What is the recommended assessment and treatment for an adult patient with a suspected arm injury, potentially with pre-existing conditions such as osteoporosis, and impaired bone health?

Orthopedic Assessment and Treatment of Arm Injury in Adults with Impaired Bone Health

Initial Imaging Assessment

Radiographs of the affected arm region (elbow, forearm, wrist, or hand) are the mandatory first-line imaging study for any suspected arm injury, regardless of bone health status. 1

• Conventional radiographs effectively exclude fractures and dislocations in the acute setting 1
• In adults, radial head or neck fractures account for 50% of elbow fractures 1
• Joint effusion with fat pad elevation on radiographs suggests occult fracture even when no obvious fracture line is visible 1
• For hand and wrist trauma, radiographs remain the initial study of choice 1

Advanced Imaging When Radiographs Are Negative or Equivocal

When initial radiographs are normal but clinical suspicion remains high, proceed with:

For elbow/forearm injuries: CT without contrast is the preferred next study, as it identifies occult fractures in 12.8% of patients with negative radiographs but positive clinical findings 1

For wrist injuries: Three equivalent options exist - repeat radiographs in 10-14 days, MRI without contrast, or CT without contrast 1

For hand injuries: MRI without contrast or ultrasound are equivalent alternatives for suspected tendon/ligament trauma 1

Critical Assessment in Patients with Osteoporosis or Impaired Bone Health

Immediate Multidisciplinary Evaluation

For patients aged 50 years or older with arm fractures and known or suspected osteoporosis, immediate orthogeriatric comanagement must be initiated to reduce mortality, morbidity, and hospital length of stay. 1

The comprehensive preoperative assessment must include: 1

• Adequate pain relief (multimodal analgesia, avoiding opioids as first-line in elderly) 2
• Chest X-ray and ECG 1
• Full blood count, clotting studies, renal function 1
• Cognitive function baseline 1
• Assessment for exacerbations of chronic medical conditions 1

Surgical Timing and Treatment Decisions

Surgery should occur within 24-48 hours of admission when indicated, as delays significantly increase mortality and medical complications. 1

• Treatment requires balanced consideration of operative versus non-operative approaches in elderly patients with fragile bones 1
• Careful selection of fixation devices and techniques is essential given compromised bone quality 1

Secondary Fracture Prevention - The Critical Component

Every patient aged 50 years or older with an arm fracture must be systematically evaluated for risk of subsequent fractures, as this represents a sentinel event indicating elevated imminent fracture risk. 1, 3

Comprehensive Fracture Risk Assessment

The evaluation must include: 1

• DXA scanning of spine and hip to measure bone mineral density 1
• Spine imaging (radiography or vertebral fracture assessment) to detect subclinical vertebral fractures 1, 3
• Review of clinical risk factors (age, prior fractures, family history, medications, smoking, alcohol) 1
• Falls risk evaluation 1
• Laboratory screening for secondary osteoporosis causes 1, 3

Pharmacological Treatment Initiation

Oral bisphosphonates (alendronate or risedronate) should be initiated as first-line treatment for patients at moderate-to-high fracture risk, as these reduce vertebral fractures by 65% and non-vertebral fractures by 53%. 3, 4

• Consider initiating anti-osteoporotic therapy even before DXA results are available in elderly patients with typical fragility fracture patterns 3
• Treatment duration should be 3-5 years initially, with continuation in high-risk patients 3
• Denosumab is an alternative if bisphosphonates are contraindicated 4
• Anabolic medications (teriparatide, abaloparatide, romosozumab) should be considered for very high-risk individuals, followed by antiresorptive therapy 3, 4

Essential Adjunctive Therapy

All patients require: 1, 3, 4

• Calcium 1,000-1,200 mg/day (dietary plus supplementation) 1, 3
• Vitamin D 800 IU/day (target serum level ≥20 ng/ml) 1, 3
• Smoking cessation and alcohol limitation 1, 3

Rehabilitation and Fall Prevention

An appropriate rehabilitation program must include early postfracture physical training, muscle strengthening, and long-term balance training with multidimensional fall prevention. 1

Implementation Through Fracture Liaison Services

A local responsible coordinator must oversee secondary fracture prevention, liaising between surgeons, rheumatologists/endocrinologists, geriatricians, and primary care physicians. 1, 3

• Fracture liaison services increase appropriate osteoporosis management to 45% within 6 months versus only 26% in standard care 3
• These services achieve up to 90% medication adherence rates 3
• Systematic follow-up is essential as long-term adherence is typically poor without structured programs 3

Common Pitfalls to Avoid

• Never delay pain management while waiting for imaging - provide immediate multimodal analgesia 2
• Never use opioids as first-line in elderly patients due to increased fall risk, delirium, and mortality 2
• Never rely solely on radiographs - clinical examination and mechanism of injury are essential, particularly in older patients with weaker bone 5
• Never miss the opportunity for secondary fracture prevention - the highest risk period for subsequent fractures is immediately after the initial fracture 3, 6
• Never assume normal BMD excludes osteoporosis - a prior low-trauma fracture may indicate osteoporosis even with normal bone density 1