Fragility Fractures: Nonpharmacologic Treatment
After an introduction to fragility fractures, we will move forward with what clinicians can do once treatment is deemed appropriate. There are many ways that health systems accommodate patients once a fragility fracture occurs. Many of the original programs (Capture the Fracture, Own the Bone) were designed to make appointments or address follow up before leaving the hospital through a nurse manager or social worker. This liaison is responsible for updating the local and national databases and scheduling follow up with a provider that deals with secondary prevention. Fractures that present to an urgent care or emergency department and discharged are naturally harder to track for health systems.
XR of a fragility fracture in a patient with osteoprosis (courtesy of AAOS)
Vitamin D also plays a major role in bone health, balance and calcium absorption. The National Osteoporosis Foundation recommends an intake of 800 to 1000 international units (IU) for adults aged 50 and older. Most dietary sources of vitamin D are usually fortified and include milk, fish, liver, juices and cereal. It carries a similar recommendation that individuals that do obtain enough dietary vitamin D should supplement. There are many different health conditions (IBD, celiac disease), medications (antiseizure medications), situations (homebound) and genetic traits (very dark skin) that can affect the absorption of vitamin D (1).
Displaced left midshaft femur fracture in a patient with known osteopetrosis (Case courtesy of Samir Benoudina, Radiopaedia.org, rID: 76940)
Displaced left midshaft femur fracture in a patient with known osteopetrosis (Case courtesy of Samir Benoudina, Radiopaedia.org, rID: 76940)
Providers must proceed with some caution and knowledge of the evidence, however. One large randomized controlled trial did show a 16 % decrease in fracture incidence rate in 9,605 community dwelling individuals aged greater than 66 years with supplementation of 400 IU of vitamin D and 1,000 mg of calcium (3). The WHI (Women’s Health Initiative Study) clinical trial involved more than 35,000 postmenopausal women aged 50-79 that were supplemented with 400 UI of vitamin D and 1,000 mg of calcium. The trial concluded there was a small, but significant increase in bone mineral density, no significant reduction in hip fracture (11.9% to 11.6%) and an increased risk of kidney stones (4). A 2016 meta-analysis performed by the National Osteoporosis Foundation (NOF) concluded there was a statistically significant 15 % reduced risk of total fractures and a 30 % reduced risk of hip fractures with calcium and vitamin D supplementation (5).
Many major risk factors exist for falls and some of them can be modified. Several strategies have been demonstrated to reduce falls and many of these are multifactorial. Individual risk assessment is important and may be performed by a trained individual such as a physical therapist. Home safety assessment and home modifications are also beneficial, especially when done by an occupational therapist. Collaborative care may be needed to withdraw any psychotropic or mind-altering medications if appropriate or correct vision. Other conditions may need addressed such as orthostatic hypotension, arrhythmias, depression or malnutrition.
Risk factors for falls (Cosman 2014)
Regular weight-bearing (bones and muscles work against gravity as the feet and legs bear the body’s weight) and muscle-strengthening exercises have been shown to reduce the risk of falls and fractures. A Cochrane review in 2011 concluded there is a small increase in BMD when compared to control groups. These changes were more prevalent in the lumbar spine with weight bearing activities and more prevalent in the neck of the femur with high force or resistance non-weight bearing exercises (9). Fall prevention programs that lasted at least 5 months were shown to have an overall reduction in falls of 9-12 % (10).
Alcohol intake recommendations are a little more complicated than tobacco use recommendations. There is great variability in the literature of what constitutes “light,” “moderate,” and “excessive” alcohol use. Most alcoholic beverages contain around 10 grams of ethanol and moderate is defined in some countries with levels as low as 20 grams per day and others as high as 70 grams per day. The other issue with labeling them as “drinks per day” is the varying levels of alcohol in some drinks related to strength and size. Older studies show a possible increase in bone density (particularly mostly wine and an increase in the lumbar spine BMD) and lower fracture risk in postmenopausal women with moderate alcohol intake (20).
An 88-year-old woman with osteoporisis sustained a pertrochanteric fracture. a–b Preoperative x-rays. c A medial proximal tibial fracture was detected, most probably sustained at the same accident as the hip fracture and treated conservatively. d–e The fracture healed after fixation with a proximal femoral nail antirotation (PFNA). f Due to severe coxarthritis, total joint replacement was performed. (Image courtesy of musculoskeletalkey.com)
