Fracture patterns in patients with multiple fractures: the probability of multiple fractures and the most frequently associated regions

  • Xaver FeichtingerEmail author
  • Roland Kocijan
  • Rainer Mittermayr
  • Andreas Baierl
  • Jakob Schanda
  • Robert Wakolbinger
  • Heinrich Resch
  • Christian Fialka
  • Christian Muschitz
Original Article



Multiple fractures are of high clinical relevance, as a significant increase in mortality rate has been described. The purpose of this study was to evaluate differences in age and gender distribution in multiple fractures dependent on severity of trauma. Furthermore, affected anatomic regions and frequently associated fracture regions were investigated.


Patients who had sustained multiple fractures between 2000 and 2012 were included in this study. At hospital admission, patients were divided according to trauma severity (high- vs low-traumatic), gender, and age for demographic analysis. Fractures were grouped in anatomical regions, and multiple fracture event probabilities as well as frequently associated regions were calculated.


In total, 25,043 patients at an age range of 0–100 years (5.8% of all fracture patients; 14,769 male and 10,274 female patients) who sustained 57,862 multiple fractures were included. The lumbar/thoracic spine, cervical spine, femoral shaft, skull, and pelvis showed a probability of more than 40% of the presence of further fractures in each high-traumatic fracture event. In high-traumatic fracture events, male patients were more affected (p < 0.001). Considering low-traumatic fractures, female patients had a significantly higher proportion (p < 0.001) of multiple fractures among all fractures than male patients.


As a novelty, gender as well as age distributions in multiple fracture patients and a probability statement with the most affected anatomic regions, the risk of presence of further fractures for every region, and the frequently associated fracture regions including the percentage of occurrence are provided. These aspects yield new opportunities for clinical work and may reduce the high rate of overlooked fractures stated in the literature.


Multiple fractures Fracture patterns Associated regions Fracture probability 



The authors thank Karl Thomanek for proofreading.


No funding in any form has been received from a commercial party related directly or indirectly to the subject of this article.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no competing interests.


