Evaluation and Medical Management of Fragility Fractures of the Upper Extremity

Osteoporosis continues to be a major health condition plaguing the aging population. The major manifestation of osteoporosis, the development of fragility fractures, is a burden both clinically and economically on patients and the nation’s health care system, with up to half of all American women sustaining a fragility fracture in their older years. The high frequency of injuries to the distal radius and proximal humerus should lead upper extremity surgeons to take pause and recognize the magnitude of impact these fractures have on their patient population. Recommended interventions span a spectrum of aggressiveness and have various financial implications.

Key points

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Osteoporosis is a silent and painless disease until a fracture occurs from a low-energy injury.
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The goal of treatment is early diagnosis and prevention.
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Diagnosis is made through bone mineral density testing, most commonly through dual-emission x-ray absorptiometry (DEXA) scanning.
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The Fracture Risk Algorithm (FRAX) tool (World Health Orgainziation Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK) uses clinical grounds to assess one’s 10-year fragility fracture risk.
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Prevention is provided through avoiding alcohol and tobacco, performing regular weight-bearing exercises, dietary supplementation, and pharmacologic management when indicated.
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DEXA scanning is indicated in women aged 65 years and older and men aged 70 years and older. Testing can be performed earlier in postmenopausal women of any age or men with higher risk profiles.
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Adequate daily calcium intake consists of at least 1200 mg and vitamin D of 800 to 1000 IU, each per day. Dietary supplementation should be used accordingly.
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Pharmacologic management is indicated in those who have incurred a hip or vertebral fracture or in those with a DEXA scan T-score of less than or equal to −2.5 standard deviations (osteoporosis) at the femoral neck or spine.
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Pharmacologic management is also indicated in those with a DEXA scan T-score of between −1.0 and −2.5 standard deviations (osteopenia) with a FRAX 10-year fracture probability of more than 20%.
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Current Food and Drug Administration–approved pharmacologic agents for osteoporosis prevention and treatment include bisphosphonates, parathyroid hormone, calcitonin, and hormone therapy.