This is the second report of an atypical peri-implant femoral fracture occurring at the distal screw after intramedullary nail fixation of a pertrochanteric fracture. A 94-year-old Japanese female with a 5-year history of alendronate intake presented with prodromal pain in her right thigh after intramedullary nail fixation. Plain radiographs showed an incomplete noncomminuted transverse fracture at the distal screw, suggesting an atypical peri-implant femoral fracture. The pathogenesis of an atypical peri-implant femoral fracture could be a combined systemic bone metabolism disorder and repetitive overloading at the screw, similar to the pathogenesis of an atypical periprosthetic femoral fracture around stem implantation.