We performed a retrospective review of all patients admitted to two large University Hospitals in the United Kingdom over a 24-month period from January 2008 to January 2010 to identify the incidence of atypical subtrochanteric and femoral shaft fractures and their relationship to bisphosphonate treatment. Of the 3515 patients with a fracture of the proximal femur, 156 fractures were in the subtrochanteric region. There were 251 femoral shaft fractures. The atypical fracture pattern was seen in 27 patients (7%) with 29 femoral shaft or subtrochanteric fractures. A total of 22 patients with 24 atypical fractures were receiving bisphosphonate treatment at the time of fracture. Prodromal pain was present in nine patients (11 fractures); 11 (50%) of the patients on bisphosphonates suffered 12 spontaneous fractures, and healing of these fractures was delayed in a number of patients. This large dual-centre review has established the incidence of atypical femoral fractures at 7% of the study population, 81% of whom had been on bisphosphonate treatment for a mean of 4.6 years (0.04 to 12.1).

This study does not advocate any change in the use of bisphosphonates to prevent fragility fractures but attempts to raise awareness of this possible problem so symptomatic patients will be appropriately investigated. However, more work is required to identify the true extent of this new and possibly increasing problem.

A prospective review was undertaken examining referrals from A& E to fracture clinic with the objective to examine diagnosis and timing of fracture clinic appointment made by A& E with that suggested by an Orthopaedic Specialist Registrar (SpR).

Over a 4 week period, xrays of all fracture clinic referrals from A& E were assessed daily by an Orthopaedic SpR. Time to presentation, site of injury, A& E diagnosis, and A& E time to clinic review, were noted alongside the diagnosis and suggested time to review clinic by the Orthopaedic SpR.

A total of 233 patients were referred. Less than 5% were excluded as non-bony injury and were given an A& E review instead. Overall the majority (85%) of cases had no significant difference in time to clinic review requested by that of the A& E staff and of that requested by the orthopaedic staff. In 4.3% of cases, time to review was increased by more than 4 days whereas 11.3% of cases were seen 5 or more days earlier than that initially requested. There was a variance in diagnosis between A& E and Orthopaedic staff in 24 (10.4%) of cases. The actual time to clinic was within 5 days of that requested by the orthopaedic SpR in 84.7% of patients.

A& E appropriately refer cases to fracture clinic, and in a timely fashion. Review of all A& E referrals by Orthopaedic staff would seem not to be a cost efficient use of time.