Introduction

Intraarticular calcaneal fractures often need open reduction and internal fixation (ORIF) with plate osteosynthesis. The wound complication is one of the common problems encountered following this and affects the outcome adversely. Our study was done to assess how far postoperative slab/cast can avert wound complications.

Abstract. Objective. Bi-condylar tibia plateau fractures are one of challenging injuries due to multi-planar fracture lines. The risk of fixation failure is correlated with coronal splits observed in CT images, although established fracture classifications and previous studies disregarded this critical split. This study aimed to experimentally and numerically compare our innovative fracture model (Fracture C), developed based on clinically-observed morphology, with the traditional Horwitz model (Fracture H). Methods. Fractures C and H were realized using six samples of 4th generation tibia Sawbones and fixed with Stryker AxSOS locking plates. Loading was introduced through unilateral knee replacements and distributed 60% medially. Loading was initiated with six static ramps to 250 N and continued with incremental fatigue tests until failure. Corresponding FE models of Fractures C and H were developed in ANSYS using CT scans of Sawbones and CAD data of implants. Loading and boundary conditions similar to experimental situations were applied. All materials were assumed to be homogenous, isotropic, and linear elastic. Von-Mises stresses of implant components were compared between fractures. Results. Fracture C showed 46% lower static stiffness than Fracture H, and it was 38–59% laxer than Fracture H during cyclic loading. Fractures C and H failed at 368±63N and 593±159N, respectively. Von-Mises stress distributions of locking plates indicated that for Fracture C peak stresses, observed around the proximal-inferior and proximal-threadless holes, were 55% higher than Fracture H's, which occurred around the kick-stand hole. The Kick-stand screw of Fracture C demonstrated 65% higher stress than Fracture H's. Conclusions. Experimental outcomes revealed that coronal splits significantly reduced structural stability. Von-Mises stress distributions demonstrated that potential fatigue failure points of implant components depend on the fracture geometry. Therefore, coronal fracture lines should be counted to precisely assess different fixation methods and find the optimum option for this problematic trauma

There is still no consensus on which concentration of mesenchymal stem cells (MSCs) to use for promoting fracture healing in a rat model of long bone fracture. To assess the optimal concentration of MSCs for promoting fracture healing in a rat model. Wistar rats were divided into four groups according to MSC concentrations: Normal saline (C), 2.5 × 106 (L), 5.0 × 106 (M), and 10.0 × 106 (H) groups. The MSCs were injected directly into the fracture site. The rats were sacrificed at 2 and 6 자 post-fracture. New bone formation [bone volume (BV) and percentage BV (PBV)] was evaluated using micro-computed tomography (CT). Histological analysis was performed to evaluate fracture healing score. The protein expression of factors related to MSC migration [stromal cell-derived factor 1 (SDF-1), transforming growth factor-beta 1 (TGF-β1)] and angiogenesis [vascular endothelial growth factor (VEGF)] was evaluated using western blot analysis. The expression of cytokines associated with osteogenesis [bone morphogenetic protein-2 (BMP-2), TGF-β1 and VEGF] was evaluated using real-time polymerase chain reaction. Micro-CT showed that BV and PBV was significantly increased in groups M and H compared to that in group C at 6 wk post-fracture (P = 0.040, P = 0.009; P = 0.004, P = 0.001, respectively). Significantly more cartilaginous tissue and immature bone were formed in groups M and H than in group C at 2 and 6 wk post-fracture (P = 0.018, P = 0.010; P = 0.032, P = 0.050, respectively). At 2 wk post fracture, SDF-1, TGF-β1 and VEGF expression were significantly higher in groups M and H than in group L (P = 0.031, P = 0.014; P < 0.001, P < 0.001; P = 0.025, P < 0.001, respectively). BMP-2 and VEGF expression were significantly higher in groups M and H than in group C at 6 wk postfracture (P = 0.037, P = 0.038; P = 0.021, P = 0.010). Compared to group L, TGF-β1 expression was significantly higher in groups H (P = 0.016). There were no significant differences in expression levels of chemokines related to MSC migration, angiogenesis and cytokines associated with osteogenesis between M and H groups at 2 and 6 wk post-fracture. The administration of at least 5.0 × 106 MSCs was optimal to promote fracture healing in a rat model of long bone fractures

