What is the appropriate management for an older adult with a suspected buckle fracture and potential osteoporosis?

Management of Buckle Fractures in Older Adults

In older adults with a suspected buckle (torus) fracture, immediate immobilization with a removable splint for 3 weeks without routine follow-up is appropriate for the fracture itself, but the critical priority is systematic evaluation and treatment for underlying osteoporosis, as this represents a fragility fracture indicating high risk for subsequent fractures that significantly impact mortality and morbidity. 1, 2

Immediate Fracture Management

• Provide adequate pain relief immediately before starting any diagnostic investigations, as this is critical for patient comfort and optimal outcomes 1, 2
• Immobilize with a removable splint (such as a Futura-type wrist splint) for 3 weeks—this is as effective as casting and allows for better hygiene and comfort 3, 4
• No routine radiological or clinical follow-up is necessary for the fracture itself once the diagnosis is confirmed and appropriate patient education is provided 3, 4
• Complete definitive treatment within 48 hours of injury if any intervention beyond simple immobilization is needed 1, 2

Important Caveat for Older Adults

While buckle fractures in children are straightforward, in adults over 50 years, any low-trauma distal radius fracture is a fragility fracture that signals underlying osteoporosis and dramatically elevated risk for subsequent hip and vertebral fractures 1, 2. The fracture management is simple, but the systemic evaluation is mandatory.

Mandatory Osteoporosis Evaluation (The Critical Component)

Every patient aged 50 years or older with a buckle fracture must receive systematic evaluation for osteoporosis 1, 2:

• DXA scanning of spine and hip to quantify bone mineral density 1, 2
• Spine imaging (radiography or vertebral fracture assessment) to detect asymptomatic vertebral fractures, which are present in many patients and independently increase fracture risk 1, 2
• Clinical risk factor assessment including age, gender, body mass index, family history, smoking, alcohol use, and prior fractures 1
• Falls risk evaluation with history of falls in the past year and specific testing when indicated 1, 2
• Laboratory evaluation for secondary osteoporosis: calcium, albumin, creatinine, thyroid-stimulating hormone, vitamin D, and additional tests as clinically indicated 1

Coordinated Care Model

Implement a Fracture Liaison Service (FLS) model with a dedicated coordinator (often a specialized nurse under supervision of an orthopedic surgeon, endocrinologist, or rheumatologist) who ensures identification, investigation, and treatment initiation 1. This model has been proven most effective, with 45% of patients receiving appropriate management versus only 26% in usual care 1.

Pharmacological Treatment

Pharmacological treatment should be initiated using drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures 1:

• First-line options: Oral bisphosphonates (alendronate or risedronate) for patients with eGFR ≥30 mL/min 5
• Alternative: Denosumab 60 mg subcutaneously every 6 months for patients with eGFR <30 mL/min or oral intolerance 5, 6
• All patients require calcium 1000-1200 mg/day and vitamin D 800 IU/day supplementation 1, 2, 5
• Regular monitoring for tolerance and adherence is essential 1

Critical Warning for Denosumab

In patients with advanced chronic kidney disease (eGFR <30 mL/min), evaluate for chronic kidney disease-mineral bone disorder (CKD-MBD) prior to initiating denosumab, as severe hypocalcemia can occur 6. Treatment should be supervised by a provider with expertise in CKD-MBD management 6.

Non-Pharmacological Interventions

• Smoking cessation and alcohol limitation are essential 1, 2, 5
• Early post-fracture physical training and muscle strengthening should begin once fracture stability allows 1, 2, 5
• Long-term balance training and multidimensional fall prevention programs to reduce subsequent fracture risk 1, 2, 5

Patient Education

Educate patients about the burden of osteoporosis, risk factors for fractures, follow-up requirements, and duration of therapy 1, 2. Many patients do not understand that a "simple wrist fracture" indicates systemic bone fragility requiring long-term management.

Common Pitfalls to Avoid

• Do not dismiss this as "just a buckle fracture" in older adults—it is a sentinel event for osteoporosis 1, 2
• Do not over-treat the fracture with casting and multiple follow-ups when a splint suffices 3, 4
• Do not under-treat the underlying osteoporosis—the subsequent fracture risk is highest immediately after the initial fracture 1
• Do not delay osteoporosis evaluation—ideally complete within 3-6 months of the fracture 1