From the Guidelines
The diagnostic approach for suspected osteoporotic or traumatic fractures should begin with a thorough clinical assessment and appropriate imaging, prioritizing plain radiographs as the initial imaging modality, followed by CT scans or MRI as needed, and bone mineral density testing via dual-energy X-ray absorptiometry (DXA) to assess for underlying osteoporosis, as recommended by the most recent guidelines 1. The diagnostic and treatment approach for suspected osteoporotic or traumatic fractures involves several key steps:
- A thorough clinical assessment to determine the severity and location of the fracture
- Appropriate imaging, including plain radiographs, CT scans, and MRI, to confirm the diagnosis and assess the extent of the fracture
- Bone mineral density testing via DXA to assess for underlying osteoporosis, which is a critical step in identifying patients at high risk for future fractures 1
- Treatment depends on fracture location, severity, and patient factors, with options ranging from conservative management with immobilization to surgical intervention with internal fixation
- For osteoporotic fractures, initial management includes pain control with acetaminophen, NSAIDs, or short-term opioids, as well as immobilization and osteoporosis treatment with calcium, vitamin D, and bone-specific medications such as bisphosphonates, denosumab, or teriparatide 1
- Rehabilitation is crucial for both types of fractures, with physical therapy focusing on strength, mobility, and fall prevention
- Follow-up should include monitoring of fracture healing, functional recovery, and for osteoporotic patients, bone density reassessment every 1-2 years to evaluate treatment efficacy, as recommended by the international working group on DXA best practices 1 Key considerations in the diagnostic and treatment approach include:
- The importance of identifying and treating underlying osteoporosis to reduce the risk of future fractures
- The need for a comprehensive treatment plan that addresses pain management, immobilization, and rehabilitation
- The role of bone mineral density testing via DXA in assessing for underlying osteoporosis and guiding treatment decisions
- The importance of regular follow-up and monitoring to evaluate treatment efficacy and adjust the treatment plan as needed, as recommended by the American College of Radiology 1 and the American College of Physicians 1.
From the FDA Drug Label
For the treatment of postmenopausal women with osteoporosis at high risk for fracture (defined herein as having a history of osteoporotic fracture or multiple risk factors for fracture) or who have failed or are intolerant to other available osteoporosis therapy In postmenopausal women with osteoporosis, teriparatide injection reduces the risk of vertebral and nonvertebral fractures. To increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture or who have failed or are intolerant to other available osteoporosis therapy For the treatment of men and women with osteoporosis associated with sustained systemic glucocorticoid therapy (daily dosage equivalent to 5 mg or greater of prednisone) at high risk for fracture or who have failed or are intolerant to other available osteoporosis therapy.
The diagnostic approach for suspected osteoporotic or traumatic fractures involves identifying patients at high risk for fracture, such as those with a history of osteoporotic fracture or multiple risk factors for fracture.
- Key factors to consider in the diagnostic approach include:
- History of osteoporotic fracture
- Multiple risk factors for fracture
- Bone mineral density (BMD) measurements
- Presence of systemic glucocorticoid therapy The treatment approach for osteoporotic fractures typically involves pharmacotherapy, such as teriparatide injection, to reduce the risk of vertebral and nonvertebral fractures 2.
- Treatment options may include:
- Teriparatide injection for postmenopausal women with osteoporosis at high risk for fracture
- Denosumab for the treatment of bone loss in men with prostate cancer receiving androgen deprivation therapy 3
From the Research
Diagnostic Approach
- The diagnostic approach for suspected osteoporotic or traumatic fractures involves a combination of medical history, physical examination, laboratory testing, and imaging studies 4.
- Screening for osteoporosis with dual energy x-ray absorptiometry should be considered for all women 65 years and older or women who are postmenopausal with clinical risk factors 5.
- Osteoporosis can be diagnosed by a T-score of -2.5 or less or the presence of a fragility fracture 5.
- Bone mineral density (BMD) testing is most efficient in women over 65 years old but is also helpful for men and women with risk factors 4.
Treatment Approach
- The treatment approach for osteoporotic fractures is influenced by the patient's fracture risk, the effectiveness of fracture risk reduction, and medication safety 5.
- Patients at high risk of fracture should consider treatment with antiresorptive therapy, including bisphosphonates and denosumab 5, 6.
- Anabolic agents such as teriparatide, abaloparatide, and romosozumab should be considered for patients at very high risk or with previous vertebral fractures 5, 6, 7.
- Bisphosphonates, such as zoledronic acid and alendronate, have been shown to be effective in preventing vertebral, nonvertebral, and hip fractures 8.
Comparison of Treatments
- A systematic review and network meta-analysis found that denosumab, raloxifene, romosozumab, and teriparatide were all statistically significantly clinically effective for reducing vertebral fractures when compared to placebo 7.
- Zoledronic acid seemed to be the most effective in preventing vertebral fracture, nonvertebral fracture, and any fracture, and alendronate or zoledronic acid seemed to be the most effective in preventing hip fracture 8.
- The choice of treatment should be individualized based on the patient's specific needs and risk factors 5, 6.