PMC7395992_01
(a) The patient suffered a subtrochanteric AFF without prodromal pain on the right side as a result of a fall. (b) At that time, the left femoral roentgenogram showed periosteal and endosteal thickening of the lateral cortex at the diaphysis (circle; see magnification). (c) Fifteen months later, the patient suffered a diaphyseal AFF on the left side by falling without prodromal pain. (d) A small gap at the lateral cortex of fracture site (asterisk) remained on the right and left sides at 29 and 14 months after the surgery, respectively.
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fig1
A 58-year-old female patient, who had received denosumab therapy for osteoporosis for more than 3 years, suffered a subtrochanteric AFF on the right side by falling from a standing height without prodromal pain (Figure 1(a)). At that time, the left femoral roentgenogram showed periosteal and endosteal thickening of lateral cortex at the diaphysis (Figure 1(b)). Fifteen months later, she suffered a diaphyseal AFF on the left side by falling from a standing height without prodromal pain (Figure 1(c)). A small gap at the lateral cortex of the fracture site remained on the right and left sides at 29 and 14 months after surgery, respectively (Figure 1(d)).
PMC7395992_02
(a) The patient experienced bilateral thigh pain, and incomplete AFFs were detected. (b, c) Incomplete fracture lines, so called "dreaded black lines," were clearly present on lateral view (circles; see magnifications). (d) The patient suffered a subtrochanteric AFF on the right side by falling. (e) Complete bone unions were achieved on the right and left sides at 24 and 15 months after surgery, respectively.
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fig2
She had experienced bilateral thigh pain, and incomplete AFFs were detected (Figures 2(a)-2(c)). Three months later, she suffered a subtrochanteric AFF on the right side by falling from a standing height (Figure 2(d)) and underwent an internal fixation with intramedullary nailing. Complete bone unions were achieved on the right and left sides at 24 and 15 months after surgery, respectively (Figure 2(e)).
PMC7395992_03
(a) The patient suffered a subtrochanteric AFF on the left side by sprain. At that time, the right femoral roentgenogram showed periosteal thickening of the lateral cortex at the subtrochanter (circle; see magnification). (b) Periosteal thickening of the lateral cortex progressed to incomplete fracture (circle; see magnification). (c) Incomplete fracture progressed to complete fracture by falling. (d) Complete bone unions were achieved on the left and right sides at 58 and 25 months after the surgery, respectively.
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fig3
At that time, the right femoral roentgenogram showed periosteal thickening of the lateral cortex at subtrochanter (Figure 3(a)). Two years and 9 months after surgery, she experienced thigh pain on the right side, and the roentgenogram showed an incomplete fracture (Figure 3(b)). In the meantime, the incomplete fracture progressed to a complete fracture when she experienced a fall from a standing height (Figure 3(c)). Complete bone unions were achieved on the left and right sides at 58 and 25 months after surgery, respectively (Figure 3(d)).
PMC7395992_04
Both femur roentgenograms of case 4 at the time of injury (a) and final follow-up (b). There were no curvatures at both femoral diaphyses.
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fig4
A 41-year-old female patient, who had received BP therapy for osteoporosis since 3 years and prednisolone (8 mg/day) for systemic lupus erythematosus, was injured with subtrochanteric AFF on the right side by falling from a standing height without prodromal pain (Figure 4(a)). Complete bone union was achieved on the right side at 19 months after surgery (Figure 4(b)).