Do I need to order more testing or send the patient to the emergency room (ER) from the Skilled Nursing Facility (SNF) for further evaluation due to new findings of an age-indeterminate fracture and degenerative changes?

No ER Transfer or Additional Testing Required

The new imaging findings do not represent acute changes requiring emergency evaluation—the patient can be managed conservatively at the SNF with appropriate osteoporosis treatment and clinical monitoring. 1

Clinical Reasoning

The "New" Fracture is Not Actually New

• The recent hip X-ray shows an "age-indeterminate minimally offset fracture of the left superior pubic ramus and parasymphyseal region" [@Patient imaging]
• The prior pelvis X-ray from the ER visit documented "early healing bilateral pubic rami fractures" [@Patient imaging]
• This represents the same fracture in the healing phase, not a new acute injury 1
• The radiologist's recommendation to "correlate for focal point tenderness" and "compare with prior imaging" has already been satisfied—the prior imaging confirms this is a known, healing fracture 1

No High-Risk Features Requiring Emergency Evaluation

The ACR Appropriateness Criteria for stress/insufficiency fractures establish that further imaging is unnecessary when radiographic findings are conclusive for insufficiency fracture and the clinical picture is consistent 1:

• No evidence of displacement progression
• No new neurological deficits documented
• Patient already evaluated in ER with comprehensive imaging that ruled out acute changes [@Patient imaging]
• The mild degenerative hip changes are chronic, not acute [@3@]

Low-Energy Mechanism Does Not Warrant Advanced Imaging

In patients with stable vital signs, no evidence of complicated injury, and low-energy trauma, additional testing provides no clinical benefit [@4@]:

• This elderly patient with known bilateral pubic rami fractures and osteoporosis sustained a simple fall mechanism
• No signs of pneumothorax, hemothorax, or other complications requiring CT evaluation [@4@]
• The prior comprehensive trauma series (cervical spine, lumbar spine, shoulder, pelvis) already excluded associated injuries [@Patient imaging]

Required Management at SNF

Immediate Pain Management

• Initiate acetaminophen as first-line analgesia, avoiding NSAIDs given age and likely cardiovascular comorbidities 2
• Avoid prolonged bed rest, which accelerates bone loss and increases DVT risk 2

Osteoporosis Evaluation and Treatment (Critical Priority)

This patient requires immediate osteoporosis treatment given multiple fragility fractures (bilateral pubic rami, old C2 fracture, old L1/L2 compressions with vertebroplasty) 1, 2:

• Order DXA scan of lumbar spine and hip to quantify bone mineral density 1, 2
• Obtain laboratory workup: serum calcium, albumin, creatinine, TSH, ESR to identify secondary osteoporosis 1
• Initiate oral bisphosphonate therapy (alendronate 70mg weekly or risedronate 35mg weekly) as first-line treatment—reduces vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51% 1, 2
• Prescribe calcium 1000-1200mg daily and vitamin D 800 IU daily—reduces non-vertebral fractures by 15-20% and falls by 20% 1, 2

Weight-Bearing and Mobilization

• Allow weight-bearing as tolerated immediately—this is standard for pubic rami fractures 1
• Implement supervised physical therapy with weight-bearing exercises to improve BMD and muscle strength 1

Fall Prevention

• Conduct multidimensional fall risk assessment addressing environmental hazards and medications that increase fall risk 1
• The patient's history of simple falls with multiple fragility fractures indicates high fall risk requiring intervention 1

VTE Prophylaxis

• Continue VTE prophylaxis with sequential compression devices or pharmacologic prophylaxis if not contraindicated 1
• This is particularly important given limited mobility from bilateral pubic rami fractures 1

Clinical Monitoring at SNF

Patients with insufficiency fractures are followed clinically until pain-free, then gradually increase activity 1:

• Monitor for focal point tenderness over the pubic rami
• Assess pain levels daily
• No repeat imaging is typically performed after diagnosis unless clinical deterioration occurs 1

Red Flags Requiring ER Transfer

Send to ER only if the following develop 1:

• New neurological deficits (bowel/bladder dysfunction, lower extremity weakness)
• Severe uncontrolled pain despite appropriate analgesia
• Signs of infection (fever, wound complications)
• Hemodynamic instability
• Evidence of new trauma with suspected acute fracture

Critical Pitfall to Avoid

Do not dismiss this as a trivial finding requiring no action—while ER transfer is unnecessary, this patient has severe untreated osteoporosis with multiple fragility fractures requiring immediate pharmacologic intervention to prevent future hip or vertebral fractures, which carry significant morbidity and mortality 1, 2. The presence of old C2 nonunion, L1/L2 compressions with vertebroplasty, and bilateral pubic rami fractures represents a pattern of recurrent fragility fractures demanding aggressive osteoporosis management 1, 2.