This study was conducted to investigate the characteristics, complications, radiologic features and clinical course of patients undergoing reduction of forearm fractures in order to better inform patient prognosis and postoperative management. We conducted a retrospective cohort study of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comonution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements. 80 cases, averaging 13.5±8.3 years, were identified as having a complete fracture of the radius and/or ulna with 69 receiving closed reduction and 11 receiving fixation via an intramedullary device or percutaneous pinning. Eight patients (10%) experienced complications with four resulting in a refracture and four resulting in significant loss of reduction (LOR) without refracture. Fractures in the proximal ⅔s of the radius were associated with a significant increase in complications compared to fractures in the distal ⅓ of the radius (31.6% vs 3.4%) (P=.000428). Likewise, a higher percent fracture displacement was associated with a decreased risk of complications (28.7% vs 5.9% displacement)(P=0.0403). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age or arm affected. Our result highlights radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing risk of complications following forearm fracture

Healing after bone fracture is assessed by frequent radiographs, which expose patients to radiation and lacks behind biological healing. This study aimed to investigate whether the electrical impedance using electrical impedance spectroscopy correlated to quantitative scores of bone healing obtained from micro-CT and mechanical bending test. Eighteen rabbits were subjected to tibial fracture that was stabilized with external fixator. Two electrodes were positioned, one electrode placed within the medullary cavity and the other on the lateral cortex, both three millimeters from the fracture site. Impedance was measured daily across the fracture site at a frequency range of 5 Hz to 1 MHz. The animals were divided into three groups with different follow-up time: 1, 3 and 6 weeks for micro-CT (Bone volume/tissue volume (BV/TV, %)) and mechanical testing (maximum stress (MPa), failure energy (kJ/cm3), young modulus (Mpa)). There was a statistically significant correlation between last measured impedance at 5 Hz frequency immediately prior to euthanasia and BV/TV of callus (−0.68, 95%CI: (−0.87; −0.31)). Considering the mechanical testing with three-point bending, no significant correlation was found between last measured impedance at 5 Hz frequency immediately prior to euthanasia and maximum stress (−0.35, 95%CI: (−0.70; 0.14)), failure energy (−0.23, 95%CI: (−0.63; 0.26)), or young modulus (−0.28, 95%CI: (−0.66; 0.22)). The significant negative correlation between impedance and BV/TV might indicate that impedances correlate with the relative bone volume in the callus site. The lack of correlation between impedance and mechanical parameters when at the same time observing a correlation between impedance and days since operation (0-42 days), might indicate that the impedance can measure biological changes at an earlier time point than rough mechanical testing

Introduction and Objective. When using radiation intraoperatively, a surgeon should aim to maintain the dose as low as reasonably achievable to obtain the diagnostic or therapeutic goal. The UK Health Protection Agency reported mean radiation dose-area-product (DAP) of 4 Gy cm2 for hip procedures. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures. Materials and Methods. We assessed 369 neck of femur fractures between April 2019 and April 2020 in one district general hospital. Fractures were classified as extracapsular or intracapsular and into subtypes as per AO classification. Data was collected on type of fractures, implants used, level of surgeon, duration of surgery and DAP. Types of fractures were subclassified as complex (multifragmentary, subtrochanteric and reverse oblique) or simple. Results. Patients with fractures fixed with DHS, short PFNA, long PFNA and cannulated screws were included. 50% of our patients were fixed with hemiarthroplasty or total hip replacement and were therefore excluded. 184 patients were included in the analysis. There was a significant association of higher DAP with fracture subtype (P=0.001), fracture complexity (P<0.001), if an additional implant was used (P=0.001), if fixation was satisfactory (P=0.002) and the operative time (P<0.001). DAP was higher in PFNA than DHS and greatest in Long PFNA. There was some evidence of association between the level of the surgeon and DAP, although this was not statistically significant (P=0.069) and remained not significant after adjusting for the variables (fracture complexity, fixation or implant used) (p=0.32). Conclusions. Increased radiation in proximal femur fractures is seen in fixation of complex fractures, certain subtypes, the type of implant used and if an additional implant was required. Seniority of surgeon did not result in less radiation exposure even when adjusting for other factors, which is in contrast to other published studies

