A 55-year-old on bisphosphonate therapy for 8 years presents with a prodromal aching thigh pain. X-ray shows lateral cortical thickening of the subtrochanteric femur with a transverse fracture line. This is BEST described as which fracture type?

• A Pathological fracture due to metastatic disease
• B Stress fracture due to repetitive loading in a runner
• C Intertrochanteric fracture with lateral cortical extension
• D Atypical femoral fracture (AFF) associated with bisphosphonate use ✓

Explanation

Atypical femoral fractures (AFFs) are a recognised complication of prolonged bisphosphonate use; they suppress bone turnover, preventing repair of microdamage and leading to stress risers in the subtrochanteric or femoral shaft region. The hallmark features are lateral cortical thickening ('beaking'), a transverse or short oblique fracture line, prodromal pain, and bilateral occurrence in some cases. Management includes stopping bisphosphonates, vitamin D/calcium supplementation, and prophylactic IM nailing if stress reaction is advanced.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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