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. They may be sent to follow up with an orthopedic surgeon or sports medicine physician in 3-5 days. If the orthopedic provider does not manage osteoporosis, another referral needs to be made to a provider to address this after care is complete. The burden typically falls upon primary care, sports medicine, orthopedic and rheumatology providers to treat the underlying decrease in bone mineral density (BMD) and attempt to prevent future fractures. Treatments generally fall into nonpharmacologic and pharmacologic options.
Nonpharmacologic methods. There are general recommendations to preserve bone strength that can be recommended to the general population and also to individuals that have suffered a fragility fracture (1). Calcium is required for acquisition of peak bone mass and subsequent bone health. All individuals should obtain an adequate intake of dietary calcium and vitamin D. A balanced diet rich in dairy products, fruits and vegetables will typically provide calcium and nutrients. The Institute of Medicine (IOM) recommends that women age 51 or older and men aged 71 and older consume 1200 mg/day of calcium (2). The average daily dietary calcium intake in adults age 50 and older is 600 to 700 mg per day. If one is not able to obtain adequate calcium through diet, then supplementation should be added.
The use of ultrasound is generally suggested for prolotherapy. Some areas, such as the tibial tubercle may not require ultrasound. However most pathologic tendons benefit from increased procedural accuracy with ultrasound use and some obviously require it. Prolotherapy also appears to demonstrate sonographic changes associated with tissue healing .
Figure 2. 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). Due to these factors, vitamin D (serum 25(OH)D levels are typically measured. Treatment typically occurs with levels below 30 ng/mL and a maintenance dose is recommended at this level. If levels are below 20 ng/mL, many providers will treat with 50,000 IU once a week for 8-12 weeks and then recheck the vitamin D levels. If normalized, dosages between 1000-3000 IU are started as a maintenance dose and adjusted depending on follow up levels.
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). The USPSTF (United States Preventive Service Task Force) stated in 2013 there was insufficient evidence to recommend vitamin D supplementation with or without calcium with doses greater than 400 IU for community dwelling women (6). An updated 2018 statement by the USPSTF concluded that vitamin D supplementation alone or with calcium was not associated with reduced fracture incidence among community-dwelling adults without known vitamin D deficiency, osteoporosis, or prior fracture and vitamin D with calcium was associated with an increase in the incidence of kidney stones (7). There was no statistically significant increase in heart disease or cancer. The recommendations for many professional organizations continue to favor vitamin D and calcium supplementation for osteoporosis.
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. There is paucity in evidence in regards to wearing protective hip devices with a very small decrease in hip fracture in nursing care facilities without serious side effects. Compliance was poor and there was shown to be a small increase in risk of pelvic fracture with these devices (8). It is also worth noting that vitamin D was previously recommended by the USPSTF for fall prevention in community dwelling elderly and recently went from a “B” grade to a “D” grade and is no longer recommended.
Figure 1. 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). Another analysis showed reduced rate of falls with both group and home-based exercise programs along with home safety interventions (11). Exercise programs that included challenging balance exercises such as standing closer together, minimizing hand use to assist and practiced controlled movement of center of mass were shown to decrease the rate of falling by 17% (12). Core-strength and pilates exercises were shown to be feasible and have high adherence rates for older adults (13). Tai Chi was also shown to reduce the risk of falling (11). The NOF endorses lifelong physical activity at all ages, both for prevention and overall health.
Tobacco use has many detrimental effects to health and several studies have shown it to be a risk factor for osteoporosis. Smoking tobacco causes an imbalance in the mechanisms of bone turnover, leading to lower bone mass and bone mineral density (14). This, in turn, makes tobacco users more vulnerable to osteoporosis and fractures (15). An association with lower bone mineral density and increased risk of osteoporotic fractures in a dose- and duration-related manner to smoking has been implicated (16-18). Recent studies have suggested that smoking is an independent risk factor for osteoporotic fracture (18). It was recently shown that current smokers were less likely to be compliant with treatment for osteoporosis (19). Encouragement and implementation of a tobacco cessation program remains a staple of nonpharmacologic management for osteoporosis and secondary fractures.
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). In other studies involving moderate alcohol (11-29 g of ethanol or up to three drinks per day showed an increase in BMD in post menopausal women and a decrease in BMD for pre-menopausal women consuming 5-24 grams per day (21-22). It is generally accepted that chronic heavy alcohol use (100-200 grams per day) leads to a decrease in BMD in multiple sites (23). It has also been shown that chronic alcoholics are at a four times more likely to have a fracture than age-matched controls (24). Chronic alcoholics are also more likely to fall, have increased fracture healing times and increases complications following fracture (25). Finally, a recent meta-analysis showed a 1.34 times risk in persons consuming 1-2 drinks per day and a 1.63 times risk in individuals consuming >2 drinks per day (26). It is clearly recommended to avoid heavy daily alcohol use and there is conflicting evidence in regards to moderate or light alcohol use.
In summary, there are nonpharmacologic options that should be recommended to each individual that suffers from a fragility fracture or osteoporosis. Most professional societies, including the National Osteoporosis Foundation recommend 1000-1200 mg of calcium and 800-1000 IU of vitamin D per day. If these cannot be obtained by diet, supplementation is recommended. Fall prevention should be addressed and elderly individuals should have a personal and home assessment by a trained provider. Both home and group exercises have been shown to be effective to prevent falls and core strengthening, difficult balance training, Tai Chi and Pilates may be a good option. A cessation and education program should be implemented for tobacco users. There is conflicting evidence on light and moderate alcohol use, but chronic daily alcohol use should be discouraged.
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