What is the recommended treatment for a patient with a hairline fracture?

Treatment of Hairline Fractures

Hairline fractures should be managed with immobilization followed by early mobilization exercises, appropriate analgesia, and—critically for patients over 50—initiation of bisphosphonate therapy with calcium and vitamin D supplementation to prevent subsequent fractures. 1

Immediate Management

Pain Control

• Start with acetaminophen (paracetamol) as first-line analgesia, providing appropriate pain management as soon as possible before diagnostic investigations 2, 3
• Add short-term opioids only if necessary for severe pain, with caution if renal function is unknown (approximately 40% of trauma patients have moderate renal dysfunction) 3
• Avoid NSAIDs if cardiovascular, renal comorbidities exist, or if renal function has not been assessed 2, 3

Immobilization Strategy

• Apply appropriate immobilization (casting, splinting, or sling depending on fracture location) for initial pain control and fracture stability 4
• Avoid prolonged bed rest beyond what is absolutely necessary for acute pain control, as it accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis and pressure ulcers 2

Early Mobilization Protocol

Timing and Approach

• Begin range-of-motion exercises for adjacent joints immediately after immobilization to prevent edema and stiffness 4, 1
• For distal radius fractures: start early finger motion immediately after casting to prevent edema and stiffness 4
• For shoulder fractures: begin range-of-motion exercises including shoulder, elbow, wrist and hand motion within the first postoperative days if surgical treatment was performed 4
• When immobilization is discontinued, initiate aggressive finger and hand motion exercises to facilitate the best possible outcomes 4, 1

Activity Restrictions

• Restrict above chest level activities (for upper extremity fractures) until fracture healing is evident 4
• Avoid overly aggressive physical therapy and exercises in the early postoperative period, as this may increase the risk of fixation failure 4

Rehabilitation Program

Early Phase

• Implement early post-fracture physical training and muscle strengthening as the patient tolerates 1, 2
• Identify individual functional goals and needs before developing the specific rehabilitation plan 1, 2
• The primary aim is to regain the level of mobility and independence enjoyed before the fracture occurred 4

Long-Term Phase

• Establish long-term balance training and multidimensional fall prevention programs, which reduce fall frequency by approximately 20% 2
• Continue weight-bearing exercise programs to improve bone mineral density and muscle strength 2

Pharmacological Treatment for Fracture Prevention (Age >50)

First-Line Therapy

• All patients over 50 with a hairline fracture should be started on oral bisphosphonates (alendronate or risedronate) as first-choice agents, which reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 40-51% 1
• Prescribe bisphosphonates for 3-5 years initially, with longer duration for patients remaining at high fracture risk 1, 2
• For patients with oral intolerance or non-compliance, use alternatives such as zoledronic acid or denosumab 1

Essential Adjunctive Therapy

• All patients must receive calcium 1000-1200 mg/day plus vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% 1, 2, 3
• Do not use calcium supplementation alone without bisphosphonates, as calcium alone has no demonstrated fracture reduction effect and should not be used as monotherapy 1, 2
• Avoid high pulse dosages of vitamin D as they are associated with increased fall risk 2

Non-Pharmacological Interventions

Lifestyle Modifications

• Implement smoking cessation and limit alcohol intake to improve bone mineral density, bone quality, and reduce fall risk 2
• Address environmental hazards in the home 2
• Review medications that may increase fall risk 2

Systematic Follow-Up Protocol

Fracture Liaison Service Approach

• Implement a five-step approach: (1) identify the patient with recent fracture, (2) invite for fracture risk evaluation, (3) perform differential diagnosis, (4) initiate therapy, and (5) establish systematic follow-up 1, 2
• A dedicated coordinator should organize diagnostic investigations and interventions under supervision of an orthopedic surgeon or endocrinologist 1
• Monitor regularly for medication tolerance and adherence, as long-term adherence is typically poor 2

Patient Education

• Educate patients about the burden of the disease, risk factors for fractures, follow-up requirements, and duration of therapy 4
• Use risk communication and shared decision-making to improve adherence 2

Critical Pitfalls to Avoid

• Do not allow prolonged immobilization beyond what is necessary, as this leads to stiffness and poor functional outcomes 4
• Do not delay osteoporosis treatment in patients over 50 with confirmed fractures, as the risk of subsequent fractures is highest in the first year 1
• Do not overlook the need for early finger and hand motion exercises when treating upper extremity fractures, as delayed mobilization leads to permanent stiffness 4
• Do not prescribe calcium alone without vitamin D and bisphosphonates for fracture prevention 1, 2

Special Considerations

For Frail Elderly Patients

• Establish orthogeriatric co-management for frail elderly patients with multiple comorbidities and polypharmacy 4, 2
• Perform comprehensive admission assessment including investigations for malnutrition, electrolyte disturbances, anemia, cardiac or pulmonary diseases 3

Coordination of Care

• Coordinate between orthopedic surgery, rheumatology/endocrinology, and primary care for optimal outcomes 4, 2
• Implementation should adapt to local needs and restrictions based on collaboration between specialists 4