Bilateral Hip Fractures in an Elderly Man

Monique Bethel, MD; Laura D. Carbone, MD, MS


June 14, 2016


Although osteoporosis is a common disease among older individuals, it remains less common in men than in women. Therefore, clinicians may not readily identify men at high risk for osteoporosis and its major complications, including hip fractures.

When evaluating male patients with known osteoporosis who present with bilateral fractures, such as in this case, ruling out secondary causes is important.[1] Secondary causes include any specific diseases or medications that may cause bone loss. Numerous conditions can induce bone loss, but important causes to consider in an elderly man include testosterone deficiency, vitamin D deficiency, hyperparathyroidism, hypercalciuria, underlying kidney disease, hyperthyroidism, multiple myeloma, and a history of prostate cancer (with use of antiandrogen therapy).

The laboratory test results obtained in this case indicated that a hypogonadal state, kidney disease, osteogenesis imperfecta, multiple myeloma, hyperparathyroidism, hypercalciuria, or hyperthyroidism were unlikely causes. Thus, the most likely cause of osteoporosis in this case is chronic steroid use; furthermore, glucocorticoid-induced osteoporosis has been cited as an import risk factor for hip fractures in men.[2]

Although osteoporosis is less common in men, at least one third of all hip fractures happen in men. Furthermore, the incidence of hip fractures in men is expected to increase at a faster rate than in women.[3] Despite this, men are less likely to receive treatment for osteoporosis than women, even after sustaining a fracture.[4]

Bisphosphonates are commonly used in the treatment of osteoporosis. Hip fractures are on the decline in the United States and in other industrialized countries, a fact that has been attributed, in part, to the use of bisphosphonates to treat osteoporosis and osteopenia.[5] In the mid-2000s, multiple case reports of "atypical" femur fractures (AFFs) began to emerge in patients receiving routine bisphosphonate therapy; this called into question the safety of the long-term use of bisphosphonate medications. One of the first case reports was in a series of nine patients receiving chronic alendronate therapy (ranging in duration from 1 to 8 years), with ages ranging from 49 to 76 years, including one man.[6]


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