Introduction and Objective. Scaphoid waist fractures (SWF) are notable in upper limb trauma and predominantly occur in young men. Morbidities associated with SWF include fracture non-union, premature arthritis and humpback deformity. Delayed treatment and non-adherence to fracture immobilisation increases likelihood of these complications. There is evidence that men engage in negative health behaviours such as delayed help-seeking. The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) conducted interviews in individuals who had sustained a SWF. Although SWIFFT showed multiple social determinants for the overall injury and healing experience, a key factor this novel study considers is age and sex. This study aimed to analyse interview data from young male participants in SWIFFT to help distinguish the experience of SWF in young men, through exploring the influence of masculinity. Materials and Methods. A purposive sample of 12 young male participants were selected from SWIFFT. These participants were enrolled from a possibility of 13 different centres across Britain. There were 17 semi-structured interviews produced from these participants, and this was thought to be sufficient for data saturation. These interviews were evaluated through deductive thematic analysis with an open-coding approach, with respondents’ experiences being compared against themes documented in men's health literature. The “Braun and Clarke (2006) Six Phases of Thematic Analysis” methodology was adopted to perform this. Results. There were three thematic models developed in the data set, which then were further divided into subthemes. Model 1: Negative Health Behaviour Prior to Treatment, model 2: Feeling Frail and model 3: Need for Speed. Model 1 corroborated that participants were inclined to sustain the injury as a result of risk-taking and would subsequently hesitate to seek treatment. Model 2 indicated that as a result of the injury, respondents were unable to engage in physical activities and activities of daily living. Respondents exercised caution to varying extents after sustaining a SWF. Model 3 highlighted that interviewees were prone to non-adherence with fracture immobilisation and in hindsight resumed employment prematurely. Conclusions. The findings of this study demonstrate that masculinity is significantly influential on the experience of SWF in young men. This was indicated through the results of thematic analysis strongly corresponding with behaviours established in men's health literature. Educational interventions could be of value in addressing behaviours observed in this population group, such as delayed help-seeking and non-compliance with fracture immobilisation. Further work in patient education and concordance with treatment after sustaining a SWF may be beneficial to longer term outcomes. In turn, this may reduce complications associated with SWF in young men

Abstract. Objectives. Clavicle fractures are common, yet debate exists regarding which patients would benefit from conservative versus operative management. Traditionally shortening greater than 2cm has been accepted as an indicator for surgery. However, clavicle length varies between individuals. In a cadaveric study clavicle shortening greater than 15% was suggested to affect outcomes. There is no clinical correlation of this in the literature. In this study we investigate outcomes following middle third clavicle fractures and the effect of percentage shortening on union rates. Methods. We identified a consecutive series of adults with primary midshaft clavicle fractures presenting to our institution from April 2015-March 2017. Clinical records and radiographs were reviewed to elicit outcomes. Time to union was measured against factors including; percentage shortening, displacement, comminution and smoking. Statistical significance was calculated. Results. 127 patients were identified, of whom 90 were managed conservatively and 37 operatively. Fractures were displaced in 86 patients (68%). Mean age was 41.7 years (range 18–89). Mean time to union for displaced fractures was longer than for undisplaced at 13.4 and 8.9 weeks respectively (p=0.0948). Displaced fractures treated operatively had mean time to union of 12.8 weeks, three weeks shorter than those managed conservatively (p=0.0470). Mean time to union for fractures with >15% shortening was 16.0 weeks, nearly double the 8.7 weeks with <15% shortening (p= 0.0241). Smokers had 8 weeks longer time to union (p=0.0082). Nonunion rate was 10% in fractures managed conservatively and 0% in those treated operatively. Complications following operative management were plate removal (13.5%), frozen shoulder (8.1%) and infection (2.9%). Conclusions. Nonunion rate is higher in fractures managed conservatively. Shortening >15% leads to significantly longer union time and should therefore be used as an indicator for surgery. Displacement and smoking also lengthen time to union and should be considered in the operative decision process. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction and Objective

Some periprosthetic femoral fractures (PFFs) present history and radiographic aspect consistent with an atypical femoral fracture (AFF), fulfilling the criteria for AFF except that PFFs by themselves are excluded from the diagnosis of AFFs. The aim of this study was to evaluate in a single Institution series of PFFs if any of them could be considered a periprosthetic atypical femoral fracture (PAFF), and their prevalence.

