What is the appropriate management for a patient with a FOOSH (Fall On Outstretched Hand) fracture, considering potential underlying conditions such as osteoporosis?

Management of FOOSH (Fall On Outstretched Hand) Fractures

For patients over 50 years with a FOOSH fracture, immediate orthopedic stabilization must be coupled with systematic enrollment in a Fracture Liaison Service (FLS) and initiation of oral bisphosphonates within 3-6 months, as secondary fracture risk peaks immediately post-injury and these interventions reduce subsequent fractures by up to 53%. 1, 2

Acute Fracture Management

Initial Orthopedic Care

• Provide appropriate fracture stabilization based on the specific fracture pattern (distal radius, scaphoid, or other carpal/metacarpal fractures), using either casting, splinting, or surgical fixation as indicated by fracture characteristics 3
• Ensure adequate pain control with multimodal analgesia, as pain evaluation should be part of routine postoperative observations 3
• Begin early mobilization once fracture stability allows, as limited mobility in the postoperative phase increases risk of future fractures 3

Red Flags Requiring Urgent Evaluation

• New neurological deficits (median or ulnar nerve compromise) 4
• Severe uncontrolled pain despite appropriate analgesia 4
• Signs of compartment syndrome or vascular compromise 4
• Evidence of open fracture or infection 4

Secondary Fracture Prevention: The Critical Priority

Fracture Liaison Service Enrollment (Within Days of Injury)

Every patient aged 50 years and over with a FOOSH fracture must be systematically evaluated through an FLS, which increases appropriate osteoporosis management to 45% within 6 months versus only 26% in standard care. 1, 3

• The FLS coordinator identifies all elderly fracture patients, organizes diagnostic investigations, and initiates treatment 1
• FLS programs achieve up to 90% medication adherence rates compared to typical poor adherence with standard care 1, 3
• This structured approach is the single most effective organizational intervention for preventing subsequent fractures 1, 3

Comprehensive Fracture Risk Assessment (Within 3-6 Months)

Timing is critical: secondary fracture risk is highest immediately after the initial fracture and gradually decreases over time, making urgent evaluation within 3-6 months essential. 1

Bone Mineral Density Testing

• Perform DXA scanning of spine and hip to measure BMD, which independently contributes to fracture risk assessment 1, 3
• In settings where DXA is unavailable, use quantitative ultrasound or calcaneal DXA 3
• For frail elderly patients with typical fragility fracture patterns, consider initiating anti-osteoporotic therapy even before DXA results are available 1, 4

Vertebral Fracture Assessment

• Obtain spine imaging (radiography or vertebral fracture assessment) to detect subclinical vertebral fractures, which are frequent in patients with non-vertebral fractures and independently predict future fracture risk 1
• Only one-third of vertebral fragility fractures are symptomatic, so imaging is essential 5

Clinical Risk Calculation

• Use FRAX, Garvan, or Q-Fracture risk calculator incorporating age, gender, BMI, personal/family fracture history, and falls risk 1
• Treatment is indicated for 10-year probability of ≥20% for major osteoporotic fractures or ≥3% for hip fractures 3, 2

Falls Risk Evaluation

• Begin with history of falls in the past year, followed by specific balance testing 1
• Implement multidimensional fall prevention strategies, which reduce fall frequency by approximately 20% 5, 1

Laboratory Screening for Secondary Causes

• Obtain ESR, serum calcium, albumin, creatinine, TSH, vitamin D level 1
• Consider protein electrophoresis or testosterone in men 1
• Evaluate for hypercortisolism, hyperparathyroidism, hyperthyroidism, and other endocrine causes if clinically suspected 3, 6

Pharmacological Treatment: First-Line Therapy

Oral Bisphosphonates (Alendronate or Risedronate)

Initiate oral bisphosphonates as first-line treatment for patients at moderate-to-high fracture risk, as these reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51%. 1, 5, 4, 2

• Alendronate and risedronate are preferred due to proven efficacy, low cost (generics available), good tolerability, and extensive clinical experience 1, 7
• Treatment duration should be 3-5 years initially, with continuation in patients who remain at high risk 1
• For patients with GFR <30 mL/min, consider alternative agents 5

