What is the best course of treatment for an older adult patient presenting with a wrist fracture, potentially complicated by underlying osteoporosis?

Management of Wrist Fractures in Older Adults

Every patient aged 50 years and older presenting with a wrist fracture requires immediate orthopedic evaluation for fracture stabilization AND systematic assessment for underlying osteoporosis with initiation of secondary fracture prevention, as this represents a sentinel fragility fracture signaling high risk for subsequent hip and vertebral fractures. 1

Immediate Fracture Management

Initial Imaging Protocol

• Obtain standard 3-view radiographs (posteroanterior, lateral, and 45° semipronated oblique) as first-line imaging 2, 3
• Add a fourth projection (semisupinated oblique) to increase diagnostic yield for distal radius fractures 2, 3
• If radiographs are negative but clinical suspicion remains high, proceed to CT without IV contrast to identify occult fractures 2, 3
• Consider MRI without IV contrast if ligamentous injury is suspected, as this may alter surgical planning 2

Fracture Stabilization Decision Algorithm

Non-displaced fractures: Immobilize with splinting or casting 2, 3

Displaced fractures require surgical fixation if ANY of the following criteria are present: 2, 3

• Articular step-off >2mm
• Coronally oriented fracture line
• Die-punch depression
• More than three articular fragments

Pain Management

• Initiate multimodal analgesia immediately with acetaminophen 4
• Minimize opioid use in elderly patients due to increased fall risk and cognitive side effects 3

Critical Early Mobilization (Within 3 Days)

Begin aggressive range-of-motion exercises for ALL non-immobilized fingers and hand within 3 days of injury to prevent debilitating stiffness. 1, 4 This intervention is cost-free but has profound impact on functional outcomes, as finger stiffness becomes extremely difficult to treat after fracture healing and may require additional surgical intervention 4. Ensure splints or casts do not obstruct movement of uninjured fingers 4.

For shoulder mobility following any associated upper extremity injury, begin range-of-motion exercises including shoulder, elbow, wrist and hand motion within the first postoperative days, restricting only above-chest-level activities until fracture healing is evident 1.

Mandatory Osteoporosis Evaluation and Treatment

Why This Matters for Morbidity and Mortality

Wrist fractures in patients over 50 represent fragility fractures that increase the risk of subsequent hip and vertebral fractures, especially within the first 7 years 5, 6. Despite this high risk, fewer than 10-20% of patients with fragility fractures receive appropriate osteoporosis evaluation or treatment, representing a critical treatment gap. 7, 8, 6

Immediate Assessment (Within First Visit)

• Review clinical risk factors: advanced age, female gender, low BMI, personal/family history of fracture, falls history 1
• Order DXA scan of lumbar spine and hip 1
• Obtain spine imaging (radiography or VFA) to detect subclinical vertebral fractures, which are frequent in patients with recent non-vertebral fractures 1
• Order laboratory tests: ESR, serum calcium, albumin, creatinine, TSH, vitamin D, and consider protein electrophoresis and testosterone in men 1
• Assess fall risk through history of falls in the past year, followed by specific testing when indicated 1

Treatment Initiation

In elderly patients with typical fragility fracture patterns, initiate anti-osteoporotic treatment even before DXA results are available. 2, 3, 4 This aggressive approach is justified because:

• 78% of patients with fragility wrist fractures have osteoporosis or osteopenia on bone densitometry 6
• Secondary fracture risk is highest immediately after the initial fracture and decreases over time 1
• Multifaceted interventions increase treatment rates from 7-10% to 22-40% within 6 months 7, 8

First-line pharmacologic therapy: Alendronate or risedronate 2

Alternative options for patients with: 2

• Oral intolerance: Zoledronic acid or denosumab
• Dementia: Zoledronic acid or denosumab
• Malabsorption: Zoledronic acid or denosumab
• Non-compliance concerns: Zoledronic acid or denosumab

Non-pharmacologic interventions (mandatory for all patients): 1, 2

• Calcium 1000-1200 mg/day (diet plus supplementation if needed)
• Vitamin D 800 IU/day
• Smoking cessation
• Alcohol limitation
• Fall prevention education and home safety assessment

Optimal Care Delivery Model

Implement Fracture Liaison Service (FLS) coordination, which is the most effective organizational structure for secondary fracture prevention. 1 The FLS model includes:

• A dedicated coordinator (often a well-educated nurse) working under supervision of an orthopedic surgeon, endocrinologist, or rheumatologist 1
• Systematic identification of all elderly patients with recent fractures 1
• Organization of diagnostic investigations 1
• Treatment initiation and patient/physician education 1

Evidence supporting FLS: RCTs demonstrate that FLS coordination increases appropriate osteoporosis management from 26% to 45% within 6 months after fracture 1. Physician reminder letters alone (without coordination) increase treatment rates with an OR of 3.29 1, but comprehensive FLS models achieve superior outcomes 1.

Orthogeriatric Co-Management

For frail elderly patients with multiple comorbidities and polypharmacy, implement orthogeriatric co-management from the time of presentation. 1, 3, 4 This multidisciplinary approach improves functional outcomes, reduces hospital stay, and addresses the complex medical needs of geriatric patients 1, 3.

Rehabilitation Protocol

Early Phase (First 6 Weeks)

• Physical training and muscle strengthening exercises 1, 3
• Aggressive finger and hand motion for all non-immobilized digits 1, 4
• Sling for comfort only, discarded as early as pain allows 1

Long-Term Phase (Beyond 6 Weeks)

• Balance training 1, 3
• Multidimensional fall prevention programs 1, 3, 4
• Continuation of muscle strengthening 1, 3

Follow-Up and Monitoring

Fracture Healing Monitoring

• Regular radiographic assessment until healing is confirmed 2, 3
• Monitor for complications including tendon rupture, complex regional pain syndrome, and fixation failure 2, 4

Osteoporosis Treatment Adherence

• Systematic follow-up to ensure medication adherence 2, 3
• Patient education about disease burden, risk factors, and treatment duration 1, 2
• Re-assessment at 3-6 months post-fracture for those not initially evaluated 1

Critical Pitfalls to Avoid

Failure to address underlying osteoporosis: This is the most common and consequential error, leaving patients at dramatically increased risk for subsequent hip or vertebral fractures that carry significant morbidity and mortality 4, 7, 8, 6

Delayed mobilization: Waiting for pain to completely resolve before beginning motion exercises leads to debilitating stiffness requiring extensive therapy or additional surgery 4

Inadequate patient education: Most patients with wrist fractures do not believe their fracture resulted from osteoporosis and underestimate the seriousness of bone fragility 6. Directed education addressing this misconception is essential for treatment adherence 6.

Immobilizing uninjured fingers: Stiffness can develop in unfractured fingers, especially with associated crush injuries, if they are not actively mobilized from day one 4