Rib fractures (RF) represent the most common bone fracture after blunt trauma, occurring in 10–20% of all trauma patients and leading to concomitant injuries of the inner organs in severe cases. However, a standardized classification system for serial rib fractures (SRF) does still not exist. Basic knowledge about the facture pattern of SRF would help to predict organ damage, support forensic medical examinations, and provide data for in vitro and in silico studies regarding the thoracic stability. The purpose of our study was therefore to identify specific SRF patterns after blunt chest trauma. All SRF cases (≥3 subsequent RF) between mid-2008 and end of 2015 were extracted from the CT database of our University Hospital (n=383). Fractures were assigned to anterior, antero-lateral, lateral, postero-lateral, and posterior location within the transverse plane (36° each) using an angular measuring technique (reliability ±2°). Rib level, fracture type (transverse, oblique, multifragment, infracted), as well as degree of dislocation (none, </≥ rib width) were recorded and each related to the cause of accident. In total, 3747 RF were identified (9.7 per patient, ranging from 3 (n=25) to 33 (n=1)). On average, most RF occurred in crush/burying injuries (15.9, n=13) and pedestrian accidents (12.2, n=14), least in car/truck accidents (8.8, n=76). Altogether, RF gradually increased from rib 1 (n=140) towards rib 5 (n=517) and then decreased towards rib 12 (n=49), showing a bell-shaped distribution. More RF were detected on the left thorax (n=2027) than on the right (n=1720). Overall, most RF were found in the lateral (33%) and postero-lateral (29%) segment. Posterior RF mostly occurred in the lower thorax (63%), whereas anterior (100%), antero-lateral (87%), and lateral (63%) RF mostly appeared in the upper thorax. RF were distributed symmetrically to the sagittal plane, showing a hotspot (up to 98 RF) at rib levels 4 to 7 in the lateral segment and rib level 5 in the antero-lateral segment. In the car/truck accident group, 47% of all RF were in the lateral segment, in case of frontal collision (n=24) even 60%. Fall injuries (n=141) entailed mostly postero-lateral RF (35%). In case of falls >3 m (n=45), 48% more RF were detected on the left thorax compared to the right. CPR related SRF (n=33) showed a distinct fracture pattern, since 70% of all RF were located antero-laterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all RF were dislocated (15% ≥ rib width). SRF show distinct fracture patterns depending on the cause of accident. Additional data should be collected to confirm our results and to establish a SRF classification system

Abstract

Abstract

Bone regeneration is pivotal for the healing of fractures. In case this process is disturbed a non-union can occur. This can be induced by environmental factors such as smoking, overloading etc. Co-morbidities such as diabetes, osteoporosis etc. may be more intrinsic factors besides other disturbances in the process. Those pathways negatively influence the bone regeneration process. Several intrinsic signal transduction pathways (WNT, BMP etc.) can be affected. Furthermore, on the transcriptional level, important mRNA expression can be obstructed by deregulated miRNA levels. For instance, several miRNAs have been shown to be upregulated during osteoporotic fractures. They are detrimental for osteogenesis as they block bone formation and accelerate bone resorption. Modulating those miRNAs may revert the physiological homeostasis. Indeed, physiological fracture healing has a typical miRNA signature. Besides using molecular pathways for possible treatment of non-union fractures, providing osteogenic cells is another solution. In 5 clinical cases with non-union fractures with defects larger than 10 cm, successful administration of a 3D printed PCL-TCP scaffold with autologous bone marrow aspirate concentrate and a modulator of the pathogenetic pathway has been achieved. All patients recovered well and showed a complete union of their fractures within one year after start of the regenerative treatment.

Thus, non-union fractures are a diverse entity. Nevertheless, there seem to be common pathogenetic disturbances. Those can be counteracted at several levels from molecular to cell. Compositions of those may be the best option for future therapies. They can also be used in a more personalized fashion in case more specific measurements such as miRNA signature and stem cell activity are applied.

Abstract

The need to accurately forecast the injury burden has never been higher. With an aging, ever expanding trauma population and less than half of the beds available compared to 1990, the National Health Service (NHS) is stretched to breaking point^1,2.

