What is the initial management for a closed, complete, middle distal 3rd humerus fracture due to a fall in a patient with potential osteoporosis and on medications such as anticoagulants, steroids, or bisphosphonates?

Initial Management of Closed Complete Middle-Distal Third Humerus Fracture

For a closed, complete middle-distal third humerus fracture in a patient with potential osteoporosis on anticoagulants, steroids, or bisphosphonates, immediate orthogeriatric co-management should be initiated, followed by comprehensive fracture assessment, neurovascular examination with specific attention to radial nerve function, and early decision-making regarding operative versus non-operative management based on fracture alignment, bone quality, and patient functional demands. 1

History Taking: Critical Elements

Mechanism and Fracture Details

• Document exact mechanism of fall: height, surface type, direct versus indirect trauma, and whether protective reflexes were intact 1
• Timing of injury: exact time of fall to assess for compartment syndrome risk and surgical timing 2
• Immediate post-injury symptoms: ability to move fingers/wrist, presence of paresthesias, and any open wounds 2

Medication History with Fracture Implications

• Glucocorticoid exposure: current dose (particularly if ≥7.5 mg/day prednisone), duration (especially if >3 months), and cumulative exposure, as this defines glucocorticoid-induced osteoporosis risk 3
• Anticoagulation status: specific agent (warfarin, DOACs, aspirin), dose, indication, last dose timing, and INR if on warfarin—critical for surgical planning and bleeding risk 1
• Bisphosphonate therapy: type (oral versus IV), duration, adherence, and whether initiated post-fracture or for prevention, as this affects fracture healing concerns 4
• Other bone-affecting medications: denosumab (risk of rebound fractures if discontinued), teriparatide, romosozumab, or raloxifene 5

Osteoporosis Risk Stratification

• Prior fracture history: any previous fragility fractures (hip, spine, wrist, humerus), age at occurrence, and whether asymptomatic vertebral fractures were identified 3, 6
• FRAX score calculation (if age ≥40): 10-year risk for major osteoporotic fracture and hip fracture, with glucocorticoid adjustment if applicable 3
• Risk factors: parental hip fracture, smoking status, alcohol intake (>2 drinks/day), body weight <50 kg, significant recent weight loss, hypogonadism, thyroid disease, rheumatoid arthritis, malabsorption, chronic liver disease 3, 1

Comorbidity Assessment

• Renal function: estimated GFR to guide bisphosphonate versus denosumab selection (bisphosphonates contraindicated if GFR <30-35 mL/min) 1
• Cardiovascular disease: ischemic heart disease, hypertension, heart failure—affects anesthesia risk and romosozumab contraindication (black box warning for cardiovascular events) 6
• Gastrointestinal pathology: active or recent peptic ulcer disease, esophageal disorders, dysphagia—contraindicates oral bisphosphonates but allows teriparatide 6
• Diabetes mellitus: glycemic control status affects surgical infection risk and fracture healing 1
• Functional status: baseline mobility, independence in ADLs, living situation, fall history in past year 1

Physical Examination: Systematic Approach

Inspection

• Deformity assessment: visible angulation, shortening, or rotation of the arm compared to contralateral side 2
• Soft tissue integrity: open wounds (requires immediate operative debridement), skin tenting, ecchymosis pattern, swelling extent 7, 2
• Compartment assessment: tense forearm compartments, severe pain with passive finger extension (early compartment syndrome sign) 2

Neurovascular Examination (Critical Priority)

• Radial nerve function (most commonly injured in distal third fractures): wrist extension strength, thumb extension (extensor pollicis longus), finger extension at MCPs, sensation over first dorsal web space 8, 7
  • Document whether radial nerve palsy is present at initial presentation versus post-manipulation, as this affects management 7
• Median nerve: thumb opposition, sensation over thenar eminence and palmar thumb/index/middle fingers 2
• Ulnar nerve: finger abduction (interossei), thumb adduction (adductor pollicis), sensation over hypothenar eminence and small finger 2
• Vascular status: radial and ulnar pulses, capillary refill <2 seconds, hand warmth and color, Allen test if vascular injury suspected 2

Range of Motion Assessment

• Shoulder: active and passive forward flexion, abduction, internal/external rotation—document baseline as post-fracture stiffness is common 7
• Elbow: flexion/extension arc if patient can tolerate gentle examination without manipulation 7
• Wrist and hand: full active range to confirm distal neurovascular integrity 7

Bone Quality Clinical Assessment

• Body habitus: underweight (BMI <18.5 kg/m²) significantly increases osteoporosis risk 6
• Kyphosis or height loss: suggests prior vertebral compression fractures 3
• Muscle strength and balance: Timed Up and Go test if ambulatory, grip strength if contralateral arm available 1

