What is the best treatment approach for an older adult with osteoporosis who has a fracture of the proximal radius?

Treatment of Proximal Radius Fracture in Older Adults with Osteoporosis

For an older adult with osteoporosis and a proximal radius fracture, initiate non-operative management with brief immobilization (1-2 weeks maximum) followed by early range-of-motion exercises, while simultaneously establishing a multidisciplinary orthogeriatric care pathway and implementing pharmacological osteoporosis treatment to prevent subsequent fractures. 1

Acute Fracture Management

Initial Diagnostic Approach

• Obtain standard 3-view radiographs (posteroanterior, lateral, and 45-degree semipronated oblique) as the initial imaging modality for all suspected proximal radius fractures 1
• A fourth semisupinated oblique view increases diagnostic yield for detecting occult fractures 1

Primary Treatment Strategy

Non-operative management is the first-line treatment for most proximal radius fractures in older adults, even when displaced. 1, 2

• Immobilize with rigid splinting for 1-2 weeks only to prevent shoulder and elbow stiffness 1
• Begin early range-of-motion exercises immediately after the brief immobilization period 1, 3
• Inadequate immobilization increases displacement risk, but prolonged immobilization beyond 2 weeks causes significant disability from joint stiffness 1, 4

Indications for Surgical Intervention

Consider operative management only if:

• Significant displacement with loss of radial length, inclination, or tilt that cannot be maintained with closed reduction 1, 2
• Multiple fracture fragments (>3 articular fragments) or die-punch depression requiring anatomic restoration 1
• Failure of conservative management after 6-8 weeks 1
• Vascular compromise to surrounding structures 1

Surgical Options (When Indicated)

• External fixation or percutaneous pinning are supported by available evidence, though precise indications remain unclear 2
• Open reduction and internal fixation carries considerable complication rates in elderly osteoporotic patients 1, 5
• Patients with osteoporosis have significantly increased risk of hardware failure (P=0.01), surgical site infection (P<0.0001), and malunion (P<0.0001) after operative fixation 5

Critical Pitfalls to Avoid

• Do not allow immobilization beyond 2 weeks - shoulder and elbow stiffness is a major source of long-term disability in upper extremity fractures 1, 3
• Do not rush to surgery - complication rates with operative management are substantial in osteoporotic patients, and anatomic reduction does not consistently translate to better functional outcomes 2, 5
• Ensure adequate pain control to facilitate early mobilization and prevent frozen joints 1, 3

Mandatory Multidisciplinary Approach

Orthogeriatric Care Coordination

Every patient over 50 years with a fragility fracture requires a systematic, coordinated approach including orthogeriatric care. 1

• Designate a care coordinator to establish a systematic process for investigating future fracture risk 1
• Implement the Fracture Liaison Service (FLS) model for secondary fracture prevention 6
• This multidisciplinary approach is essential because fragility fractures are associated with increased morbidity and mortality 1

Comprehensive Osteoporosis Evaluation (Mandatory)

All patients aged 50 and over with a proximal radius fracture must undergo systematic evaluation for subsequent fracture risk. 1

Order the following:

• DEXA scan for bone mineral density assessment 6
• Vitamin D level 6
• Calcium level 6
• Parathyroid hormone level 6

Pharmacological Treatment for Secondary Prevention

Initiate pharmacological treatment with drugs demonstrated to reduce vertebral, non-vertebral, and hip fracture risk. 1

• Begin bisphosphonate therapy or alternative anti-osteoporotic medication based on DEXA results 1, 5
• Ensure adequate calcium and vitamin D supplementation 1
• Counsel on smoking cessation and alcohol limitation 1

Rehabilitation Protocol

Phase 1 (Weeks 1-2): Acute Phase

• Brief rigid immobilization for bone stability 4, 3
• Pain management to enable early mobilization 1, 3

Phase 2 (Weeks 2-8): Recovery Phase

• Early range-of-motion exercises for elbow, wrist, and shoulder 1, 3
• Progressive strengthening exercises 4, 3
• Education on proper and safe activities of daily living to prevent subsequent fractures 3

Phase 3 (Months 2-6+): Maintenance Phase

• Continue muscle strengthening exercises for minimum 6 months 4
• Maintain skills learned in previous phases 3
• Monitor for complications and healing progression 3

Evidence Quality Considerations

The evidence base for proximal radius fracture management in osteoporotic patients is limited. While 114 randomized trials exist for distal radius fractures, only 5 provide sufficient evidence for definitive conclusions about specific interventions 2, 7. The strongest evidence supports non-operative management as first-line treatment, with surgical intervention reserved for specific indications. 2 The critical distinction in older adults with osteoporosis is that anatomic reduction, while achievable surgically, does not consistently produce better functional outcomes and carries substantially higher complication rates 2, 5.