What is the appropriate treatment and management for an elderly patient with a paramedian pubic fracture, potential underlying osteoporosis, and a history of previous fractures?

Management of Paramedian Pubic Fracture in Elderly Patients

For an elderly patient with a paramedian pubic fracture and suspected osteoporosis, initiate conservative management with early mobilization as tolerated, combined with immediate osteoporosis evaluation and pharmacological treatment to prevent subsequent fractures. 1, 2

Acute Fracture Management

Initial Treatment Approach

• Most pubic ramus fractures are minimally displaced and do not require surgical intervention, even in the presence of osteoporosis 3, 2
• Provide adequate pain control to facilitate early mobilization and prevent complications from prolonged immobility 2
• Allow weight-bearing as tolerated rather than enforcing strict bed rest, as early mobilization reduces mortality and prevents recumbency complications 1, 2
• Monitor for progressive displacement or instability that would indicate need for surgical intervention 3

When Surgery Is Indicated

• Surgical stabilization should be considered only if there is insidious progression to complex displacement, vertical sacral ala fractures, fracture dislocations of the sacroiliac joint, or spinopelvic dissociation 3
• Angular stable bridge plating or transsacral positioning bars are adapted techniques for low bone mineral density in the pelvic ring 3
• Critical pitfall: Most elderly patients with pubic ramus fractures do NOT require surgery; avoid rushing to operative intervention 3, 2

Multidisciplinary Acute Care

Orthogeriatric Comanagement

• Implement orthogeriatric comanagement for frail elderly patients with multiple comorbidities and polypharmacy to decrease complications and improve outcomes 1
• Establish collaboration between orthopedic surgeons, rheumatologists/endocrinologists, and general practitioners 1

Rehabilitation Protocol

Early Phase (First 2 Weeks)

• Begin physical training and muscle strengthening exercises immediately post-fracture to regain pre-fracture mobility and independence 1
• Identify individual goals and needs before developing the rehabilitation plan 1

Long-Term Phase

• Continue balance training and multidimensional fall prevention programs to reduce risk of subsequent fractures 1
• Exercise programs reduce fall frequency, though direct evidence for fracture prevention is limited 1

Osteoporosis Evaluation and Treatment

Immediate Diagnostic Workup

• Order outpatient DEXA scan during hospitalization 4, 5
• Measure vitamin D level, calcium level, and parathyroid hormone level 4, 5
• Systematically evaluate fracture risk in all patients over 50 years with a recent fracture 1

Non-Pharmacological Treatment

• Prescribe vitamin D 800 IU daily plus adequate calcium intake (1000-1200 mg/day total from diet and supplementation), which reduces non-vertebral fractures by 15-20% and falls by 20% 1
• Avoid high-pulse dosages of vitamin D as they increase fall risk 1
• Counsel on smoking cessation and alcohol limitation 1
• Critical pitfall: Calcium alone has no demonstrated fracture reduction effect and causes gastrointestinal side effects; always combine with vitamin D 1

Pharmacological Treatment

• Initiate alendronate or risedronate as first-line agents because they reduce vertebral, non-vertebral, and hip fractures, are well-tolerated, low-cost, and widely available as generics 1
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, use zoledronic acid (intravenous) or denosumab (subcutaneous) as alternatives 1
• For very severe osteoporosis, consider anabolic agents such as teriparatide 1
• Prescribe treatment for 3-5 years initially, extending duration in patients who remain at high risk 1
• Monitor systematically for tolerance and adherence, as long-term adherence is typically poor 1

Patient Education

Key Educational Points

• Educate about the burden of osteoporotic fractures, risk factors for subsequent fractures, and importance of treatment adherence 1
• Explain that patients with a recent fracture have significantly elevated risk for subsequent fractures 1
• Discuss expected follow-up schedule and duration of therapy 1

Critical Pitfalls to Avoid

• Do not enforce prolonged bed rest beyond what pain dictates, as immobility increases mortality and complications in elderly patients 1, 2
• Do not delay osteoporosis treatment; initiate evaluation and pharmacological therapy during the acute hospitalization 1, 4, 5
• Do not use calcium supplementation alone without vitamin D, as it provides no fracture benefit 1
• Do not operate on minimally displaced pubic fractures, as most heal well with conservative management 3, 2