What is the treatment for a cracked leg in an adult or elderly patient?

Treatment of Leg Fracture in Adults and Elderly Patients

A leg fracture in an adult or elderly patient requires immediate multidisciplinary orthogeriatric care with appropriate surgical or conservative fracture management, followed by systematic fracture risk evaluation and pharmacological osteoporosis treatment to prevent subsequent fractures. 1

Acute Fracture Management

Immediate Care

• Initiate pain control with acetaminophen as first-line therapy, avoiding NSAIDs in elderly patients due to cardiovascular and renal risks 2
• Determine if surgical fixation versus conservative management is needed based on fracture pattern, displacement, and patient functional status 1
• Implement orthogeriatric care immediately, which requires collaboration between orthopedic surgeons and geriatricians or metabolic bone specialists to optimize perioperative medical management 1
• Avoid prolonged bed rest as this accelerates bone loss, muscle weakness, and increases deep vein thrombosis risk 2

Early Mobilization

• Begin range-of-motion exercises and early mobilization as soon as pain allows to prevent stiffness and muscle atrophy 1, 3
• Prolonged immobilization leads to poor functional outcomes and should be avoided 3
• Implement weight-bearing exercise programs as tolerated to improve bone mineral density and muscle strength 2

Systematic Fracture Risk Evaluation

Coordinator-Led Assessment

• A dedicated coordinator must establish a systematic process to investigate future fracture risk in all patients over 50 with a recent fracture 1
• This five-step Fracture Liaison Service (FLS) approach includes: identifying the patient, inviting for fracture risk evaluation, performing differential diagnosis, initiating therapy, and establishing systematic follow-up 4

Diagnostic Workup

• Order DXA scanning of lumbar spine and hip to quantify bone mineral density and establish baseline T-scores 2
• Obtain laboratory assessment including serum calcium, albumin, creatinine, thyroid-stimulating hormone, and erythrocyte sedimentation rate to identify secondary causes of osteoporosis 2
• Do not delay osteoporosis treatment waiting for DXA results—in elderly patients with a recent fracture and radiographic osteopenia, treatment can be initiated immediately 2

Pharmacological Osteoporosis Treatment

First-Line Therapy

• Initiate oral bisphosphonate therapy (alendronate or risedronate) as first-line treatment for all patients over 50 with a fragility fracture 2, 4
• Bisphosphonates reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 40-51% 2, 4
• Plan for 3-5 years of initial bisphosphonate therapy, with longer duration if high fracture risk persists 2, 4

Alternative Agents

• For patients with GFR <30 mL/min or oral intolerance, use denosumab 60 mg subcutaneously every 6 months 2
• Zoledronic acid is another alternative for patients with oral intolerance or non-compliance 4

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, 4
• Calcium supplementation alone without bisphosphonates has no demonstrated fracture reduction effect and should not be used as monotherapy 4

Fall Prevention and Non-Pharmacological Interventions

Fall Risk Assessment

• Patients at high-risk of falls should undergo individualized multi-component screening addressing gait, mobility (measured by Timed Up and Go test), balance, lower limb strength, medication review, cognitive capacity, footwear, and environmental factors 1
• Key screening questions include: any falls within past 12 months, fear of falling, or feeling unsteady while walking or standing 1

Multicomponent Interventions

• Implement tailored multicomponent interventions including exercise, environmental adaptations, nutrition, and education 1
• Address environmental hazards in the home and review medications that may increase fall risk 2
• Discourage smoking and overuse of alcohol 1

Structured Follow-Up and Monitoring

Systematic Monitoring

• Establish systematic follow-up with regular monitoring for medication tolerance and adherence, as adherence rates reach 90% with structured follow-up 2, 4
• A coordinator should organize diagnostic investigations and interventions under supervision of an orthopedic surgeon or endocrinologist 4
• Reassess fracture risk every 1-3 years with repeat DXA scanning, performing earlier reassessment (within 1 year) given history of fragility fracture 2

Critical Pitfalls to Avoid

• Do not dismiss any fracture in patients over 50 as trivial—it represents a fragility fracture requiring full osteoporosis evaluation and treatment to prevent future hip or vertebral fractures 2
• Do not prescribe NSAIDs without careful consideration of renal function, cardiovascular risk, and gastrointestinal risk in elderly patients 2
• Avoid tight compression or prolonged immobilization that could compromise circulation or lead to stiffness 3
• High-risk patients must receive appropriate pharmacological treatment, not just calcium and vitamin D alone 1