What is the recommended management for a fracture according to Rockwood and Green's Fractures in Adults (10th edition)?

Fracture Management According to Rockwood and Green's Principles

Critical Note on Available Evidence

I must clarify that the evidence provided does not contain content from Rockwood and Green's Fractures in Adults 10th edition. The available evidence consists primarily of EULAR/EFORT guidelines for fragility fracture management in patients over 50 years old. I will provide recommendations based on this high-quality guideline evidence, which represents current best practices in fracture care.

Immediate Fracture Management

All fractures should be managed within a multidisciplinary clinical system that guarantees adequate preoperative assessment, appropriate pain relief, fluid management, and surgery within 48 hours of injury when operative treatment is indicated. 1

Initial Assessment and Stabilization

• Provide immediate pain management before diagnostic investigations using nerve blocks when appropriate, as they significantly reduce acute pain in fracture patients 1
• Perform systematic multidisciplinary assessment including chest X-ray, ECG, full blood count, clotting studies, renal function, and cognitive baseline function 1
• Identify and treat modifiable variables including malnutrition, electrolyte disturbances, anemia, cardiac/pulmonary diseases, and delirium 1
• Transfer patients safely and rapidly from emergency room to appropriate ward with definitive treatment within 24-48 hours to reduce mortality and complications 1

Operative vs Non-Operative Decision-Making

Treatment requires a balanced approach regarding operative versus non-operative management with careful selection of fixation devices and techniques, particularly in elderly patients with frail bones. 1

Specific Fracture Management

Hip Fractures:

• Stable non-displaced femoral neck fractures: Treat with percutaneous cannulated fixation 1
• Displaced femoral neck fractures in healthy, active elderly: Perform total hip replacement 1
• Frail patients with displaced femoral neck fractures: Consider hemiarthroplasty due to shorter operative time and lower dislocation risk 1
• Stable intertrochanteric fractures: Use sliding hip screw 1
• Unstable intertrochanteric and subtrochanteric fractures: Use antegrade cephalomedullary nail 1

Distal Radius Fractures:

• Treatment options include cast immobilization, locking plates, Kirschner wires, or external fixation, though optimal treatment in elderly populations remains unclear from current evidence 1
• After casting or surgery: Begin early finger motion immediately to prevent edema and stiffness 1
• When immobilization discontinued: Initiate aggressive finger and hand motion exercises 1

Shoulder Fractures:

• Begin range-of-motion exercises within first postoperative days including shoulder, elbow, wrist, and hand motion 1
• Restrict above-chest activities until fracture healing is evident to prevent fixation failure 1

Orthogeriatric Co-Management

For elderly patients, especially those with hip fractures, orthogeriatric co-management must be provided to improve functional outcomes, reduce hospital stay, and decrease mortality. 1

• Joint care model between geriatrician and orthopedic surgeon on dedicated orthogeriatric ward produces shortest time to surgery, shortest hospital stay, and lowest mortality rates 1
• Comprehensive geriatric assessment should be performed for all elderly fracture patients 1

Rehabilitation Protocol

An appropriate rehabilitation program must consist of early postfracture physical training and muscle strengthening, followed by long-term balance training and multidimensional fall prevention. 1

Early Phase Rehabilitation

• Primary goal: Regain pre-fracture mobility and independence 1
• Identify individual goals and needs before developing rehabilitation plan 1
• Begin mobilization early to prevent complications from immobility 1

Long-Term Rehabilitation

• Continue balance training and fall prevention programs long-term 1
• Implement multicomponent interventions including exercise, environmental adaptations, nutrition, and education 1

Secondary Fracture Prevention

Every patient aged 50 years and older with a recent fracture must be systematically evaluated for risk of subsequent fractures. 1

Risk Assessment Components

• Review clinical risk factors including age, low BMI, smoking, family history, height loss ≥4 cm, thoracic kyphosis 1
• Perform DXA of spine and hip 1
• Image spine for vertebral fractures 1
• Evaluate falls risk using individualized multicomponent screening 1
• Identify secondary osteoporosis through appropriate investigations 1

Implementation Requirements

• Establish local responsible lead (person/group) to coordinate secondary fracture prevention, liaising between surgeons, rheumatologists/endocrinologists, geriatricians, and general practitioners 1
• Refer patients to Fracture Liaison Service (FLS) or coordinated multidisciplinary post-fracture prevention program 1

Non-Pharmacological Treatment

Non-pharmacological treatment is essential for fracture prevention in high-risk patients and must include adequate calcium and vitamin D intake, smoking cessation, and alcohol limitation. 1

• Ensure calcium intake of 1000-1200 mg/day through diet and supplementation when necessary 1, 2, 3
• Provide vitamin D 800 IU/day 1, 2, 3
• Strongly discourage smoking due to negative effects on bone density and fracture risk 1, 2
• Limit alcohol intake to prevent bone quality deterioration 1, 2

Pharmacological Treatment

Pharmacological treatment should preferably use drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures, with regular monitoring for tolerance and adherence. 1

First-Line Treatment

• Bisphosphonates are first-line therapy for patients at high fracture risk, reducing vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 40-51% 2, 4
• Prescribe for initial duration of 3-5 years with reassessment for drug holiday after 5 years unless patient remains high risk 2, 4

Very High-Risk Patients

• Consider anabolic agents (teriparatide, abaloparatide, romosozumab) first-line for patients with recent vertebral fractures, hip fracture with T-score ≤-2.5, or multiple prior fractures 4
• Transition to antiresorptive agent after completing anabolic therapy to preserve gains and prevent rebound vertebral fractures 4

Special Populations

• For elderly with hip/pelvic insufficiency fractures: Anti-osteoporotic treatment can be started without DXA scan 1
• For glucocorticoid users: Alendronate, risedronate, and teriparatide all reduce fracture risk 4

Patient Education

Patients must be educated about disease burden, fracture risk factors, follow-up requirements, and treatment duration. 1

• Address medication adherence through structured follow-up and monitoring 1
• Discuss calcium and vitamin D intake focusing on actual versus recommended intake, food sources, and individual risk/benefit profile 1
• Emphasize shared decision-making between patients and healthcare professionals 1

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours unless acute medical optimization is absolutely necessary, as prolonged immobility increases complications and mortality 1
• Do not use overly aggressive physical therapy in early postoperative period as this may increase fixation failure risk 1
• Do not discontinue anabolic agents without immediately starting antiresorptive therapy due to serious rebound vertebral fracture risk 4
• Do not continue bisphosphonates indefinitely without reassessment as atypical fracture risk increases substantially after 8 years 4