Archives of Osteoporosis

, 9:171 | Cite as

The clinical characteristics of patients with hip fractures in typical locations and atypical femoral fractures

  • Soledad Velasco
  • Sandra Kim
  • Robert Bleakney
  • Sophie A. Jamal
Original Article



The pathophysiology of atypical fractures is unknown. We compared characteristics of patients with atypical femoral fractures and hip fractures in typical locations of the femur. Patients with atypical fracture reported a longer duration of use of bisphosphonates, had higher body mass index, and higher total hip bone mineral density. Further studies are needed.


This study aims to describe the characteristics of patients with typical and atypical fractures of the femur assessed in a tertiary care osteoporosis center.


We abstracted clinical, laboratory, and radiographic data on subjects with a history of a low-impact fracture at the femur and/or hip (confirmed by review of radiograph and/or radiology report) from January 2008 to October 2011. Available radiographs were reviewed and fracture categorized as typical or atypical by a radiologist blinded to the original diagnosis.


Radiology reports were available for 72 subjects: 40 hip fractures in typical locations (typical fracture), 16 atypical femoral fracture (atypical fracture), and 16 were excluded. While both those with typical and atypical fractures reported taking bisphosphonates at the time of fracture, duration of use was longer with atypical fractures (104.2 ± 42.0 months) compared with typical (71.1 ± 62.8 months) (p = 0.04). Body mass index (BMI) was higher in patients with atypical fractures (26.2 ± 3.2 kg/m2) than in those with typical (23.1 ± 4.3 kg/m2) (p = 0.006). Total bone mineral density (BMD) was higher in patients with atypical fracture (0.795 ± 0.102) versus typical (0.686 ± 0.130) (p = 0.003) Previous history of cancer was reported by 7 of 16 patients with atypical and 7 of 40 patients with typical fracture (p = 0.04).


Compared to those with typical fractures, patients with atypical fracture report a longer duration of use of bisphosphonates, higher BMI, and higher total hip BMD. Future studies should examine if these differences contribute to the pathophysiology of atypical fractures.


Atypical fracture Atypical femoral fracture Bisphosphonate 


  1. 1.
    Nieves JW, Bilezikian JP, Lane JM, Einhorn TA, Wang Y, Steinbuch M, Cosman F (2010) Fragility fractures of the hip and femur: incidence and patients characteristics. Osteoporosis Int 21:399–408CrossRefGoogle Scholar
  2. 2.
    Abrahamsen B, Eiken P, Eastell R (2009) Subtrochanteric and diaphyseal femur fractures in patients treated with alendronate: a register-based national cohort study. J Bone Miner Res 24:1095–1102PubMedCrossRefGoogle Scholar
  3. 3.
    Wang Z, Bhattacharyya T (2011) Trends in incidence of subtrochanteric fragility fractures and bisphosphonate use among the US elderly, 1996–2007. J Bone Miner Res 26:553–560PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Girgis CM, Sher D, Seibel M (2010) Atypical femoral fractures and bisphosphonate use. N Engl J Med 362:1848–1849PubMedCrossRefGoogle Scholar
  5. 5.
    Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG (2008) Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma 22:346–350PubMedCrossRefGoogle Scholar
  6. 6.
    Koh JS, Goh SK, Png MA, Kwek EB, Howe TS (2010) Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture? J Orthop Trauma 24:75–81PubMedCrossRefGoogle Scholar
  7. 7.
    Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A (2011) Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA 305:783–789PubMedCrossRefGoogle Scholar
  8. 8.
    Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster DW, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O’Keefe R, Papapoulos S, Sen HT, van der Meulen MC, Weinstein RS, Whyte M, American Society for Bone and Mineral Research (2014) Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res May 29(1):1–23CrossRefGoogle Scholar
  9. 9.
    Bessette L, Ste-Marie LG, Jean S, Davison KS, Beaulieu M, Baranci M, Bessant J, Brown JP (2008) The care gap in diagnosis and treatment of women with a fragility fracture. Osteoporosis Int 19:79–86CrossRefGoogle Scholar
  10. 10.
    Lenart BA, Neviaser AS, Lyman S, Chang CC, Edobor-Osula F, Steele B, Van Der Meulen MCH, Lorich DG, Lane JM (2009) Association of low-energy femoral fractures with prolonged bisphosphonate use: a case control study. Osteoporosis Int 20:1353–1362CrossRefGoogle Scholar
  11. 11.
    Schneider JP, Hinshaw WB, Su C, Solow P (2012) Atypical femur fractures: 81 individual personal histories. J Clin Endocrinol Metab 97:4324–4328PubMedCrossRefGoogle Scholar
  12. 12.
    Giusti A, Hamdy N, Dekkers OM, Ramautar SR, Dijkstra S, Papapoulos SE (2011) Atypical fractures and bisphosphonate therapy: a cohort study of patients with femoral fracture with radiographic adjudication of fracture site and features. Bone 48:966–971PubMedCrossRefGoogle Scholar
  13. 13.
    Edwards MH, McCrae FC, Young-Min SA (2010) Alendronate-related femoral diaphysis fracture—what should be done to predict and prevent subsequent fracture of the contralateral side? Osteoporosis Int 21:701–703CrossRefGoogle Scholar
  14. 14.
    Giusti A, Hamdy NA, Papapoulos SE (2010) Atypical fractures of the femur and bisphosphonate therapy: a systematic review of case/case series studies. Bone 47:169–180PubMedCrossRefGoogle Scholar
  15. 15.
    Jamal SA, Dion N, Ste-Marie LG (2011) Atypical femoral fractures and bone turnover. N Engl J Med 365:1261–1262PubMedCrossRefGoogle Scholar
  16. 16.
    Napoli N, Schwartz AV, Palermo L, Jin JJ, Wustrack R, Cauley JA, Ensrud KE, Kelly M, Black DM (2013) Risk factors for subtrochanteric and diaphyseal fractures: the study of osteoporotic fractures. J Clin Endocrinol Metab 98:659–667PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Ensrud KE, Lipschutz RC, Cauley JA, Seeley D, Nevitt MC, Scott J, Orwoll ES, Genant HK, Cummings SR (1997) Body size and hip fracture risk in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Am J Med 103:274–280PubMedCrossRefGoogle Scholar
  18. 18.
    Ensrud KE, Cauley J, Lipschutz R, Cummings SR (1997) Weight change and fractures in older women. Study of Osteoporotic Fractures Research Group. Arch Intern Med 157:857–863PubMedCrossRefGoogle Scholar
  19. 19.
    Odvina CV, Levy S, Rao S, Zerwekh JE, Rao DS (2010) Unusual mid-shaft fractures during long-term bisphosphonate therapy. Clin Endocrinol 72:161–168CrossRefGoogle Scholar
  20. 20.
    Kwek EB, Goh SK, Koh JS, Png MA, Howe TS (2008) An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury 39:224–231PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2014

Authors and Affiliations

  • Soledad Velasco
    • 1
  • Sandra Kim
    • 2
  • Robert Bleakney
    • 3
  • Sophie A. Jamal
    • 2
    • 4
  1. 1.Unidad de Endocrinología, Clínica Alemana de Santiago, Facultad de Medicina Clínica AlemanaUniversidad del DesarrolloSantiagoChile
  2. 2.Division of Endocrinology and Metabolism, Women’s College HospitalUniversity of TorontoTorontoCanada
  3. 3.Department of Medical Imaging, Mount Sinai HospitalUniversity of TorontoTorontoCanada
  4. 4.Women’s College Research InstituteUniversity of TorontoTorontoCanada

Personalised recommendations