What is the standard treatment for a fracture?

Standard Treatment for Fractures

The standard treatment for fractures depends critically on fracture location, stability, and patient factors, but generally follows the three "R's" principle: reduction, retention, and rehabilitation, with surgical intervention required for most hip fractures and unstable fractures, while stable fractures may be managed conservatively. 1, 2

Treatment Decision Framework

Operative vs. Conservative Treatment

The decision between surgical and conservative management requires a balanced approach considering:

• Fracture stability and alignment - Stable, well-aligned fractures without syndesmotic injury may be treated conservatively 2
• Fracture location and classification - Hip fractures almost universally require surgical intervention due to devastating effects if left untreated 1
• Patient age, functional status, and pre-existing conditions - These factors determine surgical approach and fixation method 1
• Timing considerations - Elderly patients with hip fractures should receive surgery within 48 hours, as delays beyond this increase mortality significantly 3

Specific Fracture Management

Hip Fractures:

• Stable non-displaced femoral neck fractures: Percutaneous cannulated fixation 1, 3
• Displaced femoral neck fractures in healthy, active elderly patients: Total hip replacement arthroplasty allowing immediate full weight-bearing 1, 3
• Displaced femoral neck fractures in frail patients: Hemiarthroplasty is preferred due to shorter operative time and lower dislocation risk 1, 3
• Stable intertrochanteric fractures: Sliding hip screw 1
• Unstable intertrochanteric, subtrochanteric, or reverse oblique fractures: Antegrade cephalomedullary nail 1

Distal Radius Fractures:

• Can be treated by cast immobilization or operative methods (locking plates, Kirschner wires, external fixation), though recent RCTs have not identified clear superiority for optimal treatment in elderly populations 1
• Early finger motion after casting or surgery is essential to prevent edema and stiffness 1

Proximal Humerus Fractures:

• Most can be treated non-operatively with good functional outcomes 1
• Displaced three-part and four-part fractures remain controversial; reverse shoulder arthroplasty may provide satisfactory function in geriatric patients 1
• Range-of-motion exercises should begin within first postoperative days if surgery is performed 1

Postoperative Care Components

Comprehensive postoperative management must include:

• Pain management appropriate to the fracture type and patient needs 1, 3
• Antibiotic prophylaxis to prevent infection 1, 3
• Correction of postoperative anemia 1, 3
• Early mobilization to prevent pneumonia, deep vein thrombosis, and pressure ulcers 3
• Regular assessment of cognitive function, nutritional status, renal function, pressure sore risk, and bowel/bladder function 1, 3
• Wound assessment and care 1

Orthogeriatric Comanagement for Elderly Patients

For all elderly patients with hip fractures, orthogeriatric comanagement should be provided to improve functional outcomes, reduce hospital stay, and decrease mortality. 3

This requires coordination between surgeons, geriatricians, and other specialists throughout the perioperative period 3

Rehabilitation Program

An appropriate rehabilitation program must consist of:

• Early postfracture physical training and muscle strengthening 1, 3
• Long-term balance training and multidimensional fall prevention 1, 3
• Tailoring to patient's prefracture functional status and comorbidities 3

Secondary Fracture Prevention (Age ≥50 Years)

Each patient aged 50 years and over with a recent fracture should be systematically evaluated for risk of subsequent fractures through a Fracture Liaison Service (FLS), which is the most effective organizational structure. 1, 3

Risk Evaluation Components:

• Clinical risk factors review including age, gender, BMI, lifestyle, personal/family history of fracture, and falls risk 1
• DXA of spine and hip to measure bone mineral density 1
• Spine imaging (radiography or VFA) to detect subclinical vertebral fractures 1
• Falls risk evaluation starting with history of falls in the last year 1
• Laboratory examination including ESR, serum calcium, albumin, creatinine, TSH, and vitamin D when indicated 1

Non-Pharmacological Treatment:

• Calcium intake of 1000-1200 mg/day (diet plus supplementation if necessary) 1
• Vitamin D 800 IU/day - associated with 15-20% reduction in non-vertebral fractures and falls 1
• Smoking cessation and alcohol limitation 1

Caution: High pulse dosages of vitamin D are associated with increased fall risk 1

Pharmacological Treatment:

Pharmacological treatment should preferably use drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures, with regular monitoring for tolerance and adherence. 1, 3

• First-choice agents: Alendronate and risedronate (well-tolerated, low cost, extensive experience) 1
• Alternatives for oral intolerance, dementia, malabsorption, or non-compliance: Zoledronic acid (IV) or denosumab (subcutaneous) 1
• Very severe osteoporosis: Anabolic agents such as teriparatide 1
• Treatment duration: Usually 3-5 years, longer in patients who remain at high risk 1

Note: Zoledronic acid is the only drug specifically studied following recent hip fracture 1

Common Pitfalls to Avoid

• Delaying surgery beyond 48 hours in elderly hip fracture patients increases mortality 3
• Underestimating the importance of orthogeriatric comanagement leads to suboptimal outcomes 3
• Failing to implement comprehensive rehabilitation and secondary fracture prevention increases risk of poor functional recovery and future fractures 3
• Neglecting nutritional support, cognitive assessment, and early mobilization increases postoperative complications 3
• Overly aggressive physical therapy after shoulder fracture surgery may increase risk of fixation failure 1
• Poor adherence monitoring - systematic follow-up is essential as long-term adherence to osteoporosis drugs is typically poor outside FLS programs 1