What is the appropriate management for a 43-year-old female with multiple non-traumatic, non-union fractures over less than 5 years?

Management of Multiple Non-Traumatic, Non-Union Fractures in a 43-Year-Old Female

This patient requires immediate comprehensive fracture risk evaluation including DXA scanning, vertebral imaging, laboratory workup for secondary osteoporosis, and initiation of pharmacological osteoporosis treatment with bisphosphonates as first-line therapy. 1

Immediate Diagnostic Evaluation

This clinical presentation of multiple non-traumatic fractures with non-union over less than 5 years in a premenopausal woman is highly concerning and demands systematic investigation:

Essential Laboratory Assessment

• Serum calcium, albumin, creatinine, thyroid-stimulating hormone, and erythrocyte sedimentation rate to identify secondary causes of osteoporosis 1
• 25-hydroxyvitamin D levels - vitamin D deficiency is endemic and strongly associated with non-union fractures (60% prevalence in non-union cases versus 30% in normal healing) 2
• Parathyroid hormone (PTH) - secondary hyperparathyroidism occurs in 33% of non-union cases versus 9.3% in normal healing 2
• Additional testing when indicated: protein electrophoresis, sex hormones, markers of bone turnover 1

Bone Density and Structural Assessment

• DXA scanning of lumbar spine and hip to quantify bone mineral density and establish baseline T-scores 1
• Spinal imaging (radiography or vertebral fracture assessment) to detect subclinical vertebral fractures, which are frequently present and independently increase fracture risk 1
• Assessment of existing non-union sites to determine if they are atrophic (57% of cases) or hypertrophic, as this guides surgical planning 3

Pharmacological Treatment Strategy

First-Line Therapy: Oral Bisphosphonates

Alendronate or risedronate should be initiated immediately as first-choice agents because they:

• Reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51% 1, 4
• Are well-tolerated, low-cost (generic available), and have extensive clinical experience 1
• Should be prescribed for 3-5 years initially, with longer duration if high fracture risk persists 1

Alternative Pharmacological Options

• Zoledronic acid (IV) or denosumab (subcutaneous) if oral intolerance, malabsorption, or non-compliance occurs 1
• Teriparatide (anabolic agent) should be strongly considered given the severity of this presentation with multiple non-unions, as it is reserved for very severe osteoporosis and patients with declining BMD despite bisphosphonate treatment 1, 5
  • Teriparatide reduces vertebral fractures by 65% and non-vertebral fractures by 53% 6
  • Particularly effective for patients at highest fracture risk 5

Essential Non-Pharmacological Interventions

Vitamin D and Calcium Supplementation

• Vitamin D 800 IU daily (avoid high pulse doses which increase fall risk) 1
• Calcium 1000-1200 mg daily (dietary plus supplementation if needed) when using anti-osteoporosis drugs 1
• This combination reduces non-vertebral fractures by 15-20% and falls by 20% 1

Lifestyle Modifications

• Smoking cessation and alcohol limitation - both negatively affect bone mineral density, bone quality, and fall risk 1

Surgical Management of Non-Union Fractures

Given the presence of established non-unions, revision surgery is necessary in the majority of cases to achieve osseous healing 3:

Surgical Principles

• Careful investigation of causes leading to non-union must precede surgical planning 3
• Address fracture gap and bone loss - these are the primary risk factors for non-union 3, 7
• Conventional surgical techniques (revision fixation with bone grafting) remain the mainstay, as biological augmentation has limited proven benefit 7
• Expected healing time: approximately 6.45 months after revision surgery for non-unions 3

Fracture-Specific Considerations

• Atrophic non-unions (57% of cases) require biological stimulation with bone grafting 3
• Upper limb non-unions (if present) most commonly affect the clavicle and humerus 3

Multidisciplinary Coordination and Follow-Up

A structured collaboration between healthcare providers is essential 1:

• Designated coordinator (often a specialized nurse under supervision of rheumatologist/endocrinologist) should manage the five-step plan: identification, fracture risk evaluation, differential diagnosis, therapy initiation, and systematic follow-up 1
• Regular monitoring for medication tolerance and adherence - adherence rates reach 90% with structured follow-up versus poor adherence without it 1
• Shared decision-making and risk communication positively influence treatment adherence 1

Critical Pitfalls to Avoid

• Do not delay pharmacological treatment while awaiting complete diagnostic workup - the pattern of multiple non-traumatic fractures with non-union warrants immediate intervention 1
• Do not use calcium supplementation alone - it has no demonstrated fracture reduction effect and causes gastrointestinal side effects 1
• Do not overlook vitamin D deficiency - it is present in 60% of non-union cases and must be corrected 2
• Do not assume all non-unions require surgery immediately - optimize metabolic bone health first, but recognize that most will ultimately need surgical revision 3, 7