What is the next step in management for a 65-year-old female patient with a distal ulnar fracture, tibial plateau fracture, and osteoporosis, as indicated by a recent Dual-Energy X-ray Absorptiometry (DEXA) scan showing a lumbar spine T score of -2.2, proximal femur T score of -1.9, and femoral neck T score of -2.4?

Management of Osteoporosis in a 65-Year-Old Female with Fragility Fractures

This patient requires immediate initiation of pharmacological osteoporosis treatment with oral bisphosphonates (alendronate or risedronate) as first-line therapy, along with calcium (1200 mg daily) and vitamin D (600-800 IU daily) supplementation. 1, 2

Rationale for Immediate Treatment

This patient has multiple compelling indications for urgent osteoporosis treatment:

• Two recent fragility fractures (distal ulnar and tibial plateau fractures) in a 65-year-old woman, which are diagnostic of osteoporosis regardless of DEXA results 1, 3
• DEXA confirmation of osteoporosis with femoral neck T-score of -2.4 (diagnostic threshold is ≤-2.5) and lumbar spine T-score of -2.2 (osteopenia approaching osteoporosis) 1
• Age 65 years, which is the standard screening threshold where treatment is routinely indicated 1

The presence of fragility fractures alone justifies treatment even without DEXA confirmation, as vertebral and other low-trauma fractures are considered diagnostic of osteoporosis 1, 3

Specific Pharmacological Treatment Recommendations

First-Line Therapy: Oral Bisphosphonates

Alendronate or risedronate should be prescribed as first-line agents based on the strongest evidence for fracture reduction in this population 1, 2:

• Alendronate: Reduces vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51% 2, 4
• Risedronate: Reduces vertebral fractures by 44-81% (depending on duration) and has demonstrated efficacy in patients ≥75 years 5
• Treatment duration: Initially prescribe for 3-5 years, with continuation if high fracture risk persists 1, 2

Alternative Options if Oral Bisphosphonates Not Tolerated

If the patient has oral intolerance, malabsorption, dementia, or non-compliance concerns, consider 1, 2:

• Zoledronic acid (intravenous, once yearly)
• Denosumab (subcutaneous, every 6 months) - reduces vertebral fractures by 68% and hip fractures by 40% at 3 years 6

For Very Severe Osteoporosis

Teriparatide (anabolic agent) should be reserved for patients with very severe osteoporosis or those who have failed other therapies 1

Essential Concurrent Interventions

Calcium and Vitamin D Supplementation

Mandatory supplementation for all patients on anti-osteoporosis therapy 1, 2:

• Calcium: 1200 mg daily (age 51-70 years) 1, 2
• Vitamin D: 600-800 IU daily (600 IU for age 51-70; 800 IU for age ≥71) 1, 2
• Target serum vitamin D level: ≥20 ng/mL (50 nmol/L) 1

Laboratory Evaluation for Secondary Causes

Before initiating treatment, obtain baseline laboratory tests to exclude secondary osteoporosis 2:

• Serum calcium and albumin
• Serum creatinine
• Thyroid-stimulating hormone (TSH)
• Erythrocyte sedimentation rate (ESR)

Vertebral Fracture Assessment

This patient meets criteria for vertebral imaging given her age and T-scores 1:

• Women aged ≥65 years with T-score ≤-1.0 at femoral neck should undergo vertebral fracture assessment (VFA) or standard radiography 1
• This identifies subclinical vertebral fractures that further confirm treatment necessity 2

Lifestyle Modifications

Counsel on non-pharmacological interventions to reduce fall risk and optimize bone health 1, 2:

• Smoking cessation (if applicable)
• Alcohol limitation (≤2 drinks daily)
• Weight-bearing exercise to improve bone density and reduce fall risk
• Fall prevention strategies given her recent fractures

Follow-Up and Monitoring Strategy

Implement structured follow-up to ensure adherence and monitor treatment response 1, 2:

• Medication adherence monitoring: Adherence rates reach 90% with structured follow-up versus poor adherence without it 1, 2
• Repeat DEXA scanning: After minimum 12 months of therapy, then at 1-2 year intervals 1
• Monitor for medication tolerance: Assess for gastrointestinal side effects with oral bisphosphonates 1
• Assess for new fractures and height loss at each visit 1

Critical Pitfalls to Avoid

Do not delay treatment pending additional testing - the presence of two fragility fractures in a 65-year-old woman with confirmatory DEXA is sufficient to initiate therapy immediately 1, 3

Do not use FRAX calculation in this patient - she already has documented fragility fractures, which supersedes the need for fracture risk estimation tools 1

Do not prescribe calcitonin - it has weaker efficacy data compared to bisphosphonates and should only be used when other treatments cannot be tolerated 1

Ensure adequate calcium/vitamin D before starting bisphosphonates - these are required for optimal efficacy and to prevent hypocalcemia 2, 4