An 80-year-old female was admitted to Inje University Busan Paik Hospital for left elbow pain that occurred after lifting something heavy three days prior to admission. She had hypertension and osteoporosis as underlying diseases. She was diagnosed with osteoporosis at a local clinic 20 years ago and had since been under a treatment regimen of ibandronate injections, in 3-month intervals, with 1 to 2 year drug holiday after 5 years of medication. She did not present prodromal symptoms and was found to have direct tenderness in her left proximal forearm on physical examination. The X-rays that were taken during her first visit showed a transverse fracture without displacement in the proximal third of the shaft (Fig. 1).

Her blood calcium level was 9.2 mg/dl (8.6–10.4 mg/dl), and her phosphorus level was 2.7 mg/dl (2.6–4.4 mg/dl). Her 1,25-dihydroxyvitamin D3 level was 27.2 pg/ml (19.6–54.3 pg/ml) and her C-telopeptide level was 0.264 ng/ml (premenopausal<0.573 ng/ml, postmenopausal<1.008 ng/ml). Her bone mineral density (BMD) T-score was 0.6 in the vertebra and −2.1 in the femoral neck. Three days after her first visit, open reduction and internal fixation of the ulnar fracture was performed using metal plates (Fig. 2). After the surgery, BP was discontinued, and a parathyroid hormone (PTH) injection was administered. Her forearm was immobilized using a cast with her elbow neutrally flexed to 90° for three weeks. One year and two months after surgery, the callus formation, indicating early fracture union (Fig. 3). She completely recovered her elbow range of motion at 16 months.

A 77-year-old female had been diagnosed with osteoporosis 10 years ago at a local clinic and had been taking risedronate, which contained nitrogen (risedronate Sodium Tab., 150 mg once a month, and 5 years after her first treatment, she was offered a “drug holiday” of 2 years). Since then, she complained of pain and swelling in the left forearm for 3 months, before visiting the clinic. She reported a cracking sound that occurred as she lifted herself up from a chair using her left hand on the day of the visit. She had pressure, pain, and swelling over her left proximal ulna on physical examination. The X-rays showed a transverse ulnar fracture in the proximal third of the shaft, without displacement (Fig. 4). Her blood calcium level was 9.5 mg/dl (8.6–10.4 mg/dl) and her phosphorus level was 2.7 mg/dl (2.6–4.4 mg/dl). Her 1,25-dihydroxyvitamin D₃ level was 45.7 (19.6–54.3 pg/ml) and her C-telopeptide level was 0.234 ng/ml (premenopausal<0.573 ng/ml, postmenopausal<1.008 ng/ml). Her BMD T-scores were 1.4 in the vertebra and −1.4 in the femoral neck. After a diagnosis of knee arthritis, a local clinic prescribed steroids for 6 months. The patient's skin was thin and lacked elasticity. Because of concerns regarding wound healing after surgical treatment of the ulnar fracture, closed reduction and internal fixation using intramedullary nails was performed 2 weeks later (Fig. 5). After the surgery, she was prescribed a PTH injection (teriparatide, 20 µg daily), in addition to calcium and vitamin D, and the BP was discontinued. Her forearm was immobilized, with the elbow extended for 8 weeks.

Nine months of the surgery, although the pain reduced, callus formation was not observed and displacement was found (Fig. 6). The patient complained of a continuous sense of pressure at the fracture site and was informed about the possibility of nonunion. Since bone union had not taken place, additional surgery was planned.