What is the appropriate treatment and management plan for a 65-year-old female patient with a history of a recent fall from an e-bike, presenting with left rib, hand, and elbow pain, worsening rib pain upon coughing or laughing, symptoms suggestive of a head injury, and X-ray confirmed fractures of the fifth metacarpal and left seventh and eighth ribs, in the context of pre-existing mild osteoarthritis?

Management of Multiple Fractures Following E-Bike Fall in 65-Year-Old Female

This patient requires immediate head injury evaluation with CT imaging, conservative management of rib fractures with aggressive pain control to prevent pulmonary complications, hand-based functional splinting for the fifth metacarpal fracture, and initiation of osteoporosis treatment given her age and multiple fractures from low-energy trauma.

Immediate Priority: Head Injury Assessment

• The patient's report of hitting her head and "feeling off" mandates urgent neurological evaluation with non-contrast head CT to rule out intracranial hemorrhage or other traumatic brain injury, as delayed presentation of symptoms can occur up to a week post-injury in elderly patients on anticoagulation or with underlying cerebrovascular disease.
• Perform focused neurological examination including mental status, cranial nerves, motor/sensory function, and gait assessment if safe.
• Any concerning findings (confusion, persistent headache, focal deficits, altered consciousness) require immediate imaging and neurosurgical consultation.

Rib Fracture Management

Pain Control Strategy

• Aggressive multimodal analgesia is essential to prevent respiratory complications including pneumonia, atelectasis, and respiratory failure, which are the primary causes of morbidity and mortality in elderly patients with rib fractures 1.
• Start acetaminophen 1000mg every 6-8 hours as first-line therapy 2.
• Add short-acting opioids (oxycodone 5-10mg every 4-6 hours as needed) for breakthrough pain, as inadequate pain control leads to splinting, hypoventilation, and pulmonary complications 2.
• Avoid NSAIDs if cardiovascular or renal comorbidities exist 2.

Respiratory Management

• Incentive spirometry every 1-2 hours while awake is critical to prevent atelectasis and pneumonia 1.
• Encourage deep breathing exercises and coughing (with pillow splinting for comfort).
• Monitor for signs of respiratory compromise: increasing dyspnea, hypoxia, fever, or productive cough.
• The minimally displaced seventh and eighth rib fractures with no pneumothorax can be managed conservatively, but close monitoring for delayed pneumothorax or hemothorax is warranted 1.

Activity Modifications

• Avoid prolonged bed rest as it accelerates bone loss and increases DVT risk 2.
• Early mobilization as tolerated while protecting the injured areas 2.
• No heavy lifting or strenuous activity for 6-8 weeks until fracture healing.

Fifth Metacarpal Fracture Management

Treatment Approach

• The acute, mildly offset fracture of the proximal head-to-neck portion of the fifth metacarpal requires hand-based functional splinting rather than cast immobilization 3.
• This fracture location (proximal head-to-neck) is more unstable than typical boxer's fractures and may require closer monitoring 4, 5.

Splinting Protocol

• Apply hand-based splint maintaining metacarpophalangeal (MCP) joint in 60-90 degrees flexion with interphalangeal (IP) joints free 4, 3.
• Functional splinting allows MCP, IP, and radiocarpal joint motion, which maintains function throughout treatment and prevents stiffness 3.
• Average splint duration is 24 days with excellent maintenance of fracture reduction 3.
• Obtain repeat radiographs (PA and oblique pronated views) at 7-10 days to confirm maintained alignment 6.

Surgical Indications

• Monitor for malrotation (check finger cascade with flexion), displacement >30 degrees, or shortening >5mm 4.
• If closed reduction fails or fracture becomes unstable, percutaneous pinning or open reduction with K-wire fixation may be required 5, 7.
• Fractures at the base of the fifth metacarpal are inherently unstable and inadequate reduction may result in pain, functional disability, and osteoarthritic changes 5.

