What is the appropriate management for an older adult patient with a history of falls and fractures, including femoral neck and humeral fractures, who presents with heterogeneous sclerosis and patchy opacities on X-ray, suggestive of an underlying bone disorder such as osteoporosis or metastatic disease?

Management of Fragility Fractures with Concerning Radiographic Findings

This patient requires immediate enrollment in a Fracture Liaison Service (FLS) with urgent workup to differentiate osteoporosis from metastatic disease, followed by initiation of bisphosphonate therapy if malignancy is excluded, as the risk of subsequent fracture and mortality peaks immediately after the initial fracture. 1

Urgent Diagnostic Evaluation

The heterogeneous sclerosis and patchy opacities on X-ray are red flags that demand immediate investigation to rule out metastatic bone disease before attributing fractures solely to osteoporosis.

Essential Laboratory Workup

• Obtain ESR, serum calcium, albumin, creatinine, and TSH to identify secondary causes of bone fragility 1
• Add protein electrophoresis to screen for multiple myeloma, which can present with patchy sclerotic lesions 1
• Measure vitamin D levels (target ≥20 ng/mL) and testosterone in men 1
• Consider tumor markers (PSA in men, cancer-specific markers based on clinical suspicion) given the atypical radiographic appearance

Critical Imaging Studies

• Perform DXA scanning of spine and hip to measure bone mineral density, which independently predicts fracture risk 1, 2
• Obtain spine imaging (radiography or vertebral fracture assessment) to detect subclinical vertebral fractures, which are frequent in patients with non-vertebral fractures and independently predict future fracture risk 1
• Consider advanced imaging (CT or MRI) if heterogeneous sclerosis suggests possible metastatic disease rather than simple osteoporosis—this distinction is critical before initiating osteoporosis treatment 1

Fracture Liaison Service Enrollment

Every patient aged 50+ with a fragility fracture must be systematically evaluated through an FLS, which increases appropriate osteoporosis management to 45% within 6 months versus only 26% in standard care. 1

• The FLS coordinator (typically a specialized nurse under physician supervision) identifies all elderly fracture patients, organizes diagnostic investigations, and initiates treatment 1
• Secondary fracture risk is highest immediately after the initial fracture and gradually decreases over time, making urgent evaluation within 3-6 months essential 1, 3
• This patient's multiple fractures from falls represent extremely high risk for subsequent fractures and mortality 4

Comprehensive Falls Risk Assessment

Given this patient's history of falls resulting in fractures, multifactorial falls risk assessment is mandatory.

• Ask three key screening questions: any falls in past 12 months, fear of falling, and feeling unsteady while walking or standing 1
• Perform Timed Up and Go test to evaluate gait and mobility 1
• Assess balance, lower limb strength, medication review (especially polypharmacy), cognitive capacity, footwear, and environmental hazards 1, 5
• Major fall risk factors include: impaired balance and gait, polypharmacy, previous falls, advancing age, female gender, visual impairments, and cognitive decline (especially attention and executive dysfunction) 5

Pharmacological Treatment (If Malignancy Excluded)

First-Line Therapy

Initiate oral bisphosphonates (alendronate or risedronate) immediately once metastatic disease is excluded, as these reduce vertebral fractures by 57% (RR 0.57,95% CI 0.41-0.78) and are first-line treatment with proven efficacy in reducing hip and non-vertebral fractures. 1, 2

• Bisphosphonates are preferred due to proven efficacy, low cost (generics available), good tolerability, and extensive clinical experience 3, 2
• Treatment duration should be 3-5 years initially, with continuation in patients who remain at high risk 3, 2
• Consider stopping bisphosphonates after 5 years unless strong indication for continuation exists, to reduce risk of osteonecrosis of the jaw and atypical femoral fractures 2

Alternative Agents

• Denosumab 60 mg subcutaneously every 6 months is recommended for patients with contraindications to bisphosphonates (e.g., severe renal impairment, esophageal disorders) 1, 6
• Denosumab increases BMD by 4.8% at lumbar spine, 2.0% at total hip, and 2.2% at femoral neck at 1 year 6
• For very high-risk patients (multiple fractures, very low BMD), consider romosozumab or teriparatide 2

Essential Adjunctive Therapy

• Calcium 1,000-1,200 mg/day (dietary plus supplementation as needed) 1, 2
• Vitamin D 800-1,000 IU/day (doses >800 IU may be necessary in high-risk populations), which reduces non-vertebral fractures by 15-20% and falls by 20% 1, 2
• Avoid high-pulse dosages of vitamin D, which paradoxically increase fall risk 3

Multicomponent Fall Prevention Interventions

Implement customized multifactorial interventions targeting individualized fall-risk factors, which reduce falls rate by 28% (incidence rate ratio 0.72,95% CI 0.61-0.86; NNT=3). 1

Exercise Prescription

• Multicomponent exercise incorporating dynamic weight-bearing, strength, and balance training undertaken 2-3 days per week for at least 10 weeks reduces fall risk 1
• Exercise for >1 year positively influences BMD 1
• Weight-bearing impact exercise and/or resistance training promotes strong bones and improves physical performance 1
• For patients at high fall risk (e.g., with peripheral neuropathy affecting balance), exercise programs should be individually tailored and supervised initially 1

Additional Interventions

• Home hazard modification to remove environmental fall risks 1
• Medication review to reduce polypharmacy and eliminate fall-risk medications 1
• Nutrition and lifestyle counseling, including smoking cessation and alcohol limitation (≤1-2 drinks/day) 3, 2

Risk Stratification Using FRAX

• Calculate 10-year fracture probability using FRAX, Garvan, or Q-Fracture incorporating age, gender, BMI, personal/family fracture history, and falls risk 1
• Treatment is indicated if: T-score ≤-2.5 at femoral neck, total hip, or lumbar spine, OR 10-year probability ≥20% for major osteoporotic fractures, OR ≥3% for hip fractures 1, 2
• This patient with multiple fragility fractures already meets treatment criteria regardless of BMD results 1

Critical Pitfalls to Avoid

• Do not assume osteoporosis without ruling out metastatic disease when radiographs show heterogeneous sclerosis or patchy opacities—this requires protein electrophoresis and potentially advanced imaging 1
• Do not delay treatment while awaiting DXA results in elderly patients with typical fragility fracture patterns, as secondary fracture risk peaks immediately post-fracture 3
• Do not neglect falls risk assessment—87% of fractures in the elderly result from falls, making fall prevention as important as bone-directed therapy 5
• Avoid inadequate calcium and vitamin D supplementation during osteoporosis treatment, as this undermines pharmacological efficacy 2
• Do not fail to coordinate care between orthopedic surgeons, rheumatologists/endocrinologists, geriatricians, and primary care physicians through the FLS structure 1, 3

Monitoring and Follow-Up

• BMD testing every 2 years for patients at high risk 2
• Systematic follow-up is essential as long-term adherence to osteoporosis treatment is typically poor (only 4.6% of fracture patients receive treatment in usual care) 7
• FLS programs achieve up to 90% adherence rates because patients are more motivated after experiencing a fracture 3
• Monitor for bisphosphonate adverse effects including osteonecrosis of the jaw and atypical femoral fractures 2