings: Non comminuted fractures with transverse or short oblique configuration at the sub trochanteric region or femoral shaft. Radiological features of incomplete fracture include: localised periosteal thickening in the lateral cortex and general thickening of the cortex. MRI/ CT scan/ bone scintigraphy may be needed for further evaluation of incomplete AFF.

Conclusions: High index of suspicion is needed. BP and Denosumab should be discontinued. Anabolic agents like teriperatide can be considered.

Australasian Menopause Society

The Australasian Menopause Society (AMS) is the peak body representing doctors and other health care professionals who each have a special interest in women’s midlife health, the menopause and the promotion of healthy ageing.


The aim of the AMS is the advancement of knowledge about the menopause.  As well as holding an annual scientific congress in Australia and New Zealand, some AMS members are involved with the Asia-Pacific and International Menopause Societies, recognising that women living in Australia and New Zealand may have widely differing experiences of menopause.


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