PMC4254865_01
Radiograph imaging at the time of admission. a Radiograph imaging at the time of admission shows the right subtrochanteric fracture with breaking of the lateral cortex (white arrow) and spiking of the medial cortex (black arrow). b Zoomed image of the left thigh shows thickening of the lateral cortex (white arrow) and a transverse radiolucent fracture line (black arrow)
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Fig1
Radiography revealed a subtrochanteric right femur fracture (Fig. 1a). In addition, her contralateral thigh showed thickening of the lateral cortex and a transverse radiolucent fracture line in the subtrochanter (Fig. 1b).
Radiograph imaging of the right thigh at the time of surgery
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Fig2
Four days after admission, the authors performed minimally invasive osteosynthesis using intramedullary nails (Fig. 2).
Radiograph and CT imaging after 3 months of LIPUS therapy. a Radiograph imaging after 3 months of LIPUS therapy shows delayed union at the fracture site. b CT imaging after 3 months of LIPUS therapy shows delayed union at the fracture site. CT computerized tomography, LIPUS low-intensity pulsed ultrasonography
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Fig3
In June 2012, radiography and computed tomography imaging revealed signs of delayed union at the right fracture site (Fig. 3).  
Trabecular surfaces (x200 magnification, Villanueva bone stain) show a total absence of osteoblasts and osteoclasts (photomicrographs were taken at the Niigata Bone Science Institute, Niigata, Japan)
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Fig4
Bone biopsy samples collected at the intramedullary nail insertion site revealed an absence of osteoblasts and osteoclasts on trabecular surfaces (Fig. 4), as well as low bone volume (Table 2).  
Radiograph and CT imaging after 3 months of TPTD therapy. a Radiograph imaging after 3 months of TPTD therapy shows complete union of fractures. b CT imaging after 3 months of TPTD therapy shows complete union of the right thigh fracture. c CT imaging after 3 months of TPTD therapy shows complete union of the left thigh fracture. CT computerized tomography, TPTD teriparatide
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Fig5
After 3 months of TPTD treatment, the patient's fractures had improved (Fig. 5). Administration of TPTD was terminated in February 2013 and the patient can now walk independently without crutch.  