How should a fragility fracture be evaluated and managed, including osteoporosis assessment and appropriate pharmacologic and non‑pharmacologic therapy?

Fragility Fracture Management

All patients over 50 years with a fragility fracture should receive systematic fracture risk evaluation, immediate initiation of calcium (1000-1200 mg/day) and vitamin D (800 IU/day), and pharmacologic treatment with oral bisphosphonates (alendronate or risedronate) as first-line therapy for 3-5 years, with alternatives reserved for specific contraindications or very high-risk patients. 1

Immediate Evaluation After Fragility Fracture

Clinical Assessment

• Identify the fracture as a sentinel event requiring both acute management and secondary prevention 1
• Document fracture location, mechanism (low-energy trauma), and any prior fractures
• Assess for undiagnosed vertebral fractures through clinical signs (height loss, kyphosis, back pain) 2
• Evaluate fall risk factors and mobility status before the fracture 1

Laboratory Investigation

Obtain the following tests to identify secondary causes of osteoporosis 3:

• Calcium, vitamin D (25-OH), alkaline phosphatase
• Thyroid-stimulating hormone
• Erythrocyte sedimentation rate
• Serum protein electrophoresis
• Consider bone turnover markers (optional, not consensus-required) 3

Bone Density Assessment

• Perform DXA scanning with vertebral fracture assessment to quantify bone mineral density and detect occult vertebral fractures 2, 4
• The presence of a fragility fracture itself indicates high fracture risk regardless of T-score 1
• FRAX calculation can supplement but should not delay treatment in patients with documented fragility fractures 4

Pharmacologic Treatment Strategy

First-Line Therapy: Oral Bisphosphonates

Alendronate or risedronate are the preferred initial agents because they:

• Reduce vertebral, non-vertebral, and hip fractures 1
• Are well-tolerated with extensive clinical experience
• Are available as generics at low cost 1
• Should be prescribed for 3-5 years initially 1

Alternative Agents for Specific Situations

Intravenous zoledronic acid or subcutaneous denosumab when patients have 1:

• Oral intolerance or esophageal contraindications
• Dementia or inability to follow oral bisphosphonate instructions
• Malabsorption syndromes
• Documented non-adherence to oral therapy

Anabolic agents (teriparatide) for patients with 1, 3:

• Very severe osteoporosis (multiple vertebral fractures, very low T-scores)
• Declining BMD despite bisphosphonate treatment
• Recent vertebral fractures with very high imminent fracture risk
• Prescribe for 24 months, then transition to antiresorptive therapy (denosumab or bisphosphonate) to maintain gains 3

Critical warning: Never discontinue anabolic therapy without immediately starting antiresorptive therapy—this causes rebound vertebral fractures 5

Treatment Duration and Drug Holidays

• After 5 years of bisphosphonate therapy, reassess fracture risk 5
• Consider temporary discontinuation (drug holiday) only in patients who:
  • Have improved BMD
  • Have no new fractures during treatment
  • Do not have very high baseline fracture risk 5
• Continue treatment beyond 5 years if patient remains high risk (prior hip/vertebral fracture, very low BMD, age >75) 5

Non-Pharmacologic Interventions

Mandatory for All Patients

• Calcium 1000-1200 mg/day (dietary plus supplementation if needed) 1
• Vitamin D 800 IU/day (reduces non-vertebral fractures by 15-20% and falls by 20%) 1
• Avoid high-pulse vitamin D dosing (increases fall risk) 1
• Smoking cessation and alcohol limitation 1

Fall Prevention and Rehabilitation

• Balance training and multidimensional fall prevention programs 1
• Resistance and functional training twice weekly 4
• Early mobilization post-fracture to restore pre-fracture independence 1
• Physical therapy focused on regaining mobility (especially critical in elderly with major fractures) 1

Acute Fracture Care Considerations

Orthogeriatric Approach

For frail elderly patients with major fractures (hip, pelvis, multiple vertebral):

• Multidisciplinary orthogeriatric care improves outcomes 1
• Optimize preoperative, operative, and postoperative management 1
• Limited postoperative mobility increases future fracture risk—aggressive rehabilitation is essential 1

Vertebral Augmentation

Consider vertebral augmentation (vertebroplasty/kyphoplasty) in selected patients with acute vertebral fractures and persistent severe pain despite conservative management 6

Systematic Follow-Up: The Five-Step Plan

Implement structured secondary fracture prevention 1:

1. Identify all patients with recent fragility fractures
2. Invite for fracture risk evaluation
3. Perform differential diagnosis and laboratory workup
4. Initiate appropriate therapy
5. Follow-up systematically to monitor adherence and tolerance

Monitoring Adherence

• Adherence rates reach 90% in Fracture Liaison Services versus much lower rates in usual care 1
• Use shared decision-making and risk communication to improve adherence 1
• Regular follow-up appointments to assess tolerance and continuation 1

Critical Pitfalls to Avoid

1. Do not delay osteoporosis treatment while waiting for DXA results—the fragility fracture itself justifies immediate therapy 7
2. Do not use calcium supplementation alone—it has no fracture reduction benefit and causes GI side effects 1
3. Never stop anabolic therapy without bridging to antiresorptive—risk of rebound fractures 5
4. Do not ignore the imminent fracture risk window—highest risk is immediately post-fracture 2, 7
5. Do not prescribe bisphosphonates indefinitely without reassessment—balance long-term benefits versus rare harms (atypical fractures, osteonecrosis) 5
6. Do not overlook secondary causes—perform appropriate laboratory screening 3

Special Populations

Very High Fracture Risk

Patients with recent or multiple vertebral fractures, hip fracture, or fracture while on treatment may benefit from anabolic-first or sequential therapy strategies rather than starting with bisphosphonates 2, 7

Older Adults with Polypharmacy

• Review medications that increase fall risk 5
• Individualize treatment selection based on comorbidities and drug interactions 5
• Consider parenteral options (zoledronic acid, denosumab) if adherence concerns 1

The evidence strongly supports that fragility fractures represent a critical therapeutic window—systematic identification, evaluation, and treatment of all patients over 50 with fragility fractures prevents subsequent fractures, reduces disability, and decreases mortality 1, 2.