What is the best management approach for an elderly female patient with a history of a fall, complaining of pain, and with X-ray results showing no acute bony abnormalities but evidence of previous internal fixation of the right mid-clavicle?

Management of Elderly Female with Fall and Pain but Normal X-rays

Despite normal X-rays, this elderly female with a fall and persistent pain requires comprehensive secondary fracture prevention through a Fracture Liaison Service, immediate fall risk assessment, pain management, and initiation of osteoporosis evaluation and treatment, as the absence of acute fracture does not eliminate her high risk for future fragility fractures. 1

Immediate Clinical Actions

Pain Management and Symptom Control

• Implement multimodal analgesia immediately with acetaminophen as first-line therapy, avoiding reliance on opioids due to increased risk of delirium, respiratory depression, and subsequent falls in elderly patients 2
• If pain is severe and localized to hip/groin despite negative X-rays, obtain MRI within 2-3 days as initial radiographs can be falsely negative in up to 10% of hip fractures, particularly occult femoral neck fractures 2
• Allow weight-bearing as tolerated with assistive device for 2-3 weeks while monitoring for clinical deterioration, as occult fractures can present with delayed symptoms 3

Comprehensive Fall Risk Assessment

• Conduct immediate fall risk evaluation including history of falls in the past year, assessment of gait and balance (such as Timed Up and Go test), review of medications (polypharmacy), visual impairments, and cognitive function 1
• Perform multifactorial assessment of modifiable risk factors including balance, gait, vision, postural blood pressure, medication review, home environment hazards, and psychological health 1
• Document that 30-40% of patients over age 65 fall at least once yearly, and this patient has already demonstrated fall risk requiring intervention 4

Secondary Fracture Prevention (Critical Priority)

Fracture Liaison Service Referral

• Immediately refer to Fracture Liaison Service (FLS), which is the most effective organizational structure for risk evaluation and treatment initiation in elderly patients with falls, even without acute fracture 1
• The FLS coordinator (typically a specialized nurse under physician supervision) will organize diagnostic investigations, start interventions, and provide medical information to the patient and primary care physician 1
• Secondary fracture risk is highest immediately after a fall event and gradually decreases over time, making early intervention critical 1

Osteoporosis Evaluation (Within 3-6 Months)

• Order DXA scan of lumbar spine and hip to measure bone mineral density, which independently contributes to fracture risk assessment 1, 2
• Obtain spine imaging (radiography or vertebral fracture assessment) to detect subclinical vertebral fractures, which are frequent in patients with recent falls and independently predict future fracture risk 1
• Calculate fracture risk using validated tools (FRAX, Garvan, or Q-Fracture) incorporating clinical risk factors: advanced age, female gender, low body mass index, personal/family history of fracture, and fall history 1

Laboratory Investigations

• Obtain standard laboratory panel including erythrocyte sedimentation rate, serum calcium, albumin, creatinine, thyroid-stimulating hormone, and 25-hydroxyvitamin D level to diagnose subclinical diseases that increase fracture risk 1
• Consider additional tests (protein electrophoresis, parathyroid hormone) when clinically indicated 1

Pharmacological Treatment for Fracture Prevention

Non-Pharmacological Foundation

• Prescribe calcium 1000-1200 mg/day (dietary plus supplementation if needed) combined with vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% 1
• Avoid high pulse doses of vitamin D as they are associated with increased fall risk 1
• Counsel on smoking cessation and alcohol limitation, as unhealthy lifestyle negatively affects bone mineral density and fall risk 1

Pharmacological Osteoporosis Treatment

• Initiate bisphosphonate therapy (alendronate or risedronate as first-line agents) if DXA confirms osteoporosis or high fracture risk, as these drugs reduce vertebral, non-vertebral, and hip fractures 1
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, use zoledronic acid (intravenous annually) or denosumab (subcutaneous every 6 months) as alternatives 1, 2
• Plan treatment duration of 3-5 years initially, with continuation in patients who remain at high risk 1
• Implement systematic follow-up as part of a five-step plan (identify, invite, evaluate, treat, follow-up) since long-term adherence to osteoporosis treatment is notoriously poor 1

Fall Prevention Interventions

Exercise Programs (Highest Priority)

• Prescribe supervised exercise program including gait, balance, and functional training combined with resistance training, as exercise interventions provide moderate benefit in preventing falls in at-risk older adults 1, 5
• Recommend 3 sessions per week for at least 12 months, with each session including balance training, strength exercises, and flexibility work 1
• Strength and balance training combination is most effective for fall prevention (RR = 0.71) and fracture prevention (RR = 0.54), with particularly strong effects in women 5
• Consider tai chi as an evidence-based option for balance and fall prevention 1

Multifactorial Interventions

• Implement customized interventions based on initial assessment findings, which provide small but meaningful benefit in preventing falls 1
• Address identified risk factors through targeted interventions: vision correction, medication adjustment (especially psychotropics and antihypertensives), home safety modifications, and treatment of postural hypotension 1
• Environmental modifications are significantly associated with improved outcomes (p = 0.028) in preventing fall-related injuries 6

Rehabilitation and Functional Recovery

Early Mobilization

• Begin early physical training and muscle strengthening immediately, with long-term continuation of balance training and multidimensional fall prevention 1
• The primary goal is to regain pre-fall level of mobility and independence through individualized rehabilitation planning 1
• Do not prescribe complete bed rest, as immobility increases complications including pneumonia, pressure ulcers, and deconditioning 3

Ongoing Monitoring

• Schedule systematic follow-up to monitor treatment adherence, assess for new falls, evaluate pain resolution, and adjust interventions as needed 1
• Re-evaluate fall risk at regular intervals and intensify interventions if additional falls occur 1

Critical Pitfalls to Avoid

• Never dismiss persistent pain with normal X-rays without considering occult fracture requiring advanced imaging (MRI or CT) 2, 3
• Never assume normal X-rays mean no fracture risk – this patient has already demonstrated fragility through her fall and requires full secondary prevention workup 1
• Never rely solely on vitamin D supplementation for fall prevention, as it has no net benefit when used alone without calcium and exercise 1
• Never prescribe opioids as primary analgesia in elderly patients due to increased delirium and fall risk 2
• Never delay osteoporosis evaluation – secondary fracture risk is highest immediately after the fall event 1