Abstract
IntroductionAtypical insufficiency fractures of the femur in patients on long-term bisphosphonate therapy have been well described in recent literature. The majority of cases are associated with minimal or no trauma and occur in the subtrochanteric or diaphyseal region.Case presentationWe describe the case of a 76-year-old British Caucasian woman who presented initially to an emergency department and then to her primary care physician with a long-standing history of bilateral knee pain after minor trauma. Plain radiographs showed subtle linear areas of sclerosis bilaterally in her proximal tibiae. Magnetic resonance imaging confirmed the presence of insufficiency fractures in these areas along with her left distal femur. There are very few reports of atypical insufficiency fractures involving the tibia in patients on long-term bisphosphonate therapy and this appears to be the only documented bilateral case involving the metaphyseal regions of the proximal tibia and distal femur.ConclusionIn addition to existing literature describing atypical fractures in the proximal femur and femoral shaft, there is a need for increased awareness that these fractures can also occur in other weight-bearing areas of the skeleton. All clinicians involved in the care of patients taking long-term bisphosphonates need to be aware of the growing association between new onset lower limb pain and atypical insufficiency fractures.
Highlights
Atypical insufficiency fractures of the femur in patients on long-term bisphosphonate therapy have been well described in recent literature
All clinicians involved in the care of patients taking long-term bisphosphonates need to be aware of the growing association between new onset lower limb pain and atypical insufficiency fractures
We describe a case of atypical bilateral proximal tibial and unilateral distal femoral insufficiency fractures in an adult woman who had been receiving tri-monthly intravenous pamidronate treatment for approximately six years
Summary
The above case highlights that atypical insufficiency fractures can occur in other weight-bearing areas of the skeleton, such as the distal femur and proximal tibia. A high index of suspicion is recommended for early diagnosis and prompt treatment amongst all clinicians involved in the treatment of patients taking longterm bisphosphonates. This is important as such patients are commonly taking other medications which have been implicated in increasing the risk of fracture. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Authors’ contributions AI prepared the manuscript, revised it critically for important intellectual content and performed a review of the literature. NJ acquired data and helped prepare the manuscript. All authors read and approved the final manuscript for publication.
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