Missed Monteggia Fracture Dislocation in a 10-year-old Child - A Step-by-Step Approach to Properly Solving a Complex Problem: A Case Report.

Introduction: Monteggia injuries are relatively rare in the pediatric population. They can be missed leading to complications arising from a chronic radial head dislocation. There is limited information about their proper management in the literature. Thus, their treatment remains controversial. Case Report: We present a case of a 10-year-old boy who was examined in the orthopedic outpatient clinic of our hospital, due to limited range of motion of his left elbow and difficulty in extending his left thumb, after a forearm injury which occurred 9 months before and was initially treated conservatively. After appropriate imaging was obtained, a Bado type I Monteggia lesion was diagnosed. This was treated by open reduction of the head of radius, osteotomy of the ulna and lengthening using an external fixator, as well as annular ligament reconstruction by the use of synthetic tendon graft. The patient was followed up for 18 months after surgery and during his last examination showed very good clinical and functional results. Conclusion: Missed Monteggia injuries in children are complex problems warranting a step-by-step approach. Their management with ulnar osteotomy, bone lengthening, and reconstruction of the annular ligament presents a viable option with excellent clinical, functional, and radiological outcomes.

A Rare Case of an Intertrochanteric Hip Fracture Combined with an Ipsilateral Incomplete Atypical Femoral Fracture Treated with a Long Gamma Intramedullary Nail.

Introduction: Osteoporotic hip fractures can occur at the femoral neck and intertrochanteric area, with the peritrochanteric fracture being responsible for half of these fractures in the geriatric population. Atypical femoral fractures have been associated in the literature with long-term use of bisphosphonates or denosumab. However, few cases with the characteristics of these fractures have been reported in the past in patients not receiving antiresorptive drugs. To date, no combination of an intertrochanteric fracture with an impending incomplete atypical fracture of the ipsilateral femoral diaphysis has been previously reported in the literature. Case Report: We present a rare case of a 97-year-old female patient with an intertrochanteric femoral fracture, with a preexisting focal cortical thickening along the lateral aspect of the ipsilateral proximal femoral diaphysis which is a warning sing for an incomplete atypical femoral fracture. A long gamma nail was used to fix the intertrochanteric fracture and simultaneously to stabilize and protect the area of the atypical femoral fracture. Conclusion: Any patient with a peritrochanteric hip fracture who was under long-term treatment with antiresorptive agents against osteoporosis, or has other risk factors predisposing to atypical femoral fracture, should undergo a thorough radiological examination of the ipsilateral femur, to exclude the possibility of simultaneous presence of both of the above pathologies. In any such case, the use of a long hip cephalomedullary nail seems to be the best treatment option, because it can treat both fractures at the same time.

Atypical femoral fracture in a metastatic bone disease patient six months after discontinuation of denosumab received sequentially to previous bisphosphonate therapy - A case report.

Although, both bisphosphonates and denosumab are effective in reducing the risk of skeletal-related events in patients with metastatic bone disease, many concerns were being raised about the possible association between their use and atypical femoral fractures. A case of an atypical femoral fracture in a metastatic bone disease patient, six months after discontinuation of long-term zoledronic acid therapy and sequential treatment with denosumab is reported. After extensive laboratory and imaging examination, the fracture was classified as atypical and it was finally treated with discontinuation of denosumab, long cephalomedullary interlocking nailing and vitamin D administration. Sequential treatment with bisphosphonates and denosumab in patients with metastatic bone disease, may lead to an overlapping treatment effect, increasing bone suppression and the risk of atypical femoral fracture. In addition, discontinuation of denosumab may activate bone remodeling units in an area with microdamage accumulation in cortical bone caused by the previous bone suppression from the antiresorptive treatment. The activation of bone remodeling units may accelerate the occurrence of the atypical femoral fractures.

Atypical Femoral Fracture in a Patient without Bisphosphonate or Denosumab Exposure-A Case Report.

Introduction: Atypical femoral fractures (AFF) are associated with the use of bisphosphonates (BPs) or denosumab. However, few cases that meet the characteristics of these fractures, as established by the American Society of Bone and Mineral Research, have occurred in patients who have never used antiresorptive drugs. Case Report: We report a case of AFF in a 67-year-old woman who had never used antiresorptive medications. The history and comorbidities of the patient, the characteristics of the fracture, and the subsequent treatment are presented. Conclusion: AFFs may occur even in patients who have never been exposed to BPs or denosumab. The absence of antiresorptive osteoporosis therapy and the lack of radiographic focal periosteal reaction in the lateral femoral cortex, as in our case, can make it difficult to detect and prevent the disorder. Prolonged use of proton pump inhibitors and Vitamin D deficiency-related osteomalacia may contribute to the occurrence of these fractures. Further studies are required to accurately understand all inciting factors contributing to the development of AFFs.