Elbow Pain Evaluation

• Although X-rays showed no acute fracture or dislocation, the patient's persistent elbow pain warrants:
  • Careful examination for ligamentous injury, radial head fracture (which can be radiographically occult), or soft tissue injury.
  • Consider MRI if pain persists beyond 2 weeks or if mechanical symptoms develop, as initial radiographs can miss occult fractures.
  • Conservative management with rest, ice, compression, elevation (RICE protocol) and NSAIDs if no contraindications.

Osteoporosis Evaluation and Treatment

Why This Matters

• A 65-year-old woman sustaining multiple fractures from low-energy trauma (e-bike fall) has presumptive osteoporosis requiring immediate evaluation and treatment 8, 9.
• Multiple non-traumatic or low-energy fractures significantly increase future fracture risk and mortality.

Diagnostic Workup

• Order DXA scan of lumbar spine and hip to quantify bone mineral density and establish baseline T-scores 8.
• Obtain laboratory assessment: serum calcium, albumin, creatinine, TSH, ESR, 25-OH vitamin D to identify secondary causes of osteoporosis 8.
• Consider vertebral imaging (lateral thoracic/lumbar spine X-rays or vertebral fracture assessment) to detect subclinical vertebral fractures 8.

Pharmacological Treatment

• Initiate oral bisphosphonate (alendronate 70mg weekly or risedronate 35mg weekly) as first-line therapy, which reduces vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51% 8, 9, 2.
• Prescribe for 3-5 years initially, with longer duration if high fracture risk persists 8, 9, 2.
• Add calcium 1000-1200mg daily plus vitamin D 800 IU daily, which reduces non-vertebral fractures by 15-20% and falls by 20% 8, 9, 2.
• Avoid high pulse dosages of vitamin D as they increase fall risk 2.

Non-Pharmacological Interventions

• Implement weight-bearing exercise programs and balance training to reduce fall frequency by approximately 20% 2.
• Smoking cessation and alcohol limitation to improve bone mineral density 9, 2.
• Home safety assessment to address environmental fall hazards 2.
• Review medications that may increase fall risk (sedatives, anticholinergics, antihypertensives) 2.

Follow-Up and Monitoring

Short-Term (1-2 Weeks)

• Reassess head injury symptoms - any worsening requires immediate imaging.
• Repeat hand radiographs to confirm maintained alignment of fifth metacarpal 3, 6.
• Monitor respiratory status and pain control effectiveness.
• Ensure patient can perform incentive spirometry and deep breathing exercises.

Medium-Term (4-6 Weeks)

• Clinical and radiographic assessment of fracture healing.
• Begin gentle range-of-motion exercises for hand and elbow as pain allows.
• Transition from splint to buddy taping if fifth metacarpal shows healing.

Long-Term (3-6 Months)

• Establish structured follow-up for osteoporosis management with regular monitoring for medication tolerance and adherence 8, 2.
• DXA scan at 1-2 years to assess treatment response.
• Coordinate care between orthopedics, primary care, and rheumatology/endocrinology 2.

Critical Pitfalls to Avoid

• Do not dismiss the head injury symptoms - elderly patients can develop delayed intracranial hemorrhage, especially if on anticoagulation.
• Do not undertreat rib fracture pain - inadequate analgesia leads to respiratory complications which are the primary cause of morbidity in elderly patients with rib fractures 1.
• Do not use rigid cast immobilization for the metacarpal fracture - functional hand-based splinting provides superior outcomes with maintained motion and faster return to activities 3.
• Do not delay osteoporosis treatment - multiple fractures from low-energy trauma mandate immediate bisphosphonate initiation 8, 2.
• Do not allow prolonged bed rest - early mobilization prevents complications of immobility including DVT, pressure ulcers, and accelerated bone loss 2.
• Do not use calcium supplementation alone - calcium without vitamin D and bisphosphonates has no demonstrated fracture reduction effect 2.