Alternative Antiresorptive Agents

• Intravenous bisphosphonates or subcutaneous denosumab may be offered if oral bisphosphonates are contraindicated or not tolerated 3, 2
• Denosumab reduces vertebral fractures by 68% and hip fractures by 40% 2
• Choice should be based on patient preference, potential adverse effects, adherence, safety, cost, and availability 3

Anabolic Agents for Very High-Risk Patients

Consider teriparatide, abaloparatide, or romosozumab for very high-risk individuals (recent vertebral fractures, hip fracture with T-score ≤-2.5), followed by an antiresorptive agent. 2, 8

• Anabolic agents stimulate bone formation and increase BMD more than antiresorptives 9
• These agents are superior to antiresorptives in preventing fractures in patients with severe osteoporosis 9
• Must be followed by antiresorptive treatment to maintain fracture risk reduction 9, 2

Essential Adjunctive Therapy

Calcium and Vitamin D Supplementation

All patients require calcium 1,000-1,200 mg/day (dietary plus supplementation as needed) and vitamin D 800 IU/day (target serum level ≥20 ng/mL), which reduces non-vertebral fractures by 15-20% and falls by 20%. 1, 5, 4, 3, 2

• Avoid high-pulse dosages of vitamin D, which paradoxically increase fall risk 1
• If intake is not being consumed through diet, supplements to reach those levels are recommended 3

Non-Pharmacological Interventions

Exercise and Physical Activity

• Prescribe supervised weight-bearing exercise programs and balance training to improve BMD, muscle strength, and reduce fall risk 5, 1
• Encourage combination of exercise types: balance training, flexibility/stretching, endurance exercise, and resistance/progressive strengthening exercises 3
• Exercise should be tailored according to needs and abilities of the individual patient 3

Lifestyle Modifications

• Smoking cessation and alcohol limitation (≤1-2 drinks/day) due to negative effects on BMD, bone quality, and fall risk 1, 3, 2
• Maintain weight in recommended range 1

Nutritional Support

• Up to 60% of fracture patients are malnourished; nutritional supplementation reduces mortality 3, 5
• Ensure adequate calorie and protein intake 3

Multidisciplinary Collaboration

Orthogeriatric Co-Management for Frail Elderly

• For frail elderly patients with multiple comorbidities and polypharmacy, implement orthogeriatric co-management during the acute fracture care phase 1, 3
• This multidisciplinary approach improves outcomes in elderly patients with major fractures 1, 3

Coordinated Care Structure

• Establish collaboration between orthopedic surgery, rheumatology/endocrinology, primary care, physical therapy, occupational therapy, and social work 3, 5
• The critical point is not who takes care of the patient, but that all patients receive optimal care through structured collaboration 3

Follow-Up and Adherence Monitoring

Systematic Long-Term Management

• Systematic follow-up is essential as long-term adherence to osteoporosis treatment is typically poor outside of FLS programs 1
• Risk communication and shared decision-making positively influence adherence 3, 1
• Monitor for medication adverse effects and adherence at regular intervals 5

Repeat BMD Testing

• For patients prescribed bone loss medications or with baseline BMD near treatment threshold, offer BMD testing every 2 years, or more frequently if medically necessary 3
• Testing should generally not be conducted more than annually 3

Common Pitfalls to Avoid

• Failing to recognize that FOOSH fractures in patients over 50 are sentinel events requiring systematic osteoporosis evaluation, not just orthopedic treatment 1, 3
• Delaying osteoporosis assessment beyond 6 months, missing the window when secondary fracture risk is highest 1
• Treating the fracture without addressing underlying bone fragility, which leaves patients at 2-3 times increased risk for subsequent fractures 2
• Assuming younger postmenopausal women (50-65 years) don't need evaluation when they present with low-energy wrist fractures—these are fragility fractures requiring full assessment 1, 3
• Prescribing calcium and vitamin D alone without bisphosphonates in high-risk patients, which provides inadequate fracture protection 1, 2