Osteoporotic fractures in the elderly are increasingly numerous, but diaphyseal locations on native bone are quite rare.

Pathological and periprosthetic fractures are not included in this review, as they are specific in terms of context and treatment.

Cortical thinning and widening of the medullary canal alter local mechanical properties, necessitating adaptation of internal fixation. Thus, for nailing, the diameter of the implant has to be greater, and fixed-angle or multidirectional locking screws are used; for plate fixation, locking screws are required.

To avoid secondary periprosthetic fracture, fixation must protect the entire bone segment. Long plates should be used, with several divergent epiphyseal end-screws; in the femur, cervicocephalic proximal fixation is recommended.

In practice, nailing is mostly used in femoral and tibial isthmic locations. In case of metaphyseal extension, nail and locking plate fixation, ideally percutaneous, show comparable results in terms of function, consolidation and complications. In the tibia, it is mandatory to be soft-tissue friendly given the fragility of pretibial skin in the elderly.

In the humerus, the choice is wider. For nailing, passage through the rotator cuff seems acceptable in elderly patients.

V; expert opinion.