Disclosures: Shaohua Xu, MD, PhD: No financial relationships or conflicts of interest

Case Diagnosis: A 65-year-old male with bilateral simultaneous subtrochanteric atypical femur fracture

Case Description or Program Description: The patient presented to his primary care office with acute onset of right posterolateral hip pain without precipitating events other than moderate increase in daily walking distance from a quarter of mile to one mile, for which the hip x-ray revealed bilateral subtrochanteric lateral cortical thickening and beaking suggestive stress fractures. He was referred to the Sports Medicine clinic for further evaluation. He currently takes no medications other than supplements. The patient had a remote history of self-resolved sarcoidosis. Between 2013 to 2014, the patient developed uncontrolled asthma, for which he was taking both inhaled and oral glucocorticoids as needed. In November 2014, the patient was diagnosed with mixed connective tissue disorder, and he was treated by a rheumatologist with prednisone 40 mg daily for a year.

Setting: Tertiary care hospital

Assessment/Results: MRI of bilateral hip confirmed chronic appearing, incomplete subtrochanteric fractures involving the lateral cortex of proximal femur. Laboratory studies including basic metabolic panel, complete blood count, phosphorus and Vitamin D levels were unremarkable. The patient was urgently referred to orthopedic surgery and underwent bilateral intramedullary nail placement for pending complete fracture. He was discharged home uneventfully the day after the surgery.

Discussion (relevance): Characterized with radiographic findings as described in this case, atypical femur fracture (AFF) refers to a rare fracture patten that occurs at subtrochanteric or shaft of femur with no or minimal trauma. American Society for Bone and Mineral Research (ASBMR) defined the term in 2010 and revised in 2013. AFF is associated with long term use of bisphosphonate use. Concomitant use of glucocorticoids has been identified as a risk factor, but glucocorticoids use alone is an exceedingly rare association. Extensive literature search yielded no previous reports of bilateral simultaneous AFF associated with glucocorticoids use solely.

Conclusions: We reported a rare case of bilateral simultaneous atypical femur fracture in a 65-year-old male with historical long-term use of glucocorticoids as the only known risk factor. This case stressed the importance of physicians’ awareness of this unique but potentially catastrophic fracture in patients with historical long-term glucocorticoids use with even benign complaints of hip pain.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-rare-case-of-bilateral-simultaneous-atypical-femur-fracture-with-history-of-glucocorticoid-use-a-case-report/