We utilised a dataset of 22,585 trauma patients across the four countries of the United Kingdom (UK) admitted to 83 hospitals between 22/08/22 – 16/10/22 to determine whether it is possible to predict the proportionality of injuries treated operatively within orthopaedic departments based on their number of Neck of Femur fracture (NOF) patients.

More operations were performed for elderly hip fractures alone than for the combined totals of the next four most common fractures: ankle, distal radius, tibial shaft and forearm (6387 vs 5922). Conversely, 10 out of the 13 fracture types were not encountered by at least one hospital and 93% of hospitals encountered less than 2 fractures of a certain type.

60% trauma is treated within Trauma Units (TUs) however, per unit, Major Trauma Centres (MTCs) treat approximately 43% more patients.

After excluding NOF, lower limb fractures accounted for approximately 57% of fractures in all countries and ankle and distal radius fracture combined comprised more than 50% in 74% of regions.

The number of hip fractures seen on average by an individual unit remains relatively consistent as does the regional variation of any given fracture; resultantly, it is possible to predict injury proportionality based off a unit's hip fracture numbers. This powerful tool could transform both resource allocation and recruitment.

Objectives. Fracture non-union poses a significant challenge to treating orthopaedic surgeons. These patients often require multiple surgical procedures. The incidence of complications after Autologous Bone Graft (ABG) harvesting has been reported up to 44%. These complications include persistent severe donor site pain, infection, heterotopic ossification and antalgic gait. We retrospectively compared the use of BMP-7 alone in long bone fracture Non-union, with patients in whom BMP-7 was used in combination with the Autologous Bone Graft (ABG). Material and Methods. The databases of our dedicated Limb Reconstruction Unit were searched for patient with three common long bone fractures Non-unions (Tibia, Femur and Humerus). The patients who had intra-operative use of Bone Morphogenetic Protein (BMP-7) alone and in combination with ABG were evaluated. 53 Patients had combined use of ABG and BMP-7, and 65 patients had BMP-7 alone. Results. In the ABG and BMP-7 group, the union rate for femoral (n=18) Non-unions was 83%, for humeral (n=16) Non-unions 81%, and for tibia (n=19) Non-unions it was 47%. In the BMP-7 alone group, 83% of the femoral (n=12) Non-unions, 87% of the humeral (n=16) and 56% of the tibial (n=37) Non-unions healed. The common risk factors for Non-union were comparable in both the groups and included location and nature (open vs closed) of fracture, infection, smoking and NSAIDs use. The average time to union in ABG+BMP-7 group was 8.1 months (range 3-30 months) and in BMP-7 alone group it was 7.2 months (range 3-24 months). Conclusion. Autologous Bone Grafting has a pivotal role in limb reconstruction surgery but its indication should be carefully evaluated in view of considerable morbidity associated with graft donor site. Our study did not show any significant difference in the union rates of common long bone fracture Non-unions treated with BMP-7 alone or with a combination of Autologous Bone Graft and BMP-7

Background. Fractures of the metatarsal bones are the most frequent fracture of the foot. Up to 70% involve the fifth metatarsal bone, of which approximately eighty percent are located proximally. Low-intensity pulsed ultrasound (LIPUS) has been shown to be a useful adjunct in the treatment of delayed fractures and non unions. However, there is no study looking at the success rate of LIPUS in fifth metatarsal fracture delayed unions. Objectives. The aim of our study was to investigate the use of LIPUS treatment for delayed union of fifth metatarsal fractures. Study Design & Methods. A retrospective review of patients who were treated with LIPUS following a delayed union of fifth metatarsal fracture was conducted over a three-year period (2013 – 2015). Delayed union was defined as lack of clinical and radiological evidence of union, bony continuity or bone reaction at the fracture site if 3 months has elapsed from the initial injury. Results. There were thirty patients (9 males, 21 females) in our cohort. The average age was 39.3 years. Type 2 fractures made up 43% of our cohort. Twenty-seven (90%) patients went on to progress to union clinically and radiologically following LIPUS treatment. Smoking (p=0.014) and size of fracture gap (p=0.045) were predictive of non-union. Conclusions. This is the first study looking at the use of LIPUS in the treatment of delayed union of fifth metatarsal fractures. We report a success rate of 90%. There is a role in the use of LIPUS in delayed union of fifth metatarsal fractures and can serve as an adjunct prior to consideration of surgery

With an aging population and increase in total knee arthroplasty, periprosthetic distal femur fractures (PDFFs) have increased. The differences between these fractures and native distal femur fractures (NDFF) have not been comprehensively investigated. The purpose of this study was to compare the demographic, fracture, and treatment details of PDFFs compared to NDFFs.

