Arch Hand Microsurg.  2022 Mar;27(1):1-11. 10.12790/ahm.21.0098.

Atypical forearm fractures associated with long-term bisphosphonate use: the perspective of hand surgeons

• Cha SM
• Shin HD
• Heo YM
• Park SE
• Lee SH

• KMID: 2526643
• DOI: http://doi.org/10.12790/ahm.21.0098

Abstract

Bisphosphonates are widely used to treat osteoporosis, but atypical femoral fractures have emerged as a serious complication. Similar fractures of the forearm have been reported since 2010, and retrospective studies have revealed a number of details. Clinicians should remember that bisphosphonates can affect all bony structures in the body. When an atypical fracture is misdiagnosed as an ordinary fracture and treated with surgical fixation, unexpected nonunion may occur. Therefore, the authors would like to share our experiences from the perspective of hand surgeons.

Keyword

Bisphosphonate; Forearm; Atypical fracture

Figure

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  Fig. 1. Incomplete atypical fracture of the ulna.

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  Fig. 2. Incomplete fracture lines (the dreaded black line, white arrow) and endosteal/periosteal thickening are also seen (black arrows).

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  Fig. 3. Primary surgery had been performed elsewhere 13 months earlier. Three years before the left ulna fracture, a complete atypical left femoral fracture occurred. Reproduced from Cha et al. [20] with permission of Springer.

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  Fig. 4. Displaced, complete atypical fracture of the ulna. The radiological features are nearly identical to those of an atypical femoral fracture.

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  Fig. 5. Incomplete atypical fracture of the radius.

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  Fig. 6. (A) A very early lesion seen as endosteal thickening (flaring) in multiple locations; this can precede a single incomplete fracture. (B) A similar lesion is found incidentally at the distal ulnar metaphysis in another patient with an atypical radioulnar complete fracture. This patient had been treated with bisphosphonates for over 6 years.

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  Fig. 7. Treatment algorithm of atypical ulnar fractures (AUFs).

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  Fig. 8. Revision surgery using a tricortical iliac bone graft was performed after removing the metal. Approximately 31 mm of bone was resected with an oscillating saw after debridement around the fracture. After fixation with a longer locking plate/screw, a strut graft was firmly inserted. The additional cancellous graft was packed between the graft and resected bone. Union was completed 5 months after the revision surgery. Reproduced from Cha et al. [20] with permission of Springer.

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  Fig. 9. A patient who refused revision surgery.

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  Fig. 10. A 62-year-old woman presented with diffuse endosteal flaring (category 1) of the left femur. The lesion was discovered incidentally while evaluating the mechanical axis of the lower extremity for knee pain. Before this, bisphosphonates had been administered for 49 months and were stopped when this lesion was discovered. However, a complete fracture (category 3) of the left femur occurred 8 months later.

Reference

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