What is the recommended workup and treatment for a male patient with a fragility fracture?

Workup and Treatment for Male Patients with Fragility Fractures

All men with a prior fragility fracture should be considered for treatment with anti-osteoporosis medications, as fragility fractures are strong indicators of underlying osteoporosis and significantly increase the risk of future fractures. 1

Diagnostic Workup

Initial Assessment

• Fracture risk assessment using FRAX (Fracture Risk Assessment Tool) 1
• Dual-energy X-ray absorptiometry (DXA) of spine and hip 1
• Imaging of spine for vertebral fractures 1
• Falls risk evaluation 1
• Assessment for secondary causes of osteoporosis 1

Laboratory Testing

• Serum total testosterone (mandatory for male patients) 1
• Complete blood count
• Comprehensive metabolic panel (calcium, phosphorus, creatinine, liver function)
• 25-hydroxyvitamin D level
• Thyroid-stimulating hormone
• Parathyroid hormone if calcium abnormalities present
• Consider bone turnover markers to assess adherence to therapy 1

Treatment Algorithm

Non-Pharmacological Interventions

• Ensure vitamin D and calcium repletion for all men above age 65 1
  • Calcium: 1000-1200 mg daily (diet and supplements)
  • Vitamin D: 800 IU daily
• Physical exercise and balanced diet 1
• Smoking cessation and limitation of alcohol intake 1
• Fall prevention strategies 1

Pharmacological Treatment

First-Line Treatment Options

• For men at high risk of fracture:

  • Oral bisphosphonates (alendronate or risedronate) 1

• For men at very high risk of fracture:

  • Sequential therapy starting with a bone-forming agent followed by an anti-resorptive agent 1
  • Abaloparatide is considered an appropriate first-line treatment for men with osteoporosis at very high risk 1

Second-Line Treatment Options

• Denosumab or zoledronic acid for men at high risk of fracture 1
• Consider denosumab for patients with oral intolerance, dementia, malabsorption, or non-compliance 1

Hormone Replacement Consideration

• Appropriate hormone replacement therapy should be considered in men with low levels of total or free serum testosterone 1

Monitoring and Follow-up

• Regular monitoring for tolerance and adherence to treatment 1
• Biochemical markers of bone turnover to assess adherence to anti-resorptive therapy 1
• Long-term follow-up as part of a structured program 1

Implementation Considerations

• Treatment should be adapted to an individual's baseline fracture risk 1
• Bone-forming agents should be used in accordance with regulatory authorities' recommendations 1
• Typical treatment duration is 3-5 years, and longer in patients who remain at high risk 1

Common Pitfalls and Challenges

• Underdiagnosis and undertreatment: Less than 20% of patients with fragility fractures receive appropriate osteoporosis evaluation and treatment within 2 years post-fracture 2
• Male patients are significantly less likely to receive proper management (odds ratio 0.23) 2
• Treatment rates have been declining over time despite clear guidelines 3
• Poor adherence to treatment: average 12-month adherence is only 56-61% 3

Multidisciplinary Approach

• Implement a coordinated system between orthopedic surgeons, rheumatologists/endocrinologists, and primary care physicians 1
• Consider orthogeriatric comanagement for elderly patients, especially with hip fractures 4
• Early rehabilitation planning is essential for optimal recovery 1

By implementing this comprehensive approach to fragility fracture management in male patients, clinicians can significantly reduce the risk of subsequent fractures and improve long-term outcomes.