How should I manage an older adult with a fragility fracture due to osteoporosis, including acute fracture care, laboratory evaluation, imaging, pharmacologic therapy, and fall‑prevention?

Management of Fragility Fractures in Older Adults

Every patient aged 50 years and older with a fragility fracture should receive immediate multidisciplinary fracture care with surgery within 48 hours when indicated, systematic osteoporosis evaluation, and pharmacological treatment with bisphosphonates (alendronate or risedronate) combined with calcium and vitamin D supplementation to reduce subsequent fracture risk by approximately 50%. 1, 2

Acute Fracture Management

Immediate Care Priorities (First 48 Hours)

• Provide adequate pain relief using multimodal analgesia, prioritizing non-opioid analgesics to minimize complications in elderly patients. 1, 3
• Ensure appropriate fluid management and correct any electrolyte abnormalities preoperatively. 1
• Perform surgery within 48 hours of injury for fractures requiring operative intervention (particularly hip fractures) to reduce mortality and improve functional outcomes. 1
• Implement orthogeriatric comanagement immediately, especially for hip fractures, as this reduces length of hospital stay, improves functional outcomes, and reduces mortality. 1

Fracture-Specific Treatment Decisions

• Hip fractures almost always require surgical intervention, with treatment options dependent on fracture location, patient age, functional status, and presence of pre-existing osteoarthritis. 1
• Most vertebral compression fractures (90%) should be managed conservatively with analgesics, activity modification, and bracing, as only 10% require hospitalization for severe pain. 1, 3
• Distal radius fractures can typically be treated with cast immobilization. 1
• For comminuted proximal humerus fractures in elderly osteoporotic patients, choose reverse shoulder arthroplasty over hemiarthroplasty or internal fixation, as it provides more reliable functional outcomes. 4

Postoperative Care Essentials

• Provide antibiotic prophylaxis and correct postoperative anemia. 1
• Perform regular assessments of cognitive function, pressure sore risk, nutritional status, and renal function. 1
• Assess and regulate bowel and bladder function. 1
• Begin early mobilization immediately to prevent deconditioning and complications. 1

Systematic Fracture Risk Evaluation (Within First Week)

Required Laboratory Testing

• Order DXA scanning of spine and hip to assess bone mineral density. 1, 2, 4
• Obtain spine imaging (lateral thoracic and lumbar radiographs or vertebral fracture assessment) to identify prevalent vertebral fractures, as only one out of three vertebral fractures are symptomatic. 1, 4
• Check serum calcium, vitamin D (25-hydroxyvitamin D), and parathyroid hormone levels to identify secondary causes of osteoporosis. 4

Clinical Risk Factor Assessment

• Review all clinical risk factors for subsequent fractures including age, prior fracture history (reported in 7-67% of patients), family history, smoking status, alcohol intake, and medication use (particularly corticosteroids and anticonvulsants). 1, 5, 6
• Perform comprehensive falls risk assessment including evaluation of gait, balance, vision, home environment, and medications that increase fall risk. 1, 2
• Identify secondary causes of osteoporosis including chronic kidney disease, thyroid disorders, and nutritional deficiencies. 1, 5

Pharmacological Treatment (Start Within 6 Months)

First-Line Therapy

Prescribe bisphosphonates (alendronate or risedronate) as first-choice agents due to tolerability, low cost from generic availability, extensive clinical experience, and proven efficacy in reducing vertebral, non-vertebral, and hip fractures by approximately 40-50%. 2, 4

• Begin bisphosphonate therapy within the first 6 months post-fracture to maximize benefit during the period of highest subsequent fracture risk. 2
• Do not wait for "perfect consolidation" to initiate osteoporosis therapy—start immediately to avoid the osteoporosis care gap. 2, 6
• Prescribe for 3-5 years initially, with longer duration for patients remaining at high risk after reassessment. 3, 4
• For elderly patients with immobility and comorbidities (such as those with hip or pelvic insufficiency fractures), anti-osteoporotic treatment can be started even without a DXA scan. 1

Monitoring and Adherence

• Regularly monitor for tolerance and adherence, as long-term compliance is often poor (only 1-65% of patients receive treatment in routine practice). 2, 3, 6
• Implement Fracture Liaison Service (FLS) model with a dedicated coordinator, as adherence rates reach up to 90% in FLS programs compared to much lower rates in usual care. 1, 4

Essential Non-Pharmacological Interventions

Nutritional Supplementation

• Prescribe calcium 1000-1200 mg/day combined with vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20%. 2, 3, 4
• Avoid high-pulse dosages of vitamin D, as these increase fall risk rather than prevent it. 2
• Ensure adequate nutritional status throughout treatment, as malnutrition is common in fracture patients. 1, 3

Lifestyle Modifications

• Counsel patients to stop smoking and limit alcohol intake to no more than moderate consumption. 1, 3

Rehabilitation and Fall Prevention

Early Phase (First 3 Months)

• Begin early postfracture physical training and muscle strengthening immediately after fracture stabilization to prevent deconditioning and improve functional outcomes. 1, 2, 4
• Avoid delayed mobilization due to fear of pain, as early activity improves outcomes. 3

Long-Term Phase (Ongoing)

• Continue long-term balance training and multidimensional fall prevention strategies indefinitely, as fracture risk remains acutely elevated for 24 months before gradually declining. 1, 2

Multidisciplinary Coordination and Implementation

Care Coordination Structure

• Designate a local responsible lead person or group to coordinate secondary fracture prevention, liaising between surgeons, rheumatologists/endocrinologists, geriatricians (for elderly patients with hip or other major fractures), and general practitioners. 1, 4
• The critical point is not which specialty takes care of the patient, but that all patients receive optimal care through structured collaboration between healthcare workers. 1

Patient Education

• Educate patients about disease burden, risk factors for fractures, follow-up requirements, and expected duration of therapy to improve adherence. 1, 2, 3
• Emphasize that fracture risk remains acutely elevated for 24 months and that a prior fracture dramatically increases risk of subsequent fractures (7-22% experience subsequent fracture during 6 months to 5 years follow-up). 2, 6

Critical Pitfalls to Avoid

• Do not delay fracture risk assessment and osteoporosis treatment in patients who have already sustained a fragility fracture—a fragility fracture is diagnostic for osteoporosis even without bone density testing. 2, 3, 7
• Do not overlook osteoporosis treatment after acute fracture care, as only 1-45% of patients receive an osteoporosis diagnosis and only 1-65% receive pharmacological therapy in routine practice, creating a dangerous "osteoporosis care gap." 6, 8
• Do not rely solely on pain management without addressing underlying osteoporosis, as this leaves patients vulnerable to subsequent fractures. 3
• Do not assume younger patients or men do not need treatment—while osteoporosis diagnosis is more common in older patients, treatment should be based on fracture risk regardless of age or gender. 6