What should be done for an elderly patient with a history of osteoporosis who has fallen hard onto their buttocks?

Management of Elderly Patient with Osteoporosis Who Fell Hard on Buttocks

Obtain immediate radiographs of the pelvis and hip to rule out fracture, and if initial radiographs are negative but clinical suspicion remains high due to persistent pain or inability to bear weight, obtain MRI within 48-72 hours to detect occult fractures. 1

Immediate Assessment and Imaging

• Radiographs are the first-line imaging modality for any elderly patient with osteoporosis presenting with acute hip or buttock pain after a fall 1
• Obtain AP pelvis and lateral hip views to evaluate for proximal femur fractures (femoral neck, intertrochanteric, basicervical) and pelvic fractures 1
• If radiographs are negative but the patient has persistent groin, hip, or buttock pain with difficulty bearing weight, do not send them home without further imaging 1
• MRI is the gold standard for detecting occult hip fractures when initial radiographs are negative but clinical suspicion remains high 1
• In one case series, a patient with negative initial radiographs returned 2 days later with worsening pain, and MRI revealed a mildly displaced basicervical femoral neck fracture 1

Clinical Examination Priorities

• Assess for pain with internal and external rotation of the hip, which suggests hip fracture even with negative radiographs 1
• Evaluate ability to bear weight and ambulate independently 1
• Document any new-onset groin, hip, or buttock pain that worsens with movement 1
• Common pitfall: Sending patients home after negative radiographs without clear return precautions or follow-up imaging plan when clinical suspicion remains 1

If Fracture is Identified

• Admit for surgical management within 24-48 hours to minimize morbidity and mortality 1
• Implement orthogeriatric co-management immediately, which improves outcomes in frail elderly patients with multiple comorbidities 2
• Initiate VTE prophylaxis (sequential compression devices in hospital, followed by pharmacologic prophylaxis such as enoxaparin for 4 weeks postoperatively) 1
• Maintain hemoglobin transfusion threshold no higher than 8 g/dL in postoperative asymptomatic patients 1
• Allow immediate weight-bearing as tolerated after surgical fixation 1

If No Fracture is Identified

• Provide appropriate analgesia with acetaminophen as first-line; avoid NSAIDs in patients with chronic kidney disease and cardiovascular disease 2
• Instruct on protected weight-bearing with assistive device (crutches or walker) until pain resolves 1
• Provide explicit return precautions: return immediately if pain worsens or does not improve within 2-3 days 1
• Consider repeat imaging (MRI preferred) if symptoms persist or worsen 1

Comprehensive Osteoporosis Management Post-Fall

Pharmacological Treatment

• Initiate calcium 1000-1200 mg/day and vitamin D 800 IU/day immediately, which reduces non-vertebral fractures by 15-20% and falls by 20% 1, 2, 3
• For patients with GFR ≥30 mL/min, start oral bisphosphonates (alendronate or risedronate) as first-line therapy, which reduce vertebral, non-vertebral, and hip fractures 1, 2, 3
• For patients with GFR <30 mL/min or oral intolerance, use denosumab 60 mg subcutaneously every 6 months 2, 3
• For patients with very severe osteoporosis or recent vertebral fractures, consider anabolic agents (teriparatide, abaloparatide, or romosozumab) followed by antiresorptive therapy 1, 3, 4

Fall Prevention Strategy

• Implement multifactorial risk assessment since this patient has presented with an acute fall 1
• Evaluate balance and mobility, vision, orthostatic hypotension, medication review, and home environment 1
• Prescribe structured exercise program including balance, gait, and strength training at least 150 minutes per week of moderate-intensity activity plus muscle-strengthening twice weekly 1
• Balance training should occur 3 or more days per week for older adults at risk for falling 1
• Consider tai chi classes with individual instruction, which reduces falls by approximately 50% in community-dwelling older adults 1

Non-Pharmacological Interventions

• Counsel on smoking cessation and limiting alcohol intake, as these negatively affect bone mineral density and fall risk 1, 2
• Avoid prolonged bed rest, which accelerates bone loss, muscle weakness, and increases DVT risk 2
• Begin range-of-motion exercises for all extremities within the first few days 2
• Address environmental hazards in the home 2

Follow-Up and Monitoring

• Establish multidisciplinary collaboration between orthopedics, rheumatology/endocrinology, primary care, and other specialists managing comorbidities 2
• Monitor for medication adherence, as long-term adherence to osteoporosis treatment is typically poor (improved to 90% with fracture liaison services) 1
• Educate patient about fracture risk, importance of medication adherence, and expected duration of therapy 2
• Common pitfall: Failing to initiate osteoporosis treatment after a fall in a high-risk patient, missing the opportunity to prevent subsequent fractures 1, 3