  1. 1.
    Rennie L, Court-Brown CM, Mok JYQ, Beattie TF. The epidemiology of fractures in children. Injury. 2007;38:913–22.CrossRefGoogle Scholar
  2. 2.
    Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37:691–7.CrossRefGoogle Scholar
  3. 3.
    Clement ND, Aitken S, Duckworth AD, McQueen MM, Court-Brown CM. Multiple fractures in the elderly. J Bone Jt Surg Br. 2012;94:231–6.CrossRefGoogle Scholar
  4. 4.
    Court-Brown CM, McQueen MM. Global forum: fractures in the elderly. J Bone Jt Surg Am. 2016;98:e36.CrossRefGoogle Scholar
  5. 5.
    Court-Brown CM, Bugler KE, Clement ND, Duckworth AD, McQueen MM. The epidemiology of open fractures in adults. A 15-year review. Injury. 2012;43:891–7.CrossRefGoogle Scholar
  6. 6.
    Tscherne H, Regel G, Pape HC, Pohlemann T, Krettek C. Internal fixation of multiple fractures in patients with polytrauma. Clin Orthop Relat Res. 1998;347:62–78.CrossRefGoogle Scholar
  7. 7.
    Pressley JC, Kendig TD, Frencher SK, Barlow B, Quitel L, Waqar F. Epidemiology of bone fracture across the age span in blacks and whites. J Trauma. 2011;71:541–8.CrossRefGoogle Scholar
  8. 8.
    Court-Brown CM, Clement ND, Duckworth AD, Aitken S, Biant LC, McQueen MM. The spectrum of fractures in the elderly. Bone Jt J. 2014;96-B:366–72.CrossRefGoogle Scholar
  9. 9.
    Kocijan R, Muschitz C, Geiger E, Skalicky S, Baierl A, Dormann R, et al. Circulating microRNA signatures in patients with idiopathic and postmenopausal osteoporosis and fragility fractures. J Clin Endocrinol Metab. 2016;101:4125–34.CrossRefGoogle Scholar
  10. 10.
    Reniu AC, Ong T, Ajmal S, Sahota O. Vertebral fracture assessment in patients presenting with a non-hip non-vertebral fragility fracture: experience of a UK Fracture Liaison Service. Arch Osteoporos. 2017;12:23.CrossRefGoogle Scholar
  11. 11.
    Hawley S, Javaid MK, Rubin KH, Judge A, Arden NK, Vestergaard P, et al. Incidence and predictors of multiple fractures despite high adherence to oral bisphosphonates: a binational population-based cohort study. J Bone Miner Res. 2016;31:234–44.CrossRefGoogle Scholar
  12. 12.
    Dimai HP, Svedbom A, Fahrleitner-Pammer A, Resch H, Muschitz C, Thaler H, et al. Epidemiology of distal forearm fractures in Austria between 1989 and 2010. Osteoporos Int. 2014;25:2297–306.CrossRefGoogle Scholar
  13. 13.
    Muschitz C, Kocijan R, Baierl A, Dormann R, Feichtinger X, Haschka J, et al. Preceding and subsequent high- and low-trauma fracture patterns-a 13-year epidemiological study in females and males in Austria. Osteoporos Int. 2017;28:1609–18.CrossRefGoogle Scholar
  14. 14.
    Razi H, Birkhold AI, Weinkamer R, Duda GN, Willie BM, Checa S. Aging leads to a dysregulation in mechanically driven bone formation and resorption. J Bone Miner Res. 2015;30:1864–73.CrossRefGoogle Scholar
  15. 15.
    Ashpole NM, Herron JC, Mitschelen MC, Farley JA, Logan S, Yan H, et al. IGF-1 regulates vertebral bone aging through sex-specific and time-dependent mechanisms. J Bone Miner Res. 2016;31:443–54.CrossRefGoogle Scholar
  16. 16.
    Siris ES, Adler R, Bilezikian J, Bolognese M, Dawson-Hughes B, Favus MJ, et al. The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporos Int. 2014;25:1439–43.CrossRefGoogle Scholar
  17. 17.
    Greenspan AI, Coronado VG, Mackenzie EJ, Schulman J, Pierce B, Provenzano G. Injury hospitalizations: using the nationwide inpatient sample. J Trauma. 2006;61:1234–43.CrossRefGoogle Scholar
  18. 18.
    Beerekamp MSH, de Muinck Keizer RJO, Schep NWL, Ubbink DT, Panneman MJM, Goslings JC. Epidemiology of extremity fractures in the Netherlands. Injury. 2017;48:1355–62.CrossRefGoogle Scholar
  19. 19.
    Bruno AG, Burkhart K, Allaire B, Anderson DE, Bouxsein ML. Spinal loading patterns from biomechanical modeling explain the high incidence of vertebral fractures in the thoracolumbar region. J Bone Miner Res. 2017;32:1282–90.CrossRefGoogle Scholar
  20. 20.
    R Development Core Team. R: a language and environment for statistical computing [Internet]. Vienna, Austria: R Foundation for Statistical Computing; 2017. Accessed 9 July 2017.
  21. 21.
    Statistics Austria. The Austrian Federal Statistical Institute. Accessed 5 Jan 2019.
  22. 22.
    Macdonald HM, Nishiyama KK, Kang J, Hanley DA, Boyd SK. Age-related patterns of trabecular and cortical bone loss differ between sexes and skeletal sites: a population-based HR-pQCT study. J Bone Miner Res. 2011;26:50–62.CrossRefGoogle Scholar
  23. 23.
    Laurent MR, Jardí F, Dubois V, Schollaert D, Khalil R, Gielen E, et al. Androgens have antiresorptive effects on trabecular disuse osteopenia independent from muscle atrophy. Bone. 2016;93:33–42.CrossRefGoogle Scholar
  24. 24.
    Llompart-Pou JA, Chico-Fernández M, Sánchez-Casado M, Alberdi-Odriozola F, Guerrero-López F, Mayor-García MD, et al. Age-related injury patterns in Spanish trauma ICU patients. Results from the RETRAUCI. Injury. 2016;47(Suppl 3):61–5.CrossRefGoogle Scholar
  25. 25.
    Ran T, Hua X, Zhenyu Z, Yue L, Youhua W, Yi C, et al. Floating knee: a modified Fraser’s classification and the results of a series of 28 cases. Injury. 2013;44:1033–42.CrossRefGoogle Scholar
  26. 26.
    Heng K. “Floating shoulder” injuries. Int J Emerg Med. 2016;9:13.CrossRefGoogle Scholar
  27. 27.
    Mosheiff R, Segal D, Wollstein R, Sagiv S, Liebergall M. Midshaft femoral fracture, concomitant ipsilateral hip joint injury, and disruption of the knee extensor mechanism: a unique triad of dashboard injury. Am J Orthop. 1998;27:465–73.Google Scholar
  28. 28.
    Monma H, Sugita T. Is the mechanism of traumatic posterior dislocation of the hip a brake pedal injury rather than a dashboard injury? Injury. 2001;32:221–2.CrossRefGoogle Scholar
  29. 29.
    Chan D, Kraus JF, Riggins RS. Patterns of multiple fracture in accidental injury. J Trauma. 1973;13:1075–82.CrossRefGoogle Scholar
  30. 30.
    Tyson S, Hatem SF. Easily missed fractures of the upper extremity. Radiol Clin N Am. 2015;53:717–36.CrossRefGoogle Scholar
  31. 31.
    Yu JS. Easily missed fractures in the lower extremity. Radiol Clin N Am. 2015;53:737–55.CrossRefGoogle Scholar
  32. 32.
    Brozek W, Reichardt B, Zwerina J, Dimai HP, Klaushofer K, Zwettler E. Antiresorptive therapy and risk of mortality and refracture in osteoporosis-related hip fracture: a nationwide study. Osteoporos Int. 2016;27:387–96.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Xaver Feichtinger
    • 1
    • 2
    Email author
  • Roland Kocijan
    • 2
  • Rainer Mittermayr
    • 1
  • Andreas Baierl
    • 3
  • Jakob Schanda
    • 1
    • 2
  • Robert Wakolbinger
    • 2
  • Heinrich Resch
    • 2
    • 4
  • Christian Fialka
    • 1
    • 4
  • Christian Muschitz
    • 2
  1. 1.AUVA Trauma Center Vienna-MeidlingViennaAustria
  2. 2.St. Vincent Hospital-Metabolic Bone Diseases UnitThe VINFORCE Study GroupViennaAustria
  3. 3.Department of Statistics and Operations ResearchUniversity of ViennaViennaAustria
  4. 4.Center for the Musculoskeletal System, Medical FacultySigmund Freud UniversityViennaAustria

Personalised recommendations