BackgroundAtypical femoral fractures (AFFs) are rare events associated with increased duration of bisphosphonate exposure. Recommended management of AFFs include cessation of bisphosphonates and imaging of the contralateral femur. The aims of this study were to identify the local incidence of AFFs in bisphosphonate users and to audit the medical management of AFFs against published recommendations.MethodsA retrospective analysis of the admissions database for a major trauma centre identified all femoral fractures (3150) in a five-year period (July 2009 to June 2014). Electronic health records and radiographs were reviewed using the 2013 American Society for Bone and Mineral Research (ASBMR) diagnostic criteria for AFF to establish the number of cases. To estimate incidence, the total number of bisphosphonate users was derived from primary care prescription and secondary care day-case records. Medical management of cases with AFF on bisphosphonates was audited against guidance from ASBMR and Medicines & Healthcare Products Regulatory Agency.Results10 out of 3150 femoral fractures met criteria for AFF; 7 of these patients had a history of exposure to bisphosphonates (6 oral, 1 intravenous). There were 19.1 AFFs per 100,000 years of bisphosphonate use in our region. Bisphosphonates were stopped and the contralateral femur imaged in only 2 of the 7 patients treated with bisphosphonates.ConclusionOur local incidence is in line with published figures; however, this is the first published evidence suggesting that medical management and identification of AFF may be suboptimal. Managing these patients remains challenging due to their rarity and possible lack of awareness.

SUMMARYA 73-year-old man was admitted with symptoms of large bowel obstruction. An emergency CT scan revealed pneumobilia and large bowel obstruction at the level of the rectosigmoid due to a 4×4 cm impacted gallstone. Flexible sigmoidoscopy confirmed the diagnosis but initial attempts to drag the stone into the rectum failed. An endoscopic mechanical lithotripter was employed to repeatedly fracture the gallstone into smaller fragments, which were passed spontaneously the next day. The patient made a complete recovery avoiding the potential dangers of surgery. This case report discusses cholecystoenteric fistula and a novel minimally invasive treatment for large bowel obstruction due to gallstones. BACKGROUND

A 60-year-old farmer was admitted with symptoms and signs suggestive of appendicitis. The diagnosis was confirmed at open appendicectomy where the appendix base was ligated and inverted into the caecum with a purse-string suture. Following an uneventful recovery and discharge, a barium enema identified a 2 cm filling defect in the caecal pole. A subsequent colonoscopy revealed only a tiny sessile polyp in the caecum with histology demonstrating normal colonic mucosa. This case report discusses the rare occurrence of an inverted appendix stump mimicking caecal pathology and the rationale of post-appendicectomy colonic investigation in the elderly patient.

DESCRIPTIONA 67-year-old right-handed man, with known renal cell carcinoma (RCC), presented to the hospital with a painful and swollen right wrist joint and severe hypercalcaemia (albumin-corrected serum calcium level of 3.6 mmol/L) with low parathyroid hormone levels (0.6 pmol/L). He was known to have RCC (histologically proven clear cell subtype) with metastasis to the lung (disease stage IV; T3aN1M1). Physical examination revealed a swollen and deformed right wrist joint that was tender to palpation.A plain radiograph showed a large soft tissue swelling of the right wrist and a 3 cm lytic lesion in the radius (figure 1) with permeative bony destruction and a pathological fracture of the distal epiphysis. There was dislocation of the wrist with permeative bone loss of the distal ulnar metaphysis and epiphysis (figure 2). MRI of the wrist showed destruction of the distal right radial epiphysis with a large fleshy tumour measuring 6.1×5.5×5.8 cm (figure 3) with involvement of the skin and subcutaneous tissues. MRI showed prominent flow voids in the tumour consistent with RCC metastasis.Administration of intravenous fluids and palmidronate brought the hypercalcaemia under control and his wrist was immobilised in a plaster-of-Paris cast. The patient declined external fixation of the joint for definitive treatment and chose palliativecare with opioid analgesics.RCC accounts for 3% of all adult cancers and about 90% of renal neoplasms. 1 RCC metastasises predominantly to the axial skeleton 2 and metastasis to the radius is unusual. There are two prognostic models for RCC, namely, the Memorial Sloan-Kettering Cancer Center (MSKCC) model and the Heng model. 3 In the MSKCC model, Figure 1 An anteroposterior radiograph of the right wrist showing osteolysis of the radius (black arrow).