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Date:____________________ Dear Dr. __________________________ Your patient was seen as part of our Fracture Liaison Service Program, having presented with a femoral fracture due to a simple fall or low impact trauma. Upon further assessment, this fracture was determined to be a subtrochanteric/femoral shaft fracture which falls outside the scope of our Program. As the assessment of such fractures is complicated, we have referred your patient to Dr. _________ (local osteoporosis specialist). The information below is derived from the American Society of Bone and Mineral Research Task Force on Atypical Femoral Fractures and is provided to you for your information. There are two types of subtrochanteric/femoral shaft fragility fractures: true osteoporotic fractures and atypical femoral fractures. The following characteristics may help differentiate between the two. Frequency Cause Prodromal symptoms Mechanism of injury X-ray findings True osteoporotic fracture Atypical femoral fracture Infrequent: 10% of all femoral fractures In 70-90% of these cases, this is due to undiagnosed/untreated osteoporosis. A minority of patients will have been on osteoporosis medication (in which case, this may represent failure or relative failure of treatment). There is no prodromal leg/groin pain. Common arthritic complaints may be a confounder. A fall occurred that lead to the fracture (the bone breaks once it hits the ground). Comminuted or spiral. Rare: less than 1% of all femoral fractures. Only 25% of subtrochanteric/femoral shaft fractures are atypical. 90% will have had exposure to osteoporosis medications. Atypical femoral fractures have been reported with all bisphosphonates and with denosumab, usually after prolonged exposure (greater than 5 years). Patients with typical osteoporotic Osteoporosis fractures are at HIGH RISK for management considerations repeat fractures and should be continued on an appropriate osteoporosis medication (although a review/consideration of changing the agent may be warranted). 70% will have experienced prodromal pain in the thigh or groin (for weeks/months prior to fracture). Minimal or no trauma. The patient may describe that the leg let go or bone snapped/cracked BEFORE the fall occurred Non-comminuted. It has transverse or short oblique configuration, with a medial spike. There may also be cortical thickening of the lateral cortex at the site of the fracture. The medical management of atypical femoral fractures is complicated as there is a need to balance the risks of continuing treatment (risk of developing a contralateral atypical femoral fracture) vs. the risks of discontinuing treatment (risk of suffering any of the many other types of classic osteoporotic fractures). Such patients would benefit from referral to an osteoporosis specialist to help determine the best course of treatment. We hope this information will prove useful in guiding the management of your patient. Sincerely, Nurse Smith, NP FLS Coordinator Dr. White, MD FRCPC/FRCSC FLS Medical Director, Orthopaedic Surgeon or Local opinion leader