Intended for healthcare professionals

Endgames Case Report

Repeated falls and broken bones

BMJ 2010; 341 doi: (Published 30 December 2010) Cite this as: BMJ 2010;341:c5755
  1. M Hossain, associate specialist1,
  2. Paresh Jobanputra, consultant physician and clinical lead2
  1. 1Department of Trauma and Orthopaedics, Ysbyty Gwynedd, Bangor LL57 2LW, UK
  2. 2Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Selly Oak Hospital, Birmingham, UK
  1. Correspondence to: M Hossain munierh{at}

A 72 year old woman attended the emergency department because of a painful right hip after a fall the day before. She had been unable to get up from the floor, and had lain there until she was found by her son. She had broken her left wrist three years ago after a fall outside her house. This had been managed conservatively. She was taking antihypertensives but no other drugs and rarely drank alcohol. She lived alone and was independent for activities of daily living. She was independently mobile within and outside the house but could not walk long distances. She was otherwise in good health. She had pain in the right groin and was unable to move her leg. On examination, she had no localised bruising and her right leg was shortened and externally rotated. She could not raise the leg. She had no pain anywhere else and physical examination was otherwise unremarkable. A radiograph showed an intertrochanteric fracture of the right neck of the femur, which was treated with surgery.


  • 1 What underlying condition(s) should you consider in this patient?

  • 2 What further investigations should be done?

  • 3 How should the risk of further fractures be assessed?

  • 4 How should the underlying condition be managed?


1 What underlying condition(s) should you consider in this patient?

Short answer

The patient has sustained two consecutive low energy fractures from a fall at low height. Both injuries suggest fragility fractures of the bone, and underlying osteoporosis is the most likely cause.

Long answer

Osteoporosis is characterised by low bone mineral density and alterations in bone quality, not just loss of trabecular bone. Cortical bone is also affected. The resulting structural weakness leads to bone fragility and predisposes to low energy fractures.1 Fragility fractures are caused by falls from standing height or less. The three major sites of osteoporosis related fragility fractures are the distal …

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