How do you treat a patient with a fracture to ensure proper healing, especially considering potential underlying conditions such as osteoporosis?

Treatment of Fractures with Underlying Osteoporosis

For patients with fractures and underlying osteoporosis, immediately initiate oral bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) along with calcium 1000-1200 mg/day and vitamin D 800 IU/day to prevent future fractures, while managing the acute fracture with appropriate immobilization and early mobilization. 1, 2, 3

Immediate Fracture Management

Acute Phase (First 5 Days)

• Confirm the fracture with radiographic imaging and assess for neurologic compromise 1
• For acute osteoporotic vertebral compression fractures, initiate calcitonin 200 IU for 4 weeks to provide clinically meaningful pain reduction 1
• Implement appropriate pain control with acetaminophen as first-line, avoiding NSAIDs in patients with renal or cardiovascular disease 4
• Avoid prolonged bed rest as it accelerates bone loss, muscle weakness, and increases thrombosis risk 4, 5
• Begin early range-of-motion exercises within the first postoperative days to prevent stiffness and maintain function 4

Vertebral Compression Fracture-Specific Considerations

• Strongly recommend against vertebroplasty for symptomatic osteoporotic vertebral compression fractures based on high-quality evidence 1
• Consider kyphoplasty as a weak recommendation for neurologically intact patients with symptomatic fractures 1
• For L3 or L4 fractures, L2 nerve root blocks are an option for pain management 1
• Evidence for bracing is inconclusive and cannot be routinely recommended 1

Pre-Treatment Evaluation (Before Starting Bisphosphonates)

Mandatory assessments before initiating osteoporosis pharmacotherapy: 2, 3

• Dental screening examination to identify and address dental issues before bisphosphonate therapy, as these medications increase osteonecrosis of the jaw risk, particularly with invasive dental procedures 2
• Check serum calcium level to exclude hypocalcemia, which is an absolute contraindication to bisphosphonate therapy 2, 3
• Assess renal function (creatinine clearance <35 mL/min contraindicates zoledronic acid; for GFR <30 mL/min, use denosumab instead) 2, 4
• Screen for esophageal abnormalities which contraindicate oral bisphosphonates 3

Pharmacologic Treatment Algorithm

First-Line Therapy (Standard Risk)

Oral bisphosphonates are the strongly recommended initial treatment based on safety, cost-effectiveness, proven fracture reduction, and extensive clinical experience 1, 2, 3

Dosing options: 2

• Alendronate: 70 mg weekly or 10 mg daily
• Risedronate: 35 mg weekly, 150 mg monthly, or 5 mg daily

These agents reduce vertebral, non-vertebral, and hip fractures with high-certainty evidence 1, 4

Second-Line Therapy

If oral bisphosphonates are contraindicated or not tolerated: 1, 3

• Denosumab 60 mg subcutaneously every 6 months (particularly for GFR <30 mL/min) 1, 4
• IV bisphosphonates or raloxifene as alternatives 3

Very High-Risk Patients (Anabolic Therapy First)

For patients with recent vertebral fracture, multiple fractures, or T-score ≤-3.5, initiate anabolic agents first, then transition to antiresorptive therapy: 2, 3

• Romosozumab (sclerostin inhibitor) 1
• Teriparatide or abaloparatide (recombinant PTH) 1, 3
• Avoid teriparatide in patients with open epiphyses, Paget's disease, prior skeletal radiation, bone metastases, or hereditary disorders predisposing to osteosarcoma 3

Prevention of Additional Fractures

Ibandronate and strontium ranelate are options to prevent subsequent symptomatic fractures in patients presenting with an existing osteoporotic compression fracture 1

Essential Supportive Measures (All Patients)

Nutritional supplementation is mandatory: 2, 3, 4

• Calcium: 1000-1200 mg/day (dietary plus supplementation if needed)
• Vitamin D: 800 IU/day, targeting serum 25-OH vitamin D ≥20 ng/mL
• These reduce non-vertebral fractures by 15-20% and falls by 20% 4

Lifestyle modifications: 2, 3, 4

• Weight-bearing and resistance training exercises to improve bone mineral density and muscle strength
• Smoking cessation
• Limit alcohol consumption
• Multidimensional fall prevention programs (reduce fall frequency by approximately 20%) 4

Monitoring Strategy

Bone density reassessment: 2, 3

• Repeat DXA scan in 1-2 years to assess treatment response
• Continue monitoring every 1-2 years during treatment
• Significant BMD change is ≥1.1% based on facility protocol 2

Treatment duration: 3

• Bisphosphonates typically 3-5 years
• Assess adherence and tolerance at regular intervals 2

Critical Pitfalls to Avoid

The osteoporosis care gap is a major problem: Only 1-45% of fracture patients receive an osteoporosis diagnosis, and only 1-65% receive pharmacological therapy 6

Do not delay osteoporosis treatment after a fragility fracture—this represents a critical opportunity to prevent subsequent fractures, which occur in 1-22% of patients during 6 months to 5 years of follow-up 6

Most patients discontinue treatment within 1 year despite effectiveness, so develop strategies to improve adherence 7

Implement orthogeriatric co-management for frail elderly patients with multiple comorbidities to improve outcomes 4