What is the best course of treatment for an elderly patient with dementia and a non-displaced S5-C1 (fifth sacral vertebra to first cervical vertebra) midline fracture, with normal hip appearance aside from degenerative changes?

Management of Non-Displaced Sacral Fracture in Elderly Patient with Dementia

For an elderly patient with dementia and a non-displaced sacral fracture, immediate orthogeriatric comanagement with multimodal analgesia (avoiding opioids as first-line), early mobilization within 24-48 hours, and systematic osteoporosis treatment initiation are essential, as sacral insufficiency fractures carry mortality and morbidity risks comparable to hip fractures in this vulnerable population. 1

Immediate Pain Management

• Start with scheduled acetaminophen (paracetamol) as first-line analgesia before any diagnostic workup to prevent immobility-related complications 2, 1
• Consider regional nerve blocks combined with acetaminophen rather than opioids as first-line treatment, as opioids dramatically increase delirium risk, falls, and mortality in elderly dementia patients 1
• Avoid NSAIDs until renal function is assessed, as approximately 40% of trauma patients have moderate renal dysfunction and NSAIDs are relatively contraindicated with impaired kidney function 2
• Document pain scores at rest and with movement before and after analgesia administration 2

Orthogeriatric Comanagement (Critical Priority)

Implement immediate multidisciplinary orthogeriatric comanagement on a dedicated ward, as this approach reduces mortality, length of stay, and complications in frail elderly patients with fragility fractures 3, 1. This is particularly crucial for dementia patients, who have 2.7 times higher fracture risk and face significant management challenges 4.

Comprehensive Geriatric Assessment Must Include:

• Nutritional status evaluation with oral supplementation implementation 1
• Electrolyte and volume disturbances requiring correction 1
• Anemia screening with appropriate transfusion thresholds 1
• Cardiac and pulmonary comorbidities assessment 1
• Cognitive function baseline and delirium risk stratification 3, 1
• Complete medication review and polypharmacy optimization 1
• Renal function assessment 1

Early Mobilization Protocol

Begin weight-bearing as tolerated within 24-48 hours to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning 3, 1. Non-displaced sacral fractures are typically stable and can tolerate early mobilization.

• Implement supervised ambulation initially with fall prevention strategies including room modifications 1
• Physical training and muscle strengthening should begin immediately post-fracture 3, 1
• Continue long-term balance training and multidimensional fall prevention 3

Common pitfall: Delaying mobilization due to pain concerns—this dramatically increases complications in elderly dementia patients who are already at high risk for deconditioning 4.

Thromboembolism Prophylaxis

• Administer pharmacologic VTE prophylaxis with low molecular weight heparin 1
• Add mechanical compression devices 1
• Use mechanical prophylaxis alone if anticoagulation is contraindicated 1

Delirium Prevention

Implement multi-component non-pharmacological prevention including hydration management, sleep-wake cycle normalization, and cognitive orientation 1. This is critical as dementia patients have extremely high delirium risk during hospitalization 5.

• Avoid opioids which dramatically increase delirium risk in this population 1
• Maintain familiar routines and orientation cues when possible

Secondary Fracture Prevention (Mandatory)

Systematically initiate anti-osteoporotic treatment even without DXA scan, as sacral insufficiency fractures in elderly patients are typical fragility fracture patterns indicating high subsequent fracture risk 3, 1.

Evaluation Components:

• Review clinical risk factors for osteoporosis 1
• DXA of spine and hip when feasible 1
• Imaging of spine for vertebral fractures 1
• Falls risk assessment 3, 1
• Identification of secondary osteoporosis causes 1

Pharmacological Treatment:

For patients with dementia, prescribe zoledronic acid (intravenous) or denosumab (subcutaneous) as first-line agents rather than oral bisphosphonates, given issues with oral intolerance, malabsorption, and non-compliance in this population 3. These drugs have demonstrated reduction in vertebral, non-vertebral, and hip fractures 3.

• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation, which is associated with 15-20% reduction in non-vertebral fractures and falls 3, 1
• Avoid high pulse dosages of vitamin D as they are associated with increased fall risk 3
• Monitor regularly for tolerance and adherence 3, 1
• Prescribe for 3-5 years initially, longer if high risk persists 3

Important consideration: Despite low overall treatment rates (11.6%) for NH residents with dementia and fractures 6, evidence supports treatment in this population given their high fracture risk and potential for meaningful functional recovery.

Care Coordination

• Designate a local responsible lead to coordinate secondary fracture prevention between orthopaedic surgeons, rheumatologists/endocrinologists, geriatricians, and general practitioners 3, 1
• Educate patients (and caregivers for dementia patients) about disease burden, risk factors, follow-up, and treatment duration 3, 1
• Establish systematic follow-up as part of a structured care plan 3

Hip Considerations

The normal hip appearance aside from degenerative changes is reassuring and requires no specific intervention beyond standard osteoporosis management 3. The degenerative changes do not contraindicate early mobilization or standard fracture prevention protocols.