Imaging Protocol

Initial Radiographs

• Orthogonal views: true AP and lateral humerus radiographs including shoulder and elbow joints 2
• Traction view: helpful for preoperative planning in comminuted fractures to assess articular involvement 2
• Contralateral humerus: if severe osteoporosis suspected, for comparison and surgical planning 8

Advanced Imaging Indications

• CT with 3D reconstruction: strongly recommended for preoperative planning in all operative candidates, especially with comminution, intra-articular extension, or coronal plane fractures 2
• MRI: not routinely indicated unless concern for occult fracture extension or osteonecrosis risk assessment 3

Osteoporosis Imaging

• DXA scan with VFA (vertebral fracture assessment): should be ordered urgently (within days) if not previously performed, as results guide pharmacologic management 3
• Spine radiographs: if DXA with VFA unavailable, to identify asymptomatic vertebral fractures that elevate risk category 3

Immediate Management Decisions

Pain Control Strategy

• First-line: acetaminophen 1000 mg every 6 hours (safe in renal disease and cardiovascular disease) 1
• Avoid NSAIDs: particularly in patients with CKD, cardiovascular disease, or on anticoagulation due to bleeding risk and potential fracture healing interference 1
• Opioids: short-term use only if acetaminophen insufficient, with fall precautions emphasized 1
• Regional anesthesia: consider brachial plexus block for severe pain in operative candidates 2

Immobilization

• Coaptation splint or hanging arm cast: initial immobilization with elbow at 90 degrees, forearm neutral rotation 7, 2
• Avoid prolonged immobilization: increases bone loss, muscle weakness, DVT risk, and pressure ulcers—begin early range-of-motion exercises for hand/wrist immediately 1

Anticoagulation Management

• Warfarin: hold and reverse with vitamin K if INR >1.5 and surgery planned; consult cardiology regarding bridging based on indication 1
• DOACs: hold for 24-48 hours pre-operatively based on renal function; shorter half-life allows faster surgical intervention 1
• Aspirin: generally continue unless high bleeding risk procedure 1

Operative Versus Non-Operative Decision Algorithm

Operative Indications (Preferred for Most Patients)

• Any degree of articular involvement: requires anatomic reduction and stable fixation 8, 2
• Unacceptable alignment: >20 degrees angulation in any plane, >3 cm shortening, or rotational deformity >30 degrees 7
• Radial nerve palsy after closed reduction attempt: requires exploration 7
• Polytrauma or ipsilateral upper extremity injuries: facilitates mobilization 2
• Patient functional demands: even elderly patients benefit from stable fixation allowing early motion 2

Non-Operative Management (Selective Use)

• Acceptable alignment: <10-15 degrees varus/valgus, <20 degrees anterior/posterior angulation, minimal shortening 7
• Low-demand elderly patients: medically unwell, non-ambulatory, or limited life expectancy 2
• Patient refusal of surgery or prohibitive anesthetic risk 7
• Functional bracing protocol: weekly radiographs for 3 weeks to monitor alignment, transition to functional brace when soft tissue swelling resolves, expect 10-30 degrees final angulation but usually excellent function 7

Surgical Approach Considerations

• Parallel plating in sagittal plane: biomechanically superior to 90/90 orthogonal plating, with interdigitating screws creating fixed-angle construct 8
• Principles for osteoporotic bone: maximize screw purchase in distal fragments (every screw through plate, longest possible screws, engage opposite cortex, lock screws together), achieve compression at supracondylar level, use strong plates resistant to bending 8
• Severe osteoporosis with comminution: consider supracondylar shortening to manage metaphyseal bone loss 8
• Elderly low-demand patients with poor bone quality: total elbow arthroplasty may be superior to osteosynthesis in complex comminuted patterns 2

Osteoporosis Pharmacologic Management Post-Fracture

Immediate Supplementation (All Patients)

• Calcium: 1000-1200 mg daily in divided doses 3, 6, 1
• Vitamin D: 800-1000 IU daily, targeting serum 25(OH)D ≥30 ng/mL 3, 6, 1

Risk Stratification for Treatment Intensity

Very High Risk (requires anabolic therapy first-line):

• Age >74 years with this fracture 6
• Multiple prior osteoporotic fractures 6
• T-score ≤-3.0 on DXA 6
• FRAX major osteoporotic fracture risk ≥20% or hip fracture risk ≥3% 6

High Risk (bisphosphonates or denosumab first-line):

• This humeral fracture with T-score -2.5 to -3.0 3, 6
• FRAX major osteoporotic fracture risk 10-20% 3
• On glucocorticoids ≥7.5 mg/day prednisone for >3 months 3

