What are the treatment options for an older adult with a history of osteoporosis and a recent fall who has a sacrum fracture?

Treatment of Sacrum Fractures in Older Adults with Osteoporosis

For an older adult with osteoporosis and a sacrum fracture from a fall, initiate conservative management with early mobilization, pain control using acetaminophen as first-line, and immediately start bisphosphonate therapy to prevent subsequent fractures, while reserving surgical intervention for displaced fractures or persistent immobility. 1, 2

Immediate Pain Management and Mobilization

Conservative treatment is the foundation for non-displaced sacral fractures:

• Start acetaminophen as first-line analgesia, avoiding NSAIDs if cardiovascular or renal comorbidities exist 1
• Use short-term narcotic medications only if necessary for severe pain 1
• Avoid prolonged bed rest as it accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis and pressure ulcers 1
• Begin early mobilization as tolerated to prevent complications of immobility 1
• Initiate range-of-motion exercises within the first postoperative days 1

The clinical presentation of osteoporotic sacral fractures varies from longstanding low back pain to complete immobilization, often with diffuse low back pain accompanied by hip, buttock, or thigh pain 3, 2. Physical findings are typically limited to sacral tenderness on palpation and decreased range of low back motion 3.

Surgical Indications

Surgical treatment should be considered for:

• Displaced fractures that prevent mobilization 2
• Persistent pain despite conservative management 1
• Fractures combined with anterior pelvic ring injuries (fragility fractures of the pelvis) 2

Surgical options include:

• Minimally invasive sacro-iliac screws 2
• Trans-sacral bar osteosynthesis 2
• Open reduction and internal fixation 2
• Spinopelvic stabilization for high-grade fracture dislocations 4, 5
• Kyphoplasty for persistent pain, which provides immediate pain relief and can be performed as outpatient care in the majority of cases 1

In the context of high complication rates associated with immobilized patients, an operative approach is often indicated to accelerate mobility 2.

Essential Osteoporosis Treatment to Prevent Subsequent Fractures

Every patient over 50 with a fragility fracture must be systematically evaluated and treated for osteoporosis: 6

First-Line Pharmacological Treatment:

• Start oral bisphosphonates (alendronate or risedronate) immediately as they reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 40-51% 1, 7
• Prescribe bisphosphonates for 3-5 years initially, with longer duration for patients who remain at high risk 1, 7
• Add calcium 1000-1200 mg/day plus vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% 1, 8, 7
• Avoid high pulse dosages of vitamin D as they increase fall risk 1

The National Osteoporosis Foundation recommends oral bisphosphonates as first-choice agents because they are well-tolerated, cost-effective, and widely available as generics 1. This is particularly critical in patients with chronic steroid use, which contributes to poor outcomes through continued bone loss 1.

Risk Assessment Required:

• Perform DXA of spine and hip to measure bone mineral density 6
• Obtain imaging of the spine for vertebral fractures (radiography or VFA) 6
• Evaluate falls risk with history of falls during the last year 6
• Order limited laboratory examination including ESR, serum calcium, albumin, creatinine, and TSH 6
• Use fracture risk assessment tools such as FRAX, Garvan, or Q-Fracture 6

The secondary fracture risk is highest immediately after the initial fracture and gradually decreases over time 6.

Rehabilitation Strategy

Implement a structured rehabilitation program:

• Begin early post-fracture physical training and muscle strengthening 1
• Establish long-term balance training and multidimensional fall prevention programs, which reduce fall frequency by approximately 20% 1
• Implement weight-bearing exercise programs to improve BMD and muscle strength 1
• Address environmental hazards in the home 1
• Review medications that may increase fall risk 1

Organized Post-Fracture Care System

The Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation: 6

• A dedicated coordinator (often a well-educated nurse) should identify all elderly patients with recent fractures 6
• The coordinator organizes diagnostic investigations and starts interventions under supervision of an orthopedic surgeon, endocrinologist, or rheumatologist 6
• RCTs demonstrate that a nominated coordinator significantly improves osteoporosis treatment implementation: 45% of patients receive appropriate management within 6 months versus only 26% in control groups 6

Critical Pitfalls to Avoid

• Do not allow prolonged bed rest beyond what is absolutely necessary for acute pain control, as it accelerates complications 1
• Do not delay osteoporosis treatment in patients with confirmed sacral fractures 1, 7
• Do not use calcium or vitamin D alone without bisphosphonates, as calcium alone has no demonstrated fracture reduction effect 1, 7
• Do not overlook the need for surgical intervention in patients with displaced fractures or persistent immobility, given the high complication rate of prolonged immobilization 2
• Do not miss the diagnosis—sacral fractures are often not visible on plain radiographs and require CT scan or bone scan for detection 3, 9

Monitoring and Follow-Up

• Monitor regularly for medication tolerance and adherence, as long-term adherence is typically poor 1
• Reassess for bisphosphonate drug holiday after 5 years unless the patient remains at high fracture risk 7
• Coordinate care between orthopedic surgery, rheumatology/endocrinology, and primary care 1
• Establish orthogeriatric co-management for frail elderly patients with multiple comorbidities 1