Does a patient with a humeral fracture need osteoporosis treatment?

Osteoporosis Treatment for Patients with Humeral Fractures

Yes, patients with humeral fractures should receive osteoporosis treatment as these fractures are considered fragility fractures that indicate underlying osteoporosis and significantly increase the risk of subsequent fractures.

Rationale for Treatment

Humeral fractures in adults, particularly proximal humeral fractures, are strong indicators of underlying osteoporosis and require intervention for several reasons:

• Fragility fractures of the proximal humerus represent approximately 20% of all osteoporotic fractures 1
• A humeral fracture is classified as a "high fracture risk" indicator according to international guidelines 2
• These fractures are associated with compromised bone strength and predict future fractures 2
• Despite their significance, patients with humeral fractures often receive the least osteoporosis treatment (only 21.4%) compared to other fragility fracture types 3

Assessment After Humeral Fracture

Following a humeral fracture, the patient should undergo:

1. Bone mineral density (BMD) testing via DXA scan of:

   • Hip and lumbar spine (standard)
   • Distal radius (critical for upper limb assessment)

   Important: BMD measurements at the hip and spine alone may underestimate osteoporosis in the upper limb. Including the distal radius increases sensitivity from 46% to 66% 4

2. FRAX calculation to determine 10-year fracture risk 5

3. Evaluation of secondary causes of osteoporosis and contributing factors 2

Treatment Algorithm

Step 1: Risk Stratification

Categorize the patient based on fracture risk:

• Very High Risk: Humeral fracture already qualifies the patient as high risk 2, 5
  • Proximal humeral fracture is considered a major osteoporotic fracture 2
  • Table 2 in the Mayo Clinic guidelines specifically lists proximal humerus fractures as indicating very high fracture risk 2

Step 2: First-Line Treatment

• Bisphosphonates are recommended as first-line therapy 2, 5
  • Strong recommendation with high-certainty evidence 2
  • Oral bisphosphonates (alendronate or risedronate) preferred initially 5

Step 3: Alternative Options (if contraindications to bisphosphonates)

• Denosumab as second-line treatment 2, 5
  • Especially for patients with renal impairment or esophageal conditions 5

Step 4: For Very High-Risk Patients

• Consider anabolic agents followed by antiresorptive therapy 2, 5
  • Teriparatide, romosozumab, or abaloparatide 5
  • Particularly for patients with multiple fractures or very low BMD (T-score ≤ -3.5) 5

Step 5: Adjunctive Measures

• Calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) supplementation 5
• Weight-bearing exercise, smoking cessation, limiting alcohol intake 5

Monitoring and Follow-up

• BMD testing every 1-3 years 5
• Clinical fracture risk assessment at regular intervals 5
• Evaluation for medication adherence and side effects 5

Common Pitfalls to Avoid

1. Underdiagnosis: Only 23.2% of fracture patients receive BMD testing 3
2. Undertreatment: Less than one-third of patients receive pharmacotherapy within 1 year after fracture 3
3. Incomplete assessment: Failure to measure distal radius BMD may miss significant osteoporosis in the upper limb 4
4. Delayed intervention: The risk of subsequent fracture is highest in the first 2 years after an initial fracture 2
5. Inadequate surgical planning: Failure to assess local bone quality can lead to suboptimal surgical outcomes in osteoporotic bone 6, 7

Special Considerations for Humeral Fractures

• Cortical index (ratio between cortical thickness and total diameter of humeral diaphysis) below 0.231 indicates high fracture risk 1
• Surgical fixation in osteoporotic humeral fractures requires special techniques:
  • Load-sharing rather than load-bearing constructs
  • Thin, flexible implants rather than bulky, stiff ones
  • Possible augmentation with calcium phosphate cement or fibular grafts 6, 7

The EULAR/EFORT guidelines emphasize that all elderly patients with recent fractures should undergo systematic investigation for future fracture risk, with high-risk patients receiving appropriate pharmacological treatment to decrease subsequent fracture risk 2.