What is the role of bisphosphonates (BPs) in managing patients with an arm fracture, particularly those with suspected or confirmed osteoporosis?

Bisphosphonates in Patients with Arm Fractures

Bisphosphonates are strongly recommended as first-line treatment for patients with arm fractures who have confirmed or suspected osteoporosis to reduce the risk of future fractures. 1

Assessment of Fracture Risk

When a patient presents with an arm fracture, particularly of the humerus or forearm, this should trigger osteoporosis evaluation as these are considered major osteoporotic fracture sites:

• Perform BMD testing via DXA scan with vertebral fracture assessment (VFA) or spinal x-rays 1
• For patients ≥40 years: Calculate 10-year fracture risk using FRAX tool 1
• Assess for additional risk factors:
  • Prior fracture history
  • Glucocorticoid use
  • Family history of hip fracture
  • Low body weight
  • Smoking status
  • Alcohol intake

Treatment Algorithm Based on Risk Assessment

1. Confirmed Osteoporosis (T-score ≤ -2.5 or Fragility Fracture)

• First-line: Oral bisphosphonates (alendronate, risedronate, or zoledronate) 1

  • Preferred due to high-certainty evidence for fracture reduction, favorable safety profile, and low cost
  • Reduces risk of vertebral fractures (ARD: 56 fewer events per 1000 patients)
  • Reduces risk of hip fractures (ARD: 6 fewer events per 1000 patients)
  • Reduces risk of any clinical fracture (ARD: 24 fewer events per 1000 patients) 1

• Second-line (if bisphosphonates contraindicated or not tolerated): Denosumab 1

• For very high-risk patients: Consider anabolic agents (teriparatide, abaloparatide) 1

2. Low Bone Mass/Osteopenia (T-score between -1.0 and -2.5)

• Individualized approach based on FRAX score:
  • If 10-year risk of major osteoporotic fracture ≥20% or hip fracture ≥3%: Consider bisphosphonate therapy 1
  • If lower risk: Focus on calcium, vitamin D, and lifestyle modifications

Special Considerations

Patients on Glucocorticoids

For patients on glucocorticoid therapy (≥2.5 mg/day for >3 months) with arm fractures:

• Strong recommendation for bisphosphonates in adults with medium, high, or very high fracture risk 1
• For very high-risk patients: Consider anabolic agents over antiresorptives 1

Cancer Survivors with Arm Fractures

• Bisphosphonates are recommended for cancer survivors with osteoporosis (T-scores ≤-2.5) or high fracture risk 1
• Avoid hormonal therapies for osteoporosis in patients with hormone-responsive cancers 1

Monitoring and Safety

Potential Adverse Effects

• Osteonecrosis of jaw: Rare but serious complication, risk increases with treatment duration 2, 3

  • Higher risk with invasive dental procedures, poor oral hygiene, cancer, and concomitant therapies 2

• Atypical femoral fractures: Low-energy fractures that can occur with long-term use 2, 3

  • Patients may report prodromal thigh pain weeks to months before fracture 2

• Renal impairment: Not recommended for patients with creatinine clearance <35 mL/min 2

Duration of Therapy

• Consider drug holiday after 3-5 years of bisphosphonate therapy for patients at lower risk 4
• Patients with confirmed osteoporosis or history of fragility fractures may benefit from continued therapy as benefits likely outweigh risks 4, 3

Practical Recommendations

• Start bisphosphonate therapy as soon as possible after arm fracture if osteoporosis is confirmed
• Ensure adequate calcium and vitamin D intake
• Recommend weight-bearing and resistance training exercises when appropriate
• Advise smoking cessation and limiting alcohol intake
• Choose generic formulations when possible to reduce cost 1

Bisphosphonates have demonstrated long-term safety and effectiveness with increased BMD and reduced fracture risks, resulting in reduced morbidity and mortality and improved quality of life 3. The benefits of bisphosphonate therapy in patients with arm fractures and osteoporosis clearly outweigh the risks of rare adverse events.