Intended for healthcare professionals

Endgames Case Report

Sequential bilateral femoral fractures

BMJ 2012; 345 doi: (Published 14 November 2012) Cite this as: BMJ 2012;345:e7361

This article has a correction. Please see:

  1. Seyed Ali Moeinoddini, foundation year 2 trainee, orthopaedic surgery 1,
  2. Rajkumar James Parikh, consultant geriatrician1,
  3. Sarah Ruth Moore, specialist registrar, rheumatology and general (internal) medicine 2,
  4. David James Moore, consultant radiologist 3
  1. 1Pennine Acute Hospitals NHS Trust, Royal Oldham Hospital, Oldham OL1 2JH, UK
  2. 2Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Sheffield, UK
  3. 3East Cheshire NHS Trust, Macclesfield District General Hospital, Macclesfield, UK
  1. Correspondence to: R J Parikh raj.parikh{at}

A 78 year old woman presented to the emergency department with an off-ended, shortened, anteriorly deviated, long oblique fracture of the right femoral diaphysis. She had been experiencing thigh pain for several weeks before this acute presentation and analgesia had been prescribed.

She described feeling the bone “crack” as she turned around. There was no history of trauma. The fracture was surgically treated with an intramedullary nail.

Six months earlier she had sustained a similar fracture of the midshaft of her left femur. Again, there was no trauma and she described feeling the bone “crack” as she twisted slightly to go through her front door. She was unable to reach a telephone to call for help and spent some time on the ground before a passer by called an ambulance. After initial treatment with a Thomas splint, she was treated surgically with an intramedullary nail. After two weeks of rehabilitation she returned home to live independently and was able to go out with one stick to do her shopping.

Her medical history included osteoporosis and hypovitaminosis D. The diagnosis of osteoporosis was made after she sustained a vertebral crush fracture. She had been receiving bisphosphonates to prevent further fractures for nearly five years.


  • 1 Why are such fractures described as “atypical”?

  • 2 What underlying mechanism might explain such fractures?

  • 3 What are the main clinical and radiological features of atypical femoral fractures?

  • 4 How would you investigate her thigh pain?


1 Why are such fractures described as “atypical”?

Short answer

Atypical fractures involve little or no trauma.1

Long answer

“Typical” subtrochanteric or femoral shaft (ST/FS) fractures are comminuted (sometimes obliquely, rarely transversely) and result from trauma. In atypical fractures, structural failure occurs in the absence of trauma.1 Thus, they are by definition pathological. The differential diagnoses of atypical fractures include well described causes such as a bony metastasis from a …

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