Breast carcinoma is the most common cause for bony metastases. Skeletal complications in women with meta-static breast carcinoma often occur multiple times in a single patient and significantly contribute to the patient morbidity. We describe a 62 year old lady with a known metastatic breast carcinoma who presented with simultaneous quadruple extremity diaphyseal long bone fractures after a trivial fall. To the author’s best knowledge, similar report has never been previously described in the literature.

The wish and general condition of the patient, and concurrent occurrence of four long bone fractures dictated the non-operative mode of treatment in this case.Where the life expectancy is assumed to be less than six weeks, the multidisciplinary team should give careful consideration on selection of best treatment choice between simultaneous or sequential surgical fixation of multiple long bone fractures and conservative palliative treatment. With treatment suited for an end-of-life circumstance, the educational lesson for dissemination to the readers is that in a patient where there is an extremely high likelihood of imminent perioperative mortality after sustaining quadruple extremity diaphyseal proximal long bone fractures simultaneously, conservative palliative treatment should be primarily considered over an aggressive operative fixation.

Introduction: Metal-on-metal hip resurfacing arthroplasty is recommended for younger patients with advanced hip disease who are likely to outlive a conventional primary total hip arthroplasty and wish to be reasonably active. Intraoperative or immediate postoperative femoral neck fracture is a well described technical complication as a result of notching and stress shielding of the femoral head. We report two cases of femoral neck fracture incurred eight to fifteen months following the index operation.

Case 1: A 47 year old lady was admitted after sustaining a fall. Radiograph confirmed left femoral neck fracture with resurfacing prosthesis in situ. She underwent metal-on-metal surface hip replacement 15 months ago for advanced osteoarthritis. The periprosthetic fracture was treated by revising the femoral component, using Eurocone cormet modular endo head 44mm size. At one year follow up, she was able to mobilise unassisted and had a good range of movements.

Case 2: A 52 year old gentleman presented with a painful right hip. While walking in the supermarket, he suddenly felt a click in the right hip. Radiograph confirmed right femoral neck fracture with resurfacing prosthesis in place. The metal-on-metal surface hip replacement was performed 8 months previously for advanced avascular necrosis. His medical history was significant for epilepsy. The Femoral component was revised, using Eurocone cormet modular endo head 52mm. He made a satisfactory progress at 18 months follow up since his periprosthetic fracture.

Conclusion: We recommend that patient selection should be given prime importance before embarking on metal on metal surface hip replacement. The surgeons’ factors are meticulous technique in preventing neck notching and femoral head fixation in varus angulation. Revising femoral component, using large head and leaving resurfaced cups in place should be considered as mode of treatment. Large multicentric trials are needed to evaluate the exact incidence of periprosthetic fractures in metal on metal hip resurfacing

We report the results of application of a strategy for deformity correction in hypophosphataemic rickets using careful preoperative planning, multiple osteotomies where appropriate and acute or gradual correction using internal or circular external fixation or a combination.

7 patients with 25 limb segments (14 femur and 11 Tibia) had deformity correction with either intramedullary nailing (10 Femur and 3 Tibia) or llizarov ring fixator (4 femur and 8 Tibia). The average age was 18 years (7–39 years), 5 were female and 2 male, had an average follow up of 36 months (10–77 months). All patients had adequate control of rickets pre operatively.

Clinical examination and analysis of pre and post-operative X-rays were carried out by an observer not involved in the surgical procedures. Standardised X-rays were analysed using the method of Paley and Tetsworth (Clin Orthop 280 48–71. 1992).

Satisfactory correction of deformity was achieved in both frontal and sagittal plane. There were total 8 episodes of soft tissue infection with no long-term consequence. Average ankle ROM was 7–44 and knee ROM was 0–128. There is no recurrence of the deformity.

All patients were happy with outcome and are prepared to undergo same treatment if required, even though some were restricted in terms of sport and leisure activities.

We conclude that satisfactory correction of deformity in VDRR can be achieved and maintained with nailing or llizarov fixator in short term with minimal complications, no recurrence and excellent outcome.