A retrospective study of patients ≥ 18 years old who underwent surgical treatment for either a NDFF or a PDFF from 2010 to 2020 at a level 1 trauma center was performed. Demographics, AO/OTA fracture classification, quality of reduction, fixation constructs, and unplanned revision reoperation were compared between PDFF patients and NDFF patients using t-test and Fisher's exact test. 209 patients were identified with 70 patients having a PDFF and 139 patients having a NDFF. Of note, 48% of NDFF had a concomitant fracture of the ipsilateral knee (14%) or tibial plateau (15%). The most common AO/OTA classification for PDFFs was 33A3.3 (71%). NDFFs had two main AO/OTA classifications of 33C2.2 (28%) or 33A3.2. (25%). When controlling for patient age, bone quality, fracture classification, and fixation, the PDFF group had increased revision reoperation rate compared to NDFF (P < 0.05).

PDFFs tend to occur in elderly patients with low bone quality, have complete metaphyseal comminution, and be isolated; whereas, NDFF tend to occur in younger patients, have less metaphyseal comminution, and be associated with other fractures. When controlling for variables, PDFF are at increased risk of unplanned revision reoperation. Surgeons should be aware of these increased risks in PDFFs and future research should focus on these unique fracture characteristics to improve outcomes.

Neck of femur fractures are a common trauma presentation and patients with a history of malignancy are sent for long leg femur views (LLF), to exclude a distal lesion which would alter the management plan (Intra-medullary nail/Long stem Hemiarthroplasty). The aim of this is to identify incidence of malignancy on LLF views, the length of time in between each xray (XR) and to identify demographics.

Data was retrospectively collected from 01/01/2021 to 31/01/2021 from a single centre. All patients admitted to the Queen Elizabeth University Hospital had their electronic records (Bluespier, PACS, Clinical Portal) accessed. These confirmed if patients had a past medical history of malignancy, if they had LLF view and the time differences between diagnostic pelvis XR and LLF XR.

A total of 784 patients were identified in the specified time period. Of these, 138 were identified with a malignancy and there were 85 LLF views completed. LLF views diagnosed 1 patient with known prostate cancer that had a new distal femoral metastasis (Incidence = 1.28 cases per 1000). This patient underwent further imaging (MRI Femur) and received a long stem hip hemiarthroplasty. The average length of wait between the images was 9 hours 27 minutes.

LLF views can alter management of patients with malignancy and are therefore useful to perform. There can be a long delay between each image. Therefore we recommend imaging tumour with common bony metastasis (Renal, Thyroid, Breast, Prostrate, Lung) and other remaining tumours with known secondary metastasis. Imaging primary low risk (eg basal cell carcinoma) can lead to long delays in a frail patient cohort and consideration should be given to rationalise appropriate use of resources.

Renal Osteodystrophy is a type of metabolic bone disease characterized by bone mineralization deficiency due to electrolyte and endocrine abnormalities. Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. Treatment involves medical management to resolve the etiology of the underlying renal condition, as well as management (and prevention) of pathological fractures.

A 66-year-old female patient, with severe osteoporosis and chronic kidney disease undergoing haemodialysis, has presented with multiple fractures along the years. She was submitted to bilateral proximal femoral nailing as fracture treatment on the left and prophylactically due to pathological bone injury on the right, followed by revision of the left nail with a longer one after varus angulation and fracture distal to the nail extremity. Meanwhile, the patient suffered a pathological fracture of the radial and cubital diaphysis and was submitted to conservative treatment with cast, with consolidation of the fracture. Posteriorly, she re-fractured these bones after a fall and repeated the conservative treatment.

Clinical management: There is a multidisciplinary approach to manage the chronic illness of the patient, including medical management to resolve the etiology and consequences of her chronic kidney disease, pain control, conservative or surgical fracture management and prevention of falls.

The incidence of chronic renal disease is increasing and the patients with this condition live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Their quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. A multidisciplinary approach is required to treat these patients, controlling their chronic diseases, managing fractures and preventing falls.