Treatment Selection Algorithm

For Very High Risk Patients:

• First-line: Teriparatide 20 mcg subcutaneous daily for 18-24 months, preferred over romosozumab due to superior non-vertebral fracture reduction and no cardiovascular contraindication 6
  • Compatible with active GI ulcers (subcutaneous route) 6
  • Monitor serum calcium at 1 month, then as indicated 6
  • Mandatory transition to bisphosphonate or denosumab after completion to maintain bone gains and prevent rebound fractures 6, 5
• Alternative: Romosozumab 210 mg subcutaneous monthly for 12 months if no cardiovascular disease history 6

For High Risk Patients (Not Very High Risk):

• First-line: Oral bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) if GFR ≥30-35 mL/min and no GI contraindications 3, 6, 1
  • Timing: initiate as early as 2 weeks post-fracture—does not impair fracture healing or increase non-union/malunion rates 4
  • Generic formulations strongly recommended (equivalent efficacy, lower cost) 6
• Second-line: Denosumab 60 mg subcutaneous every 6 months if GFR <30 mL/min, oral bisphosphonate intolerance, or active GI pathology 6, 1
  • Critical warning: if denosumab ever discontinued, must transition to bisphosphonate to prevent rebound vertebral fractures 5
• Third-line: IV bisphosphonates (zoledronic acid 5 mg annually) if oral adherence concerns 3

For Glucocorticoid-Induced Osteoporosis:

• Very high risk: anabolic agents (teriparatide or romosozumab) conditionally recommended over antiresorptives 3
• High risk: oral bisphosphonates strongly recommended 3
• Moderate risk: oral/IV bisphosphonates, denosumab, or anabolic agents conditionally recommended 3

Contraindications to Verify Before Prescribing

• Teriparatide: Paget's disease, prior skeletal radiation, bone metastases, active malignancy prone to bone metastases 6
• Romosozumab: myocardial infarction or stroke within past year 6
• Bisphosphonates: GFR <30-35 mL/min (relative), esophageal disorders, inability to remain upright 30-60 minutes post-dose 1

Non-Pharmacologic Interventions

Fall Prevention (Mandatory)

• Home safety assessment: remove throw rugs, improve lighting, install grab bars, clear walkways 1
• Medication review: discontinue or reduce sedatives, anticholinergics, antihypertensives causing orthostasis 1
• Vision and hearing assessment: correct deficits that increase fall risk 1
• Assistive devices: cane or walker if balance impaired 1

Exercise Prescription

• Weight-bearing exercises: walking, stair climbing when fracture healed 3, 1
• Resistance training: progressive strengthening of all major muscle groups 2-3 times weekly 3, 1
• Balance exercises: tai chi, standing on one foot, tandem walking to reduce fall frequency by ~20% 1
• Early mobilization: range-of-motion for shoulder, elbow, wrist, hand within first postoperative days 1

Lifestyle Modifications

• Smoking cessation: mandatory counseling and pharmacotherapy if applicable 3, 1
• Alcohol reduction: limit to ≤1-2 drinks daily 3, 1
• Nutrition: adequate protein intake (1.0-1.2 g/kg/day), balanced diet 1

Multidisciplinary Coordination

Essential Team Members

• Orthopedic surgery: fracture management and surgical decision-making 1, 2
• Rheumatology or endocrinology: osteoporosis treatment optimization 1
• Nephrology: if CKD present for medication selection guidance 1
• Cardiology: if on anticoagulation or cardiovascular disease complicating anesthetic risk 1
• Primary care: longitudinal osteoporosis management and fall prevention 1
• Physical therapy: early mobilization and progressive strengthening 1

Follow-Up Protocol

• Fracture healing: radiographs at 2,6, and 12 weeks post-injury or post-operatively 7, 2
• Osteoporosis monitoring: DXA scan every 1-2 years depending on treatment and risk factors 3
• Medication adherence: assess at every visit, as non-adherence is primary cause of treatment failure 1

Common Pitfalls to Avoid

• Delaying bisphosphonate initiation: concern about fracture healing is unfounded—initiate at 2 weeks post-fracture 4
• Iatrogenic radial nerve injury: occurs in 3/19 (16%) operative cases in one series—meticulous surgical technique mandatory 7
• Discontinuing denosumab without transition: causes rebound vertebral fractures—always transition to bisphosphonate 5
• Stopping anabolic therapy without antiresorptive: bone gains rapidly lost—sequential therapy is mandatory, not optional 6, 5
• Accepting malalignment in non-operative management: >30 degrees angulation compromises function—consider operative conversion 7
• Prolonged immobilization: accelerates osteoporosis and muscle loss—early controlled motion essential 1